Friday, February 16, 2018

The Responsible Use of Nicotine

What was learned at the, 13 February, Resident Council meeting has been summarized in the chart in operational terms: Condition of Employment, Training, and Uniform. The chart was distributed at a, 14 February, meeting at Provision Living with the Central Missouri Area Agency on Aging (CMAAA), Donna Wobbe, Director, 573-443-5823.
A few edits have been made to keep the chart on one page. It will be used in a working paper presentation to the staff at Provision Living, Thursday, 22 February 2018. Other comments:
Conditions of Employment
Employers who hire people with addictions that have a harmful effect on others at the site have a responsibility to minimize or eliminate the effect on smokers and non-smokers. This is the flip side of providing special arrangements for the physically and mentally “challenged”. A well established practice.
There is a counter culture that promotes tobacco smoking. Many states have laws prohibiting “life style” city ordinances. This made some sense at the time we knew little about the immediate effects of tobacco smoke.
Columbia, MO, promotes tobacco smoking by outdoor “smoker stations” in the downtown “The District” area to “protect the wild life” at the other end of the sewer system. This promotion also comforts nicotine addicted and non-addicted persons with the reassuring words, “If you smoke cigarettes, you have every right to do so.”
This is one of the main tobacco company lies. There is no such right (except where smoking has no effect on other people). It is important to the people taking in the money, to say this, so everyone is happy with their operation. The specter of “excess” deaths hanging over the area must be kept out of mind.
[Columbia, MO, City Code 16-231 Littering, states it is a Class A misdemeanor with up to one year in jail and up to $1,000 fine if (cigarette butt) litter escapes from property that permits littering.
This is a perfect example of how laws, that look good to the public, are passed with little if any attempt at enforcement. Owners are not interested in paying $1,000 fine for each night that butts stray into the street.]
Our understanding of when tobacco smoke injures is changing as we learn more about how it injures. Blood platelets become sticky in about 30 minutes; promoting heart attacks and strokes (both tobacco and e-cigarettes). Vascular endothelial function is reduced in seconds; arteries then fail to enlarge when added oxygen is needed.
I measured indoor and outdoor air quality in northwest Missouri for several years. It came as a surprise to find an article, in March, 2017, that compared the fine particulate concentration from tobacco, marihuana, and “vaping”. They have the same concentration of toxic fine particles! It never occurred to me that burning and heating (charring?) would generate the same toxic particles.
It is the fine particulates that contribute to illness and “excess” deaths in smog. Burning tobacco with or without nicotine made no difference in their results. It is the smoke; not the nicotine, that is toxic.
“Vaping” seems to be a truth and another big lie. It can get a person, addicted to nicotine, to switch from tobacco to vaping (for about $60, at one store I visited). It can also get a non-addicted person addicted.
The CDC and FDA have yet to sort this out. Until they do, avoid vaping. Vaping generates a colorful third hand “smoke” with its own drug rituals.
Several people have mentioned the smell of tobacco smoke. That used to be the end of the matter. Now it is a warning, of the presence of third hand tobacco smoke and the immediate results on health; that an addicted person is sharing for lack of knowing how to use, non-smoke containing, nicotine sources.

Thursday, February 15, 2018

Tobacco Smoke Control in Memory Care

The chart relates important parts of effective tobacco smoke control in memory care presented at the Provision Living at Columbia, 13 February 2018, Resident Council meeting.

My trip to a smoke free city last week, San Antonio, Texas, made it very clear that common tobacco smoke control terms are confusing and misleading.
Source: First hand tobacco smoke is taken in by a smoker through the mouth. Second hand tobacco smoke is taken in through the nose. Smokers hold their cigarettes so as to avoid new second hand smoke. Third hand tobacco smoke exposure in memory care comes from the smoke that has settled in hair, clothes and bodies of smokers.
Restriction: Smoke free is an area that is free of smokers. It is not an area free of tobacco smoke. Tobacco free is an area free of smoking and free of tobacco smoke except for third hand tobacco smoke. Smoker free is free of tobacco smoke but can still be invaded by third hand tobacco smoke. These restrictions are not effective in memory care.
Smoker: The non-addicted smoker can honor a request to not smoke on the job and to even wait until after work to enjoy a smoke. Such a person does not carry a risk of tobacco smoke exposure to memory care residents. Addicted smokers must have an appropriate source of nicotine (lozenge) in a timely manner or burn tobacco to take in the needed nicotine in a toxic smoke.
Stage: Smokers who are quitting now find the smoke free environment in Provision Living a safe place to work. One still smokes when with relatives, however she no longer buys cigarettes.
Smokers can be classified by their readiness to quit and the amount they smoke by the Center for Disease Control (CDC) Missouri Quit Line, 1-800-784-8669, along with free counseling and a kit of alternative smokeless nicotine sources.
Alternative safe nicotine sources free of tobacco smoke not only provide help in breaking addiction but also provide an immediate elimination of third hand tobacco smoke in memory care. I found the lozenge is the most popular in local pharmacies.
Addicted caregivers could pick up needed lozenges for the shift when clocking in.
Three residents recited their experiences in quitting “cold turkey”. One left smoking behind when moving to Provision Living. One just quit; health and cost. Another was teased by friends to the point that he gave in. He then found out how much non-smokers “hated smokers”; for over 35 years that he had been smoking. 
A tobacco smoke cessation group was suggested. We now know that this must be done with the encouragement of the entire community to be successful.
The comment that membership would be kept private struck me as very odd. Success in breaking addiction demands a positive cooperative atmosphere. There must a celebration of purpose that overpowers the negative aspects of breaking free from addiction, or a significant emotional event like the three residents had before they moved into Provision Living.
The time has come that the “dirty secret” of exposing residents to third hand tobacco smoke in the residential health care community in Columbia needs to be made public to keep the air clean. Residential property is not a private place for people addicted to nicotine to share their toxic wastes.
The damage tobacco smoke does to the human body is no longer something that takes decades: lung cancer. The heart doctor we had an appointment with, prior to the resident counsel meeting, had the walls decorated with “Stop Smoking” and “Avoid Second Hand Tobacco Smoke.”
The threat to health is now known to be immediate. Blood platelets become sticky within 30 minutes of tobacco smoke exposure. Sticky platelets form clots. Clots cause heart attacks and strokes. Avoid second hand and third hand tobacco smoke.
My travels in the past four years still show Provision Living at Columbia to be the best for our money and for our care by radiant caregivers. Replace tobacco smoke with smokeless nicotine.

Sunday, February 11, 2018

Third Hand Tobacco Smoke Petition

The prior post stated the situation we are in with current tobacco control laws. Smoke-free means an area in which no one should smoke. It is also an area free from smoke drifting in from other areas.
This misses the third hand tobacco smoke carried into “smoke-free” and “tobacco-free” areas on a smokers hair, clothes, and body for the first 30 minutes to several hours after smoking.
Third Hand Tobacco Smoke Petition

The Third Hand Tobacco Smoke Petition puts this into an operational perspective. Tabulated confidential petitions record a patient’s or resident’s awareness of tobacco smoke exposure.
The tabulated petitions become votes. Columbia, MO, is divided into five legislative districts. The two central town districts are Democrat. The three more rural districts are Republican.
My first political act was to attend the annual League of Women Voters event at the library last Tuesday evening where I met the five representatives. Representative Chuck Basye was very respective to the handout in the prior post.
The tabulated petitions also provide feedback to owner management. Friday I had another call from San Antonio. A site our daughter-in-law picked out three years ago reported that their memory care is now staffed entirely by non-smokers. We can check this out next month.
A “smoker-free” site can eliminate most tobacco smoke exposure, however, there is still the problem with littering reported by our site director. Missouri House Bill No. 533 would add “cigarettes, cigars” to the state code on littering. A new Section 577.070.2 (3) ”If the offense of littering involves cigarettes or cigars the fine imposed under this section shall be twice the amount imposed for an offense not involving cigarettes and cigars”.
A class C misdemeanor carries a maximum 15 days in jail and a $700 fine in Missouri. Proper signage and a fake camera at the front door might reduce the time to police up the area each day. Cigarette buts are highly visible in the paved entry area.
Insurance purchased on the exchanges covers smoking cessation. Along with the CDC, 1-800-784-8669, the city of Columbia, 573-874-7356, has a free program.
Preventable illness and early death, from cigarette smoke used to get nicotine, are now being taken seriously by health agencies, but “the state tobacco control program is currently funded at only 0.1% of the CDC-recommended level”.

Wednesday, February 7, 2018

Tobacco Addiction Politics

The handout was prepared for a Resident Council meeting on 6 February, 2018. It turned out I had the wrong week! The meeting is next week.
Resident Council Handout

The top box contains the basis for actions now being taken by the Center for Disease Control (CDC) at one end of the spectrum of tobacco control and by well-informed responsible people everywhere. That means no tobacco smoke; first hand, second hand, and third hand.
My trip to San Antonio made it very clear that third hand tobacco smoke, the smoke from hair, clothes and body for the next 30 minutes to hours after smoking, that exposes patients and residents, was very confused with “smoke free” or as one person put it, “smoking free”.
2 Feb 2018 Wall Street Journal
People smoke to satisfy their need for nicotine.
The Wall Street Journal, Friday, 2 February, 2018, ran a full page “tombstone” ad making this every clear. [Tombstone ad; A full blank page with a simple message (addictive).] Thank W_____ for subscribing.
E_____ has quit smoking some time ago. L_____ is now on her second attempt. She stopped smoking at work. Work provided a safe place to not smoke. She no longer buys cigarettes. She is now down to smoking when she encounters others smoking. The smell of smoke is a powerful trigger to light up again.
The one site in San Antonio, we did not see, has confirmed that they are “encouraging” all employees to not smoke at work in memory care. They are aware of the effect of tobacco smoke on ill and aging people who do not smoke.
They may also be aware that people are increasingly asking for air as clean as in their own homes. The tourist industry is aware of this as it brings in new business. If we had to move, this place would be our first choice to check out.
The simplest way to obtain tobacco free conditions is to ban smoking on the property. For those so addicted that they cannot go nine hours without needing to adjust their blood nicotine levels, there are alternate nicotine sources to burning tobacco and breathing [a part of] the smoke.
Just Ask
Provision Living still has the opportunity to be the first large health care residential community in Columbia, Missouri, to offer a tobacco free memory care environment. We have one smoker in assisted living who, each day, makes an early morning trip out the front door to smoke.
The Best Place a Senior Adult Has Ever Lived
I am willing to put up to $1,000 into supporting the transition from cigarettes to lozenges to quitting, if others will match my contributions. [It cost a lot more to move.] Provision Living at Columbia has everything (radiant caregivers and facilities) in one building that my wife and I need to “thrive” with the exception of the every present third hand tobacco smoke.

[Bring fidget devices and nicotine lozenges to Resident Council meeting.]

Friday, February 2, 2018

Smoke Free San Antonio TX

A trip over the weekend, to a smoke free city, did not change how memory care residents are sheltered from third hand tobacco smoke. There are very few smoking control signs; as they are no longer needed.
We toured five residential care sites. In each we recited my wife’s Alzheimer’s behaviors and my problem with third hand tobacco smoke. One memory care site questioned taking a person who hit back when hurried.
Texas licenses sites as 16-bed or fewer and more than 16-beds. A 16-bed site optimizes construction and operation cost.
No showers in the apartments; just one big, warm, shower room. The residents like warm showers. No problem getting them into the shower,
The kitchen is the focal point for the four-table dining and activity area. Every move the cook makes can be observed. Every food odor is detected. The cook knows them well enough that food waste is at a minimum.
The activity area looked just like Provision Living, when we moved in two years ago, and there was a full time memory care director. There is little problem getting residents to take part in activities or to eat their meals. 
Well-trained worker turnover is also at a minimum. A set of 25 cameras showed all areas except in apartments. There was a general practice of attempting a service three times on a shift; noting failure on a communication log; attempting the service three times on the next shift; and again on the third shift if needed (the need for proper tooth brushing for example observed by our dentist).
A more expensive site had an aromatherapy dispenser running in every apartment and scattered through out the public areas. They had no effect on my sense of smell or congestion! The other sites considered it a marketing fad. My lack of response was do to “the carefully selected pure oils we use.”
[I detected a change in odor between the hall and the living room near the entry door, this morning. This was a surprise. I was in a hurry getting to the 8:30 fitness class. Another person has had headaches since the latest odorant was installed and who can detect it throughout the day. Proper operation is for a detectable odor for one or two breaths; to promote a 10% increase in cash flow in a boutique.
Using a stronger, always detectable, concentration is common in homes, bathrooms, and elegant formal occasions. It is not recommended where people are already under respiratory stress, especially those with COPD (chronic obstructive pulmonary disease); an illness most often caused by the tobacco smoke needed to self-treat their nicotine addiction. They need to avoid fumes, toxins, second & third hand tobacco smoke and dust. WebMD]
Our best arrangement, if in San Antonio, may be with my wife in a memory care unit and me living with the grandkids, tobacco free, a few miles apart. We will check this out in April when I accompany the grandkids to the NASA rocket contest in Huntsville, AL.
We observed no overweight residents. My wife now has problems, recently more often, standing up from a chair. She cannot get up from the floor.
Current thinking is we remain in place and I fly to San Antonio 3-4 times a year for a 1-2 week visit. I was informed my wife got along well while I was gone but does better when I am here.
We have yet to find anything like the fitness program I take part in here. Again, it is easy to place one person, it is very difficult to place two with very different needs:
My wife treated me almost as a stranger when I returned this afternoon, before an endless fire alarm drill that was most upsetting to the residents. She broke out into a smile more than once later when residents were commenting about the lecturing by another resident: her walking buddy and our former eye doctor.
[On the second day of my return, my wife knew who I was and gave me a big hug and grin before returning to her keepsakes.]
My wife did not eat breakfast for many years before coming to Provision Living. Trying to get her to eat breakfast, “to get with the system” failed. Times have changed.
My wife was found on the floor in our apartment the first two mornings that I was gone. Thereafter a caregiver got her up before her normal mid-morning time and out of the apartment to breakfast. No more falls.
Today she was finishing brunch with three other residents, as I returned at 10:00 from “Start Your Day with Stretching” followed by physical therapy. My trip to San Antonio paid off in the discovery of yet another adjustment to my wife’s ever changing behaviors.

This is getting too long. I have survived the hurt of going alone and not sharing the trip. It is Friday and I need to cheer up by completing our income tax returns.

Saturday, January 20, 2018

Are They Happy?

At breakfast this morning, the question was raised, “Are the people in memory care happy?”
This struck a responsive cord. I have noticed a difference in caregiver behavior in the past few months. It is more than forewarning new hires to allow my wife “her” time to respond; to avoid a sound smack.
It is more than the extra work needed when several residents show behaviors we thought, last year, were related to our 3-month flood evacuation to skilled nursing at South Hampton Place. There is something different in some of the new hires.
As I am writing this, Maggie gets up and goes to the bathroom: 9:05. A lady who has been with us from the beginning happens by to check in to see how things are going.
Without little more than a friendly greeting and hug, she changes my wife out of night clothes and into day cloths in a well rehearsed ritual; perfect timing in sequencing and spacing of each necessary step. I did not hear a single word spoken by either one after I left the bathroom: 9:10 and ready for the day.
“Your gown is wet. Pause. We need to change it. Pause. Sit down. Pause, etc.”, in her gentle commanding voice. Each garment is displayed. Pause. And put on (often she will do this herself when sitting on the daybed and not rushed).
There is something different about Provision Living. We are all two years older for sure. There will probably never be another man like the guy who could do every thing when we first moved in. He made memory care and the dining hall a circus. But we are two years older now. And nearly 100 residents; double when we moved in. Both caregivers and residents have changed.
Happiness is most easily detected in the interaction between radiant caregivers and residents. The caregivers create the climate and situation for happiness to occur. The long-lost-friend hug (in many forms) is the best example; often proceeded by, “May I give you a hug” or “May I hug you.” The positive head node and/or smile are indicators of happiness.
This week everyone in, memory care one, was at a table with every chair filled at an evening meal. After serving everyone, the caregivers did not have a spare seat to share tables with the residents.
The group dynamics of 24 residents is different than for a smaller number. The optimum number that changes behavior from a big family to a restaurant/hotel seems to be between 16 and 20 residents.
Indicators of unhappiness are easy to observe, especially in a resident’s first few days. The patience and skill of the best radiant caregiver can be taxed. 
The breaking point is running out of patience or taking something in the event personally (loosing that sense of detachment needed to remain a good observer). “Are you just bugging me?” Now, neither person is happy.
“I have no money to pay the bill”, is frequently stated by more than one resident. “The food is free.” “The food Is part of your rent.” “Your (brother, mother, father, sister, son or daughter) paid the bill.” All delivered with or without a hug.
Two years ago the delivery of our meals in the main dining hall and in memory care was accompanied with, “Miss Margaret”; “Miss Maggie”; “Mr. Richard”; “Dr. Hart”; etc. It was a welcome to the meal and a way we all learned the names of others for the umpteenth first time. And those who could said, “Thank you.”
That greeting is a reaffirmation that this is real for all residents. It is a feel good moment. I will never forget when I first understood this. A memory care resident asked me, “Dr. Hart, how did you know my name?”
This is just one case of, how it is done, is as important as what is done. The gracious performance of formal dining changes eating into a positive event. Positive events promote better health, even though they may be quickly forgotten.
In memory care, a resident’s fleeting moments of happiness are often a reflection from a caregiver. Feeding and fitness (stretching, strength, balance, tai chi,  yoga, and meditation) are the main communal settings in which happiness occurs at Provision Living. These are modified for memory care residents.
In general, an adaptable, radiant, huggable caregiver who can step into the theater of residential care by anticipating the needs of residents before hand, can deliver a positive performance with a minimum of stress. In my wife’s case, this is a painless “no hit” performance with a minimal use of “calming” drugs.
The flood of 2016 produced a natural experiment. We were evacuated three months to a skill-nursing site. Xanax was put on daily dose of 0.25 mg, 0.25 mg, and 0.50 mg when my wife’s behavior became too “aggressive” (top chart). The unexpected effect was six falls, every other day, until Provision Living took control of her medications again.
8 Days and 8 mg

48 Days and 4 mg, 1/12 the Above Dosage

Now a year later, with comparable behavior in the holiday period, and in memory care, where diversion and distraction replace drugs, we see an entirely different pattern of drug usage (bottom chart). Only once was a 0.25 mg pill used more than once a day (red). No pills were used for a 12-day period.
Happiness is possible when free from “anxiety” and “agitation”. Skilled caregivers, familiar with the resident, reduce the need for medication.
9:35, and several days later. A greeting, a hug, a pill and yogurt. Some conversation. “You want the rest of that yogurt?” Pause. “Come with me.” A long pause as Maggie finishes working on the refrigerator. At the very instant her attention changes: “Come on with me.” A long pause. She turns toward the door. Stops. “Ok, come on with me.” She drifts out the door. “We’re out of here.” Pauses. Then, on her way.  A perfect match of caregiver and resident. A perfect performance. It still brings tears.

Happiness is in a spontaneous expression and interaction with patient, experienced, caregivers. It also seems to be in quiet moments, playing with keepsakes, doing things you now have the time to do. In meditation it is in mindless “being”; existing as a milkweed plant or a chrysalis rather than a butterfly.

Wednesday, January 17, 2018

Cultural Smoker Rescue

I need a webpage to hold easy to find information for this blog. The following draft pages have been prepared. Your comments will be appreciated. I now have something worthwhile to do in winter when I cannot work out on the Monarch Butterfly Sanctuary.
1.    New Website.
2.    Tobacco Free Pledge
3.    Definitions
4.    Together We Can
5.    Terminology
Two years at Provision Living at Columbia show a need to rescue smokers and residents from tobacco smoke. Nicotine addiction is not a private matter using cigarettes.
Cultural norms over the past 50 years have changed from ancient customs of ceremonial use to a society becoming fully aware of the health consequences of cigarettes designed for maximum addiction that thus yield maximum profit.
The new norm is no exposure. Instant elimination of exposure is now legally available from nicotine sources other than smoke.
The long term approach is culturally imbedded. It took 30 years for hospitals to discover they were health care facilities. And longer for airlines to be smoke free because it was more profitable. And 50 years for MU Health Care to be smoker free.
The general public is now smoking less, but 75% of smokers still want to quit. Many do all by themselves. A pack-a-day smoker can save the equivalent of a $1/hr raise. But most smokers need a close knit support group: church, club, job site.
I think the following homework allows me to make a valid comparison between tobacco free (if it exists) residential care in San Antonio and a plan to develop such here if we remain in Columbia.
1. New Website            13Jan18
Three years ago I started www.residentialcarefortwo.blogspot to record our search for a place for my wife and me. We have now lived for two years in Provision Living at Columbia, MO, in assisted living and in memory care.
Our family situation has changed. We are looking again. Columbia, MO, is not a tobacco smoke free city. Employees can smoke on the job in designated areas. San Antonio, TX, is a tobacco smoke free city. Many workplaces are smoke free.
This time we would like to find a site that is free from third hand tobacco smoke. Tobacco smoke: first hand, second hand, and now third hand, has been found to be equally damaging to health, in comparable amounts (with the exception of triggering my allergies). Tobacco smoke has no place in health care facilities including assisted living and memory care.
Unfortunately, big money still controls tobacco use at the federal and stage level. Current smokers finance the infamous tobacco settlement that pays states for 25 years for damages to health and to promote non-smoking. That money, however, is not used to promote non-smoking but put into the state general fund.
The tobacco tax is also seen as an important revenue source for states; when governors worry about a loss in the tobacco tax as the price of cigarettes is increased to reduce sales to minors. Missouri collects about $20,000 per 20 cases of cigarettes. Most states collect about $180,000 for 20 cases. That is the value of one life lost from tobacco.
Protection of the general public then falls to the general public, and to the advantage, companies see in declaring; first, smoke free, then tobacco free, and finally, totally, smoker free (first hand, second hand, and third hand smoke).
Provision Living at Columbia is a good [candidate]. It was constructed with no tobacco use in the building. It is just two years old. It has a skilled, experienced work force that includes many former smokers. It has only one resident smoker who diligently goes outside, come whatever weather, each morning.
This is a college town. This helps promote a high turnover rate. The opportunity exists to expose a large number of people to an effective smoke secession program as new hires are welcomed into productive [groups] (or rejected).
Now to explore the status of tobacco in residential health care facilities near Columbia, and not waste the effort, by posting what we find on this [website]. We may move to San Antonio, for a year or two, or work at clearing the air here.
--DRAFT--                           2. Tobacco Free Pledge                              --DRAFT--
Your residential health care facility will be tobacco free soon, if it has not already been established as tobacco free. Also help the 75% of smokers who want to quite, to quite. This is easier to do in a model Smoke-Free City.
San Antonio City Ordinance: 2010-08-19-0697, Chapter 36: (Bold my emphasis.)
WHEREAS, numerous studies have found that tobacco smoke is a major contributor to indoor air pollution, and that breathing secondhand smoke is a cause of disease in healthy nonsmokers, including heart disease, stroke, respiratory disease and lung cancer; and
WHEREAS, secondhand smoke is particularly hazardous to elderly people, individuals with cardiovascular disease, and individuals with impaired respiratory function, including asthmatics and those with obstructive airway disease; and
WHEREAS, the United States Surgeon General has stated that there is no risk-free level of exposure to second-hand smoke (U.S. Surgeon General’s Report – 2006, The Health Consequences of Involuntary Exposure to Tobacco Smoke);
Company: _____________________________________
          Independent Living    Assisted Living    Memory Care    Skilled Nursing
Beds:            _____                    _____                _____                 _____
Date to be tobacco smoke free: _____________

Date to be a tobacco free site:   _____________

Date to be a smoker free site:   _____________

Date to be a clean air site:        _____________
Address: _________________________________________________________
Phone: __________________ 
Email: __________________________________
Name: __________________________________  Date: ___________________

Post to: [] (near Columbia, MO, and San Antonio, TX)
3. Definitions
As detailed as these three definitions are, they still do no state clearly current situations. This leaves the code open to interpretation.
Is a residential care facility such as Provision Living ranked as a health care facility?
The tobacco free status of the MU campus includes the medical center and all outdoor areas, including parking lots and sidewalks.
Health care facility means an office or institution providing care or treatment of diseases, whether physical, mental, or emotional, or other medical, physiological, or psychological conditions, including but not limited to, hospitals, rehabilitation hospitals or other clinics, weight control clinics, nursing homes, homes for the aging or chronically ill, laboratories, and offices of surgeons, chiropractors, physical therapists, physicians, dentists, and all specialists within these professions. This definition shall include all waiting rooms, hallways, private rooms, semiprivate rooms, and wards within health care facilities.
Place of employment means an area under the control of a public or private employer that employees normally frequent during the course of employment, including, but not limited to, work areas, employee lounges, restrooms, conference rooms, meeting rooms, classrooms, employee cafeterias, hallways, and vehicles. A private residence is not a “place of employment” unless is is used as a child care, adult day care, or health care facility.
Public place means an enclosed area to which the public is invited or in which the public is permitted, including but not limited to, banks, bars, bingo facilities, educational facilities, gaming facilities, health care facilities, hotels and motels, laundromats, public transportation facilities, reception areas, restaurants, retail food production and marketing establishments, retail service establishments, retail stores, shopping malls, sports arenas, theaters, and waiting rooms. A private residence is not a “public place” unless it is used as a child care, adult day care, or health care facility.
Smoking means inhaling, exhaling, burning, or carrying any lighted or heated cigar, cigarette, pipe, or any other lighted or heated tobacco or plant product intended for inhalation.
The code does include exhaling tobacco smoke; which may include third hand smoke: out-gassing from body, hair, and clothing.
My one-week trip to San Antonio, nest week, should provide some answers. What is said and what actually happens can be very different. The following provides no protection from third hand tobacco smoke; only tobacco free does that.
“As for the smoking free environment. Yes, we are smoke free and nobody can smoke in the building. The only place that associates can smoke outside is in designated area outside.”
--DRAFT--                        4. Together We Can                                       --DRAFT--
Employers and employees have an obligation to assist fellow employees and new hires to gain control of their addiction to nicotine. It gives a pack a day smoker about a $1/hr raise at little cost to the employer.

A. Set the terms for employees to be free from nicotine addiction (as is, all other drug addictions are illegal and/or grounds for dismissal).

There is no, risk-free, level of tobacco smoke.
Nonsmokers enjoy better health and more productive time.
Employer support includes nicotine management supplies and services.
All new hires must take an active part in a support team.

B. Organize employees to support one another and recognize progress.

Organize employee support teams by job locations.
Try to include a former smoker in each team.
Award periodic prizes for progress.
Make provision for new hires.
Recognize arrival at smoke free and tobacco free site rankings.
Celebrate success when smoker free (except for new hires).
5. Terminology
Tobacco use has been a part of our culture for centuries. Life was short. Baseball players spit tobacco. Cowboys smoked Marlboro. In the past century they lived long enough to develop mouth cancer and lung cancer.
In 1964 the United States Surgeon General declared that tobacco was the greatest cause of preventable illness and death in the country. Our cultural assumption was it only involved tobacco users.
In 1994 seven tobacco company executives lied to congress, “I do not believe that cigarettes are addictive,” and lost their jobs but avoided jail time. Our culture learned that tobacco use is not a habit but a means of delivering a powerful addictive drug. The cigarette is optimized to addict and therefore to kill.
By 2006 the United States Surgeon General had determined that there is no risk-free level of exposure to second hand smoke. Our cultural response was to increase the isolation of addicted smokers and to declare tobacco free areas.
A cultural response is needed today to assist tobacco addicts to regain control of their own behavior. Tobacco companies and federal regulations are of little help to addicts. The task of becoming tobacco free falls to communities and work groups. I have experienced five levels of concern in the past two years:
*Unregulated: San Antonio, TX, lives on top of its water supply. Cigarette buts can contaminate that water.
*Smoke Free: No active smoking in the area (indoors and outdoors). Dividing a room into smoking and nonsmoking was a political maneuver. Addicts are temporarily provided an isolated smoking area (indoors or outdoors) with self-extinguishing butt collectors.
*Tobacco Free: No tobacco products allowed on the area. No butt collectors. Active therapy provided for addicts by health care services, employers and employee support groups.
*Smoker Free: No smokers!! End of air quality problem? NO.
*Clean Air: The continuous injection of air contaminates that mask or alter odder in residential care space without the consent or knowledge of the occupants is not only unethical but a health hazard. It is one more stress on people in poor health (our laundry can be marked: no softeners). The marketing pitch is they increase sales in boutiques by about 10%. They may have a clean air or fresh air effect for some people but I know of none in use that actually clean or refresh air.