While smoke-free policies on hospital grounds make sense for the objective of clean air, managing the tobacco withdrawal symptoms of hospitalized patients must also be addressed, states an article in CMAJ (Canadian Medical Association Journal).

Researchers from the University of Manitoba, University of Alberta and the Winnipeg Regional Health Authority undertook a study to understand the consequences of smoke-free policies for patients and healthcare professionals at two large acute-care hospitals in Canada (the University of Alberta Hospital and Winnipeg's Health Sciences Center). Not surprisingly, they found that patients and staff continue to smoke on hospital grounds, despite signage. Patients with limited mobility, such as those in wheelchairs and those connected to medical equipment, smoked near hospital entrances.

"As an emerging standard for Canadian hospitals, smoke-free property is intended to reduce exposure to second-hand smoke, communicate denormalization messages about smoking and enhance tobacco cessation," writes Dr. Annette Schultz and her co-authors. Dr. Schultz, an assistant professor at the University of Manitoba's Faculty of Nursing. "However, non-compliance and inadequate treatment for tobacco dependence appear to be the practice norm."

Patients and staff identified safety issues related to leaving hospital wards to smoke, such as staff being unaware of a patient's whereabouts, patients feeling unsafe going out to smoke alone, weather issues that cause equipment malfunction, and patients being locked out at entrances not open 24 hours a day. Patients leaving the ward also present challenges for delivering medical care.

"Our findings suggest that the use of tobacco continues to be framed as a habit or personal choice rather than as an addiction," write the authors. "Like other researchers, we have found that when tobacco use is framed as a habit, healthcare providers are perplexed as to why people continue to smoke when faced with health concerns and restrictions, and consider such people to not be taking responsibility for their health. Alternatively, framing tobacco use as an addiction perplexes one as to why more is not being done to address this dependence."

Schultz and her colleagues suggest that rather than focusing on enforcement of the policy — to address the non-compliance that was clearly evident at both study sites — hospitals and healthcare decision-makers need to consider smoking on hospital grounds as a treatment issue. Patients, many vulnerable and under stress because of hospitalization, need support to manage withdrawal from tobacco and successfully abstain from smoking during their hospital stay.

In a related commentary, Dr. Sharon Lawn, Department of Psychiatry, Flinders University, South Australia, states, "Schultz and colleagues show how the notion of responsibility can become distorted when smoking is viewed as a morally interpreted behaviour — a lifestyle choice — rather than an addiction that requires clinical support. What is immediately striking about the results of this current study of two Canadian general hospitals is how little the staff felt that enforcing the smoke-free policy was their responsibility."