Paula M. Minihan, PhD, MPH Tufts University School of Medicine APHA Annual Meeting

1. Another Tobacco Control Strategy for State Government: Enacting Smoking Policies in State Human Service Agencies Paula M. Minihan, PhD, MPH Tufts University School of Medicine APHA Annual Meeting November 17, 2003

2. Rationale for Presentation • State human service agencies find it difficult to provide smokefree environments because many service recipients and staff smoke. • Hundreds of thousands of employees and service recipients are associated with state human service agencies nationwide. • e.g., State mental health, mental retardation agencies. • State governments could protect these individuals from ETS exposure, although few have done so. • Experience of state MR/DD (mental retardation) agencies may explain why this strategy is underutilized by state government.

3. Case Study: Smoking Policies in State MR/DD Agencies • National survey provides information on: • Prevalence of smoking policies in agencies; • Whether agency policies reduced involuntary exposure to ETS for clients and employees; • Influences on agency policies. • State MR/DD agencies share characteristics with other state human service agencies. • Administer complex and largely privatized service systems, including residential services; Medicaid is major funding source. • Lessons learned may be applicable to other state human services agencies.

4. National Survey • Administrators in 49/51 state MR/DD agencies completed questionnaires describing agencies’ smoking policies. • 32 (65%) agencies had smoking policies; 17 (35%) did not. • All 32 policies applied to programs operated directly by state governments, albeit with variations in their restrictiveness and in the percentage of clients and employees that the policy covered. • Only 6 policies applied to programs operated by private vendors under state contracts.

5. Smoking Policies for State-Operated Programs (n=32) • General policy banned smoking (21 agencies). • Policy allowed medical exceptions for individual clients (3). • Policy exempted residences, allowing clients and sometimes staff to smoke inside (8). • General policy restricted smoking to designated smoking areas (11 agencies). • Policy allowed widespread exceptions for clients (& sometimes staff), especially in residences (6).

6. Key Findings: State MR/DD Systems Nationwide • Only one state agency policy (WY) nationwide offered every client & employee associated with agency full protection from ETS. • Policy banned smoking in state and vendor-operated programs, including residences. • Policies in remaining 48 agencies fell short of this level of protection for various reasons: • Agency had no policies. • Policy banned smoking but exempted residences. • Policy restricted smoking to designated areas that weren’t enclosed or separately ventilated. • Policy didn’t extend to vendors.

7. Major Influences on Agency Policies • State Clean Indoor Air Statutes and Executive Orders. • Concerns about clients’ rights to autonomy and self-determination in MR/DD agency policies and in federal Medicaid regulations. • Autonomy of private vendors operating services under state contracts.

8. I. State Clean Indoor Air Statutes and Executive Orders • Most state agencies with policies were simply complying with state clean indoor air statutes (28) or executive orders (8) that banned or restricted smoking in state government buildings or worksites. • By doing only what state law required, smoking policies in many agencies covered just: • The minority (16%) of clients and employees who lived or worked in residences operated directly by state government. • Minority of employees who worked in offices.

9. II. Concerns about Rights of Service Recipients • Public is reluctant to impose intrusive public policies, like smoking restrictions, in homes. • State MR/DD agency policies and federal Medicaid regulations protect clients’ rights to autonomy and self-determination. • These forces have created a culture where smoking is viewed as a client right that cannot be denied, particularly in residences. • Emerging evidence that smoking calms clients with major mental illness complicates this issue.

10. III. Vendor Autonomy • Vast majority of agencies with smoking policies (26/32) did not extend policies to private vendors operating programs under state contract. • State clean indoor air statutes do not typically apply to vendors. • Smoking policies in these agencies did not cover the majority of clients and employees who lived and worked in vendor-operated residences. • Six state agencies extended their smoking policies to vendors, so it’s possible to do so.

11. Conclusions • Majority of clients and employees associated with state MR/DD agency systems were vulnerable to chronic and involuntary exposure to ETS because: • 17 agencies had no policies restricting where and when clients and employees could smoke; • Agency policies restricting smoking to designated areas did not require areas to be enclosed and separately ventilated; • Agency policies banning smoking in state-operated programs and non-residential buildings were generally not extended to vendor-operated programs and residences.

12. Conclusions • State clean indoor air laws, which were the major determinants of agency policies, do not reflect how state government human service systems are organized at present. • Statutory emphasis on “state government buildings” or “worksites” fails to acknowledge that most state human services are currently delivered by private vendors under state contracts. • Statutory exemptions for residences ignore fact that clients’ residences also function as worksites for direct support staff.

13. Conclusions • State MR/DD agencies could potentially be liable for clients’ health problems or face workers’ compensation claims associated with exposure to ETS in state MR/DD systems.

14. Policy Recommendations • State human service agencies must do more than passively comply with state clean indoor air laws when establishing smoking policies and take steps to actively protect all clients and employees from involuntary exposure to ETS.

15. Policy Recommendations • State clean indoor air statutes and executive orders designed to protect state employees and recipients of state services from involuntary smoking should be modified to: • take into account the privatization of many state services, particularly human services; • acknowledge the needs of direct support staff who may be exposed to smoking within clients’ residences.

16. Policy Recommendations • State governments have the power to enact smoking policies in state human service agencies in the absence of statutory requirements. These should include: • Bans on smoking in residential and non-residential buildings operated by state government; • The extension of agency policies to vendors through contractual mechanisms; • The provision of smoking cessation programs and other assistance for clients, especially those with major mental illnesses for whom smoking may be calming, and employees.

17. Policy Recommendation • In state human service agencies where nonsmoking clients and employees face involuntary exposure to ETS, agencies should: • Allow clients to select whether they live in smoking or smokefree residences; • Inform direct support staff that they could be exposed to ETS on the job and allow them to select alternative smokefree worksites.