Authors: Jonathan Harris, Sheila Tucker
Smoke-free campus policies at inpatient health facilities are most effective when situated within comprehensive smoking cessation programs that include cessation support for staff and patients and effective communications and signage for staff, patients, and visitors.
Canadian jurisdictions such as Ontario, New Brunswick, Prince Edward Island, Alberta, British Columbia, and Northwest Territories have provincial smoke-free legislation that applies to the grounds of health facilities. This approach permits public health inspectors and peace officers to enforce the smoke-free grounds rules with the option of issuing fines to individuals or hospital corporations for non-compliance. There is very little existing evidence on the effectiveness of issuing fines as a means of enforcing smoke-free policies.
There can be unique considerations associated with implementing smoke-free policies in inpatient psychiatric facilities or units, given the relationship between mental health and substance use issues and tobacco use. Evidence shows that smoke-free policies are feasible and result in positive health outcomes in psychiatric facilities or units.
Staff may require additional education and training in smoking cessation and tools to support productive conversations with patients, visitors, or colleagues who are not in compliance with smoke-free policies. Examples of tools and communications materials used in other jurisdictions are provided in Appendix 1.
All Canadian jurisdictions have legislation or by-laws concerning smoking and vaping in public spaces. In some jurisdictions, this legislation or by-law sets out rules for smoking and vaping on property owned by regional health authorities (RHAs), whereas in other jurisdictions these rules are set out in facility or RHA policy. Although there are many similarities in approaches to smoking cessation in health facilities, some jurisdictions have banned smoking entirely on facility or RHA-owned property while others allow smoking in designated areas on facility grounds. This briefing note explores key success factors of smoking cessation policies at Canadian health facilities and discusses the differences in compliance models between jurisdictions with and without the force of provincial legislation.
Policies restricting smoking on the grounds of hospitals and other health facilities have been the norm in Canada for some time. The rationale behind implementing smoke-free grounds is to reduce exposure to second-hand smoke among patients, staff, and visitors; to encourage smoking cessation; and for health authorities to “lead by example” and project a healthy image in communities.1 Generally speaking, these policies have not been implemented in isolation, but have been situated within larger smoking cessation efforts. One such smoking cessation model, the Ottawa Model, developed at the University of Ottawa Heart Institute, is in use in many jurisdictions across Canada.2 Key elements of comprehensive smoking cessation programs in inpatient settings are:
Smoking cessation programs aimed at staff
Screening for tobacco use during inpatient admissions and offering smoking cessation supports and nicotine-replacement products to inpatients
Broader efforts aimed at education, awareness, and rationale for the implementation of smoke-free grounds policies, including effective signage, communication, and the use of staff champions to promote the policy2
In addition to reducing the incidence and prevalence of smoking on hospital property,3 policies on smoke-free grounds present an opportunity for health professionals to initiate a conversation about smoking cessation that may lead to quitting, as evidenced by a reduction in inpatient self-reported smokers in 1 study.4,5
All Canadian jurisdictions have legislation or by-laws concerning smoking and vaping in public spaces. In some jurisdictions, this legislation or by-law explicitly prohibits smoking or vaping on RHA or health facility property; in others, legislation or by-laws only reference general rules, such as banning smoking outdoors within a defined distance from entrances or windows.
Ontario’s legislation governing tobacco and e-cigarette use in public spaces, the Smoke-Free Ontario Act, was amended in 2016 to state that all hospitals and inpatient psychiatric facilities must be 100% smoke-free by 2018.6 At that time, some Ontario hospitals had already implemented smoke-free grounds, and others chose to become 100% smoke-free immediately because the Act’s requirement that only 1 designated smoking area be allowed per hospital was felt to be infeasible for large hospitals.6 Under the amended Act, which came into force on January 1, 2018, local public health units are responsible for enforcement, carrying out inspections, and responding to complaints regarding the consumption or sale of tobacco or vape products on hospital or psychiatric facility property. Proprietors of facilities are required to give notice to staff, patients, and visitors of the smoke-free policy; post signage at entrances, exits, washrooms, and other common areas; ensure that ashtrays are removed from premises; ensure that staff, patients, and visitors do not smoke; and ensure that individuals who refuse to comply do not remain on the facility grounds.7 There is a schedule of fines that public health units can levy to individuals or proprietors of hospitals or psychiatric facilities for non-compliance. For an individual found to be smoking or vaping indoors or outdoors on hospital or psychiatric facility grounds, this includes a maximum fine of $1,000 for a first offence or $5,000 for any subsequent offence. For hospital corporations, maximum fines for non-compliance with signage requirements are $5,000 for a first offence, $10,000 for a second offence, $25,000 for a third offence, and $75,000 for 4 or more offences. Fines for corporations for non-compliance with other responsibilities not related to signage under the Act are $100,000 for a first offence and $300,000 for 2 or more offences.8
New Brunswick’s Smoke-Free Places Act prohibits smoking on all RHA grounds.9 In 2017, regulations under the Provincial Offences Procedures Act were amended to allow both public health inspectors and peace officers to issue tickets for smoking in public places, including RHA grounds.10 Additionally, the Act requires appropriate signage to be placed at entrances and exits of public buildings, including RHA grounds.9
British Columbia’s legislation, the Tobacco and Vapour Products Control Act, prohibits the use of tobacco or vape products on “health board property,” which includes RHA property and other non-RHA organizations that provide health services.11 However, the legislation creates a carve out for RHAs and facilities to create designated smoking areas if they choose, in which case it is only an offence to smoke or vape outside of the designated area. The British Columbia Act allows for anyone designated by the Minister to enforce the Act, meaning that peace officers or public health inspectors can levy penalties, as in New Brunswick. Fines under the Act for individuals or corporations found to be contravening it are a maximum of $2,500 for a first offence or $5,000 for a second or subsequent offence. Imprisonment is also an option under the Act, although this likely would be applicable to individuals violating restrictions on where tobacco or vape products could be sold rather than individuals smoking in a prohibited place.11
Prince Edward Island’s Smoke-Free Places Act prohibits the use of tobacco and vapour products on hospital grounds, with a specific exemption made to allow for a designated smoking area at the Hillsborough Hospital,12 the province’s main inpatient psychiatric facility. Individuals who do not comply with the legislation can be charged and taken to provincial offences court, whereas owners or employers who do not comply can be fined from $100 to $2,000.13 The legislation can be enforced by environmental health officers or occupational health and safety officers, while hospital security and administrators are responsible for ensuring compliance on hospital grounds.13 The Act requires facility operators to post signage at entrances and to educate staff, patients, and visitors of the legislative requirements.13
A number of amendments were made to Alberta’s Tobacco and Smoking Reduction Act in 2020, including to extend limits to vaping and to specify that smoking or vaping on hospital property, “including the building, grounds, and parking areas,” is prohibited.14 Individuals found smoking or vaping on hospital grounds are subject to fines up to $1,000 for a first offence and up to $5,000 for a second or subsequent offence.15 Operators found not to be enforcing smoking and vaping rules are subject to fines of up to $10,000 for a first offence or $100,000 for a subsequent offence.15
Northwest Territories’ Smoking Control and Reduction Act took effect in 2020 and restricts smoking in any public place, including outdoor spaces, that the public has access to by right or invitation.16 Individuals found to be smoking in a public place are subject to a $500 fine for a first offence and fines of up to $1,000 for additional offences.16 Territorial environmental health officers are authorized to conduct inspections of public places and to issue fines.16
Quebec’s Tobacco Control Act states that health and social services institutions “must adopt a tobacco control policy geared to establishing a smoke-free environment and send it to the Minister.”17 Although the legislation does not require institutions to provide a 100% smoke-free outdoor environment,18 some Quebec hospitals have chosen to implement smoke-free grounds as part of their tobacco control policies. For example, the McGill University Health Centre adopted a smoke-free grounds policy in 2015, and in 2018 implemented fines ranging from $250 to $1,500 plus applicable taxes for individuals found to be smoking or vaping within a 9 m radius of a door, window, or air intake.19 The Centre intégré universitaire de santé et de service sociaux de l’Ouest-de-l’Ile-de-Montréal is currently implementing a phased plan that will see all grounds (hospitals, community health centres, residential care, and mental health facilities) 100% smoke-free by 2023.20
Nunavut is currently in the process of updating its tobacco control legislation following a consultation with Nunavummiut (the people of Nunavut) in 2020.21 The consultation found that people want more emphasis on enforcement of smoking rules and they were generally supportive of the use of fines for individuals caught smoking in restricted areas.21 Individuals also expressed that there may be a need for more enforcement officers to ensure rules are applied consistently.21 Individuals also stressed the need to address unique local and cultural factors when developing new legislation, including the role of intergenerational trauma in smoking and substance use and the social determinants of health as a contributor.21
Other provinces and territories, including Newfoundland and Labrador, Nova Scotia, Manitoba, Saskatchewan, and Yukon, do not specifically address smoking on hospital grounds in their smoke-free legislation. In these jurisdictions, authority for development and enforcement of smoke-free hospital grounds policies that go beyond existing provincial legislation is left to RHAs or individual facilities.
In many jurisdictions, including British Columbia and Ontario, legislation includes specified exemptions for tobacco used for cultural reasons, including Indigenous ceremonies.7,11 Under Ontario’s law, hospital corporations can be fined for failure to accommodate Indigenous ceremonies that involve smoke.7 A number of health facilities across Canada have created separate indoor spaces with specialized ventilation to accommodate smudging and other Indigenous ceremonies that involve smoke.
The literature suggests that there are unique challenges in implementing and enforcing smoke-free grounds policies in inpatient psychiatric facilities.22 Individuals living with a mental disorder are more likely to smoke, and exemptions to smoke-free grounds policies for inpatient psychiatric or substance use disorder units were once common.23 Health professionals may feel that patients will resist admission or leave treatment if they must abstain from smoking, and that tobacco or vape product use among those hospitalized for mental health or substance use treatment may be a strategy used to manage symptoms related to a mental disorder or merely as a means of relaxation or socialization.23 Despite the persistent perceptions, evidence suggests that individuals living with a mental or substance use disorder are often interested in quitting smoking and capable of doing so with access to appropriate supports.23 Evidence also suggests that psychiatric inpatients may adapt more quickly to smoke-free policies than do staff, and that smoke-free environments improve the overall health of patients and the risk of self-burn injuries.24
Toronto’s Centre for Addiction and Mental Health (CAMH) has implemented tobacco-free policies across its campuses.25 CAMH’s policy is framed as being clinically rather than enforcement focused.26 It shares many similarities with holistic smoking cessation programs, such as the Ottawa Model, in providing smoking cessation resources to staff and to patients upon admission and communicating effectively about the policy. The CAMH policy aims to “create a healing environment” where staff, patients, and visitors are not exposed to second-hand smoke or tobacco-related triggers. The focus on tobacco-related triggers recognizes that seeing or smelling tobacco or vape products may inhibit quit attempts and undermine other organizational efforts to encourage smoking cessation.26 Tobacco products, matches, and lighters are not allowed on inpatient units at CAMH, and if these cannot be sent home upon a patient’s admission, they are stored and returned upon discharge. Staff and visitors are asked not to bring tobacco products, matches, and lighters into the hospital but, if they must, these items must be stored out of view and where they are not accessible to others. Visitors are not allowed to provide these items to patients.25 All staff at CAMH are expected to engage in a conversation with anyone they find not complying with the policy.27 A 2017 study found that the CAMH policy is feasible and resulted in positive changes in patient and staff attitudes toward tobacco-free policies, as well as a statistically significant decrease in patient agitation.28
There is little available evidence on the effectiveness of fines as a means of enforcing smoke-free grounds policies. A 2018 systematic review identified 10 studies that described the use of penalties or the role of enforcement officers to enforce smoke-free policies in a variety of sectors, including hospitals and health facilities.29 The authors of the systematic review concluded that more severe penalties were associated with higher levels of compliance with smoke-free policies.29 However, all the identified studies were of low methodological quality,29 and of the 2 that were conducted in inpatient hospital or psychiatric care settings, neither assessed the use of financial penalties such as fines for smoking in outdoor areas. One study conducted in an inpatient psychiatric facility found that cohesive staff enforcement, supported by staff training, was associated with compliance30; however, staff enforcement methods were not described.29 Other enforcement measures described in the included studies — all deemed to be of low methodological quality — were policy promotion, awareness-raising activities, and clear and visible signage.29
One program evaluation examining the effects of province-wide outdoor smoking regulations in Ontario was identified.31 However, this evaluation pre-dates the most recent amendments to the Smoke-Free Ontario Act that mandated all hospital grounds become 100% smoke-free. Key findings of this evaluation include:
In 2016, hospitals had lower levels of compliance with outdoor smoking regulations than restaurant and bar patios, playgrounds, or sporting areas, with only 40% of the 52 hospitals inspected found to be in full compliance.31
Public health inspectors issued 1 or more warnings to visitors or staff for smoking outside designated smoking areas at 46% of Ontario hospitals. A further 25% of hospital inspections resulted in 1 or more charges being issued. The number of warnings and charges at hospitals were substantially higher for hospital grounds than for other outdoor public spaces.31
A limited capacity for inspections and enforcement by local public health units created a challenge. Hospital security staff were relied upon heavily for enforcement but were often unwilling to educate or warn patients or staff of the outdoor smoking rules or they were not taken seriously when they did attempt to enforce them.31
Public health units were seen as reluctant to issue fines to hospitals because they rely on hospitals for data and other supports for public health surveillance.31
Enforcement staff were reluctant to address issues with smoking in those admitted for mental health issues, older adults, non-ambulatory patients, or grieving visitors.31
Since the amendments to the Smoke-Free Ontario Act, media reports from Ontario suggest that fines are relatively rare. Ottawa Public Health reported that 435 inspections on hospital properties resulted in 300 warnings and only 30 fines over the first 3 months the new law was in effect.32
Smoke-free hospital grounds policies are most effective when implemented as part of holistic, comprehensive smoking cessation programs that offer pharmacologic and non-pharmacologic support for staff and patients who wish to quit smoking. Evidence suggests that an important element of compliance is effective communication about the policy and its intent with staff, residents, and visitors. Appropriate signage and public-facing communication materials are important, and attention should be paid to the visual appeal and effectiveness of the messaging on these materials.
Those jurisdictions with provincial legislation in place had robust enforcement mechanisms and the option to levy fines to both individuals or corporations not complying with or not adequately working to ensure compliance with existing legislation. There is limited evidence that issuing fines as a means of enforcement is effective at supporting behaviour change or on how often fines are issued. Compliance models that rely too heavily on enforcement and do not adequately recognize nicotine dependence as a health issue may be seen as needlessly punitive. However, the creation of an accountability mechanism that holds facility or RHA leaders responsible for non-compliance, as is done in Ontario, may be an option to ensure that organizational focus remains on smoke-free grounds initiatives. Having provincial legislation in place also extends enforcement responsibility to public health inspectors and peace officers, although the capacity to conduct inspections and enforce legislation consistently seems to be a challenge in many jurisdictions.
Many smoke-free hospital grounds policies create an expectation that all staff will play a role in ensuring compliance with the policies. Evidence suggests that staff may require additional training or educational resources about smoking cessation to optimally counsel patients. Additionally, staff may require tools or training resources to empower them to approach individuals who are smoking and advise them of the policy and to know when to involve security or others involved in enforcement.
Certain inpatient populations, such as individuals being treated for mental or substance use disorders, have unique concerns when considering how to apply smoke-free hospital grounds policies. CAMH’s tobacco-free initiative and focus on reducing exposure to tobacco-related triggers that may inhibit attempts to quit is an example of adapting existing best practice to meet these unique challenges. Additionally, many jurisdictions have specific exemptions or make accommodations for tobacco or smoke used in Indigenous ceremonies such as smudging, which is an important component of culturally safe and appropriate health care.
There are promising smoke-free hospital grounds practices used elsewhere in North America. A list of resources relating to the implementation and evaluation of these policies is provided in Appendix 1.
1.Sunnybrook Health Sciences Centre. Implementing Smoke-Free Property Policy in the Hospital Setting. n.d.: https://sunnybrook.ca/uploads/Sunnybrook_Smoke_Free_Policy.pdf. Accessed May 20, 2021.
2.University of Ottawa Heart Institute. Ottawa Model for Smoking Cessation. n.d.: http://ottawamodel.ca/. Accessed May 20, 2021.
3.Registered Nurses Association of Ontario. Integrating tobacco interventions into daily practice. 2017: https://rnao.ca/sites/rnao-ca/files/bpg/RNAO_Integrating_Tobacco_Interventions_into_Daily_Practice_2017_Third_Edition_Best_Practice_Guideline_0.pdf. Accessed May 15, 2021.
4.Luck KE, Doucet S. What Are the Perceptions, Experiences, and Behaviors of Health Care Providers After Implementation of a Comprehensive Smoke-Free Hospital Policy? Global Qualitative Nursing Research. 2018;5:2333393618756770. PubMed
5.Ohakim A, Mellon L, Jafar B, et al. Smoking, attitudes to smoking and provision of smoking cessation advice in two teaching hospitals in Ireland: do smoke-free policies matter? Health Psychology and Behavioral Medicine. 2015;3(1):142-153.
6.London Health Sciences Centre. Clearing the air: why Ontario hospitals are going smoke free. 2016: https://inside.lhsc.on.ca/article/summer-2016/clearing-air-why-ontario-hospitals-are-going-smoke-free. Accessed May 18, 2021.
7.Government of Ontario. Smoke-Free Ontario Act. 2017: https://www.ontario.ca/laws/statute/17s26. Accessed May 18, 2021.
8.Government of Ontario. Smoke-Free Ontario Act, 2017. How the Act Affects: Hospitals and Hospital Properties. 2018: https://ckphu.com/wp-content/uploads/2019/07/Hospitals-2018-10-09-ENGLISH.pdf. Accessed May 15, 2021.
9.Government of New Brunswick. Bill 44: An Act to Amend the Smoke-free Places Act. 2015: https://www.gnb.ca/legis/bill/file/58/1/bill-44-e.htm. Accessed May 15, 2021.
10.Government of New Brunswick. Smoking and Vaping Legislation. n.d.: https://www2.gnb.ca/content/gnb/en/departments/ocmoh/healthy_people/content/LivingTobaccoFree/legislation.html. Accessed May 18, 2021.
11.Government of British Columbia. Tobacco and Vapour Products Control Act. 2021: https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/96451_01. Accessed May 20, 2021.
12.Government of Prince Edward Island. Smoke Free Places Act. 2018: https://www.princeedwardisland.ca/sites/default/files/legislation/s-04-2-smoke-free_places_act.pdf. Accessed May 25, 2021.
13.Government of Prince Edward Island. FAQ: Smoke-Free Places. n.d.: https://www.princeedwardisland.ca/en/information/health-and-wellness/smoke-free-places. Accessed May 25, 2021.
14.Government of Alberta. Tobacco and Smoking Reduction Amendment Act, 2020. 2020: https://www.qp.alberta.ca/documents/Acts/2020ch17_unpr.pdf. Accessed May 28, 2021.
15.Government of Alberta. Tobacco and Smoking Reduction Act. 2018: https://www.qp.alberta.ca/documents/Acts/T03P8.pdf. Accessed May 28, 2021.
16.Government of Northwest Territories. Smoking Control and Reduction Act and Tobacco and Vapour Products Control Act. 2020: https://www.hss.gov.nt.ca/en/services/bill-40-41. Accessed May 28, 2021.
17.Government of Quebec. Tobacco Control Act. 2015: http://legisquebec.gouv.qc.ca/en/ShowDoc/cs/l-6.2. Accessed May 25, 2021.
18.Canadian Cancer Society. Overview Summary of Federal/Provincial/Territorial Tobacco Control Legislation in Canada. 2017: http://support.cancer.ca/documents/Legislative_Overview-Tobacco_Control-F-P-T-2017-final.pdf. Accessed May 25, 2021.
19.McGill University Health Centre. A Smoke and Vape Free MUHC. 2018: https://muhc.ca/breathe. Accessed May 25, 2021.
20.CIUSSS-Ouest Montreal. Smoke-free and vape-free environment. 2017: https://ciusss-ouestmtl.gouv.qc.ca/smoke-free/. Accessed May 25, 2021.
21.Government of Nunavut. Tobacco Control and Smoke-Free Places Act Review: What We Heard from Nunavummiut 2020: https://www.gov.nu.ca/sites/default/files/tsa_consultation_report_201105.pdf Accessed May 28, 2021.
22.Huddlestone L, Sohal H, Paul C, Ratschen E. Complete smokefree policies in mental health inpatient settings: results from a mixed-methods evaluation before and after implementing national guidance. BMC Health Services Research. 2018;18(1):542. PubMed
23.Schultz A. The ETS Project: Exploring Smoke-Free Grounds Policies within Adult Psychiatric Hospital Units. n.d.: https://umanitoba.ca/faculties/nursing/media/exploring_smoke_free_grounds.pdf. Accessed May 20, 2021.
24.The Cancer Council Victoria. Tobacco in Australia: Facts and issues. Chapter 15, Smokefree environments. 2020: https://www.tobaccoinaustralia.org.au/chapter-15-smokefree-environment/15-4-overview-of-key-public-areas-and-environments. Accessed May 20, 2021.
25.CAMH. Tobacco Free Policy. 2014: http://bidders.camhx.ca/Tobacco-Free%20Initiative.pdf. Accessed May 20, 2021.
26.Health Standards Organization. Leading Practices: CAMH Tobacco Free Initiative. n.d.: https://healthstandards.org/leading-practice/camh-tobacco-free-initiative/. Accessed May 20, 2021.
27.CAMH. Implementing a tobacco-free environment. n.d.: https://www.porticonetwork.ca/treatments/approaches-to-care/tobacco-free-policy/tobacco-free-policy-implementation. Accessed May 20, 2021.
28.Riad-Allen L, Dermody SS, Herman Y, Bellissimo K, Selby P, George TP. Becoming tobacco-free: Changes in staff and patient attitudes and incident reports in a large academic mental health and addictions hospital. The American Journal on Addictions. 2017;26(2):183-191. PubMed
29.Wynne O, Guillaumier A, Twyman L, et al. Signs, Fines and Compliance Officers: A Systematic Review of Strategies for Enforcing Smoke-Free Policy. Int J Environ Res Public Health. 2018;15(7):1386. PubMed
30.Lawn S, Campion J. Factors associated with success of smoke-free initiatives in Australian psychiatric inpatient units. Psychiatr Serv (Washington, DC). 2010;61(3):300-305. PubMed
31.Dubray J, Borland T, Chaiton M, Schwartz R. Evaluation of the Smoke-Free Ontario Act Outdoor Smoking Regulations. Ontario Tobacco Research Unit; 2017: https://otru.org/wp-content/uploads/2017/07/Special-New-Measures-March-2017.pdf. Accessed May 27, 2021.
32.May A. OPH warns people about smoking at hospitals — but fines remain rare. CBC News; 2018: https://www.cbc.ca/news/canada/ottawa/smoking-hospitals-ottawa-inspections-law-fines-january-1-1.4599347.
1.American Lung Association. Steps for Effective Enforcement of Smokefree Policies in Multi-Unit Housing. (2021). https://www.lung.org/policy-advocacy/tobacco/smokefree-environments/multi-unit-housing/steps-for-effective-smokefree-policies. Accessed May 20, 2021.
2.Island Health. Tobacco & Vapour Prevention & Control. (2021). https://www.islandhealth.ca/our-services/tobacco-prevention-control-services/tobacco-vapour-prevention-control. Accessed May 20, 2021.
3.McMaster University. Smoke Free Campus FAQ. (2021). https://dailynews.mcmaster.ca/smoke-free-campus-faq/. Accessed May 20, 2021.
4.NB Anti-Tobacco Coalition. Resources Library – Smoke-Free Environments – Outdoor Public Places. (2021). http://nbatc.ca/smoke-free-environments/outdoor-public-places/. Accessed May 20, 2021.
5.St. Joseph’s Unity Health Toronto. Smoking on hospital property. (2021). https://stjoestoronto.ca/patient-care-and-services/policies-at-the-hospital/smoking/. Accessed May 20, 2021. (Includes an online brochure about smoking cessation support and a phone number for support.)
6.Vitalite Health Network. Frequently-Asked Questions: Smoke-Free Environment. (2021). Retrieved from: https://www.vitalitenb.ca/en/smoke-free-together/frequently-asked-questions-smoke-free-environment.
7.Centre for Addictions and Mental Health. Implementing a tobacco-free environment. n.d.: https://www.porticonetwork.ca/treatments/approaches-to-care/tobacco-free-policy/tobacco-free-policy-implementation. Accessed May 20, 2021. (Includes situational re-enactment training videos for staff to manage situations of non-compliance.)
8.Centre for Addictions and Mental Health. Rolling-out tobacco free. n.d.: https://www.porticonetwork.ca/treatments/approaches-to-care/tobacco-free-policy/tobacco-free-policy-implementation/camh-timeline. Accessed May 20, 2021. (Provides a timeline of CAMH’s implementation of a tobacco-free policy, including activities undertaken to sustain and maintain focus on the initiative.)
9.Government of the UK Smokefree NHS - troubleshooting tips for hospitals. (March 17, 2017). https://publichealthmatters.blog.gov.uk/2017/03/17/tobacco-free-nhs-troubleshooting-tips-for-hospitals/ . Accessed May 20, 2021.
10.Government of Australia. Poster- We care about your health. Please don't smoke here. (March 20, 2015). https://www2.health.vic.gov.au/about/publications/policiesandguidelines/Poster--We-care-about-your-health-Please-dont-smoke-here. Accessed May 20, 2021.
11.Henry Ford Health System; The Joint Commission. (2011, April). Keeping Your Hospital Property Smoke-Free: Successful Strategies for Effective Policy Enforcement and Maintenance. The Joint Commission. Retrieved from: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/smoke_free_brochure2pdf.pdf?db=web&hash=E237FA9881AD54F78442DC3F262C2FD7. Accessed May 20, 2021.
12.Oklahoma Government. Tobacco-Free Toolkit for Community Health Facilities. (n/d). https://oklahoma.gov/content/dam/ok/en/odmhsas/documents/a0001/tf-policy-toolkit.pdf. Accessed May 20, 2021.
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