Smoking inside Canadian acute care hospitals

OBJECTIVE: To assess smoking policies at Canadian acute care hospitals. METHOD: A questionnaire was designed, piloted and faxed to all acute care hospitals in Canada. The questionnaire was designed to address the following: what is the current policy regarding patient smoking? Are staff and/or visitors allowed to smoke inside the hospital? Is there a separate policy for psychiatric patients? Are smoking cessation products available at the hospital pharmacy? Is the policy governed by regional or municipal legislation? RESULTS: A total of 852 hospitals were included in the study. Of these, 476 responded to the questionnaire, for an overall response rate of 56%. Twenty-seven per cent of respondents allowed patient smoking inside the hospital. While staff smoking was not allowed inside most hospitals (93%), 32% of hospitals in Quebec allowed staff to smoke inside the building. Thirty per cent of hospitals had a separate policy for psychiatric patients, and 27% of hospitals had provisions for visitor smoking. Sixty-seven per cent of hospitals were able to offer patients smoking cessation products while they were in hospital. CONCLUSIONS: Many Canadian hospitals continue to allow smoking inside their facilities. There is considerable variation in hospital smoking policies across the country.

T he adverse health effects of tobacco use are well established (1)(2)(3)(4).In addition to the long-term effects of smoking, patients who smoke fare worse when hospitalized.Smokers have a greater risk of postoperative complications and increased length of stay (5,6).Motivating patients to quit smoking is both difficult and frustrating for physicians.Hospitalization is recognized as an important factor in the motivation to quit smoking, and the hospital setting is ideal for the initiation of smoking cessation (7)(8)(9).As of January 1992, the Joint Council on Accreditation of Healthcare Organizations requires all hospitals in the United States (including psychiatric units) to have no-smoking policies.In 1995, compliance with this policy exceeded 95% (10).Canada lags far behind the United States with respect to in-hospital smoking; a similar national policy does not exist in Canada.The present study was stimulated by the persistence of in-hospital smoking facilities at both acute care teaching hospitals (Kingston General and Hotel Dieu Hospitals) in Kingston, Ontario, and we sought to discover whether this was the national standard.Furthermore, we sought to describe the availability of smoking cessation products (which were not available on our own hospital formularies) in Canadian acute care hospitals with the intention of facilitating discussion on this important issue.

METHODS
A questionnaire was designed, piloted and faxed to all acute care hospitals in Canada as identified in the Guide to Canadian Healthcare Facilities, Volume 8 (11).Responses were received over the period of June 2002 to October 2002.Centres that offered both acute and chronic care were included in the study.Hospitals that could not be contacted after three attempted fax transmissions were excluded, and a French language version was sent to all francophone hospitals.The questionnaire was designed to address the following issues: Question 1 -what is the current smoking policy regarding patient smoking at each hospital and how long has this policy been in place?Question 2 -are staff and/or visitors allowed to smoke inside the hospital?Question 3 -is there a separate policy for psychiatric patients, and if so, how does it differ?©2006 Pulsus Group Inc.All rights reserved

BRIEF COMMUNICATION
Question 4 -are smoking cessation products available at the hospital pharmacy, and if so, which products are available?Question 5 -is the policy governed by regional or municipal legislation?Space was also provided for comments or suggestions.Respondents were given the option of choosing 'not applicable' for questions 3 and 4, because some acute care hospitals are psychiatric hospitals and some hospitals do not have their own pharmacies.The collected data were analyzed using Microsoft Excel (Microsoft Corporation, USA).

RESULTS
A total of 969 acute care hospitals were identified in the Guide (11).Of these, 117 were excluded because they were either no longer classified as acute care hospitals or because three attempted fax transmissions failed.Thus, 852 hospitals were included in the study.Of these, 476 responded to the questionnaire, for an overall response rate of 56%.Twenty-seven per cent of respondents allowed patient smoking inside the hospital.While staff smoking was not allowed inside 93% of all hospitals, 32% of hospitals in Quebec allowed staff to smoke in the building.Thirty per cent of hospitals had a separate policy for psychiatric patients.
Twenty-seven per cent of hospitals had provisions for visitor smoking.These were typically designated outdoor areas or covered onsite outdoor smoking structures or 'huts'.Sixty-seven per cent of hospitals were able to offer patients smoking cessation products while in hospital.Full results by province are shown in Table 1.
Only one hospital allowed its patients to smoke in the cafeteria.Another defended its smoking policies with the reason that intravenous equipment freezes when patients take it outside in -40°C temperatures.In many hospitals that had 'no-smoking' policies mentioned, exceptions were made for palliative and long-term care patients.A few hospitals mentioned that smoking exceptions were made for religious ceremonies.

DISCUSSION
Patients continue to smoke inside Canadian hospitals.An alternative to abrupt nicotine withdrawal is nicotine replacement while in hospital.It has been previously demonstrated that hospitals are an ideal setting to begin smoking cessation interventions (7)(8)(9); however, little is done to take advantage of this opportunity.In one study (12), just 5% of hospitalized smokers were offered nicotine replacement therapy.In the present study, we found that pharmacological smoking cessation products were not available for prescription by physicians in 33% of hospitals.This is not a new problem.In a 1982 study of physicians who attempted to get their hospitalized patients to quit smoking, Senior concluded that "the ineffectiveness of their (physicians) efforts is primarily due to hospital policies that are not in keeping with physicians' standards of practice and with established knowledge of the deleterious effects of smoking on health" (13).
Some hospitals that have attempted to abandon their smoking rooms have met with resistance from patient advocacy groups.In particular, it was thought that smoking is a right that terminally ill or chronic care patients should not be denied.Psychiatric wards are often equipped with their own smoking facilities.In the present study, we found that 30% of hospitals surveyed had a separate smoking policy for psychiatric patients.Ontario's Psychiatric Patient Advocacy Office supports "regular access to smoking areas for those who wish to smoke while in hospital" (14).Despite this, some psychiatric hospitals have banned smoking entirely, including throughout the hospital grounds (15).
Interesting regional differences were noted in the present study.High rates of smoking inside hospitals in Quebec may be a reflection of higher smoking rates among francophones than anglophones (16).
We are pleased to report that both acute care hospitals in Kingston have now banned smoking entirely since the study was completed and have introduced smoking cessation products on their formularies.A complete ban on smoking, with pharmaceutical support of this policy, is certainly possible; it is also practical and is an advancement in health care.

ACKNOWLEDGEMENTS:
The authors thank Dr Paul Belliveau for his work translating the questionnaire.The authors also thank Jeanine MacRow for her help with data collection.
AB Alberta; BC British Columbia; MAN Manitoba; NB New Brunswick; Nfld Newfoundland; NS Nova Scotia; ON Ontario; PEI Prince Edward Island; QUE Quebec; SASK Saskatchewan