Public Health Nursing Vol. 31 No. 1, pp. 60–68 0737-1209/© 2013 Wiley Periodicals, Inc. doi: 10.1111/phn.12068
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Sharing the Air, the Legal and Ethical Considerations of Extending Tobacco Legislation to Include Multiunit Dwellings in Alberta Victoria D. Stooke, N.P., M.N. Calgary Foothills Primary Care Network, Calgary, Alberta Correspondence to: Victoria D. Stooke, Calgary Foothills Primary Care Network, 16 Woodland Place, Calgary, AB, T3R 1G4. E-mails: [email protected]; [email protected]
ABSTRACT This study explores the legal and ethical considerations of extending tobacco legislation to include multiunit dwellings (MUDs) in Alberta and the implications for public health nursing practice. The tobacco legislation in Canada currently protects individuals in public places and not private dwellings. In Alberta, there are over 1 million individuals living in MUDs who are exposed to environmental tobacco smoke. Children are particularly vulnerable to the negative health effects. As well, many apartment fires in Alberta are related to smoking which makes expanding tobacco legislation to include MUDs an important public health issue. There are many potential barriers to the adoption of this tobacco legislation including legal, ethical, and civil rights concerns, and the bureaucracy of the political process. This study articulates the position that it is both legal and ethical to expand provincial tobacco legislation to include MUDs after the consideration of individual civil rights and using the Canadian Nurses Association Code of Ethics for Registered Nurses (2008) as a guide for practice. Public health nurses must advocate for a change in the current legislation by becoming politically active and building community capacity to demonstrate accountability and promote social justice. Key words: environmental tobacco smoke, ethics, legislation, multiunit dwellings, social justice.
Population health and safety issues regarding tobacco use and exposure continue to be one of the largest global public health threats. In Canada, tobacco legislation is divided into federal, provincial, and municipal jurisdictions. The current provincial tobacco legislation in Alberta under the Tobacco Reduction Act (2005) protects individuals in public spaces and common areas. However, the legislation fails to protect individuals living in multiunit dwellings (MUDs), either rented or privately owned. A MUD is a building that contains more than one residential unit. Examples of this are semidetached houses, townhouses or row houses, condominiums or apartments (Toronto, n.d.). The purpose of this article is to investigate the ethical considerations
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from a nursing perspective of extending tobacco legislation to include MUDs in Alberta. This will be achieved by exploring the current federal and provincial tobacco legislation as it relates to residents living in MUDs. The importance of enacting such legislation will be examined including the reduction in chronic conditions, childhood illnesses, and risk of injury from fire. Through the analysis of the current tobacco legislation and using a nursing perspective on ethics, it will be revealed that extending the current legislation to include private MUDs is both legal and ethical. This is important as public health nurses are not only strong advocates for the health of individuals, families, and communities, but also for population health and agents for policy change.
Stooke: Sharing the Air As public health nurses advocate for policy change, this article will also explore implications for nursing practice and how this can be achieved through government lobbying and building community capacity.
Current Tobacco Legislation and Multiunit Dwellings Prior to addressing the ethics of expanding tobacco legislation in Alberta to include MUDs, it is important to explore the current federal and provincial tobacco legislation as they relate to the protection of persons in public and private property. Below is a brief summary of the existing legislation and Acts in Canada with a discussion regarding populations that are not currently protected. According to Health Canada (n.d.), the two federal Acts in Canada that address tobacco products and use are the Tobacco Act (1997) and the Nonsmokers’ Health Act (1985). Federal laws are made by the Canadian Parliament according to the Constitution which governs the whole of Canada. The Tobacco Act (1997) is administered by Health Canada and has jurisdiction over the manufacture, sale, and advertising of tobacco products. The Nonsmokers’ Health Act (1985), administered by the Department of Human Resources and Skills Development, restricts smoking in all workplaces and public places under federal jurisdiction. Authority is granted to the Governor in Council to make or amend regulations regarding both of these Acts. Each province in Canada has its own legislation regarding tobacco use in public places. In Alberta, the Tobacco Reduction Act was developed in 2005 and came into force in 2006 (Tobacco Reduction Act, 2005). According to Alberta Health (n.d.), the Tobacco Reduction Act then became law on January 1, 2008. The intent of the Tobacco Reduction Act was to replace the Protection of Second-Hand Smoke in Public Buildings Act (Alberta) which was in force from January 1, 2002 to December 31, 2005 (Canadian Legal Information Institute, n.d.). The Tobacco Reduction Act (2005) prohibits smoking in a public place, workplace, public vehicle, and within a prescribed distance from a public doorway, window, or air intake. The Tobacco Reduction Act (2005) includes exceptions to the smoking prohibition in public spaces, but the building manager must designate a smoking room as well as provide separate
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ventilation and a physical separation by a wall and ceiling to any adjacent area where smoking is prohibited. The Tobacco Reduction Act (2005) also states that it does not affect a municipality’s power to make bylaws regarding the regulation, restriction, or prohibition of smoking. It is clear that public places under federal jurisdiction are protected from the effects of environmental tobacco smoke. As well, public places in Alberta are protected according to the provincial legislation. However, it is evident that individuals in private residences are not protected under the current federal or provincial legislation. Ironically, Kreisman (2011) states that visitors to public places are more likely to be protected from the effects of tobacco smoke than individuals living in their own homes. There is a caveat in the Alberta Tobacco Reduction Act (2005) that would allow municipalities to create their own tobacco-related bylaws. Environmental tobacco smoke, also known as second and thirdhand smoke is smoke that is inhaled involuntarily by nonsmokers (Samet, 2011). In MUDS, environmental tobacco smoke seeps through connections between apartment units by air ventilation systems, wall outlets, cracks in the walls or floors, spaces under doors, around sinks, countertops, radiators, and off-gassing from carpets and other inanimate objects (Kreisman, 2011). The United States Surgeon General (2006) states that “separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate secondhand smoke exposure” (p. 11). There is no question that the air is shared, and it knows no boundaries. According to the Statistics Canada (2012a), the number of MUDs in Alberta was 459,360 (apartment style, semidetached, row houses, duplexes), or about 33% of the total housing market. The average persons per household in Alberta is 2.6 which equates to approximately 1,194,336 individuals living in some type of MUD. Of course, both smokers and nonsmokers living in MUDs would be exposed to environmental tobacco smoke. However, given that the smoking rate in Alberta is currently 23%, approximately 919,639 nonsmokers (77%) are particularly vulnerable and not protected from the current tobacco legislation (Statistics Canada, 2012a, b). Below is a discussion of the importance of expanding tobacco legislation to include MUDs, particularly because of the well-known negative
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health effects as well as fire safety risks. Barriers to implementing this legislation are also explored.
Importance of Tobacco Legislation and Barriers to Implementation The negative health effects from the exposure to environmental tobacco smoke are documented and numerous. In 2006, the U.S. Surgeon General report on environmental tobacco smoke determined that it was harmful to human health and that there is no risk-free level of exposure (United States Surgeon General, 2006). Although there have been fewer studies regarding the effects of environmental tobacco smoke, it was in the late 1960s when the harmful effects were first recognized. By 1986, there was evidence to conclude that environmental tobacco smoke was a contributing factor for lung cancer in nonsmokers. There is also a 25–30% increased risk of developing coronary heart disease in nonsmokers when exposed to environmental tobacco smoke (Samet, 2011). Laws that limit or prohibit public and workplace smoking have resulted in a marked reduction in hospitalizations from acute coronary syndrome in both smokers and nonsmokers. Thus, there is a causal relationship between legislation to prohibit smoking in indoor spaces and health outcomes (Samet, 2011). Children are particularly vulnerable to the effects of environmental tobacco smoke. Early childhood development is a known determinant of health, yet children are powerless with respect to choosing the accommodation imposed upon them. Environmental tobacco smoke exposure in children is related to prematurity and perinatal mortality, increased risks of sudden infant death syndrome, acute and chronic respiratory illnesses (i.e., asthma), and middle ear disease (Samet & Sockrider, 2012). Negative health effects in adulthood can be attributed to prolonged exposure to environmental tobacco smoke at an early age due to the increased time of exposure. Reducing the exposure to environmental tobacco smoke in the home is most important for children as the home is the major location of the prolonged exposure (Samet & Sockrider, 2012). Aside from the negative health effects of exposure to environmental tobacco smoke, fire safety must also be considered in the importance of expanding tobacco legislation to include MUDs. A review of a document prepared by the Office of the
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Fire Commissioner (2012) revealed that the number of fires in apartment buildings in Calgary and Edmonton, Alberta, between 2000 and 2012 totaled 3,331. The loss of life in those 12 years totaled 34 with 452 injuries. The monetary value placed on the fire losses was over $290 million. While the report indicated that cooking was the number one cause of apartment fires (27%), smoking was the second highest cause at 21%. More deaths were attributed to fires caused by smoking, but cooking ranked highest in fire injury. With the implementation of tobacco legislation to include MUDs in Alberta, virtually 21% of apartment fires would be eliminated which translates to lower rates of death and injury, but also a decrease in property loss (Non-Smokers’ Rights Association, 2008; Office of the Fire Commissioner, 2012). It is clear that there are many health and safety arguments for the implementation of more stringent tobacco legislation for MUDs. Not only will there be a positive impact on the health of both smokers and nonsmokers, but there may also be a subsequent decrease in health care spending if there is a decrease in tobacco-related illness secondary to environmental tobacco smoke exposure. The savings would also be forwarded to homeowners and landlords as insurance rates, costs for the operation and maintenance of air filtration systems, and apartment cleaning would all decrease with the prohibition of smoking in MUDs (Non-Smokers’ Rights Association, 2008; Shoenmarklin, 2010). The extended tobacco legislation may also decrease the rates of smoking in general. A study by Hanusaik et al. (2012) concluded that the provinces with the highest effort in tobacco control, also had the greatest decline in tobacco use. With the implementation of provincial legislation to prohibit smoking in MUDs in Alberta, landlords and/or condo boards would not carry the sole burden of responsibility of adopting such legislation for one particular building. This standardization would potentially decrease negative feedback directed toward landlords or building managers from owners or renters in MUDs who may not initially agree with the legislation. There are many barriers, either perceived or real, in extending tobacco legislation to include MUDs. This type of legislation may be difficult to monitor or police. In a systematic examination of smoke-free policies in Virginia, the greatest barriers to landlords and property managers in adopting
Stooke: Sharing the Air smoke-free complexes were lack of demand, privacy concerns, legal concerns, and difficulty with implementation or enforcement (Jackson & Bonnie, 2011). Also, almost half of the landlords in that study who had not adopted a smoke-free policy stated that they were concerned about losing potential renters. Lack of knowledge was also a barrier as many of the landlords who had not adopted smoke-free housing were not aware that it was an option (Jackson & Bonnie, 2011). Similar studies in Minnesota and Nebraska (Cramer, Roberts, & Stevens, 2010; Hewett, Sandell, Anderson, & Niebuhr, 2006) revealed the same barriers to landlords implementing smoke-free housing. In a study by Satterlund, Cassidy, Treiber, and Lemp (2011), the barriers to adopting local tobacco control policies involved both internal agency (local tobacco project coordinators) and external political forces. The bureaucracy of the institutions involved or the lengthy decision-making time hinder the adoption of policy. Gaining in-person access to policymakers by having to go through several layers of aides was determined to be a large barrier, adding to the time and frustration of policy adoption. Satterlund et al. (2011) also state that other barriers to tobacco policy adoption are the ambivalence of policymakers and if the policymakers themselves were smokers. Staffing issues with tobacco control project agencies are also a potential hindrance to policy adoption, especially when key members of the agency leave the position, thereby also dissolving the established relationship with the policymakers (Satterlund et al., 2011). While it is apparent that the adoption of tobacco legislation to include MUDs is important for health and safety, there are many potential barriers to implementing new legislation. The above studies regarding the barriers to the adoption of tobacco legislation are all from the United States. Although much of the information may also pertain to Canada, one cannot assume that the same results would be reproducible in Alberta due to the differing social demographics. One must also take into consideration civil rights, law, and ethics prior to the adoption of new policy or legislation.
Tobacco Legislation: Civil Rights and Ethical Considerations While implementing tobacco legislation to include MUDs may be viewed as an infringement on the
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rights of smokers, failure to implement it can be seen as an infringement on the rights of nonsmokers. Of particular concern are the legal and ethical considerations when deciding to adopt legislation that may be perceived to be against the civil liberty, particularly for those who smoke. Satterlund et al. (2011) state that there is the notion that tobacco control in MUDs infringes on the individual rights and freedoms of smokers. Although law and ethics are fundamentally different in that law is a set of rules that regulate what may or may not be done by members of society, and ethics involves the morality of those decisions, they guide one another and are therefore interconnected (Black, Groves, Hucker, & McKeown, 2009). Below is a discussion regarding the civil rights and ethical considerations of expanding legislation in Alberta to include MUDs from a nursing perspective and using the Canadian Nurses Association Code of Ethics (2008) to guide decision making.
Civil Rights Both the federal Constitution Act (1982) and the provincial Alberta Human Rights Act (2000) provide a guide for the rights and freedoms of all Albertans. The Canadian Charter of Rights and Freedoms under the Constitution Act (1982) guarantees all Canadians “the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society” (Guarantee of Rights and Freedoms, 1982, para 1). The legal rights as set out in the Constitution Act (1982) give all Canadians the right to “life, liberty and security of person not to be deprived thereof except in accordance with the principles of fundamental justice” (Legal Rights, 1982, para. 1). The Alberta Human Rights Act (2000) is based on the foundation of dignity and equal rights and responsibilities to maintain freedom, justice, and peace in the world and without regard to race, religion, color, gender, physical and mental disability, age, ancestry, place of origin, marital status, source of income, family status, or sexual orientation. These basic human rights in Alberta also apply to the right of nondiscrimination for tenants under the Alberta Human Rights Act (2000). The two Acts described above clearly demonstrate that all citizens living in Alberta, and the rest
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of Canada for that matter, have the right to liberty, but this is not with a concomitant lack of social responsibility. If there were no limits to liberty, then there would be no requirements for law. Canadians already accept that there are circumstances where civil liberties are curtailed to provide for the common good. For example, there is a restriction in travel in the form of traffic laws. Another example is the Public Health Act (2000) which imposes quarantine or forced medical treatment in case of a disease outbreak. With respect to tobacco legislation for Alberta MUDs, individuals who smoke do enjoy the same rights and freedoms as those who choose not to smoke. However, should the basic premise of liberty supersede social responsibility and others’ rights to life and security? Current tobacco legislation could be perceived as an infringement on liberty, but nonetheless has been enacted to protect the population from environmental tobacco smoke. Aside from the previously discussed legislation to prohibit smoking in public spaces, there is relatively new legislation in eight provinces and one territory that prohibits smoking in private vehicles while children are present. For example, the Smoke-free Ontario Act (1994) amended the legislation in 2008 to include private vehicles to protect children under the age of 16. However, the Alberta provincial government has not enacted such legislation, but it does exist in four municipalities; Okotoks, Medicine Hat, Athabasca, and Leduc (Reid, Hammond, Burkhalter, & Ahmed, 2012). This municipal legislation does set a precedent for MUDs as it involves private and not public property, which will be discussed in detail later in the article.
Ethical Considerations—A Nursing Perspective While law is a set of rules and regulations, ethics involves moral decision making. All nurses, including public health nurses, are of course bound by law, but are also obligated to practice under a nursing code of ethics. In Canada, the CNA Code of Ethics (2008) guides nursing practice in all contexts and domains, and is used in conjunction with law and nursing practice standards. The CNA Code of Ethics (2008) states that “nursing involves both legal and ethical dimensions” (p. 4).
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It would be logical to assume that the law and ethics are compatible; however, there may be situations where there is a conflict between the law and ethics and nurses are required to collaborate with others to change policy to reflect the core values of the Code of Ethics (CNA, 2008). According to the Canadian Nurses Association (2008), “ethics is concerned with how broad societal issues affect health and well-being” (p. 2). Nurses are expected to be aware of and maintain social justice and to advocate for change. It is also an expectation that nurses are cognizant of the core responsibilities and values at all times, and to also be aware when those values may be in conflict (Canadian Nurses Association, 2008). With respect to the issue of environmental tobacco smoke exposure in MUDs in Alberta, there is a conflict between the lack of legislation to prohibit this public health threat and the nursing Code of Ethics (Canadian Nurses Association, 2008) which obliges nurses to advocate for policy change when there is a threat to public health. The responsibilities under the Code of Ethics that guide nurses to advocate for extended legislation to include MUDs in Alberta are as follows: promoting health and well-being, promoting and respecting informed decision making, preserving dignity, promoting justice, and being accountable (Canadian Nurses Association, 2008). In promoting health and well-being, it is the public health nurse’s responsibility to understand that when care interferes with individual rights and freedoms, the nurse advocates for the least restrictive measures possible (Canadian Nurses Association, 2008). While some would argue that extending tobacco legislation to include MUDS is an infringement on human rights, for the greater good, nurses must advocate for this legislation to protect both smokers and nonsmokers. Nurses are implored to promote and respect informed decision making under the Code of Ethics (Canadian Nurses Association, 2008) to ensure that there is informed consent in matters that may affect an individual, community, or population. However, with legislation, consent is sometimes not achievable or realistic. It is nonetheless important for the public health nurse to provide information to smokers regarding the health benefits of implementing such legislation. This thereby preserves dignity by recognizing that the knowledge acquisition is essential even for those who may oppose the legislation. The responsibility of promoting justice
Stooke: Sharing the Air is much the same as the Alberta Human Rights Act (2000) regarding discrimination, human rights, and promoting the common good. The public health nurse would demonstrate accountability by not ignoring this public health threat and at the same time advocate for social justice. According to the Code of Ethics (Canadian Nurses Association, 2008), this practice expectation requires nurses to promote equality, advocate for change with unethical health, social, and legislative policies. Nurses must also advocate for health promotion and disease prevention, the reduction in environmentally harmful practices, maintain awareness of global health concerns, and advocate for discussion with others regarding ethical issues (Canadian Nurses Association, 2008). It has been established by current legislation and the Canadian Nurses Association (2008) that it is both legal and ethical, from a nursing perspective, to implement tobacco legislation to include private MUDs in Alberta. This threat to public health exists not only in Alberta, but globally. Therefore, the discussion regarding nursing implications is relevant to public health nursing practices everywhere.
Nursing Implications—Advocacy and Political Action The Canadian Nurses Association (2008) has been used as a guide to articulate the position of this article that it is ethical to expand tobacco legislation to include MUDS in Alberta. All nurses, but more specifically public health nurses, should advocate and support this legislation to endeavor to promote equality and social justice. The following will discuss the merits of enacting provincial-level tobacco legislation for Alberta MUDs as well as how the current legislation can be used as a guide or precedent. Public health nurses must also become change agents to build community capacity and lobby appropriate government departments (Canadian Nurses Association, 2000). Ideally, the proposed tobacco legislation to include Alberta MUDs should be achieved at a provincial level, rather than a local or municipal level as the health of all Albertans is important, and not just a portion living in specific municipalities or jurisdictions. However, even though the current evidence regarding health and safety issues,
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and the fact that such legislation would not be illegal, there continues to be many barriers. This is likely because doing what is right is usually more difficult than maintaining the status quo, and often there is great change involved. The public health nurse is in a position to be that change agent. One of the best catalysts in affecting change is to determine what relevant legislation currently exists so that it may be used as a precedent for proposed legislation. As stated earlier, there is current legislation in eight provinces and one territory in Canada that involves the prohibition of smoking in vehicles with children present. Although this may not seem to be relevant to MUDs, it is similar because they both involve legislation for privately owned property. If legislation can be enacted at a provincial level to include private vehicles, then this suggests that legislation can be extended to include private MUDs. In a tobacco policy analysis document created by Reid et al. (2012), tobacco legislation in Canada for MUDs is currently at the level of the building, landlord, or social housing provider with only a few regions or municipalities adopting such legislation. These authors also note that some provincial housing corporations have adopted policies or are in the process of doing so. Examples of this are the Newfoundland and Labrador Housing Corporation, Nova Scotia Department of Community Services, and the Yukon Housing Corporation. However, there is currently no province-wide legislation to prohibit smoking in privately owned MUDs. In order for this legislation to be enacted, raising awareness, building community capacity, and lobbying the government must take place. Public health nurses are in a position to become politically active to help initiate this change. Our current health care system is narrowly focused on healing the sick, a downstream approach, rather than focusing on an upstream approach of health promotion and illness prevention. According to the Canadian Nursing Association (2000), “understanding health in its social context helps us to see that the primary determinants of health and illness are social, political and economic in nature” (p. 1). To provide holistic care for populations, nurses are required to adopt a global perspective by becoming politically active to halt the root cause of illness (CNA, 2000). By identifying an item as a political issue, the nurse realizes that there is a common problem that affects
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clients, and that this has broader implications for populations (Canadian Nursing Association, 2000). In the case of the lack of tobacco legislation in Alberta to include MUDs, there is an obvious health and safety issue that involves nearly one third of the provincial population which must be addressed. There are several strategies that nurses can use to become politically active and advocate for policy change. Firstly, it is important for nurses to educate themselves regarding the issue, then enlist allies and determine the targeted decision makers for the issue. Lobbying the appropriate government officials regarding the issue, involving those who are directly affected, and creating public support are all important political activities. It may also be effective for nurses to involve the media to raise public awareness. The political process involves the influence of decision makers in implementing change to improve the health of the population (Canadian Nursing Association, 2000). In the matter of extending the tobacco legislation in Alberta, it is important for nurses to convince the policymakers that this change would be positive for everyone involved, thereby promoting equity and social justice. In any effort to influence policy, it is important for the nurse to know the appropriate stakeholders: those who may be affected, are interested in the policy, and have the influence to change the policy (Health Canada Population and Public Health Branch Atlantic Region, 2003). With respect to extending tobacco policy in Alberta, the stakeholders are the appropriate government departments, owners/landlords, condominium boards, residents of the MUDs, and health care providers. Citizens must also be engaged to build capacity. There are several motives for involving the public; however, the most significant reason is that the effectiveness of policy development is enhanced when those who are directly affected become involved. This helps to increase awareness of a health problem, provide education, enhance an exchange of dialog, and promote informed decision making. Therefore, involving the public also meets the legal and ethical commitments of policy change (Health Canada Population and Public Health Branch Atlantic Region, 2003). Public support for extending tobacco legislation in Alberta would presumably be high based on two surveys completed in 2006 in Ontario where 64% of the population living in MUDs would choose a
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smoke-free building over a building where smoking was permitted (Non-Smokers’ Rights Association, n.d.). Although there are no data in Alberta regarding public opinion for banning smoking in MUDs, data currently exist regarding the prohibition of smoking in private vehicles with children present (81% of the Alberta population and 69% of smokers agree with this proposed legislation) (Alberta Health Services, 2008). The agreement for the legislation for private vehicles may also be interpreted as an agreement to eliminate environmental tobacco smoke in MUDs. However, it would be prudent for public health nurses to gather the required data relevant to MUDs in Alberta prior to initiating political action.
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Stooke: Sharing the Air Constitution Act. (1982). c. 11 (U.K.), Schedule B, Part I: Canadian Charter of Rights and Freedoms. Retrieved from http://laws-lois.justice. gc.ca/eng/Const/page-15.html Cramer, M. E., Roberts, S., & Stevens, E. (2010). Landlord attitudes and behaviors regarding smoke- free policies: Implications for voluntary policy change. Public Health Nursing, 28(1), 3–12. doi:10.1111/j.1525-1446.2010.00904.x. Hanusaik, N., Maximova, K., Kishchuk, N., Tremblay, M., Paradis, G., & O’Loughlin, J. (2012). Does level of tobacco control relate to smoking prevalence in Canada: A national survey of public health organizations. Canadian Journal of Public Health, 103(3), 195–201. Retrieved from http://journal.cpha.ca/index. php/cjph/article/view/2815 Health Canada. (n.d.). Health concerns: Federal laws. Retrieved from http://www.hc-sc.gc.ca/ hc-ps/tobac-tabac/legislation/federal/indexeng.php Health Canada Population and Public Health Branch Atlantic Region. (2003). Public policy and public participation: Engaging citizens and community in the development of public policy. Retrieved from http://www.phac-aspc. gc.ca/canada/regions/atlantic/pdf/pub_policy_ partic_e.pdf Hewett, M. J., Sandell, S. D., Anderson, J., & Niebuhr, M. (2006). Secondhand smoke in apartment buildings: Renter and owner or manager perspective. Nicotine & Tobacco Research, 9(1), S39–S47. Jackson, S. L., & Bonnie, R. J. (2011). A systematic examination of smoke-free policies in multiunit dwellings in virginia as reported by property managers: Implications for prevention. American Journal of Health Promotion, 26(1), 37–44. doi:10.4278/ajhp.091005-QUAN329. Kreisman, S. (2011). Toward smoke-free multi-unit dwellings. BC Medical Journal, 53(8), 400– 401, 429. Retrieved from http://www.bcmj. org/sites/default/files/BCMJ_53_Vol8_premise.pdf Non-smokers’ Health Act. (1985). R.S.C., c. 15 (4th Supp.). Retrieved from http://laws-lois.justice.gc.ca/PDF/N-23.6.pdf Non-Smokers’ Rights Association. (2008). Smokefree policies make good dollars and sense: The business case for smoke-free multi-unit housing. Retrieved from http://www.smokefreehousing.ca/PDF/Business_Case_for_S-F_ MUDs.pdf
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Non-Smokers’ Rights Association. (n.d.). Secondhand smoke in multi-unit dwellings. Retrieved from http://www.nsra-adnf.ca/cms/page1433 .cfm Office of the Fire Commissioner. (2012). Fire losses in apartments in Calgary & Edmonton, Alberta: 2000-2012. Retrieved from http:// www.ofc.alberta.ca/documents/fco/FIRE_LOSSES_IN_APARTMENTS_IN_CALGARY-EDMONTON-revised_1.pdf Public Health Act. (2000). Revised Statutes of Alberta, Chapter P-37. Retrieved from http:// www.qp.alberta.ca/documents/Acts/P37.pdf Reid, L. J., Hammond, D., Burkhalter, R., & Ahmed, R. (2012). Tobacco use in Canada: Patterns and trends (Supplement: Tobacco control policies in canada) (2012 ed.). Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo. Retrieved from http://www.tobaccoreport.ca/2012/TobaccoUseinCanada_2012_PolicySuppl_Final. pdf Samet, J. M. (2011). Secondhand smoke exposure: Effects in adults. Uptodate. Retrieved from http://www.uptodate.com/contents/secondhand-smoke-exposure-effects-in-adults?sou-rce =preview&anchor=H1491250&selectedTitle=2~ 150#H1491250 Samet, J. M., & Sockrider, M. (2012). Secondhand smoke exposure: Effects in children. Uptodate. Retrieved from http://www.uptodate.com/ contents/secondhand-smoke-exposure-effects-in-children?source=search_result&search =negative+effects+of+environmental+tobacco +sm oke&selectedTitle=1~150 Satterlund, T. D., Cassidy, D., Treiber, J., & Lemp, C. (2011). Barriers to adopting and implementing local-level tobacco control policies. Journal of Community Health, 36, 616–623. doi:10.1007/s10900-010-9350-6. Shoenmarklin, S. (2010). Secondhand smoke seepage into multi-unit affordable housing. Tobacco Control Legal Consortium. Retrieved from http://publichealthlawcenter.org/sites/ default/files/resources/tclc-syn-secondhand2010_0.pdf Smoke-free Ontario Act. (1994). Chapter 10. Retrieved from http://www.e-laws.gov.on.ca/ html/statutes/english/elaws_statutes_94t10_e. htm#s9p2s1 Statistics Canada. (2012a). Calgary, Alberta (Code 825) and Alberta (Code 48) (table). 2011 Census. Statistics Canada Catalogue no. 98316-XWE. Ottawa. Released September 19,
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2012. Retrieved from http://www12.statcan. gc.ca/census-recensement/2011/dp-pd/prof/ index.cfm?Lang=E Statistics Canada. (2012b). Health Profile (table). Statistics Canada Catalogue No. 82-228XWE. Ottawa. Released June 19, 2012. Retrieved from http://www12.statcan.gc.ca/ health-sante/82-228/details/page.cfm?Lang= E&Tab=1&Geo1=HR&Code1=4832&Geo2=PR& Code2=48&Data=Rate&SearchText=Calgary% 20Zone&SearchType=Contains&SearchPR=01& B1=All&Custom= Tobacco Act. (1997). Statutes of Canada, chapter c.13. Retrieved from http://laws-lois.justice. gc.ca/PDF/T-11.5.pdf
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Tobacco Reduction Act. (2005). Statutes of Alberta, 2005, chapter T-3.8. Retrieved from http:// www.qp.alberta.ca/574.cfm?page=T03P8.cfm& leg_type=Acts&isbncln=97807797 37901 Toronto. (n.d.). Smoke-free living: Facts on secondhand smoke in multi-unit dwellings. Retrieved from http://www.toronto.ca/health/smokefree/protection/multidwellingfacts.htm United States Surgeon General. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Retrieved from http://www.surgeon general.gov/library/reports/secondhandsmoke/ fullreport.pdf
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ETHICS
Sharing the Air, the Legal and Ethical Considerations of Extending Tobacco Legislation to Include Multiunit Dwellings in Alberta Victoria D. Stooke, N.P., M.N. Calgary Foothills Primary Care Network, Calgary, Alberta Correspondence to: Victoria D. Stooke, Calgary Foothills Primary Care Network, 16 Woodland Place, Calgary, AB, T3R 1G4. E-mails: [email protected]; [email protected]
ABSTRACT This study explores the legal and ethical considerations of extending tobacco legislation to include multiunit dwellings (MUDs) in Alberta and the implications for public health nursing practice. The tobacco legislation in Canada currently protects individuals in public places and not private dwellings. In Alberta, there are over 1 million individuals living in MUDs who are exposed to environmental tobacco smoke. Children are particularly vulnerable to the negative health effects. As well, many apartment fires in Alberta are related to smoking which makes expanding tobacco legislation to include MUDs an important public health issue. There are many potential barriers to the adoption of this tobacco legislation including legal, ethical, and civil rights concerns, and the bureaucracy of the political process. This study articulates the position that it is both legal and ethical to expand provincial tobacco legislation to include MUDs after the consideration of individual civil rights and using the Canadian Nurses Association Code of Ethics for Registered Nurses (2008) as a guide for practice. Public health nurses must advocate for a change in the current legislation by becoming politically active and building community capacity to demonstrate accountability and promote social justice. Key words: environmental tobacco smoke, ethics, legislation, multiunit dwellings, social justice.
Population health and safety issues regarding tobacco use and exposure continue to be one of the largest global public health threats. In Canada, tobacco legislation is divided into federal, provincial, and municipal jurisdictions. The current provincial tobacco legislation in Alberta under the Tobacco Reduction Act (2005) protects individuals in public spaces and common areas. However, the legislation fails to protect individuals living in multiunit dwellings (MUDs), either rented or privately owned. A MUD is a building that contains more than one residential unit. Examples of this are semidetached houses, townhouses or row houses, condominiums or apartments (Toronto, n.d.). The purpose of this article is to investigate the ethical considerations
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from a nursing perspective of extending tobacco legislation to include MUDs in Alberta. This will be achieved by exploring the current federal and provincial tobacco legislation as it relates to residents living in MUDs. The importance of enacting such legislation will be examined including the reduction in chronic conditions, childhood illnesses, and risk of injury from fire. Through the analysis of the current tobacco legislation and using a nursing perspective on ethics, it will be revealed that extending the current legislation to include private MUDs is both legal and ethical. This is important as public health nurses are not only strong advocates for the health of individuals, families, and communities, but also for population health and agents for policy change.
Stooke: Sharing the Air As public health nurses advocate for policy change, this article will also explore implications for nursing practice and how this can be achieved through government lobbying and building community capacity.
Current Tobacco Legislation and Multiunit Dwellings Prior to addressing the ethics of expanding tobacco legislation in Alberta to include MUDs, it is important to explore the current federal and provincial tobacco legislation as they relate to the protection of persons in public and private property. Below is a brief summary of the existing legislation and Acts in Canada with a discussion regarding populations that are not currently protected. According to Health Canada (n.d.), the two federal Acts in Canada that address tobacco products and use are the Tobacco Act (1997) and the Nonsmokers’ Health Act (1985). Federal laws are made by the Canadian Parliament according to the Constitution which governs the whole of Canada. The Tobacco Act (1997) is administered by Health Canada and has jurisdiction over the manufacture, sale, and advertising of tobacco products. The Nonsmokers’ Health Act (1985), administered by the Department of Human Resources and Skills Development, restricts smoking in all workplaces and public places under federal jurisdiction. Authority is granted to the Governor in Council to make or amend regulations regarding both of these Acts. Each province in Canada has its own legislation regarding tobacco use in public places. In Alberta, the Tobacco Reduction Act was developed in 2005 and came into force in 2006 (Tobacco Reduction Act, 2005). According to Alberta Health (n.d.), the Tobacco Reduction Act then became law on January 1, 2008. The intent of the Tobacco Reduction Act was to replace the Protection of Second-Hand Smoke in Public Buildings Act (Alberta) which was in force from January 1, 2002 to December 31, 2005 (Canadian Legal Information Institute, n.d.). The Tobacco Reduction Act (2005) prohibits smoking in a public place, workplace, public vehicle, and within a prescribed distance from a public doorway, window, or air intake. The Tobacco Reduction Act (2005) includes exceptions to the smoking prohibition in public spaces, but the building manager must designate a smoking room as well as provide separate
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ventilation and a physical separation by a wall and ceiling to any adjacent area where smoking is prohibited. The Tobacco Reduction Act (2005) also states that it does not affect a municipality’s power to make bylaws regarding the regulation, restriction, or prohibition of smoking. It is clear that public places under federal jurisdiction are protected from the effects of environmental tobacco smoke. As well, public places in Alberta are protected according to the provincial legislation. However, it is evident that individuals in private residences are not protected under the current federal or provincial legislation. Ironically, Kreisman (2011) states that visitors to public places are more likely to be protected from the effects of tobacco smoke than individuals living in their own homes. There is a caveat in the Alberta Tobacco Reduction Act (2005) that would allow municipalities to create their own tobacco-related bylaws. Environmental tobacco smoke, also known as second and thirdhand smoke is smoke that is inhaled involuntarily by nonsmokers (Samet, 2011). In MUDS, environmental tobacco smoke seeps through connections between apartment units by air ventilation systems, wall outlets, cracks in the walls or floors, spaces under doors, around sinks, countertops, radiators, and off-gassing from carpets and other inanimate objects (Kreisman, 2011). The United States Surgeon General (2006) states that “separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate secondhand smoke exposure” (p. 11). There is no question that the air is shared, and it knows no boundaries. According to the Statistics Canada (2012a), the number of MUDs in Alberta was 459,360 (apartment style, semidetached, row houses, duplexes), or about 33% of the total housing market. The average persons per household in Alberta is 2.6 which equates to approximately 1,194,336 individuals living in some type of MUD. Of course, both smokers and nonsmokers living in MUDs would be exposed to environmental tobacco smoke. However, given that the smoking rate in Alberta is currently 23%, approximately 919,639 nonsmokers (77%) are particularly vulnerable and not protected from the current tobacco legislation (Statistics Canada, 2012a, b). Below is a discussion of the importance of expanding tobacco legislation to include MUDs, particularly because of the well-known negative
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health effects as well as fire safety risks. Barriers to implementing this legislation are also explored.
Importance of Tobacco Legislation and Barriers to Implementation The negative health effects from the exposure to environmental tobacco smoke are documented and numerous. In 2006, the U.S. Surgeon General report on environmental tobacco smoke determined that it was harmful to human health and that there is no risk-free level of exposure (United States Surgeon General, 2006). Although there have been fewer studies regarding the effects of environmental tobacco smoke, it was in the late 1960s when the harmful effects were first recognized. By 1986, there was evidence to conclude that environmental tobacco smoke was a contributing factor for lung cancer in nonsmokers. There is also a 25–30% increased risk of developing coronary heart disease in nonsmokers when exposed to environmental tobacco smoke (Samet, 2011). Laws that limit or prohibit public and workplace smoking have resulted in a marked reduction in hospitalizations from acute coronary syndrome in both smokers and nonsmokers. Thus, there is a causal relationship between legislation to prohibit smoking in indoor spaces and health outcomes (Samet, 2011). Children are particularly vulnerable to the effects of environmental tobacco smoke. Early childhood development is a known determinant of health, yet children are powerless with respect to choosing the accommodation imposed upon them. Environmental tobacco smoke exposure in children is related to prematurity and perinatal mortality, increased risks of sudden infant death syndrome, acute and chronic respiratory illnesses (i.e., asthma), and middle ear disease (Samet & Sockrider, 2012). Negative health effects in adulthood can be attributed to prolonged exposure to environmental tobacco smoke at an early age due to the increased time of exposure. Reducing the exposure to environmental tobacco smoke in the home is most important for children as the home is the major location of the prolonged exposure (Samet & Sockrider, 2012). Aside from the negative health effects of exposure to environmental tobacco smoke, fire safety must also be considered in the importance of expanding tobacco legislation to include MUDs. A review of a document prepared by the Office of the
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Fire Commissioner (2012) revealed that the number of fires in apartment buildings in Calgary and Edmonton, Alberta, between 2000 and 2012 totaled 3,331. The loss of life in those 12 years totaled 34 with 452 injuries. The monetary value placed on the fire losses was over $290 million. While the report indicated that cooking was the number one cause of apartment fires (27%), smoking was the second highest cause at 21%. More deaths were attributed to fires caused by smoking, but cooking ranked highest in fire injury. With the implementation of tobacco legislation to include MUDs in Alberta, virtually 21% of apartment fires would be eliminated which translates to lower rates of death and injury, but also a decrease in property loss (Non-Smokers’ Rights Association, 2008; Office of the Fire Commissioner, 2012). It is clear that there are many health and safety arguments for the implementation of more stringent tobacco legislation for MUDs. Not only will there be a positive impact on the health of both smokers and nonsmokers, but there may also be a subsequent decrease in health care spending if there is a decrease in tobacco-related illness secondary to environmental tobacco smoke exposure. The savings would also be forwarded to homeowners and landlords as insurance rates, costs for the operation and maintenance of air filtration systems, and apartment cleaning would all decrease with the prohibition of smoking in MUDs (Non-Smokers’ Rights Association, 2008; Shoenmarklin, 2010). The extended tobacco legislation may also decrease the rates of smoking in general. A study by Hanusaik et al. (2012) concluded that the provinces with the highest effort in tobacco control, also had the greatest decline in tobacco use. With the implementation of provincial legislation to prohibit smoking in MUDs in Alberta, landlords and/or condo boards would not carry the sole burden of responsibility of adopting such legislation for one particular building. This standardization would potentially decrease negative feedback directed toward landlords or building managers from owners or renters in MUDs who may not initially agree with the legislation. There are many barriers, either perceived or real, in extending tobacco legislation to include MUDs. This type of legislation may be difficult to monitor or police. In a systematic examination of smoke-free policies in Virginia, the greatest barriers to landlords and property managers in adopting
Stooke: Sharing the Air smoke-free complexes were lack of demand, privacy concerns, legal concerns, and difficulty with implementation or enforcement (Jackson & Bonnie, 2011). Also, almost half of the landlords in that study who had not adopted a smoke-free policy stated that they were concerned about losing potential renters. Lack of knowledge was also a barrier as many of the landlords who had not adopted smoke-free housing were not aware that it was an option (Jackson & Bonnie, 2011). Similar studies in Minnesota and Nebraska (Cramer, Roberts, & Stevens, 2010; Hewett, Sandell, Anderson, & Niebuhr, 2006) revealed the same barriers to landlords implementing smoke-free housing. In a study by Satterlund, Cassidy, Treiber, and Lemp (2011), the barriers to adopting local tobacco control policies involved both internal agency (local tobacco project coordinators) and external political forces. The bureaucracy of the institutions involved or the lengthy decision-making time hinder the adoption of policy. Gaining in-person access to policymakers by having to go through several layers of aides was determined to be a large barrier, adding to the time and frustration of policy adoption. Satterlund et al. (2011) also state that other barriers to tobacco policy adoption are the ambivalence of policymakers and if the policymakers themselves were smokers. Staffing issues with tobacco control project agencies are also a potential hindrance to policy adoption, especially when key members of the agency leave the position, thereby also dissolving the established relationship with the policymakers (Satterlund et al., 2011). While it is apparent that the adoption of tobacco legislation to include MUDs is important for health and safety, there are many potential barriers to implementing new legislation. The above studies regarding the barriers to the adoption of tobacco legislation are all from the United States. Although much of the information may also pertain to Canada, one cannot assume that the same results would be reproducible in Alberta due to the differing social demographics. One must also take into consideration civil rights, law, and ethics prior to the adoption of new policy or legislation.
Tobacco Legislation: Civil Rights and Ethical Considerations While implementing tobacco legislation to include MUDs may be viewed as an infringement on the
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rights of smokers, failure to implement it can be seen as an infringement on the rights of nonsmokers. Of particular concern are the legal and ethical considerations when deciding to adopt legislation that may be perceived to be against the civil liberty, particularly for those who smoke. Satterlund et al. (2011) state that there is the notion that tobacco control in MUDs infringes on the individual rights and freedoms of smokers. Although law and ethics are fundamentally different in that law is a set of rules that regulate what may or may not be done by members of society, and ethics involves the morality of those decisions, they guide one another and are therefore interconnected (Black, Groves, Hucker, & McKeown, 2009). Below is a discussion regarding the civil rights and ethical considerations of expanding legislation in Alberta to include MUDs from a nursing perspective and using the Canadian Nurses Association Code of Ethics (2008) to guide decision making.
Civil Rights Both the federal Constitution Act (1982) and the provincial Alberta Human Rights Act (2000) provide a guide for the rights and freedoms of all Albertans. The Canadian Charter of Rights and Freedoms under the Constitution Act (1982) guarantees all Canadians “the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society” (Guarantee of Rights and Freedoms, 1982, para 1). The legal rights as set out in the Constitution Act (1982) give all Canadians the right to “life, liberty and security of person not to be deprived thereof except in accordance with the principles of fundamental justice” (Legal Rights, 1982, para. 1). The Alberta Human Rights Act (2000) is based on the foundation of dignity and equal rights and responsibilities to maintain freedom, justice, and peace in the world and without regard to race, religion, color, gender, physical and mental disability, age, ancestry, place of origin, marital status, source of income, family status, or sexual orientation. These basic human rights in Alberta also apply to the right of nondiscrimination for tenants under the Alberta Human Rights Act (2000). The two Acts described above clearly demonstrate that all citizens living in Alberta, and the rest
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of Canada for that matter, have the right to liberty, but this is not with a concomitant lack of social responsibility. If there were no limits to liberty, then there would be no requirements for law. Canadians already accept that there are circumstances where civil liberties are curtailed to provide for the common good. For example, there is a restriction in travel in the form of traffic laws. Another example is the Public Health Act (2000) which imposes quarantine or forced medical treatment in case of a disease outbreak. With respect to tobacco legislation for Alberta MUDs, individuals who smoke do enjoy the same rights and freedoms as those who choose not to smoke. However, should the basic premise of liberty supersede social responsibility and others’ rights to life and security? Current tobacco legislation could be perceived as an infringement on liberty, but nonetheless has been enacted to protect the population from environmental tobacco smoke. Aside from the previously discussed legislation to prohibit smoking in public spaces, there is relatively new legislation in eight provinces and one territory that prohibits smoking in private vehicles while children are present. For example, the Smoke-free Ontario Act (1994) amended the legislation in 2008 to include private vehicles to protect children under the age of 16. However, the Alberta provincial government has not enacted such legislation, but it does exist in four municipalities; Okotoks, Medicine Hat, Athabasca, and Leduc (Reid, Hammond, Burkhalter, & Ahmed, 2012). This municipal legislation does set a precedent for MUDs as it involves private and not public property, which will be discussed in detail later in the article.
Ethical Considerations—A Nursing Perspective While law is a set of rules and regulations, ethics involves moral decision making. All nurses, including public health nurses, are of course bound by law, but are also obligated to practice under a nursing code of ethics. In Canada, the CNA Code of Ethics (2008) guides nursing practice in all contexts and domains, and is used in conjunction with law and nursing practice standards. The CNA Code of Ethics (2008) states that “nursing involves both legal and ethical dimensions” (p. 4).
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It would be logical to assume that the law and ethics are compatible; however, there may be situations where there is a conflict between the law and ethics and nurses are required to collaborate with others to change policy to reflect the core values of the Code of Ethics (CNA, 2008). According to the Canadian Nurses Association (2008), “ethics is concerned with how broad societal issues affect health and well-being” (p. 2). Nurses are expected to be aware of and maintain social justice and to advocate for change. It is also an expectation that nurses are cognizant of the core responsibilities and values at all times, and to also be aware when those values may be in conflict (Canadian Nurses Association, 2008). With respect to the issue of environmental tobacco smoke exposure in MUDs in Alberta, there is a conflict between the lack of legislation to prohibit this public health threat and the nursing Code of Ethics (Canadian Nurses Association, 2008) which obliges nurses to advocate for policy change when there is a threat to public health. The responsibilities under the Code of Ethics that guide nurses to advocate for extended legislation to include MUDs in Alberta are as follows: promoting health and well-being, promoting and respecting informed decision making, preserving dignity, promoting justice, and being accountable (Canadian Nurses Association, 2008). In promoting health and well-being, it is the public health nurse’s responsibility to understand that when care interferes with individual rights and freedoms, the nurse advocates for the least restrictive measures possible (Canadian Nurses Association, 2008). While some would argue that extending tobacco legislation to include MUDS is an infringement on human rights, for the greater good, nurses must advocate for this legislation to protect both smokers and nonsmokers. Nurses are implored to promote and respect informed decision making under the Code of Ethics (Canadian Nurses Association, 2008) to ensure that there is informed consent in matters that may affect an individual, community, or population. However, with legislation, consent is sometimes not achievable or realistic. It is nonetheless important for the public health nurse to provide information to smokers regarding the health benefits of implementing such legislation. This thereby preserves dignity by recognizing that the knowledge acquisition is essential even for those who may oppose the legislation. The responsibility of promoting justice
Stooke: Sharing the Air is much the same as the Alberta Human Rights Act (2000) regarding discrimination, human rights, and promoting the common good. The public health nurse would demonstrate accountability by not ignoring this public health threat and at the same time advocate for social justice. According to the Code of Ethics (Canadian Nurses Association, 2008), this practice expectation requires nurses to promote equality, advocate for change with unethical health, social, and legislative policies. Nurses must also advocate for health promotion and disease prevention, the reduction in environmentally harmful practices, maintain awareness of global health concerns, and advocate for discussion with others regarding ethical issues (Canadian Nurses Association, 2008). It has been established by current legislation and the Canadian Nurses Association (2008) that it is both legal and ethical, from a nursing perspective, to implement tobacco legislation to include private MUDs in Alberta. This threat to public health exists not only in Alberta, but globally. Therefore, the discussion regarding nursing implications is relevant to public health nursing practices everywhere.
Nursing Implications—Advocacy and Political Action The Canadian Nurses Association (2008) has been used as a guide to articulate the position of this article that it is ethical to expand tobacco legislation to include MUDS in Alberta. All nurses, but more specifically public health nurses, should advocate and support this legislation to endeavor to promote equality and social justice. The following will discuss the merits of enacting provincial-level tobacco legislation for Alberta MUDs as well as how the current legislation can be used as a guide or precedent. Public health nurses must also become change agents to build community capacity and lobby appropriate government departments (Canadian Nurses Association, 2000). Ideally, the proposed tobacco legislation to include Alberta MUDs should be achieved at a provincial level, rather than a local or municipal level as the health of all Albertans is important, and not just a portion living in specific municipalities or jurisdictions. However, even though the current evidence regarding health and safety issues,
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and the fact that such legislation would not be illegal, there continues to be many barriers. This is likely because doing what is right is usually more difficult than maintaining the status quo, and often there is great change involved. The public health nurse is in a position to be that change agent. One of the best catalysts in affecting change is to determine what relevant legislation currently exists so that it may be used as a precedent for proposed legislation. As stated earlier, there is current legislation in eight provinces and one territory in Canada that involves the prohibition of smoking in vehicles with children present. Although this may not seem to be relevant to MUDs, it is similar because they both involve legislation for privately owned property. If legislation can be enacted at a provincial level to include private vehicles, then this suggests that legislation can be extended to include private MUDs. In a tobacco policy analysis document created by Reid et al. (2012), tobacco legislation in Canada for MUDs is currently at the level of the building, landlord, or social housing provider with only a few regions or municipalities adopting such legislation. These authors also note that some provincial housing corporations have adopted policies or are in the process of doing so. Examples of this are the Newfoundland and Labrador Housing Corporation, Nova Scotia Department of Community Services, and the Yukon Housing Corporation. However, there is currently no province-wide legislation to prohibit smoking in privately owned MUDs. In order for this legislation to be enacted, raising awareness, building community capacity, and lobbying the government must take place. Public health nurses are in a position to become politically active to help initiate this change. Our current health care system is narrowly focused on healing the sick, a downstream approach, rather than focusing on an upstream approach of health promotion and illness prevention. According to the Canadian Nursing Association (2000), “understanding health in its social context helps us to see that the primary determinants of health and illness are social, political and economic in nature” (p. 1). To provide holistic care for populations, nurses are required to adopt a global perspective by becoming politically active to halt the root cause of illness (CNA, 2000). By identifying an item as a political issue, the nurse realizes that there is a common problem that affects
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clients, and that this has broader implications for populations (Canadian Nursing Association, 2000). In the case of the lack of tobacco legislation in Alberta to include MUDs, there is an obvious health and safety issue that involves nearly one third of the provincial population which must be addressed. There are several strategies that nurses can use to become politically active and advocate for policy change. Firstly, it is important for nurses to educate themselves regarding the issue, then enlist allies and determine the targeted decision makers for the issue. Lobbying the appropriate government officials regarding the issue, involving those who are directly affected, and creating public support are all important political activities. It may also be effective for nurses to involve the media to raise public awareness. The political process involves the influence of decision makers in implementing change to improve the health of the population (Canadian Nursing Association, 2000). In the matter of extending the tobacco legislation in Alberta, it is important for nurses to convince the policymakers that this change would be positive for everyone involved, thereby promoting equity and social justice. In any effort to influence policy, it is important for the nurse to know the appropriate stakeholders: those who may be affected, are interested in the policy, and have the influence to change the policy (Health Canada Population and Public Health Branch Atlantic Region, 2003). With respect to extending tobacco policy in Alberta, the stakeholders are the appropriate government departments, owners/landlords, condominium boards, residents of the MUDs, and health care providers. Citizens must also be engaged to build capacity. There are several motives for involving the public; however, the most significant reason is that the effectiveness of policy development is enhanced when those who are directly affected become involved. This helps to increase awareness of a health problem, provide education, enhance an exchange of dialog, and promote informed decision making. Therefore, involving the public also meets the legal and ethical commitments of policy change (Health Canada Population and Public Health Branch Atlantic Region, 2003). Public support for extending tobacco legislation in Alberta would presumably be high based on two surveys completed in 2006 in Ontario where 64% of the population living in MUDs would choose a
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smoke-free building over a building where smoking was permitted (Non-Smokers’ Rights Association, n.d.). Although there are no data in Alberta regarding public opinion for banning smoking in MUDs, data currently exist regarding the prohibition of smoking in private vehicles with children present (81% of the Alberta population and 69% of smokers agree with this proposed legislation) (Alberta Health Services, 2008). The agreement for the legislation for private vehicles may also be interpreted as an agreement to eliminate environmental tobacco smoke in MUDs. However, it would be prudent for public health nurses to gather the required data relevant to MUDs in Alberta prior to initiating political action.
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Non-Smokers’ Rights Association. (n.d.). Secondhand smoke in multi-unit dwellings. Retrieved from http://www.nsra-adnf.ca/cms/page1433 .cfm Office of the Fire Commissioner. (2012). Fire losses in apartments in Calgary & Edmonton, Alberta: 2000-2012. Retrieved from http:// www.ofc.alberta.ca/documents/fco/FIRE_LOSSES_IN_APARTMENTS_IN_CALGARY-EDMONTON-revised_1.pdf Public Health Act. (2000). Revised Statutes of Alberta, Chapter P-37. Retrieved from http:// www.qp.alberta.ca/documents/Acts/P37.pdf Reid, L. J., Hammond, D., Burkhalter, R., & Ahmed, R. (2012). Tobacco use in Canada: Patterns and trends (Supplement: Tobacco control policies in canada) (2012 ed.). Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo. Retrieved from http://www.tobaccoreport.ca/2012/TobaccoUseinCanada_2012_PolicySuppl_Final. pdf Samet, J. M. (2011). Secondhand smoke exposure: Effects in adults. Uptodate. Retrieved from http://www.uptodate.com/contents/secondhand-smoke-exposure-effects-in-adults?sou-rce =preview&anchor=H1491250&selectedTitle=2~ 150#H1491250 Samet, J. M., & Sockrider, M. (2012). Secondhand smoke exposure: Effects in children. Uptodate. Retrieved from http://www.uptodate.com/ contents/secondhand-smoke-exposure-effects-in-children?source=search_result&search =negative+effects+of+environmental+tobacco +sm oke&selectedTitle=1~150 Satterlund, T. D., Cassidy, D., Treiber, J., & Lemp, C. (2011). Barriers to adopting and implementing local-level tobacco control policies. Journal of Community Health, 36, 616–623. doi:10.1007/s10900-010-9350-6. Shoenmarklin, S. (2010). Secondhand smoke seepage into multi-unit affordable housing. Tobacco Control Legal Consortium. Retrieved from http://publichealthlawcenter.org/sites/ default/files/resources/tclc-syn-secondhand2010_0.pdf Smoke-free Ontario Act. (1994). Chapter 10. Retrieved from http://www.e-laws.gov.on.ca/ html/statutes/english/elaws_statutes_94t10_e. htm#s9p2s1 Statistics Canada. (2012a). Calgary, Alberta (Code 825) and Alberta (Code 48) (table). 2011 Census. Statistics Canada Catalogue no. 98316-XWE. Ottawa. Released September 19,
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2012. Retrieved from http://www12.statcan. gc.ca/census-recensement/2011/dp-pd/prof/ index.cfm?Lang=E Statistics Canada. (2012b). Health Profile (table). Statistics Canada Catalogue No. 82-228XWE. Ottawa. Released June 19, 2012. Retrieved from http://www12.statcan.gc.ca/ health-sante/82-228/details/page.cfm?Lang= E&Tab=1&Geo1=HR&Code1=4832&Geo2=PR& Code2=48&Data=Rate&SearchText=Calgary% 20Zone&SearchType=Contains&SearchPR=01& B1=All&Custom= Tobacco Act. (1997). Statutes of Canada, chapter c.13. Retrieved from http://laws-lois.justice. gc.ca/PDF/T-11.5.pdf
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Tobacco Reduction Act. (2005). Statutes of Alberta, 2005, chapter T-3.8. Retrieved from http:// www.qp.alberta.ca/574.cfm?page=T03P8.cfm& leg_type=Acts&isbncln=97807797 37901 Toronto. (n.d.). Smoke-free living: Facts on secondhand smoke in multi-unit dwellings. Retrieved from http://www.toronto.ca/health/smokefree/protection/multidwellingfacts.htm United States Surgeon General. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Retrieved from http://www.surgeon general.gov/library/reports/secondhandsmoke/ fullreport.pdf
