Blog | Monday, November 7, 2011

QD: News Every Day--No-smoking rules leave patients out in the cold

Smoking bans at two Canadian hospitals are inadvertently placing their patients at risk, driving them out into subfreezing temperatures to smoke. And the policies themselves aren't working, either because patients circumvent the rules or staff fail to enforce them.

Smokin' outside the hospital doors by Mickey van der Stap via Flickr and a Creative Commons licenseWith smoking cessation interventions incompletely incorporated into hospital routines, the problem isn't likely to end soon.

Researchers reported in CMAJ, the Canadian medical association's journal, that hospitals must offer support for smoking cessation, or deal with the consequences as patients leave hospital property to indulge.

Researchers drew these conclusions after interviewing patients, providers and administrators at two tertiary acute-care hospitals, the University of Alberta Hospital, Edmonton, Alberta, and the Winnipeg Health Sciences Centre, Winnipeg, Manitoba, during six winter months of December 2008 to May 2009.

Hospital staff said that most patients were asked during admission if they smoked, but while the information was recorded on admission forms, it was rarely forwarded along. Patients reported that their experiences varied. Sometimes hospital staff asked, but often, the patients tried to manage it themselves, such as by chewing nicotine gum.

Smoking near the entrances was a main problem. Janitors picked up 5 to 10 pounds of cigarette butts a day, which could still be tracked inside on people's shoes.

Patient reported having been locked outside on winter nights because of exits that locked from the inside. And deep snow or ice created mobility issues for some, which could underlie their decision to smoke near entrances, researchers concluded.

In the extreme cold of Canada's winters, IV lines could freeze and electronic pumps could malfunction. Patients were inadequately dressed for such temperatures, creating a risk for frostbite. Although patients in isolation (such as patients with tuberculosis) wore a mask while outside, they'd take them off to smoke. Their discarded cigarette butts, if used by another smoker, could become a vector for disease.

Wavering escursion by FeatheredTar via Flickr and a Creative commons licenseOne example from the interview (all respondents had their identities masked by code numbers): "A lot of them are patients with IVs attached, and you tell them there is no smoking on hospital property. Well, then you sometimes see them pushing this IV pole all the way down the sidewalk in the snow."

Finally, a few patients worried about getting suddenly sick while smoking outside. One patient reported, "I was in constant pain, agonizing pain, but I still managed to go for smokes." Another said, "People in hospital gowns outside the hospital sitting on a bench smoking--outrageous. If you're trying to avail yourself of publicly financed services the least you can do is not parade the insanity of smoking outside the hospital door."

Staff often don't tell patients not to smoke at or near the hospital because they smoke themselves, or because they want to avoid confrontations. One clinician's perspective was: "There is that whole piece of keeping peace on the ward, really, because these patients can get really agitated and they get really upset and then get really demanding." Another said, "When they get back after their smoke, they're just in so much pain, yelling. And I'm like, well you made it all the way downstairs."

It's the smokers who go to hospitals more often, and for longer stays, pointed out an editorial.

"Very few staff felt that enforcing the smoke-free policy was their responsibility," the editorial stated. "Fundamental to this viewpoint was the stark contrast between their perceptions and those of their patients as to whether smoking is a choice (a view held predominantly by staff) or an addiction (a view held predominantly by patients). This mismatch appears to have dire consequences for the support of smoking cessation and the enforcement of smoke-free policies."

The solution, according to the editorial is three-fold:
--Acknowledge that nicotine dependence is an addiction and not lifestyle choice;
--Make nicotine dependence a part of routine care; and
--Managing nicotine dependence as part of a continuum of care that includes the community and context in which people live.

ACP Hospitalist outlined ways facilities can help their inpatients stop smoking , including how to go beyond the ban and offer counseling and nicotine replacement products. That's the carrot.

Here's the stick: Guest columnist John Schumann, MD, FACP, described a complete ban for hospital employees, one that extends to smoking not only off-site but off-hours. Employees are fired if they flunk a blood test for smoking.