A little respect

Shouldn't hospitals have some facilities for smokers?

In September, the New Zealand Medical Journal published a letter to the editor noting one consequence of the Smokefree Environments Act:

A peculiar perversity of the Smokefree Environments Act, which has very successfully prevented indoor smoking in public places is to very visibly concentrate smokers, both patients and staff, at the front entrance or close by the entrance to many New Zealand hospitals. As legislation prohibits smoking on hospital grounds this often involves moving smokers to the street. At Wellington hospital, for example, smokers have been gradually encouraged to move further and further away from the hospital’s front entrance and down onto the street. Similarly, at the Hutt hospital, smokers have been moved further away from the hospital entrance.

One potential risk associated with this is that should they [patients] collapse they will need to re-enter hospital by ambulance. Those on telemetry who collapse in the street will not be able to rapidly access the hospital resuscitation team thus decreasing the chances of successful resuscitation.

Of course, for most hospitalised smokers in hospital, nicotine replacement which is now widely offered as part of the ABC programme2 is an important therapy which prevents much of the physical and psychological symptoms associated with nicotine withdrawal. It is likely to be only the very nicotine addicted smoker who needs to brave the elements and stand in the street to smoke.

The smokefree environments legislation was not designed to stigmatise smokers or have them in hospital gowns on the street, but it is an unintended consequence. If we consider tobacco smoking, to be a nicotine addiction that is tough for many to break, and that nicotine replacement is insufficient for some smokers, then we should assume a more compassionate stance and consider the provision of at least some shelter and privacy for patients. The upside will be to reduce the visibility of smoking and have patients where they can maintain close contact with the hospital and where cessation advice and help could be offered directly. The downside is that this may be seen as condoning smoking, a retrograde step in the smokefree vision, and it may require a law change.

In the latest NZMJ, an Auckland physician urges a more compassionate approach:

I was encouraged to read the letter from Crane et al1 pointing out the “peculiar perversity” of the Smokefree Environments Act which has moved patients with a smoking addiction from within to the public spaces around our hospitals. Their major concern is with patient safety.

I am astounded at the lack of dignity we give such patients. Our profession has abjectly ignored our obligation to treat such patients with respect. In Auckland Hospital we have a continuous band of smokers in wheelchairs on the main thoroughfare (Park Road). They sit in their hospital gowns, often with bandaged stumps or clinging onto drips or pumps displayed for the derision of the passing motorist or bus passenger. This is akin to the old village stocks where miscreants were placed for the amusement of others. Those unfortunates who are unable to make it to the open road are condemned to experience every nicotinic cell in their body crying out for its fix. The only comfort being transdermal nicotine, which is nothing like the real thing. We enforce such withdrawal on those who only have a few days or even hours left to live.

Smoking is legal. The Government receives significant revenue from the habit. We deny our smoking patients the respect that is due to them. This is in contrast to the opiate addict. Their habit is illegal, there is no cost recovery and yet we, rightly, treat them with compassion, dignity and privacy.

It is time for the Medical Profession to redress this balance and advocate for our patients while maintaining our support of policies to reduce the prevalence of smoking within our communities.

David Spriggs
General Physician
Dept of General Medicine
Auckland District Health Board
Auckland, New Zealand

What good is done by making a terminally ill patient run the gauntlet for a last cigarette?

Shouldn't the physician's default be compassion and the easing of suffering, rather than the punishing of sin?

Hospitals in general should be smokefree environments. But would it really be that hard to have a dedicated and well ventilated room for these patients? They're already covering the health costs of their habit three times over in taxes paid; surely we can do better for them.