A qualitative investigation of smoke-free policies on hospital property

It is unfortunate and even a tragedy that so many, if not most, health professionals bought into nicotine being the only substance responsible for addiction in people who smoke. Unbiased studies have consistently shown that NRT has a 93 - 98% long term failure rate to help people stop smoking. Already this should be ringing loud bells. Isn't it time that the medical community who would like us to believe that they care for people, started exploring different avenues that will lead them to understand what motivates a person to continue smoking? How many more years and unnecessary suffering will it take before serious and conscientious professionals stop perpetuating the ''nicotine addiction'' theory and started looking at the issue with an honest critical mind?

In the wise words of Pr. Robert Molimard who spent most of his career analyzing tobacco and helping smokers quit '' The big fraud in the tobacco issue was none other than the publication of the 1988 Surgeon General Report entitled "Nicotine Addiction''. This fraud is incomprehensible unless one sees the link with the launch of the nicotine gum. The major premise of the Report seems to be a syllogism that states: "Tobacco products cause a powerful addiction'' The minor premise is: "Tobacco contains a neurotropic poison - nicotine''. Hence follows the conclusion: "Therefore nicotine is responsible for the addictiveness of tobacco''. But there is no evidence that allows us to draw such a conclusion. A host of other assumptions are possible, and there are even major arguments to oppose it, such as the fact that no cases of nicotine dependence have ever been documented when this substance was used in isolation (...) This duplicity is more than amazing when you consider how common it is for addicts to experiment with the purified extracts of their plants of choice. Since no formal evidence of dependence to pure nicotine has yet to be produced, the conclusion that nicotine alone is addictive is not a syllogism, but rather, pure sophistry. And yet, against all scientific rigor, this fallacy was implanted through repetition, hammered in as an unassailable truth, all with the support of health authorities and politicians (...) '' End of citation. Read English translation of the French original at: http://cagecanada.blogspot.com/2010/12/beliefs-manipulation-and-lies- in.html

But let's pretend that we agree that smoking is a habit and that addiction is caused by nicotine alone, does the medical profession truly believe that an already stressful hospital stay is the right time to break one of their lifetime habits whether ones wants to or not, causing additional suffering and stress? And being quasi-prisoners of the healthcare establishment, wouldn't insisting on medicating someone with NRT to alleviate them of their withdrawal symptoms caused by their inability to smoke, be considered a form of forced medication? Isn't it comparable to deliberately causing unnecessary physical pain to someone and later insisting that they take pain relievers to make it all better? Only dogmatic ideology bordering sadism justifies entertaining such beliefs.

Conflict of Interest:

None declared

Iro Cyr is Vice-President of CAGE — Citizens Against Government Encroachment.

Two big thumbs up to Dr. Kreisman, the one and only health-care professional I'm aware of who truly 'gets it!'

I would only add that, while smoking is "just a habit" (as opposed to an addiction), we must recognize that, in combination with the addictiveness of nicotine (and with the smoker having full knowledge of the long-established consequences of smoking), it is, indeed, a very powerful habit, ranking very high on the scale of 1 to 10. Some have claimed that smoking must be an addiction simply because, if I may paraphrase them, "You can't compare smoking to habits like 'chewing fingernails' or 'twirling hair'!" Of course you can't! However, that does NOT automatically put smoking right out of the habit category and into addiction; it simply means that smoking scores an 8 or 9, while the above-mentioned habits probably score something less than a 3.

Regarding "smokers' rights advocates", how does anyone advocate for something that does not exist? Can you say "well-paid tobacco-industry front groups"? That's right: Somewhat like the false claim that smoking is addictive, there is simply no such thing as "smokers' rights." Over the decades, many so-called "smokers' rights" groups have sprung up...most often, just to fight one proposed smoking ban or another and nearly always funded by the tobacco industry (several years ago, the Canadian Tobacco Manufacturers' Council paid $2.5 million to set up the now-defunct mychoice.ca). Smokers have all of the same rights as everyone else does; no more and no less. Smoking -- at any time or in any place where their smoke will affect anyone else -- is NOT among those rights. And no, despite the overwhelming power of the tobacco industry, there is absolutely nothing about "smokers' rights" in any Charter of Rights and Freedoms or any Constitution. At least, not yet.

Regarding the abstract itself: I have serious concerns about some of the language used. For example, we see the word "consequences" (of smoke- free hospital policies), twice. To me, there is a negative implication to the word "consequences" (of a good policy), yet we see nothing good about the policy in the abstract...just (dare I say, "tobacco industry- perpetuated"?) doom and gloom.

We see the term "tobacco dependence" a total of 3 times and "withdrawal from tobacco" twice!

I would respectfully suggest that if the word "tobacco" (in the above two terms) was replaced by the 'correct' word "nicotine", hospital smoke- free policies would not be an issue...and, in fact, we wouldn't be having this conversation.

And finally, it seems to me that there is some sort of a (MIS)understanding/(MIS)interpretation, whereby all (hospital) smoke-free policies are somehow intended to force smokers to quit...and that falsehood is only reinforced by the use of terms like "withdrawal from tobacco."

HOSPITAL PROPERTY SMOKE-FREE POLICIES ARE GOOD! EDUCATE EVERYONE, POST CLEAR AND SUFFICIENT SIGNAGE AND AGGRESSIVELY ENFORCE THE POLICY, COMPLETE WITH LOTS OF MEDIA COVERAGE. AND PROVIDE SMOKERS WITH ONE OR MORE NICOTINE REPLACEMENT THERAPIES FOR THE DURATION OF THEIR HOSPITAL STAY!

Sincerely,

Errol E. Povah President, Airspace Action on Smoking and Health Delta, B.C.

www.airspace.bc.ca www.tobaccofreeworld.ca

Conflict of Interest:

None declared

The distinction between smoking (which is just a habit) and nicotine (which is the addictive drug) becomes blurred at several points in this article and the responses to it. It is very important that we, as health professionals, avoid this trap of convenience. Viewing smoking as addictive, which most of the population superficially does, plays directly into the hands of "smokers' rights" advocates and their claims that smoking bans (be it in hospitals or elsewhere) are discriminatory. Remembering that the actual addiction is to nicotine leads directly to realizing that there are many other forms in which nicotine can be delivered (even if less gratifying) without exposing others. Smokers can choose where and how to get their nicotine hit, the rest of us can't choose where to breathe.

Conflict of Interest:

None declared

Sirs,

The article would have been much more interesting had the issue been examined in the context of "harm reduction" as illustrated by the issue of the Insite Supervised Injection Site (see http://supervisedinjection.vch.ca/). Clearly, hospital policies requiring patients who choose to smoke to go outside in minus-35 degree weather inflict more harm than could possibly be caused by a few cigarettes.

It was most unfortunate that the paper reflected the assumption that only accredited medical personnel are qualified to determine which risks and lifestyle choices may or may not be permissable. This serves simply to increase my contempt for the medical industry and my prediliction to ignore whatever precious little sermons that may be preached at me whenever I should be unfortunate enough to fall into your clutches.

When you, as an industry, commence to understand that you are nothing more than jumped-up auto mechanics, paid - and paid very well - to mitigate and, with luck, to correct the effects of life's slings and arrows, I may listen to your advice with more interest.

In the interim, I suggest that the Strategic Initiative Advancing the Science to Reduce Tobacco Abuse and Nicotine Addiction be asked to approve a Fast Track Policy Grant for a study that includes consideration for the potential for individual choice.

Conflict of Interest:

None declared

Dr. Oyston, thank-you for sharing your passion and ideas about treating hospitalized patients who use tobacco. While the compassionate position of designating a space for people to smoke was heard among study participants, we identified a quieter voice suggesting that more treatment is necessary. That is, instead of accommodating ongoing tobacco use and delivering stronger messages about the health risks of smoking, why not institute immediate and robust treatment of withdrawal symptoms as soon as those addicted to tobacco are admitted to hospital and/or come into emergency departments. I wonder how healthcare services and treatments would change if we anticipated that all people who use tobacco will experience withdrawal during hospitalization. Even those who continue to smoke, most likely would have some level of withdrawal due to altered smoking patterns. What I imagine is instead of informing patients about the policy and the importance of quitting smoking, perhaps the conversation might include statements like "I know while in hospital you most likely will experience withdrawal. I am interested in treating these symptoms. There are a variety of medications we can use to support you during this time. Treating nicotine withdrawal is important as it will support your body in healing, make your stay in hospital more tolerable, and keep you safely on the ward. To be successful, we will work together to find the right medication combination to alleviate your symptoms. Therefore, I will be assessing your symptoms regularly until you are comfortable. Based on your current tobacco use, here is what I suggest is our first treatment option." Rather than backing down on clean air policies, I envision a health care system that truly takes the treatment of tobacco dependence seriously. This means considering how, as an organization, we can adopted stronger methods for treatment of nicotine dependence rather than accommodation of ongoing smoking. Given what is known about health risks of ongoing smoking and exposure to secondhand smoke, I am left wondering why safety risks related to going outside is more important to address than supporting healing through medically appropriate treatment offered to all people who smoke. Most people with addictions, will at first be reluctant to change, it is within our responsibility to find strategies to move them beyond this first line of defense. Clean air policies, can be a catalyst for hospitals to take the next big step regarding tobacco use and that is adopting systemic approaches to treating nicotine addiction. We have come a long way from the days of no smoking restrictions, selling tobacco products within hospitals and prescribing smoking for a variety of reasons. When young health professionals hear about a time when health providers smoked at the central ward desk, one commonly receives looks of shock and dismay that such a reality existed. How could health professionals be so remiss to smoke around sick patients? My hope is, we realize now is the time for us to herald in a new era where treatment of tobacco dependence becomes common place. Then perhaps in the near future, emerging health professionals will be equally shocked and dismayed when hearing about a time when nicotine dependence treatment was not a standard of health care.

Conflict of Interest:

None declared