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Smoking in hospitals – is a complete ban essential or even desirable?

November 27, 2013

All views and opinions expressed in this blog post are my own and are in no way reflect those of my employers or any professional bodies I am associated with. I also make no claim to this article being heavily researched and evidence-based. Rather I would describe it as my considered views on a subject which has been divisive within the health professions.

Firstly, let me say that I hate smoking. I hate all forms of smoking and all substances that are smoked (not smoked fish, ham, etc!). Cigarettes, cigars, pipes, tobacco, cannabis, crack cocaine. Tobacco smoking killed my father through him developing ischaemic heart disease and affected my mother with a stroke. They are all drugs with the potential to cause great harm. Some are legal, some are not –  a distinction that, perhaps, bears further scrutiny, but this is not the time or place for a discussion on drugs policy. The health risks of smoking tobacco are well-known and include lung cancer, oral cancer, laryngeal cancer, ischaemic heart disease and peripheral vascular disease.

For many years, the debate on how to deal with patients who smoke has continued. I can recall working as a volunteer in my local district general hospital when the day room at the end of the ward was filled with smoke. It was absolutely horrible and unbelievably unpleasant for non-smokers to go in to. In those days, however, there was no other way for patients to watch television – it was the day room or nothing. Having to go outside to smoke was never contemplated by patients, visitors or staff. Coffee rooms, canteens, offices were all places to smoke. The only thing stopping patients and others smoking in their beds was the risk of fire due to there being piped oxygen – and even that didn’t always stop everyone!
I grew up with the anti-smoking message being pushed hard through public information films in schools, in the cinemas and on the TV. I recall from my childhood the first warnings about smoking damaging health appearing on cigarette packets. It was great to see how this powerful public health message reduced the percentage of the population smoking substantially. More than half the adult population smoked at the start of the 1970s http://www.cancerresearchuk.org/cancer-info/cancerstats/types/lung/smoking/#history

The figure now is about 22% of adult males and 19% of adult females. http://www.ash.org.uk/files/documents/ASH_93.pdf

This is a massive advance, but bear in mind that the UK population has grown from approximately 56 million in 1971 to 63 million according to the 2011 Census http://en.wikipedia.org/wiki/Demography_of_the_United_Kingdom

The massive hike in taxation of tobacco has also been a major help here.

As society has changed and become less tolerant of smoking, we have moved smoking out of the working environment and hospital wards. Smoking is now banned in enclosed public spaces, an area of public health policy where Wales had to show England how to do it right 😉 We can now go into a pub or restaurant without having to endure the blue choking smog of cigarette smoke. You can now go for a night out and not come home with your clothes stinking of stale cigarette smoke. Brilliant!

Within health care, the debate about what to do with smokers has raged, with extreme views being expressed on both sides from the likes of FOREST http://www.forestonline.org/ whingeing about denial of human rights of smokers (forgetting that non-smokers human rights are being adversely affected) to the views of those who would deny treatment to people suffering from smoking-related diseases (which would make them the modern equivalent of the Bibilcal leper). Fortunately, sense has largely prevailed here – after all, why discriminate against one section of society on the basis of their own particular form of addiction? Do we discriminate against alcoholics or those addicted to heroin? No.

So we find ourselves in a situation where smoking is officially banned within hospital buildings in accordance with smoking legislation – this is a good thing. However, we now have the problem of the smokers gathering around hospital entrances, whether that be a main entrance, A&E, maternity or even the paediatric unit. Staff and visitors frequently find themselves having to “run the gauntlet” to enter and exit the hospital passing through a smoke haze reminiscent of “Stars In Their Eyes”  – without the nice treat on the other side…..

Hospitals, Trusts and Health Boards have attempted to impose more and more stringent restrictions on where smokers can smoke. Staff are now potentially at risk of disciplinary action if they smoke on work premises. While this may be the theory, it is well-known that this rule is flouted on a daily basis on the vast majority of hospital sites. Many hospitals try to deal with the issue of entrances being smoking sites by providing smoking shelters away from the entrances.

I support all moves to make the working environment, inside and out, smoke-free. NHS staff should be setting an example by not smoking at work or if wearing anything that identifies them as a member of NHS staff. However, hospitals are places where there are enormous psychological stresses in additional to the physical stresses. Everyone working at the “sharp end” of health care provision is at risk of such stress. The patients, their families and friends are, however, the ones who are more directly subjected to these stresses. Part of our job as health care providers is to help them deal with these stresses, supporting them and caring for them. When it comes to smoking – or indeed any other form of drug addiction – we should do our utmost to discourage smoking. But there are times when such discouragement is, perhaps, best put to one side in light of the bigger picture. Attempts to stop smoking are, in my opinion, best made when patients are not acutely unwell or recovering from illness but when they are well or their chronic health conditions are stable.

I work in Critical Care, possibly second only to A&E in terms of acutely stressful situations. While it’s incredibly rare for our patients to go off for a cigarette, we all too frequently find ourselves breaking bad news to the families of seriously ill patients. It would come as no surprise to find that if there are smokers in those families, then one reaction to the stressful situation they find themselves in would be to seek solace in the form of tobacco. Please note – I will say this again – I do not condone smoking. However, there is a time and a place to get the anti-smoking message across – such a time as described is not that time! So, if smoking is not permitted on hospital premises, what is the distraught relative to do? Where are they to go? Is it really justifiable to force them completely off the premises just to satisfy a desire to ban the consumption of a drug which can be bought and consumed perfectly legally?

The issue is therefore one where the need to push the anti-smoking message and prevent smoking in places where it impinges on the lives of the vast majority of us who are non-smokers has to be balanced against how we as a society treat drug addicts. We need to be clear on this – tobacco consumption is every bit as addictive as the likes of cocaine and heroin, but it’s history means that it has held an unmerited place of privilege in society for hundreds of years. In recent years we have seen an upsurge in publicity (don’t know about consumption) of so-called “legal highs”, with the evidence of harm from such agents coming to light. Imagine, therefore, what would happen if tobacco were to be such a new agent now? Highly addictive and with strong evidence of long-term harm, it would soon be banned under the current drugs legislation. But it’s not banned and neither is alcohol. (Declaration of interest here – I drink liquids that contain alcohol fairly regularly). These legal drugs are regulated through licensing and taxation and the places they can be consumed is also controlled to some extent. When people addicted to these drugs come to require inpatient health care, they are placed in an environment where their ability to continue consuming their drug(s) of addiction is severely curtailed. If they are unable to access and consume tobacco and/or alcohol they frequently experience withdrawal symptoms. This is no different to when people who consume other drugs withdraw acutely from their particular substance of addiction. The symptoms and effects of withdrawal from tobacco and alcohol can be very severe, often putting patients and staff at risk. So why are these patients being forced to go “cold turkey” in this way? It’s not the way that other drugs addicts (e.g. heroin) are treated – granted, we don’t feed their addiction but we at least try to provide a strategy to manage their withdrawal. For the alcohol consumers, benzodiazepines are frequently used to manage withdrawal with variable success. So – what about the tobacco smoker? The use of nicotine patches can be effective in helping smokers quit http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=12009105929#.UpZBd8RdVMg

However, has anyone studied acute withdrawal in those patients? Yes -sort of. A 2008 update published by the US Department of Health and Human Services entitled “Treating Tobacco Use and Dependence” covers the topic in remarkable brevity (page 149) http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/treating_tobacco_use08.pdf

It may be that we can do more to help smokers quit while they are inpatients, but is this happening? In Cardiff, there is a Hospital Smoking Cessation Service and across Wales there is “Stop Smoking Wales”. Many Trusts elsewhere in the UK also run similar services. However, the effectiveness of such services is variable according to a review published in 2009 in the “Journal of Public Health”. http://jpubhealth.oxfordjournals.org/content/32/1/71.full.pdf+html?sid=648af43e-601b-45a2-8d07-d26b346f4b33

So, it seems unlikely that we can get every inpatient smoker to quit during their stay and we might expect to see patients suffering withdrawal symptoms. We are highly likely to see relatives who are smokers feeling the need to smoke when having to deal with highly stressful situations. Should we be demonising these people? How do we balance the desirability of helping smokers to quit with the reality of not causing great distress to patients and relatives? Many hospitals have provided smoking shelters in the same way that many pubs have smoking shelters or outside areas where smokers can indulge their addiction without inflicting their smoke on others. We need to have the smokers moved away from the hospital entrances! Is it sensible to even try to have a complete ban on smoking on the hospital site? Is there any hospital site that imposes such a ban actually being 100% smoke free? I very much doubt it and I also say that such a blanket ban is undesirable. It is interesting to see how there are parts of the UK where people addicted to injectable drugs (i.e. heroin) are managed. In some, heavy-handed policing is used to drive addicts off street corners. In others, needle exchange programmes exist to reduce health risks to all. Such programmes are highly effective when combined with addiction counselling http://en.wikipedia.org/wiki/Needle_exchange_programme

Is there a risk to banning smoking on NHS hospital sites? Yes. http://www.telegraph.co.uk/health/healthnews/10478475/This-hospital-smoking-ban-may-be-bad-for-your-health.html While I may disagree with the flippancy at the start of this newspaper report, the last few paragraphs are rather better. Another article was published in the Canadian Medical Association Journal http://www.cmaj.ca/content/early/2011/10/31/cmaj.110235 also suggested that harm may result from smoking bans.

Next, let us consider the practicalities of enforcing a smoking ban on a hospital site. Whose job is it to enforce the ban? Who will patrol the hospital site 24 hours a day to ensure compliance? I would say that the majority of hospital sites simply do not have enough security staff to even have a remote chance of effecting such a ban. The security staff usually have other duties to carry out, such as protecting the safety of staff from assault (major kudos to Cardiff & Vale UHB this week – http://www.cardiffandvaleuhb.wales.nhs.uk/news/29933 ).

To my mind, a complete smoking ban is neither practical nor desirable. Of course, we must continue to educate and support those who wish to quit smoking. We must continue to emphasise the undesirability and unacceptability of smoking. But there is a time and a place to be rigid in stopping people smoking – it may well be that the time for such rigidity is not during an inpatient stay or when a loved one is critically ill.

 

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6 Comments
  1. I would have written something similar myself if it were not for the fact that my pipe addiction (it’s a matter of “no pipe, no algebra”) would just result in people saying “you would say say that, wouldn’t you”.

    An email from NICE today which recommended that “patients who smoke should be offered smoking cessation drugs, patches, and counselling as soon as they are admitted to an acute, maternity or mental health setting”. In the last few years I’ve been admitted for removal of a kidney (the tumour was malignant but very small -caught early) and for a hip prosthesis revision (the latter was not scary, but it was very painful for a while).

    Do the folks at NICE have any idea of the state of mind of someone who has just been told they have a tumour in the kidney? However small it may be, it’s hard for anyone to be entirely calm. Many are terrified. It’s the worst possible moment to inflict a counsellor on them, who would in any case, say what they’ve already heard from their GP and dentist a dozen times already. After the nephrectomy, once I was out of ICU, I’d sit on the bench on Brompton Road outside the Royal Marsden for a pipe, and felt calmed by it.

    I’m all for do anything to prevent people from starting smoking, and for offering anything that will help people to stop. But when you are worried out of your mind in hospital is not the time and place to do it. In fact I’d argue that it is rather cruel. That is not how doctors should be seen by patients.

  2. I might have added that I barely drink alcohol at all. That’s not really virtue, but just because I don’t like the taste very much, and I don’t enjoy the effects. But it does show we don’t all have the same vices.

  3. Emily permalink

    Good article. As a former inpatient at a mental hospital I am saddened that our local facility has banned smoking on the grounds and patients now need to be escorted off the premises by staff to have a cigarette. Distressed patients have to wait until busy staff members have time to do this. We need to recognise and balance the needs of the person as a whole.

  4. Kevin permalink

    David
    You make a solid argument regarding the ban, but I disagree that smoking is an addiction in the same way as heroin. Most smokers can sleep for 8hrs without any waking desire to light up. Smoking is a psychological addiction and rather than medicalising the cure, smokers require councilling rather than nicotine replacement.

    Keep up the great bloggiing.

    Thanks
    Kevin

  5. elderpegasus permalink

    Good points. The policy and practice seem a notch disjointed from goals, which must surely be primarily fire safety, to prevent harm to non smoking patients, same for visitors and staff, and to help smoking patients to quit if appropriate. Maybe some sort of indoor smoking rooms may be lesser of two evils, maybe not.

    Personal bugbear is staff smoking; going away from building no use if you return to ward with uniform stinking of smoke. Plenty of precedent for expecting staff to not let addiction impact on care.

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