A smoke-free NHS
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j500 (Published 01 February 2017) Cite this as: BMJ 2017;356:j500
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Dr Black's aim is laudable. Her technique is immoral.
I am a non-smoker. I hate tobacco smoke. . Back in the mid-seventies I used to upset colleagues in some meetings by objecting to their smoking.
When a man or woman is visiting a near and dear one who is dying in a hospital, the visitors MAY come out for a smoke and calm down, before returning to the patient. To stop such a person from a smoke is unworthy of a doctor.
Why does not Dr Black persuade Her Majesty's Govt to mount an international campaign to reduce year by year, tobacco production?
Competing interests: No competing interests
In my opinion, everybody knows explicitly the risks of tobacco smoking, including passive smoking, costs of smoking associated diseases, et cetera. For many years there have been political efforts, restrictions against smoking and many anti-smoking campaigns. However, people are still smoking. Mary E Black [1] demands no smoking anywhere in NHS buildings or grounds and that every frontline professional should discuss smoking with their patients. She incriminates medical staff who smoke in NHS uniforms. But uniforms are not human beings.
Nicotine is an alkaloid that acts as an agonist at most nicotine acetylcholine receptors and as an antagonist at 2 receptor subunits with effects on many neurotransmitters in very different brain structures It is both a stimulant and a relaxant [2] ( "Nesbitt's paradox"). This is one reason, why nicotine is highly addictive. The problem of medical staff and their addiction risks generally (alcohol, drugs, smoking) is very important, but difficult and complex [3-5].
More education, ethical simplification or social stigmatization against smoking is counterproductive. Smoking is no lifestyle problem: it is a severe psychiatric disease that can only be solved by a complex, multi modular, individual treatment.
Physicians and medical staff need professional help, if it is necessary. There is no time for dark secrets or taboos in medicine, and no time to discuss the relevance of NHS uniforms.
Ref.
1 Black ME. A smoke-free NHS. It’s time to stop tolerating tobacco smoking on NHS premises. BMJ 2017;356:j500.
2.“Effective Clinical Tobacco Intervention". 1997;Therapeutics Letter 21: 1–4.
3. Rosta J Prevalence of problem-related drinking among doctors: a review on representative samples.2005;Ger Med Sci.; 5;3:Doc07
4.Juntunen J et al. Doctors' drinking habits and consumption of alcohol. 1988; BMJ. 297(6654):951-4.
5.Sebo P et al. Use of tobacco and alcohol by Swiss primary care physicians: a cross-sectional survey. 2007; BMC Public Health. 12;7:5.
Competing interests: No competing interests
Mary Black is undoubtedly well-intentioned and largely correct, but I feel is going too far perhaps extending familial frustration into her views on the ‘innocent’ open-air use of cigarettes, which is harming only the autonomously consenting persons primarily inhaling; given there is no evidence that smoking in open spaces has harmed any other person. So, why the further victimisation of those already damaged from the selling of tobacco by the vehicles of mis-directed policy and laws and expensive physical resources being wasted in quite obviously futile attempts to change such ‘learnt and socially mediated’ intransigent behaviours?
The group of smokers huddled against the biting freezing east wind near our major acute hospital entrance tonight could hardly be regarded as a romantic Marlboro advert for smoking. Quite the contrary as they sit in their wheelchairs, display their amputated limbs and other ailments, no-one can be under the misapprehension that smoking is ‘good’. I’m sure they are the first to warn their loved ones of the dangers of smoking, which they obviously cannot help doing and for all I know enjoy enormously even as a ‘break’ from the ardours of their various smoking and non-smoking illnesses. I’d reckon absolutely no-one has been persuaded to start smoking by this sight, and many have found it their recruiting sergeant for cessation and reduction. Undoubtedly their medical attendants have tried their best, and often, to dissuade them from smoking, and I cannot imagine any vascular surgeon for example nor their staff not doing so at every available opportunity. Equally, I doubt anyone has been refused any legitimate measure of help to stop if they then so requested to try. In any event, as smokers they have weighed up the large risks and small benefits of what they are doing to themselves and accept their chances.
The security men and other staff passing do not enforce the law/policy I imagine as they possess sufficient empathy and understanding (not sympathy) to know that the law is an ass in this case as it advocates on the 6-8 large no smoking red signs there the removal from the premises (of patients undergoing treatment) as the outcome for smoking on the grounds. Not exactly a ‘caring’ sanction is it? Staff who smoke are now threatened with being disciplined if they are seen smoking in the open air part of the premises - why are we so aggressively mis-treating everyone involved as they are the biggest victims after all?
Personally I used to like the top deck of the bus going to school for the extended view and by that accepted the risk of the secondary smoke, albeit in full ignorance of its potential beyond any momentary noxious olfaction before ‘getting used to it’. It was hardly a well-informed choice on the available evidence then but I should have known better. My own entirely non-medical parents smoked, but never in front of the children - even they knew 40 plus years ago that that was ‘not good' - yet ‘good’ law is only just catching up with their wisdom now! Many like them were introduced to it in the services where it was hugely promoted, and it is still in the treasury’s best interests for smoking cessation or reduction not to be too successful. My life-long non-smoking uncle suffered criminally from a secondary-smoking related cancer and premature death, as also a hugely talented non-smoking colleague from my year.
There are still many enclosed spaces still requiring safeguarding for secondary smoke inhalation, and going after the still innocent (to others) pursuit of open-air smoking gives the false impression that the battle is won for such liberties being able to be taken against smoking in the open air beyond the credible, and by that I mean the evidence base as well as common-sense.
A large open-air area outside here was surfaced with cross hatched green lines - now weather has eroded them almost completely, shelters were erected and then de-erected, other signs erected; the PFI-platinum credit card option of alterations to the grounds is a pursuit only available at great expense which to me only underlines these futile and distracting measures. However, tonight there is not even one smoking cessation poster or notice to be seen within the scores lining walls of the 200 yard long foyer/entrance area. One could argue there is no need as secondary smoke has been eradicated this last decade and more from our hospital but, just as this freedom should be aggressively extended to any other enclosed spaces where secondary smoke is of harm to another person, at that point the inappropriate health-police agenda remit should stop!
I would wish instead to see positive (as well as negative) messages displayed about the percentage of staff who don’t smoke, have given-up, their stories; and the benefits of smoking cessation and reduction especially from reducing risks of secondary smoke inhalation by friends and relatives.
Far better to spend that money educating against the real and persisting dangers of secondary smoke to make it even more socially unacceptable, and not be side-tracked by expending effort on a make-over for non-existent health issues like smoking in the open-air by those fully-informed and consenting as outlined above. The smoking fraternity at the entrance comprise a visual and vivid interface between the health service and those addicted to cigarettes - a reminder of the real educational battle we have on our hands to resolve which should serve as motivation to re-double efforts and avoid complacency and distraction.
Mental health hospitals are a separate more complex issue I do not feel informed or qualified to comment on.
Competing interests: No competing interests
Tobacco is an addictive depressant that tricks and traps us by creating the fleeting euphoria of relaxation and aeration, but the sustained sickness of desperation and suffocation. The euphoria of relaxation and aeration, and the sickness of desperation and suffocation, are polar opposites that reinforce each other: the euphoria blinds us to the sickness, and the sickness makes us crave the euphoria. Perversely but predictably, tobacco creates, aggravates, and perpetuates the very sickness of desperation and suffocation that it falsely seems to cure, thus placing all tobacco products in a very bad light.
Competing interests: No competing interests
Black is concerned by staff who smoke in NHS uniforms because “they are sending a very clear pro-tobacco signal”.(1) Her concern is right but her reason, the pro-tobacco signal, is the tip of the iceberg. Indeed, NHS staff who smoke have not understood that tobacco is the first avoidable cause of premature death and ignore that treatments are effective and evidence based (psychotherapy, combination of nicotine patch with oral form, varenicline), higher intensity being linked to improved cessation outcomes (2). Worst, when compared with non-smoking physicians, those who smoke, are less likely to identify the smoking status of their patients, provide advice on quitting and thorough cessation counselling coverage, and initiate cessation interventions.(3)
How is it possible that despite a long training, so many healthcare professionals: a) are keeping such gross misconceptions about this drug; b) are ignoring their role model; c) have not received adequate assistance from their peers?
Why can’t we benchmark: By February 2008, 45% of US hospitals (vs 3% in 1992) had adopted a smoke-free campus.(4)
Will this new call in the Journal be more successful than the previous one?(5)
1 Black ME. A smoke-free NHS. It’s time to stop tolerating tobacco smoking on NHS premises. BMJ 2017;356:j500.
2 Aveyard P, Raw, M.. Improving smoking cessation approaches at the individual level. Tob Control 2012;21:252-257.
3 Huang C, Guo C, Yu S et al. Smoking behaviours and cessation services among male physicians in China: evidence from a structural equation model Tob. Control 2013 Suppl. 2: ii27–ii33.
4 Williams SC, Hafner JM, Morton DJ et al. The adoption of smoke-free hospital campuses in the United States. Tob Control 2009;18:451-8.
5 McKee W, McBride M, O'Brien D, Stevens A, Burns C. Smoke free hospitals: challenges need to be faced BMJ 2003 Jul 12;327:104.
Competing interests: No competing interests
Sirs:
While the sentiments expressed are absolutely, almost self-evidently, and bleedin obviously to be unreservedly endorsed, the problem is with enforcing a ban.
When patients and staff are eventually cajoled into not smoking on NHS premises, they move to just outside the boundary of hospitals, I frequently observe.
The problem is moved to somewhere else, as often happens with parking restrictions, not solved. How far can the ban be extended, while people are at still at liberty to smoke in public places? That's not to deny the need to do something, but as always to beware the unintended consequences.
John
Competing interests: No competing interests
Right question – half-right answer
Dr Mary Black is properly concerned that smoking still goes on in many NHS hospitals due, it seems, to collusion by the staff who are too soft-hearted on patients. She cites her father, a doctor who was born in 1924 and started smoking in his teens. He ‘tried but failed to stop his tobacco use’ and died of a smoking-related cancer at the age of seventy-nine.
While it is regrettable that anyone should die of a smoking-related cancer, or of any kind of cancer for that matter, I would question the idea that he ‘tried but failed to stop his tobacco use’. With all due respect to Dr Black and the memory of her father, this is incorrect: he did not try to stop smoking; he only failed to stop, unfortunately for him.
The very idea of a smoker ‘trying’ to stop is wrong-headed and a distraction from the real issue (1). A smoker could be defined as someone who has failed to stop, and this is demonstrated every time he or she lights another cigarette, or pipe as in the case of Dr Black’s father.
She continues, ‘Misguided sympathy keeps the last vestiges of tobacco acceptability alive in the NHS…I now think that staff should focus their efforts on making sure that every smoker…gets nicotine replacement therapy and stop smoking advice’. Then she states the obvious, that the NHS should be smoke-free.
What would be wrong, then, with offering so-called nicotine replacement therapy to smokers who are admitted to smoke-free NHS hospitals?
This is what is wrong: for a start, nicotine replacement therapy is incorrectly named – it is cigarette replacement or nicotine maintenance therapy. But why should smokers need a replacement for cigarettes? This is the real collusion, based on misguided sympathy which in turn is based on misunderstanding of the nature of smoking. It also sends the wrong message: stopping smoking is too difficult to do on your own, so you need a drug in the form of medicinal nicotine to assist you. This disempowers and even infantilises smokers.
Of course the ‘stop smoking advice’ part is essential, but with the right sort of advice and understanding any smoker can stop easily – without nicotine. Many smokers actually dislike smoking (2) and may welcome the opportunity of enforced abstinence while in hospital. They would then be able to demonstrate to themselves that not only can they survive but also that they feel much better without poisoning themselves with nicotine in any form.
symonds@tokyobritishclinic.com
1. http://nicotinemonkey.com/?p=683
2. Proctor R, Golden Holocaust, University of California Press, 2011, p6
Competing interests: No competing interests