Smoke-Free Policy Disparities in Long-Term Care Facilities

Abstract

Older adults in long-term care (LTC) facilities suffer disproportionately from health conditions caused or worsened by secondhand smoke. Long-term care facilities in many states and municipalities permit smoking. Americans for Nonsmokers’ Rights compiles data on smoke-free policies only in institutional facilities (e.g., nursing homes), but not in transitional (e.g., independent living) or community-based settings (e.g., adult day). A cross-sectional, observational study was conducted of smoke-free policies using cluster random sampling in Kentucky to compare differences in policy location of coverage and strength of smoke-free policies in institutional, transitional, and community-based LTC facilities by rural/urban status. Online or phone surveys of LTC administrators representing 306 facilities were conducted. Of the facilities sampled, 35.5% were institutional, 33.4% transitional, 25.1% community-based, and 6.0% multi-type. Only one in five (19.6%) facilities restricted smoking indoors and outdoors. Only 17.3% of the policies were comprehensive (i.e., prohibiting use of all tobacco products by all persons living, frequenting, or working in LTC facilities). Compared to transitional facilities, institutional and community-based facilities were more likely to have comprehensive policies and restrict smoking indoors and outdoors. Facilities located in rural communities were less likely to restrict smoking indoors or outdoors and less likely to have comprehensive smoke-free policies, reflecting a disparity in policy protections. Strong, consistent smoke-free policies and policy enforcement are needed to reduce the disparity in smoke-free protections for older adults, LTC employees, and visitors. More research is needed to investigate the best strategies for implementing and enforcing policies that completely restrict smoking in all LTC facilities.

Keywords

populations smoke-free policy long-term care facilities tobacco-free policy

Introduction

Tobacco use is the single most preventable cause of disease and premature death in the United States.¹ The CDC reports that 23.4% of Kentucky adults are current smokers, 6.1% are current e-cigarette users, and 7% are current smokeless tobacco users,² compared to 16.1%, 4.6%, and 4% in the United States, respectively.² The smoking rate for older adults 65+ years in Kentucky is 13.1%,² compared to 8.2% in the United States.³ Although the older adult smoking rate is relatively low compared to the general adult population in the United States, long-term care (LTC) facilities in many states allow smoking indoors. As a result, secondhand smoke (SHS) negatively impacts many older adults living in LTC facilities as well as those who work in and visit those locations.⁴ This is concerning because older adults suffer disproportionately from chronic health conditions and reduced cognitive function^5-7 caused or worsened by SHS. Further, adults of lower socioeconomic status (SES) and those living in rural areas are more likely to smoke than those with high SES and adults living in urban communities.⁸ In addition to the health effects of tobacco smoke and the tobacco use disparities in the older adult population, smoking is associated with 30% of all fire deaths in the United States.⁹ and fire safety is a major concern in the LTC industry.⁴

While most Kentucky adults (79%) report working in indoor worksites with smoke-free policies,³ not all individuals are protected from secondhand smoke in workplaces or public places. In fact, only 36.6% of the Kentucky population is covered by strong smoke-free laws covering all indoor workplaces and public places, and most exempt LTC facilities.¹⁰ Smoke-free policies are a high-impact public health strategy for reducing SHS exposure¹¹ and reducing hospitalizations for conditions such as chronic obstructive pulmonary disease.¹² Many states and municipalities have enacted 100% smoke-free laws prohibiting smoking in all workplaces and public places. Adults living in smoke-free communities are less likely to smoke than those living in places with no smoke-free protections.¹³ A study in Spain showed a 26.7% drop in secondhand smoke exposure following the implementation of legislation that prohibited smoking and tobacco use in all enclosed settings, including hospital venues and selected outdoor areas.¹⁴

In 2014, the S. Beshear (D-KY) Administration enacted an Executive Order that placed skilled nursing facilities, intermediate care facilities, acute care hospitals, and personal care homes under the administration of the Cabinet for Health and Family Services’ (CHFS) tobacco-free policy.¹⁵ This policy required that all indoor and outdoor property owned or operated by the Executive Branch must be tobacco-free and e-cigarette or vaping device-free in a manner and time frame established by the Secretary of the CHFS under guidelines established by the CHFS and by the Finance and Administration Cabinet. In addition, the Housing and Urban Development Department (HUD) ruled in 2016 that each public housing agency (PHA) must implement a smoke-free policy no later than 18 months from the effective date of February 3, 2017.¹⁶ This smoke-free policy prohibits tobacco products in all public housing living units, indoor common areas in public housing, and in PHA administrative office buildings. Collectively, the goals of the Kentucky Governor’s Executive Order and the HUD policy are to prohibit smoking in institutional facilities (e.g., skilled nursing) and some independent living facilities (i.e., public housing), but they do not cover all transitional facilities (e.g., independent living and assisted living) or community-based LTC facilities (e.g., adult day care centers and senior citizen centers). Despite the known consequences of smoking and SHS exposure, especially for older adults who are disparately impacted, and the benefits of smoke-free policies, there is little research on smoke-free policies and LTC facilities. The purpose of this study was to compare differences in location of coverage (indoors only vs indoors and outdoors) and strength (moderate/weak vs comprehensive) of smoke-free polices in institutional, transitional, and community-based long-term care (LTC) facilities by rural/urban status in Kentucky. We hypothesized that the coverage location and strength of smoke-free policies would vary by LTC facility category type and by rural/urban status.

Methods

The study design was cross-sectional and observational to characterize and compare the location of coverage and strength of smoke-free policies in different categories of LTC facilities in rural and urban Kentucky. As the accessible population of LTC facilities in Kentucky was not available, we created a list of all LTC facilities by category type statewide (estimated N = 1215) by searching the internet and contacting key informants from the Kentucky Office of the Inspector General, the Office of Aging and Independent Living, and the Kentucky Housing Corporation, among others. We adapted the category type of LTC facilities serving older adults as described by Rowles et al¹⁷: institutional (licensed facilities such as skilled nursing and personal care homes), transitional (assisted living and independent living), and community-based (adult day and senior centers). We used cluster random sampling by region (e.g., Area Development District) and category type of facility with a goal of 20% participation. Survey data were collected between October 2018 and August 2019.

We exceeded our recruitment goal, receiving responses from 336 facilities from 99 of the 120 Kentucky counties. Of these, 306 completed the items about facility policies and were retained for the analysis (91% of responses from 97 counties). The facilities included here comprise 25% of all LTC facilities statewide. LTC administrators were contacted via telephone and invited to complete an online or telephone survey to assess the location of coverage and strength of smoke-free policy and facility characteristics. If administrators agreed to participate but did not have time when contacted, staff sent an email with a link to the survey, asking them to complete the online survey within one business day. We reminded potential participants about the study, attempting up to five subsequent telephone contacts. Most administrators (68%, n = 207) opted to complete the survey using the link emailed by research staff. If an administrator agreed to complete the survey by phone, staff opened the survey link and coded their responses to each of the survey items. Nearly one-third (32%; n=99) of administrators chose to complete the survey over the phone. The Medical Institutional Review Board approved a waiver of documentation of informed consent. Participants who indicated “yes” after reviewing or listening to the approved online script proceeded to the survey.

Measures

Location of smoke-free policy coverage (indoor and outdoor, indoor only, or none) was based on administrator-reported smoking restrictions indoors and outside the facility. Two-items assessed these restrictions: “Does your facility allow anyone to smoke tobacco (AND use other tobacco products, e.g., e-cigs, snus, and chew) indoors?” and “Does your facility allow anyone to smoke (AND use other tobacco products) anywhere on the ground including outdoor areas?” Facilities in which the administrator indicated “yes” to allowing smoking indoors and outdoors were defined as “none.” Those with indoor-only restrictions were defined as “indoor only” and those with both restrictions were coded as “indoor and outdoor.”

Strength of smoke-free policy (comprehensive, moderate/weak, or none) was defined based on the administrator-reported use of type of tobacco product restricted (e.g., cigarettes, cigars, smokeless tobacco, and e-cigarettes) and to whom the policy applied (residents/patients, staff, and visitors). Facilities that prohibited smoking AND all tobacco products indoors AND outdoors for residents/patients, staff, AND visitors were defined as “comprehensive.” Those that prohibited smoking OR all tobacco products indoors OR outdoors for residents/patients, OR staff, OR visitors were defined as “moderate/weak” and those with no tobacco use restrictions were coded as “none.”

County-level characteristics included rural-urban continuum code (1-9, with higher codes representing more rural areas)¹⁸ and county-level smoking rate (2017-2019 aggregate weighted rates²).

Facility characteristics included type of facility, percent of residents on Medicaid and for-profit facility (yes or no). Participants were asked to check all that apply for facility type, with response options including skilled nursing, personal care home, assisted living, independent living, adult day, and senior center. We categorized the facility type into “institutional” (skilled nursing and/or personal care home), “transitional” (assisted living and/or independent living), “community-based” (adult day and/or senior center), or “multi-type,” if they chose 2 or more facility types. For example, if an administrator selected skilled nursing and personal care home, the facility was coded as multi-type in the analysis.

Analytic Procedures

Descriptive statistics, including frequency distributions and means and standard deviations, were used to summarize county- and facility-level characteristics. Generalized linear modeling, specifically ordinal logistic regression with facility nested within county, was used to evaluate predictors of policy coverage location and policy strength. All data analysis was conducted using SAS, version 9.4 (Cary, NC), with an alpha level of .05 throughout.

Results

Of the 306 facilities included in this analysis, over one-third (36%) were defined as institutional, one-third as transitional, one-quarter as community-based, and 6% were multi-type (see Table 1). The average rural-urban continuum code of the county where the facility was located was 4.4 (SD = 2.8), reflecting the rurality of the state. The mean county-level adult smoking rate was 25.0% (SD = 5.8). On average, nearly half of residents or clients served in the facilities were Medicaid recipients (M = 48.7%, SD = 38.4), and just over half (52%) of the facilities were not-for-profit. Approximately half of the facilities (51%) had indoor-only smoke-free policies and less than one-quarter (20%) restricted smoking both indoors and outdoors. Similarly, fewer than one in five facilities (17%) had adopted a comprehensive smoke-free policy, and slightly more than half (54%) had a moderate/weak policy.

Table 1.

Long-Term Care Facility Type, County, and Policy Characteristics (N = 306).

Characteristic	n (%) or Mean (SD)
Facility type^a
Skilled nursing	97 (31.7%)
Personal care	43 (14.1%)
Assisted living	40 (13.1%)
Independent living	78 (25.5%)
Adult day	34 (11.1%)
Senior center	51 (16.7%)
Facility category type
Institutional	119 (35.5%)
Transitional	112 (33.4%)
Community-based	84 (25.1%)
Multi-type	20 (6.0%)
County rural-urban continuum code (range 1-9)	4.4 (2.8)
County-level smoking rate	25.0 (5.8)
Percent of facility residents or clients on medicaid	48.7 (38.4)
For-profit facility
Yes	145 (42.8%)
No	158 (52.2%)
Policy location of coverage
Indoor and outdoor	60 (19.6%)
Indoor only	157 (51.3%)
None	89 (29.1%)
Strength of policy
Comprehensive	53 (17.3%)
Moderate/weak	164 (53.6%)
None	89 (29.1%)

^aPercentages sum to more than 100% since administrators could endorse more than one type; in these cases, the facility category type was coded as multi-type.

Figures 1 and 2 display the distributions of facility category by coverage location and strength of smoke-free policies, respectively. Institutional facilities (i.e., skilled care or personal care homes) had the highest proportion of both indoor and outdoor policies (Figure 1; albeit 29% of these facilities reported no tobacco use restrictions at all) and comprehensive policies, covering all tobacco products and all persons living, frequenting, or working in the facility (Figure 2). Community-based facilities (i.e., adult day and senior centers) were the most likely to have indoor-only policies (Figure 1) covering only some persons living, frequenting, or working in the facility (i.e., moderate/weak policies; Figure 2). Transitional facilities (i.e., independent living, assisted living) were the most likely to not have tobacco use restrictions of any type.

Figure 1.

Distribution of facility category type by location of coverage of smoke-free policy (N = 306).

Figure 2.

Distribution of facility category type by strength of smoke-free policy (N = 306).

In the ordinal logistic regression model, significant predictors of policy coverage location (indoor and outdoor, indoor only, or none) included rural-urban continuum (RUC) code, for-profit facility status and facility category type. Every one-unit increase in RUC code (indicating increasing rurality and distance from metropolitan areas) was associated with a 11% decrease in likelihood of having a more restrictive type of policy (odds ratio (OR) = .89, 95% confidence interval (CI) = .81 – .98; P = .015; see Table 2). For-profit facilities were 40% less likely to have a more restrictive policy (OR = .60, 95% CI = .39 – .94; P = .026), compared to not-for-profit facilities. Institutional (e.g., skilled care) and community-based facilities (adult day and senior centers) were approximately 200% more likely to have indoor and outdoor smoking prohibitions (OR = 3.19, 95% CI = 1.33 – 7.64, P = .009, and OR = 2.96, 95% CI = 1.45 – 6.07, P = .003, respectively), compared to transitional facilities. The location of coverage of smoke-free policy restrictions did not differ between multi-type and transitional facilities and coverage locations did not vary based on the county-level adult smoking rate or percent of Medicaid recipients in the facility. For the strength of policy model, facilities located in more rural counties were less likely to have stronger (i.e., more restrictive) smoke-free policies. For every one-point increase in RUC, facilities were 13% less likely to have a more restrictive policy (P = .003). For-profit facilities were 37% less likely to have a more restrictive policy (OR = .63, 95% CI = .40 – .99; P = .045), compared to not-for-profit facilities. Consistent with the policy location of coverage model, institutional and community-based facilities were more likely to have stronger smoke-free policy compared to transitional facilities. Compared with transitional facilities, institutional facilities were 254% more likely to have more restrictive policies while community-based facilities were 245% more likely to have them (OR = 3.54, 95% CI = 1.56 – 8.03, P =.003, and OR = 3.45, 95% CI = 1.80 – 6.62, P < .001, respectively). Policy strength did not differ between multi-type and transitional facilities, and it was unrelated to county-level smoking rate and percent of facility residents or clients on Medicaid.

Table 2.

Ordinal Logistic Regression Modeling a More Restrictive Policy Location of Coverage and Strength of Policy with Facilities Nested within County (n = 249 Facilities in 92 Counties).

Regressor	Policy Location of Coverage		Strength of Policy
Regressor	Estimated OR (95% CI for OR)	P	Estimated OR (95% CI for OR)	P
County rural-urban continuum code	.89 (.81-.98)	.015	.87 (.80-.95)	.003
County-level smoking rate	.99 (.96-1.03)	.70	.99 (.96-1.06)	.60
Percent facility residents on Medicaid	1.00 (1.00- 1.01)	.20	1.00 (1.00-1.01)	.12
For-profit facility
Yes	.60 (.39-.94)	.026	.63 (.40-.99)	.045
No		.026	Ref	.045
Facility category type
Institutional	3.19 (1.33-7.64)	.009	3.54 (1.56-8.03)	.003
Community based	2.96 (1.45-6.07)	.003	3.45 (1.80-6.62)	<.001
Multi-type	1.62 (.51-5.14)	.41	1.77 (.55-5.73)	.34
Transitional	Ref	.41	Ref	.34

Discussion

Smoke-free policies varied by the long-term care (LTC) facility category type (institutional, transitional, and community-based) and by extent of rurality in Kentucky. Facilities located in rural Kentucky were less likely to restrict smoking indoors or outdoors and less likely to have comprehensive smoke-free policies prohibiting use of all tobacco products by all persons living, frequenting, or working in LTC facilities. This finding is consistent with the fact that smoking rates are typically higher and smoke-free policies are less restrictive in rural communities.^19,20 Older adults living in rural areas and LTC employees working there may suffer disproportionately from secondhand smoke exposure. Further, the fact that LTC facilities in rural areas were less likely to provide smoke-free protections for older adults and employees implies a health disparity among rural populations. Smoke-free public and voluntary policies need to cover all workplaces²¹ including all LTC facility types (institutional, transitional, and community-based), regardless of whether older adults are residing in the facility (e.g., assisted living) or simply frequenting the facility (e.g., adult day).

Even though Housing and Urban Development (HUD) adopted a rule to prohibit indoor smoking in all public housing agencies on July 30, 2018, transitional facilities (including independent living in public housing) were the least likely to have smoke-free policies. While the transitional facility category was broader than public housing, we had expected the HUD rule might impact the location of coverage and strength of smoke-free policy in transitional facilities. Given that transitional facilities are not licensed in Kentucky and residents are more independent in their daily activities, there may be reluctance to restrict smoking. However, our findings reveal a disparity in exposure to secondhand smoke among older adults living in independent and assisted living and among the employees who work there. Unlike institutional settings, transitional care settings are not licensed and do not fall under Kentucky’s Life Safety Code.⁴ Assisted living facilities are certified annually by the Department of Aging and Independent Living,²² but there is no evidence that smoking is addressed in the certification process. It is encouraging that some independent living communities are permitted and, in some cases, required by federal, state, and/or local government entities to implement smoke-free policies.²³ Given our findings and the inconsistent policy landscape, comprehensive, indoor, and outdoor smoke-free policies are needed in transitional LTC facilities. We recommend that advocacy groups like LeadingAge, the American Association of Retired Persons (AARP), and age-friendly communities²⁴ work alongside tobacco control coalitions to urge all independent living and assisted living facilities to prohibit use of all tobacco products by all persons living, frequenting, and working in LTC facilities, both indoors and outdoors.

Although institutional (skilled and personal care) facilities in Kentucky were more likely to have stronger indoor and outdoor policies compared to transitional facilities, 29% of the institutional facilities reported no smoke-free restrictions at all, despite an Executive Order (EO; 2014-747) prohibiting the use of all tobacco products in skilled nursing facilities and personal care homes. In fact, only one-third of personal care homes and 27% of skilled facilities prohibit tobacco products indoors and out. In talking with facility administrators, many were not familiar with the EO. In addition, the EO allows flexibility in enforcement, taking into consideration “specific needs of residents.” However, cigarettes are the single greatest contributor to fire-related deaths in the United States.⁹ and fire safety is a major concern in the LTC industry.⁴ In fact, regulations related to smoking in certified LTC facilities are driven largely by fire safety concerns. The Kentucky Life Safety Code recommends locating outdoor smoking enclosures at least 20 feet away from the LTC facility to minimize fire concerns and requires there be a “suitable number of noncombustible ashtrays” designed so that cigarettes cannot be placed on the outer edge of the ashtray.⁴ According to the federal certification requirements, healthcare facilities are required to adopt regulations for the safe use of smoking materials (see NFPA 101 (00), Sec. 18/19.7.4). Similarly, the Joint Commission’s National Patient Goals that govern home healthcare agencies focus solely on fire safety concerns with oxygen.

Community-based facilities (i.e., adult day and senior centers) were the most likely to have indoor-only policies, and they tended to be moderate/weak policies, covering only some persons living, frequenting, or working in the facility. Kentucky does not have a statewide smoke-free law and few municipalities are smoke-free¹⁰; even those with local laws specifically exempt nursing homes or LTC facilities. While these community-based facilities may be protected under state and municipal smoke-free laws in the United States, policy advocacy is needed to ensure that older adults who frequent adult day care centers and senior centers are protected from exposure to SHS. Extending smoke-free protections to these workplaces and public places is essential to reducing disparities in SHS exposure.²¹

In summary, strong, consistent smoke-free policies and policy enforcement are needed to reduce the disparity in smoke-free protections for older adults, LTC employees, and visitors. Even though older adults, especially those living in more rural areas, suffer disproportionately from chronic health conditions caused or worsened by SHS, our findings reveal that only 2 of 10 LTC facilities in Kentucky prohibit all tobacco product use inside and out. In fact, most LTC facilities (83%) have moderate or weak smoke-free policies or no smoke-free restrictions at all. Further, smoke-free policies in LTC facilities vary by location of coverage (indoors or outdoors) and strength depending on the facility category. Older adults in rural areas of Kentucky and who live in or frequent long-term care facilities and their employees are disproportionately affected by secondhand smoke and weak smoke-free protections, contributing to increased health disparities.

So What?

Older adults in long-term care (LTC) facilities suffer disproportionately from health conditions caused or worsened by secondhand smoke (SHS). Smoking rates are typically higher and smoke-free policies are less restrictive in rural communities.

This study is the first to examine smoke-free polices in institutional, transitional, and community-based LTC facilities. LTC facilities in rural areas and those classified as independent or assisted living were less likely to provide smoke-free protections for older adults and employees, implying a health disparity among rural populations and by facility type.

Health promotion practitioners need to work with older adult advocacy groups to promote smoke-free policies in all types of LTC facilities by prohibiting use of all tobacco products by all persons living, frequenting, and working in LTC facilities, both indoors and outdoors.

In Brief

Many long-term care (LTC) facilities permit smoking, and smoke-free protections are less common in rural communities. We surveyed administrators in 306 Kentucky LTC facilities to compare differences in policy location of coverage and strength of smoke-free policies in institutional (e.g., nursing homes), transitional (e.g., assisted living), and community-based facilities. Only one in five (19.6%) facilities restricted smoking indoors and outdoors. LTC facilities in rural areas and those classified as transitional were less likely to provide smoke-free protections for older adults and employees, implying a health disparity among rural populations and by facility type. More research is needed to investigate the best strategies for implementing and enforcing policies that completely restrict smoking in all LTC facilities. LTC facilities need to prohibit use of all tobacco products by all persons living, frequenting, and working in LTC facilities, both indoors and outdoors, to protect older adults who are particularly vulnerable to secondhand smoke.

Footnotes

Acknowledgments

We express our appreciation and thanks to Sherry Culp, President, Kentucky State Long Term Care Ombudsman and Mary Crowley-Schmidt, Assistant Director, Bluegrass Area Agency on Aging, for their invaluable assistance in crafting survey items and connecting the research team with the organizations needed to help us recruit long-term facility administrators to complete the survey for this research study.

Author Contributions

Authors contributed to the conceptualization (EH, MR), data curation (KR, AB, KS), formal analysis (AW, MR), funding acquisition (EH), investigation (AB), project administration (AB), and writing/editing of the manuscript (all authors).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR001998. The views expressed in the submitted article are our own and not an official position of the institution or funder.

ORCID iDs

Kathy Rademacher

Mary Kay Rayens

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