Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Outdoor passive smoke
- Phillip J. Colquitt (2 May 2003)
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Smoke free hospitals in Japan
- Hiroshi Kawane, 1-2 Ajinadai-higashi, Hatsukaichi City, Hiroshima, 738-0052, Japan (2 May 2003)
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The Right to Breathe
- Aviva Sheb'a (3 May 2003)
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Witch-hunts for Smokers
- Peter A Sims (3 May 2003)
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Smoke free hospitals
- Richard F Gunstone (5 May 2003)
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Re: Smoke free hospitals are unethical
- Stephen Head (5 May 2003)
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Smoke free hospitals
- Julia Kuczynska (9 May 2003)
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What about the frail, ill, elderly?
- Conor P Maguire (10 May 2003)
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Smoking rooms are wrong
- Alexander J Clark (15 May 2003)
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What it's like in a smoke -free hospital
- colin m mailer (18 May 2003)
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Smoke free hospitals-facing the challenges
- William McKee, Michael McBride, Deirdre O'Brien, Antony Stevens, Christine Burns (23 May 2003)
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Radical action on smoking is needed
- Jocelyn R Forsyth (5 June 2003)
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Phillip J. Colquitt, Reader-writer Independent
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Sir, Smokers should have to pay a mall tax. The seats here in the Brisbane CBD mall, an “outdoor” area ostensibly for all to use on equal terms, are monopolised by rejected smokers from the indoor environment. They (smokers) can also be seen clotting at any available garden foyer entrance, such as those found at hospitals. The reader can imagine the gratitude one feels to medical professionals, who wisely eradicated indoor smoking, when one uses the only vacant mall seat downwind from a line of puffers. Apart from running the real risk of being set alight, or at least having a hole put in one’s clothing by the often expansive arm movements made by many firestick users, there is the bonus of yet to be quantified outdoor passive smoke. Upon completing their strange ritual, smokers “ventilate” their anti-social feelings by stubbing out in the nearest flower box. In a country that regularly goes up in smoke, Australians don’t seem to mind. Phillip J. Colquitt, New Farm, Queensland, Australia. Competing interests: Breathing |
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Hiroshi Kawane, professor The Japanese Red Cross Hiroshima College of Nursing, 1-2 Ajinadai-higashi, Hatsukaichi City, Hiroshima, 738-0052, Japan
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I read with great interest the editorial by Prof McKee, et al [1]. Little attention had been paid to the restriction of smoking in hospitals in Japan and it seemed difficult that smoking was totally banned about 10 years ago [2]. Although there are still few smoke free hospitals, there is a hope. The Health Promotion Law was approved in July last year and came into effect on 1 May. It aims to improve people's health and to decrease lifestyle-related diseases. The new law obliges operaters of facilities used by many people to implement measures to prevent passive smoking. The facilities include schools, gymnasiums, hospitals, etc. It is the first law clearly placing the responsibility of eliminating passive smoking on building operators rather than the smokers themselves [3]. I hope that many smoke free hospitals can be achieved as soon as possible in Japan. [1]McKee M, Gilmore A, Novotny TE. Smoke free hospitals. BMJ 2003;326:941-942. (3 May.) [2]Kawane H. A smoke-free hospital. Arch Intern Med 1990;150:1350. [3]Mainichi Daily News. Private railways in Japan launch total smoking bans. http://mdn.mainichi.co.jp/news/20030501p2a00m0dm010001c.html (accessed 2 May 2003). Competing interests: None declared |
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Aviva Sheb'a, Writer, Educator, Performer Freelance
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I understand the idea behind smoking rooms -- wherever they be. However, to place them in a hospital is beyond a printable response. Apart from the obvious effects of smoking and passive smoking on patients and staff, we need to consider visitors, volunteers, ambulance attendants etc. Then, and perhaps this should be the FIRST consideration of all, there is the effect of being nursed or otherwise treated by staff wearing tobacco residues and/or perfumes/aftershave on clothing, skin, hair, breath. This can be disastrous and delay or even prevent proper healing. How do I know this? I am asthmatic and have been in that situation. Not only do we need smoke-free hospitals, we need smoke-free employees, volunteers, entrances, grounds -- and ambulances. We've come a bit of a way, but we need to go a lot further before we can all truly claim our Right to Breathe -- the most widely abused human right. Competing interests: Asthmatic |
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Peter A Sims, Professor of Public Health Medicine The School of Medicine, The university of Papua New Guinea,POBox 5623 BOROKO, NCD11,PNG
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Sir, The editorial on Smoke free hospitals (McKee M et al.BMJ 326, p941-2, 2003) reminded me of the witch-hunts for other less desirable members of human society. It also suggests the ineffable superiority of doctors to know what is best for the rest of us. Medical history often suggests the opposite. Patients and visitors to hospital are frightened and stressed, disadvantaged by their surroundings.25-30% of the population are smokers and for the men and women using NHS hospitals this percentage is higher. It seems humane and enlightened for Belfast hospital to provide smoking space, however much the medical establishment may fulminate. It is likewise simple pragmatism to provide for the smokers among the staff.If this is not done they will either absent themselves to smoke or smoke illegally in lavatories and laundry cupboards. It is possible to see how arguements could be as easily raised against the cost, value and possible misuse of hospital chapels. Competing interests: None declared |
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Richard F Gunstone, Retired consultant physician/ Part time lecturerer in medicine Walsgrave Hospital CV2 2 DX
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"To cure occasionally, to relieve often, tp comfort always" are still words of useful guidance to doctors. There are some tobacco addicted patients in hospital who are near to death whose comfort depends on smoking. Therefore a facility for this should be provided in hospital. Competing interests: None declared |
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Stephen Head, General Practice Principal Middleton Lodge, New Ollerton, Newark, Notts. NG22 9SZ
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To bar smoking for in-patients with smoking related disease seems reasonable. To coerce smokers happening to be in hospital with an unrelated condition into accepting smoke free behaviour as a condition of their care may be questionable. What is surely beyond doubt is that where a patient has no prospect of benefit from smoking cessation, and enforced abstention aggravates their existing distress, they are being managed unethically. Their best interests as a patient (which should be the medical profession's prime concern) are being subjugated to a broader policy which does them harm. I have been asked by relatives to prescribe nicotine replacement therapy for a terminally ill patient, whose last days in hospital were made worse for nicotine withdrawl. Also one of my patients with extensive stroke related brain damage and end stage peripheral vascular disease declined admission for adequate nursing care and analgesic adjustment because he would have to give up "his one remaning pleasure". Such cases should not blunt the Public Health message. Indeed both these patients were dying of smoking related disease. But making their last days more distressed than they would otherwise have being reflects an uncritical policy enforcement that adds a cruel and condescending twist to how doctors and health managers as much as the international tobacco industry are able to create smoking related suffering. Competing interests: None declared |
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Julia Kuczynska, Pharmacist Bristol Royal Infirmary
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I strongly disagree with the statement that smoking rooms should not be provided. In the real world, where there is a lack of appropriate facilities, smokers congregate in any available sheltered space, creating a hazardous, dirty and unpleasant environment for non-smokers. Smoke-free hospitals would be highly desirable but I don't think it's going to happen. Competing interests: Desire to breathe smoke-free air |
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Conor P Maguire, Consultant in Care of the Elderly Western General Hospital, Crewe Road, Edinburgh EH4 2XU
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Sir, I am a geriatrician and work in two hospitals – one an “acute teaching” hospital, and the second a “rehabilitation”, though similarly acute, hospital. In the former, patients are restricted from smoking in the hospital buildings. In the latter, smoking rooms are provided. In the former, nursing staff frequently have to accompany elderly agitated or ill patients out of the building in order to allow them to have a cigarette. In the latter, nursing staff are left to do what they trained to do, while such patients smoke in the designated smoking room. In the acute hospital setting, I regularly encounter frail elderly patients or cachectic oncology patients huddled outside the front door of the hospital sucking on their cigarettes. Smoking cessation is difficult at any age, but is likely to be particularly difficult in the most vulnerable hospitalised patients – the ill or agitated elderly, those with certain psychiatric illnesses, and those with cancer. Although benefits may theoretically be derived from smoking cessation at any age, hospital doctors are significantly less likely to advise elderly patients than younger patients to stop smoking, particularly those with a psychiatric illness or cancer (1). In my opinion, this is for good reason – there is no evidence that forcing such frail patients to stop smoking will improve their health or well-being, but there is plenty of anecdotal evidence that allowing them to continue smoking will help them face the trauma of hospitalisation. I do not think that younger fitter patients outwith the above groups should be allowed to smoke in hospitals. I do not think that biologically fit older patients should be encouraged to smoke in hospitals. I do not think that relatives of patients should be allowed to smoke in hospitals. I do not think that NHS staff should be allowed to smoke in hospitals. I do think that we should encourage smoking cessation by educating and supporting patients and staff. I do not think, however, that I have the right to tell my seniors what habits they can and can not engage in. I am fully aware of the benefits of smoking cessation at any age, but the psychological risks of restricting an ill hospitalised octogenarian from continuing a habit they started long ago overrule any possible benefits. A smoking room can be beneficial to certain patients. (1) Maguire CP. Ryan J. Kelly A. O'Neill D. Coakley D. Walsh JB. Do patient age and medical condition influence medical advice to stop smoking? Age & Ageing. 2000; 29(3):264-6. Competing interests: None declared |
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Alexander J Clark, SHO General Medicine Royal Liverpool Hospital, Liverpool, England.L7 8XP
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From a personal point of view I dislike smoking rooms in hospitals. Like Methicillin resistant staphlococcus aureas (MRSA) smoke doesn't remain in that little room doctor wants it to, if it's going to be around at all. As a result the whole hospital knows about it. I have visited wards, indeed even worked on one, where there is no escape from the smell of smoke. I would go home with a husky voice and clothes and breath reeking of cigarette smoke. More than once I was accused by my family of having taken up the habit myself. In such an environment my right not to smoke had been removed. From a professional point of view I similarly dislike smoking rooms in hospitals. Health services not only pay for the smoking rooms but the increased disease burden amongst passive and active smokers. It is informative that, in the hospital in which I worked, the two wards thickest with smoke are cardiology and vascular surgery. Modern expensively ventilated smoking rooms may be better at keeping smoke away from clinical areas and non-smokers. However, even with a smoking room between every two wards it is amazing how many smokers (staff and patients) find it easier or more desirable to take 'fresh air' in the ward toilet, a side room, a stair well or at the entrances to the building. Professor McKee et al are entirely correct, to my mind, in suggesting resources would be better used to ban smoking and to help people give up, including projects which extend beyond the hospital grounds. Competing interests: None declared |
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colin m mailer, Ophthalmology St Josephs Health Care London, ON
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Dr McKee suggested I write to you. At St Josephs Health Care,in London Ontario, we used to have smoking in the surgeon's lounge and in a designated smoking room for patients.Now, patients who have "bad chests" and who smoke are made to stop if they wish elective procedures. Anesthetists will cancel surgeries if this is not adhered to. About five years ago all in-hospital smoking disappeared. Non-medical members of staff smoked at the Out Patient entrance and so did a few desperate patients in wheel- chairs often with IV drips. This was illegalised by Hospital Bye Law. Now neither staff nor patients smoke within 30 feet of the hospital. The cigarette residues ("butts") in disused corridors have gone. The City of London followed by making smoking illegal in all restaurants and public places. Bars have to decide if they serve food or not. If not, smoking is allowed in bars. Competing interests: None declared |
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William McKee, chief executive Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, Michael McBride, Deirdre O'Brien, Antony Stevens, Christine Burns
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In their editorial of the 3rd May 2003, Prof McKee et al1 commented on our decision to provide smoking rooms for patients' use. They emphasised the importance of sending a consistent message about reducing the use of tobacco, protecting other patients and staff from second-hand smoke, and reducing the risk of fires. They concluded that it was arguable that resources spent on smoking rooms might be better used to fund a concerted effort to implement a smoking ban, and to expand smoking cessation activities. They hoped that other hospitals in a similar situation would act differently in the future. At the Royal Hospitals, we are only too aware of the adverse consequences of smoking tobacco. In Northern Ireland, around 30% of adults smoke, but patterns vary by age, gender, employment status, religion and socioeconomic group. It has been estimated that 2,800 people die here each year because of the effects of smoking tobacco. We have trained a substantial number of clinical staff to offer opportunistic advice to patients about smoking cessation, and we offer nicotine replacement therapy to all patients who smoke when admitted to hospital. The potential of hospital based intervention is not in dispute and has been recognised by the Department of Health, Social Services and Public Safety, Northern Ireland who in “Investing in Health” committed to making extra funding available for the further development of smoking cessation services and public awareness campaigns. Two years ago as part of our smoking cessation strategy, we developed a proposal for establishing a comprehensive smoking cessation service, taking account of our regional acute health care role, and our immediate situation in one of the most socially deprived areas in the United Kingdom and Ireland. We have as yet not been able to obtain funding to establish this service. Despite our advice and encouragement, some patients do not wish to cease smoking. In a recent article, Professor Jarvis et al2, drew attention to the prevalence of “hardcore” smoking in England, and the linkages with age and socioeconomic deprivation. The majority of patients in the Royal Victoria Hospital are elderly, and many come from areas experiencing multiple deprivation. Even among pregnant women, who are known to be more motivated to stop smoking, it is recognised that complex interventions, taking account of the social and cultural circumstances, are required.3 We recognise that smoking behavioural change is a process, not an all -or- nothing event. Many people need advice and support when preparing to cease smoking, and during the subsequent weeks and months, when relapses are common. We are aware of the evidence that high intensity behavioural interventions such as we had proposed, that included at least one month of follow-up contact, are effective in promoting smoking cessation in hospitalised patients. Interventions delivered only during the hospital stay are however ineffective.4This is an important consideration given that 70% of our admissions are non-elective, with no opportunity for pre- assessment and intervention. It is our view that we can only address smoking cessation in the population with a strategy and service that links community, with primary and secondary care. In the absence of this, introducing a smoking ban in hospitals with the sole aim of sending a consistent message will be ineffective. A ban on patient smoking is also impractical. Professor McKee and his colleagues referred to Health Development Agency (HDA) documents which they suggest confirm the contrary that smoking bans in NHS hospitals can work. The guidance documents do not rule out the provision of limited and controlled smoking facilities for use by patients. Some of the hospitals sited by the HDA as exemplars have smoking facilities for patients, or alternatively leave the control of patient and visitor smoking to the discretion of ward staff. For patient safety reasons, we are unwilling to insist that patients who wish to smoke should leave the hospital building. Nor do we want smoking to take place in uncontrolled areas which will expose others to second-hand smoke, or increase the risk of fire. We also recognise the distress of terminally ill patients and relatives who may be smokers. We remain firmly of the view that in these circumstances it is entirely proper for an acute hospital to provide limited and controlled smoking facilities for patients. It is not our intention to spend £500,000 on creating 7 smoking rooms in the Royal Victoria Hospital. A decision informed by professional advice was taken to address and manage the problem of smoking in this hospital. Up to four rooms in a seven storey structure will be made available at a cost of £390,000. In the Royal Hospitals it is our aspiration to achieve a smoke free hospital, but we also have to recognise that patients don’t leave their cigarettes and matches at home. We will address the need for limited and controlled smoking facilities; a need which we believe will diminish as measures to reduce the use of tobacco take greater effect. In the meantime we must continue to work to manage all the risks. William McKee, Chief Executive
Royal Hospitals, Belfast N.Ireland 1.McKee M, Gilmore A, Novotny TE. Smoke free hospitals. BMJ 2003;326:941-2. 2.Jarvis MJ, Wardle J, Waller J, Owen L. Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study BMJ 2003; 326: 1061-0 3.Oliver S, Oakley L, Lumley J, Waters E. Smoking cessation programmes in pregnancy: systematically addressing development, implementation, women’s concerns and effectiveness. Health Educ J 2001; 60:362-70 4.Rigotti NA, Munafo MR, Murphy MFG, Stead LF. Interventions for smoking cessation in hospitalised patients (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software. Competing interests: All the authors are employed by the Royal Hospitals Trust |
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Jocelyn R Forsyth, Retired 10, Ferrier Crt, Rosanna, VIC, 3084 Australia
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Dear Sir, On returning from holiday I have been confronted by the editorials (3 May 2003) on ‘Smoke free hospitals’ and ‘Comparing cannabis with tobacco’. They add to the constant stream of evidence about smoking related disease and the stratagems of tobacco companies to fill me with anger and despair. When CFCs were shown to be associated with damage to the ozone layer, international measures to control the use of these substances followed rapidly. Hard evidence of widespread smoking related disease has been with us for more than 50 years. We know that recreational use of cannabis is already actually illegal. Why should the widespread sale of tobacco products, currently far more damaging, continue to be permitted? The programs attempting to encourage quitting and to discourage starting smoking may be admirable but are clearly inadequate. Surely all countries professing any interest in public health should be embarking on a program of, say, 15 years, at the end of which no commercial dealings in tobacco products would be permitted except under permit - for possible scientific or preventive purposes. At worst this should reduce the numbers of tobacco smokers to that of cannabis smokers - and with, quantitatively, far less exposure to smoke. Yours faithfully, J.R.L.Forsyth MD Competing interests: None declared |
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