Smoking bans backfiring at some hospitals

Intravenous lines freezing in the cold. Patients in wheelchairs being accidentally locked out of the hospital on winter nights. Patients smoking in their hospital beds. Pounds of discarded cigarette butts near "no-smoking on hospital property" signs.

New Canadian research has found that not only are patients and staff ignoring hospital smoke-free bans, but the policies are also creating unintended safety issues for patients.

Not enough support is being offered to the 5 million Canadians who smoke to help manage withdrawal symptoms if they suddenly need to be hospitalized, the researchers say. Smoking needs to be treated as an addiction, they argue, and not simply as a bad habit - because when it's framed as a habit healthcare providers can have a hard time understanding why anyone facing a serious health issue would continue to smoke.

The study is based on the "lived experiences" of 186 patients, staff and "key informants" - including housekeepers, security guards and groundskeepers - at two hospitals: the University of Alberta Hospital in Edmonton and Winnipeg's Health Sciences Centre. Data were collected over six months - December 2008 to May 2009 - that included a cold Canadian winter. Both sites had a policy banning smoking inside all buildings, entrances and all hospital grounds for three years before the study began.

Overall, the researchers found ample evidence that "non-compliance" seems to be the norm.

People were seen smoking directly under or nearby signs explicitly stipulating a smoke-free zone. Smokers, especially patients in wheelchairs or connected to equipment, were usually found near entrances or in places where they could hide while they smoked.

"Staff who had reportedly been seen smoking on hospital property included security guards, ambulance drivers, nurses and doctors," the team writes in the Canadian Medical Association Journal.

Enforcement efforts, they said, were reportedly minimal.

Cleaners described picking up five to 10 pounds of discarded cigarette butts some days, because when hospitals went smoke-free, they took away the cigarette receptacles. Staff described smokers ringing their bedside bells and asking to be taken outside constantly.

In interviews, patients said they didn't feel safe going outside alone to smoke. Some worried "about getting suddenly sick while smoking outside." Some risked frostbite. Security guards described patients "pushing this IV pole all the way down the sidewalk in the snow" after being told not to smoke on hospital grounds.

There were reports of IV lines freezing and having to be restarted, or electronic equipment malfunctioning.

The researchers described patients in isolation from infections such as tuberculosis wearing a mask outside while they smoked, but then tossing their butts on the ground, making the discarded butts potential "vectors" for infection if they're collected and smoked by someone else.

One patient was locked out of one of the hospitals at night because he didn't see the sign saying the doors lock after a certain hour. The sign was at eye level; he couldn't see it from his wheelchair.

Smoke-free policies are leading to other unintended consequences, including disruptions to nursing care when patients leave the ward for a smoke and nurses have no idea when they'll return.

Comments from health-care workers included: "I have zero understanding on the drive to make a person get out of there, have that cigarette when they're obviously having pain."

Others were more compassionate: "We need to address these people, because it is a stressful time to give up your bad habit."

Although some smokers managed to abstain while in hospital, "many received minimal or no support in doing so," the researchers report.

Clean air policies are well intentioned, the researchers say. Tobacco is the leading preventable cause of disease and death. Some hospitals in the U.S. have gone so far as to ban "third-hand smoke." According to reports, a Louisiana hospital has notified employees that, starting next summer, they won't be allowed to work if their clothes smell of smoke.

Annette Schultz is the principal investigator of the new Canadian study. A nurse and former smoker, Schultz says the primary focus of hospital smoke-free policies "is to get patients to quit.

"I think there's another option, and the other option is supporting abstinence," said 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 at St. Boniface Hospital Research Centre. "The thought of never smoking another cigarette again is really daunting."