Hospital smoke-free policies should consider patient needs

While smoke-free policies on hospital grounds make sense for the objective of clean air, managing the tobacco withdrawal symptoms of hospitalized patients must also be addressed, states an article in CMAJ.

In Canada, health care institutions have implemented policies for smoke-free hospital buildings and grounds to reduce exposure of workers, patients and visitors to harmful tobacco smoke. These policies prohibit smoking near entrances and on hospital grounds, including parking lots.

Researchers from the University of Manitoba, University of Alberta and the Winnipeg Regional Health Authority undertook a study to understand the consequences of smoke-free policies for patients and health care professionals at two large acute-care hospitals in Canada (the University of Alberta Hospital and Winnipeg's Health Sciences Centre). They enrolled 186 people, including 82 patients and 81 health care professionals. Not surprisingly, they found that patients and staff — security staff, ambulance drivers, doctors and nurses — continue to smoke on hospital grounds, despite signage. Patients with limited mobility, such as those in wheelchairs and those connected to medical equipment, smoked near hospital entrances.

"As an emerging standard for Canadian hospitals, smoke-free property is intended to reduce exposure to second-hand smoke, communicate denormalization messages about smoking and enhance tobacco cessation," writes Dr. Annette Schultz and her co-authors. Dr. Schultz, an assistant professor at the University of Manitoba's Faculty of Nursing and a principal investigator with the Psychosocial Oncology and Cancer Nursing Research Group, St. Boniface Hospital Research Centre. "However, noncompliance and inadequate treatment for tobacco dependence appear to be the practice norm."

Patients and staff identified safety issues related to leaving hospital wards to smoke, such as staff being unaware of a patient's whereabouts, patients feeling unsafe going out to smoke alone, weather issues that cause equipment malfunction, and patients being locked out at entrances not open 24 hours a day. As well, patients leaving the ward present challenges for delivering medical care.

"Our findings suggest that the use of tobacco continues to be framed as a habit or personal choice rather than as an addiction," write the authors. "Like other researchers, we have found that when tobacco use is framed as a habit, health care providers are perplexed as to why people continue to smoke when faced with health concerns and restrictions, and consider such people to not be taking responsibility for their health." Alternatively, framing tobacco use as an addiction perplexes one as to why more is not being done to address this dependence.

Schultz and her colleagues suggest that rather than focusing on enforcement of the policy — to address the noncompliance that was clearly evident at both study sites — hospitals and health care decision-makers need to consider smoking on hospital grounds as a treatment issue. Patients, many vulnerable and under stress because of hospitalization, need support to manage withdrawal from tobacco and successfully abstain from smoking during their hospital stay.

"Policy evaluators and health care accreditation bodies can draw on our findings to inform new measures to judge the outcomes of smoke-free grounds policies," the authors conclude.

In a related commentary, Dr. Sharon Lawn, Department of Psychiatry, Flinders University, South Australia, states, "Schultz and colleagues show how the notion of responsibility can become distorted when smoking is viewed as a morally interpreted behaviour — a lifestyle choice — rather than an addiction that requires clinical support. What is immediately striking about the results of this current study of two Canadian general hospitals is how little the staff felt that enforcing the smoke-free policy was their responsibility."

Dr. Lawn argues that "something can be learned from the many studies of smoking and smoke-free policies applied to a particularly vulnerable population — people with mental illness. Such studies lay bare the values, attitudes and contradictions that often underpin how patients and staff behave toward each other in psychiatric settings regarding the issue of smoking. In such settings, we have the privilege of seeing many of the same attitudes, behaviours and challenges described by Schultz and colleagues, in their starkest view — honest and unambiguous."