Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Smoking is a clinical issue, for Hospitals, not a Lifestyle or Civil liberties issue
- Cecily C Kelleher, Patricia Fitzpatrick, Anna C Clarke and Leslie Daly (12 December 2008)
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Property ban: Anywhere but not hospitals and treatment centres
- Lynn Greaves (16 December 2008)
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Addiction or choice
- Janine Paynter (16 December 2008)
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Response to my critics
- Simon Chapman (18 December 2008)
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Over Thinking
- Simon Lammy (18 January 2009)
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Common sense confirms integrity
- Diane-Marie Campbell (22 January 2009)
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Cecily C Kelleher, Professor UCD School of Public Health and Population Science, Belfield, Dublin 4, Patricia Fitzpatrick, Anna C Clarke and Leslie Daly
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Professor Chapman accepts that employees at work should desist from smoking outdoors if contractually obliged to do so, but thinks the position of hospitals and health care facilities on patients and visitors smoking is ethically muddled. The most cogent argument for banning smoking outright in healthcare facilities is that the visibility of outdoors smoking has been much raised by the indoors bans to combat passive smoking exposure. The consequence is that health care providers and smokers themselves adopt the attitude that smoking in hospital is normal in sociological terms and may not see the problem as a clinical rather than a lifestyle issue (1). Comprehensive smoking cessation services are not necessarily offered proactively. All patients have the right to refuse such services but they also have the right to be offered them, particularly given that their admitting condition has a high probability of being smoking-related. Outdoors ban in hospitals are not about passive smoke exposure, but rather about shifting norms towards more effective treatment and care for smoking-related illness by creating a smoke-free environment. 1. Corradino D. Attitudes of patients and staff to total smoking ban in indoors facilities in Ireland. Ir Med J 2005; 174(4) es5:2 Competing interests: None declared |
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Lynn Greaves, Tobacco Control Coordinator Regina Qu'Appelle Health Region
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There are two important factors that seem to be missed in looking at property bans. The first is that although denormalization is likely a positive result of such bans, evaluation of these bans has not been done to determine if there is any negative impact. Although tobacco control advocates insist on well-researched evidence -based strategies to do their work, when it comes to property bans, no research apparently is needed. We do have anecdotal evidence that some smokers will not seek hospital treatment and thus these bans may have some very negative effects. But WE DON'T KNOW to what extent this happens. And that is the point. These debates are fruitless as are any debates where the facts are not known. Another factor is the cost and time put into the implementation of these bans. They are very costly and time intensive and they give people - usually on the fringes of tobacco control - a feeling that great things are being accomplished. They can also pull tobacco control advocates out of evidence-based work and into work that is not supported by research. Competing interests: None declared |
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Janine Paynter, Research and Policy Analyst Action on Smoking and Health
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I am concerned by Simon's rhetoric that smoking is an adult choice. It sounds just like statements proffered by the tobacco industries themselves. Just what are we examining here: a choice or an addiction? Haven't we settled this debate already or were those tobacco industry executives who swore that nicotine was not addictive actually being honest! Competing interests: None declared |
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Simon Chapman, Professor of Public Health University of Sydney 2006
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Cecily Kelleher and colleagues argue that outdoor smoking bans for patients and visitors at health care facilities are justified by “shifting norms towards more effective treatment and care for smoking-related illness by creating a smoke-free environment”. However, they cite and I know of no evidence demonstrating that stopping people from smoking outdoors at health care facilities improves cessation outcomes for those trying to quit, let alone causes improvements in smoking-related illnesses inside those facilities. Their argument here is therefore spurious, and ultimately barely disguised paternalism. Janine Paynter, who blanches at my reference to smoking as a choice, appears to believe that it is never meaningful to allow that smokers can act autonomously. I agree that the addictiveness of nicotine erodes personal autonomy, that relapse is extremely common and nearly all smokers regret having started. But only the hardest determinist would argue that smokers, like drugged automatons, have zero choice in the matter and therefore disqualify themselves from the right to decide if they wish to continue smoking in situations like outdoor settings where they are not harming others. The Thompson et al side the debate centres on eliminating the very sight of smoking from children (presumably to make it the equivalent of a behaviour like sex, restricted to entirely private settings). Allowing children to even see that there are people who smoke is, by this argument, sufficient to justify interference with a smoker’s liberty to smoke outdoors. This is a very dangerous principle. History is full of determined interest groups who believed many and varied things should be kept from the eyes of children and sometimes adults. International consensus today throws up a small number of unambiguous examples (eg: child pornography, incitement to violence and racial vilification) where most civilised people would agree to absolute censorship and the denial of liberty. And with these, others are always hurt. The spectre of a society is alarming where health promoters would be able to decree that others’ personal, high risk self-harming conduct should be banned from public view. How far from this view is a call for compulsory treatment to force people to stop smoking, in case others might be influenced? Afghanistan’s Taliban are perhaps the apotheosis of such a world view let off the leash. In New Zealand from where the authors hail, the joint and tendon breaking game of rugby is almost a religion and people are regularly killed while voluntarily climbing the New Zealand alps. Children dream of playing for the All Blacks, but would rarely think about the decades of osteoarthritis commonly associated with contact sports. Harm reduction measures have been introduced into sport, just as tobacco control policy has steadily sought to denormalise smoking and smoking rates today in many nations are fraction of what they were 40 years ago . But please, can we get back a sense of proportion here? Competing interests: None declared |
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Simon Lammy, Final Year Medical Student UCL Medical School
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In our post modernistic world many educated and supposedly informed people over think basic issues that even a neanderthal would not spend a second debating. Smoking in a simplistic fashion is bad and one of the most dangerous practices around. To quote the comedian Chris Rock "smoking is so bad that it even kills people who do not smoke". We can debate ad nauseam whether banning smoking from certain public places would disadvantage the smoker and cause them to present later for health care issues. We can discuss the social exclusion and the perhaps subsequent increased incidence in depression amongst the smoking population - and thus the domino effect that one tweak here can drain services over there. We can think upon the tragic circumstances where smoking for some people is one of the limited means they have to express themselves and cope with lifes challenges. We can chew on so many issues regarding banning smoking but the common sensical bread and butter proof of the gut reaction pudding which has served mankind well through history is that smoking is bad. It kills. And through tough and perhaps legalistic ways the more that can be done to convince the general public that smoking never pays the better. There would be casualties on the way - this cannot be avoided - however the long term projection is that to exist in a society with a markedly reduced smoking population depends on some basic and common sensical things - make tobacco extortionately expensive, reduce the public areas, inside and outside where people can smoke, and better health education regarding it. Simple. Competing interests: None declared |
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Diane-Marie Campbell, itinerant emergency physician Bunbury 2281
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I was delighted to see this contribution from a world leader in this area. Refusing to countenance a restriction unjustified by evidence must enhance the credibility of demands that are justified - such as not selling tobacco to children or exposing them to second-hand smoke indoors. Some hospitals in which I work occupy large campuses, shared with Universities or other institutions. The entrance to the grounds may be literally a kilometre from the patient's ward, and access impossible unassisted. If there is a hospice or palliative care ward, or dying patients in any ward, have we the right to deny them any legal comfort? Particularly as the staff usually have hidden areas in which to smoke! Worse, to my mind, is refusing to allow involuntary mental health patients to smoke. Of course they are at risk for smoking-related disease. But restraining and sedation aren't completely safe either, and many patients become more agitated when forbidden to smoke. Indeed, experienced psychiatric registrars and nurses often carried a packet of cigarettes to offer distressed patients. Some still do, establishing a bond and showing unequivocally that they are putting the needs of the patient, sorry, "Client" first. If prisoners may smoke, how can we deny patients the same rights? Can we expect a patient who resents not being able to smoke when in pain or otherwise distressed, to listen to later advice about cessation? Surely patients are more likely to trust staff who respect their needs. Competing interests: None declared |
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