Monday 28 January 2013

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.


  1. So you have patients collapsing and having to be taken back to the hospital BY AMBULANCE because they've been pushed so far away from the premises?!

    And there are people "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"?!

    For what? No doubt to "send a message" to society that smoking will no longer be tolerated. It's good to see know there are at least two doctors who witness this pathetic spectacle and think "maybe this isn't what I got into medicine for." Sadly this sort of thing - rightly compared to the village stocks - continues because the bigots continue to hold sway. Their views are well represented by your previous commenter. (Smoked for 12 years but is going to have an asthma attack walking past a smoker in the open air. Sure.)

  2. My lifetime of smoking consists of perhaps a half-dozen cigarettes and maybe two dozen cigars.

    Note that the "have to walk past smokers" is something induced by regulations banning indoor ventilated smoking rooms, right? And that, here, the regs push them further away from the doors (to avoid inconveniencing those coming in who don't like smoke), but at the costs noted in the letters.

    I have a hard time seeing the harm imposed by having a well-ventilated, out of the way indoor or sheltered smoking area for patients in these circumstances. I can perfectly understand and respect your wish to keep heath insurance costs down for your staff. But why mandate through legislation that there cannot be some facility for these patients? Seems awfully harsh, and punitive, and pointless.

  3. It is not punitive, especially when it comes to patients. It is extremely likely what got them into the hospital in the 1st place, so I think even giving them patches or nicotine replacements is generous.

    Eric, now you know my wife is a post-doc working in lung cancer research, so I get to see the consequences of cigarettes every day. You know what maddens me so much? Hearing almost every week that she got another lung tumor from someone who never smoked!!!

    Smoking is a selfish choice that not only affects the fool (yes, I was a fool too and regret it) doing it, but also those around them. 42000 people (including close to 1000! infants) die each year in US from 2nd hand smoke! Wonder how many people are killed by smokers every year in NZ.

    Ventilated smoking rooms? For Pete's sake, you folks in NZ still haven't gotten your building to stop leaking heat. Good luck with not causing 2nd hand smoke deaths with ventilated rooms ;-)

  4. It takes a harder person than me to look at somebody who's on a terminal sentence with a few weeks to live, who wants a cigarette, and tell him "No, for your own good, go stand out in the rain with your IV drip bag if you want a smoke that badly."

  5. There are no better places to spend healthcare money than to accommodate what less than couple dozen or so individuals a year in a country the size of NZ? I thought NZ already had funding problems for healthcare. Not seeing where supporting someone's addiction makes sense.

    I am sure if someone is really deserving of being rolled down the street with an umbrella and an IV... hospital administration will turn a blind eye to a nurse who does it.

  6. Smokers cost the NZ health system about $350m per annum and pay about $1b in tobacco excise tax. We have a superannuation system that pays retirees 2/3 of the median wage; smokers die before getting paid much from it. A $100k smoking room hardly seems extravagant.

    And whatever case you want to make for encouraging kids not to smoke, is it 'supporting someone's addiction' to let a terminally ill patient have a puff?

  7. I am sure, if we included such costs to the society as healthcare for 2nd hand smoke victims, trash cleanup, fires caused by smokers (be it wildfires from flicked cigarette or house going up in flame, cause you smoked in bed), enforcement of the tax, etc. etc. etc., all the "profit" would evaporate.

    Always loved statistics. You can prove anything, as long as you "forget" to sample/collect the data that does not support the case.
    American politics is the greatest example of deceiving with selective data.

    Re. how do we stop kids from smoking. Now that I have a child of my own, it is one of the issues I would like to figure out.I don't have an answer to that.

    Neither of my parents smoked. i started, because I associated myself with the wrong kids and in college I hung out with those who smoked. It took my father passing away and me realizing how mortality affects people who love you to make me stop. Yes, I had to rethink who I hang out with too.

  8. "Also, using that logic, if someone is terminally ill and is addicted to
    cocaine, crack, PCP, meth, etc. should the hospital have "compassion" to
    let them use it?"

    As long as they pay for it themselves, why not?

  9. It seems to me the reason you give against having designated, ventilated smoking areas are that NZ lacks the infrastructure and that smoking is bad for you. The first is a non-issue: they could only build the rooms with the adequate air ventilation if they have the tools to do so. The second is not up to you.

    If people are smoking in the street, anybody who has to walk by that particular stretch of road inhales the smoke. If it is confined to a specific room or area, then nobody need approach unless he wishes to smoke. So it seems to me it would diminish second hand smoke.

  10. So pointing out that your pathetic habit that kills you and other innocent people should not be tolerated is bigotry? Really?
    What is pathetic, that patients are allowed out of the hospital to smoke, while in care. You are in a hospital to heal. If you want to smoke, then go home and stop wasting taxpayers money. You will die sooner, because you don't get it.

    What is even more pathetic, that doctors with bad addiction are bullshitting you (I even feel sadder for you, since you are buying the bullshit) so they have accommodations paid by taxpayers to feed they addiction.

    Get real!

  11. Apolinaras - I've looked at these numbers pretty carefully. The $350m figure comes from a report commissioned by Action on Smoking & Health - the main anti-tobacco lobby group. It includes 2nd hand smoke victims, which they estimate to be pretty small cost in the aggregate. Adding in fires doesn't do much.

    If you add on a pile of other stuff, primarily lost quality and duration of life among smokers, you can get a much larger figure of around $1.7b. But if you do that, you really have to add in that a lot of smokers do like smoking. And be careful if you go that route: somebody could use the same techniques used to get big smoking numbers to get a big "Social Cost of Apolinaras's Porche" figure - by assuming that the joy you get driving it isn't 'real' joy, then counting everything you spend on petrol as pure cost.

  12. Apolinaras: read the letters to the editor again. The legislation here has pushed smokers so far away from the doors that they're at risk of having to be brought back to hospital by ambulance should something go wrong.

  13. I still stand by my statement that nicotine patches, Chantix, and other aids are the only acceptable options for patients. There is no reason a patient should be outside of the premises with medical equipment. Nicotine patches work. If they don't like it, then they should be discharged on the grounds of refusing treatment.

    NZ has been on the forefront of having the courage to have legislation that balances personal responsibility and interests of society in general. This act is one of those right decisions.

  14. I can pull numbers out all day. I do that for finance, I do that for market testing, etc. etc. I think this thread has been expensive enough on my time as is.

    Bottom line for this whole thread: smoking is an addiction and accommodating it in healthcare facilities beyond nicotine replacement is a waste of taxpayers' money.

  15. Let's agree that smokers should not be granted concession more expensive than their current net contribution to the public purse: tobacco tax minus any excess cost tobacco users currently impose.

  16. I don't smoke so I don't know. But I would take it as *freakishly strong evidence that patches aren't enough* that smokers on a pile of tubes and stuff choose to go out into the cold far away from the hospital to get a smoke.

  17. You are assuming methodology for accounting for that "net contribution" is any better than accounting methods Groupon used to file for IPO.

  18. I was on a patch for two weeks. That stuff can be so strong, you actually feel nicotine high. I actually quit after 2 weeks with the patch, cold turkey did not work prior to that.

  19. I spend a reasonable amount of time looking at how crappy some of those numbers are; I've also published on the topic. But when the report commissioned by the anti-smoking lobby says that smokers only cost the NZ health system $350m, I don't expect that they underestimated the effect.

  20. And you could be absolutely right re. number.
    But that "net profit" is still blood money, especially when you consider deaths and numerous diseases 2nd hand smoke causes.
    Why not make "net profit" on all the drugs? We can have government-sponsored dopehouses on ever corner. No?

    I still think one cost to truly consider, which makes cessation programs such a good investment to both private enterprises and governments - loss of productivity. Loss of productivity is not limited to just sick days or more "breaks", but also to lower cognitive performance due to break of concentration. Say for a technology business, when one employee could be generating 4-10X their compensation in revenue, even just 10% loss of productivity is expensive. Multiply that for the entire economy, especially if it is knowledge-worker driven.