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• THANK-YOU
  Teresa R Albrecht
  Published on: 13 May 2016
• Don Cook
  Published on: 13 May 2016
• Simon Chapman
  Published on: 13 May 2016
• Smoking restrictions in confined outdoor areas are justified
  Margo Goodin
  Published on: 13 May 2016

• Published on: 13 May 2016

  THANK-YOU

  • Teresa R Albrecht, none

  thank you for this great information YOU gave me an A on my report about smoking and banning smoking thank you so much!!!!!

  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  • Don Cook

  Dear Editor

  As the person who posed four of the seven arguments, used in the March volume of Tobacco Control, supporting banning smoking in outdoor areas I would like to expand on the four points I raised. The arguments put by me apply to an Area Health Service which will shortly become totally smoke-free, this will include outside areas. Until now hospitals have regarded smoking as a special case, as a cultural...

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  Dear Editor

  As the person who posed four of the seven arguments, used in the March volume of Tobacco Control, supporting banning smoking in outdoor areas I would like to expand on the four points I raised. The arguments put by me apply to an Area Health Service which will shortly become totally smoke-free, this will include outside areas. Until now hospitals have regarded smoking as a special case, as a cultural habit, by going smoke-free we will put smoking where it belongs, in the drug/health category. The measures, which will apply to smoking, apply to many other practices common in the community but not tolerated in hospital.

  1. Outdoor bans send an important message to the community.

  I believe this is the most important reason for an Area Health Service to ban smoking on all its campuses. The first statement in the Charter of Central Coast Health is To promote, protect, and maintain public health and for that purpose to provide health services for the residents of its areas. By condoning smoking on Health Service grounds we sending the community the message that smoking is a cultural issue when in fact it is a major public health issue. The fact that many people still believe that smoking is cultural issue should not deter us from our charter. It is our duty to try to change community perception and put tobacco use firmly in the drugs/health arena. It will take time and yes some people will be unhappy. In a recent focus group an employee said, "I wonder if we do take away their right to smoke, the next thing is their right to food" The evidence of harm caused by tobacco use is overwhelming but still in many people's minds there is doubt. "If tobacco is so bad why does the Government not ban it?" is a common response to tobacco control measures. State and Federal Governments consistently give conflicting messages how they view smoking. A Health service must send a strong message that smoking is a major cause of ill health.

  2. Other freedoms are curtailed in hospitals why not smoking too?

  It's true other freedoms are curtailed in hospital to protect the health of patients. Alcohol is given to patients but not in doses that would be deemed harmful. It is unlikely that a patient in hospital with a condition caused or exacerbated by Alcohol would be allowed to drink. They would be supported with other medications to reduce the withdrawal. Narcotic dependant people are not allowed to have heroin but are given methadone. In both of these cases the patient is provided with a safer substitute. Nicotine addicted patients are offered NRT, also a safer substutute. Some patients with cardiac conditions are restricted to complete bed rest or on fluid restrictions. We make a decision based on medical ground what is good for them.

  Patients who do not wish to follow rules may and do discharge themselves. Many patients discharge themselves from hospitals every day because there is some rule or condition of being in hospital they do not like. Should we allow poker machines in hospital because some people are addicted to gambling? A condition already in the contract of the leases of the coffee shops on hospital grounds forbids gaming machines, not because we are worried about side-stream gambling.

  3. An enforced ban will be good for peoples health

  Again it's true. Prior to surgery patients are strongly discouraged from smoking for very good health reasons. In fact many surgeons refuse to operate unless the patients stops smoking. Many medical conditions may improve by having a rest from smoking. We already say to people you may want to do something, but we so disapprove that we will not lift a finger to help you. A cardiac patient, on fluid restrictions, wants to go outside and drink an unlimited amount. As a nurse, I can tell you very few nurses would assist a patient outside in those circumstances. If caught a nurse acting like that would be in serious strife. We would not take narcotic or alcohol addicted patients outside for a fix. We would not assist patients on bed rest to walk. We would not wheel a diabetic patient outside to feast on chips and chocolate. Nurses do take patients outside but, with the current exception of smoking, it is always because it will do them some benefit. Introducing a policy that stops staff taking patients outside to smoke will put smoking in the category of health not culture. Like it or not health services make decisions on who will get treated and who will not. People in hospital are not prisoners they are there by choice. An expectation of patients in hospital is that they in some way support the treatment they are given. We expect them to take the proscribed medication, to stay on bed rest, or assist in the physiotherapy.

  4. Escorting patients outside can cause staff shortages leading to patient neglect.

  " Yes your honour we took Mrs. Smith outside for a cigarette, left her there and returned to the ward. Unfortunately she dropped her cigarette on her nightie and in the fire that followed she died." I can see the headlines now. Or " Yes your honour I took Mrs. Smith outside for a cigarette and stayed with her. Unfortunately Mrs. Jones on the unattended ward and in dire need of a bedpan and unable to find anybody decided to make her way to the toilet, forgetting that she was a double amputee" Another good headline I rest my case

  I believe that many, now standard, tobacco control measures pushed the envelope at the time. The only people you alienate by pushing tobacco control are the manufactures. I would be horrified if they ever approved of any measure I support.

  Don Cook RN Health Promotion Unit Central Coast Health, Gosford NSW Australia

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  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  • Simon Chapman, editor

  Don, I was not aware that you had posed four of the seven arguments I raised in my article -- you are certainly not the only person to have done so. In your response you fail to engage with the core issue here: smoking outdoors in situations that would apply in hospital grounds harms no one but the smoker. By not disputing this, I assume that you agree. Your concern to control outdoor smoking is therefore inherently patern...

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  Don, I was not aware that you had posed four of the seven arguments I raised in my article -- you are certainly not the only person to have done so. In your response you fail to engage with the core issue here: smoking outdoors in situations that would apply in hospital grounds harms no one but the smoker. By not disputing this, I assume that you agree. Your concern to control outdoor smoking is therefore inherently paternalistic: you believe that it is ethically right for a health authority to say "when you come onto our grounds, we will restrict your liberty to smoke even in circumstances where your smoking is endangering no one but yourself."

  You repeat and offer justifications for four of the arguments I rehearsed. First, you claim that hospitals and health care facilities should send an important message to the community by banning smoking outdoors. You argue that your employer's charter gives you justification for imposing its aspirations onto patients and visitors, as distinct from encouraging them to not smoke via educational strategies. But what exactly is the message being sent here by such a policy? Paternalism's message is that people's autonomy in exercising their freedom to smoke when it is not affecting others is to be devalued against the goals of health evangelism. Much as we would all like to see people decide for themselves that they would stop smoking, many of us draw the line at forcing people to change.

  Next you argue that because we restrict patients' behaviour when in hospital "for medical reasons" that this justifies stopping them going outdoors to smoke. This is the most persuasive of your arguments, but of course it says nothing about visitors who are also banned from smoking because of this policy. This invites questions of when smoking should be prevented because of the imminent danger it poses to a person, versus when smoking should be considered merely chronically risky. When does general risk turn the corner and become "medical risk" that justifies intervention in the patient's best interest? Indications for not smoking by cardiac patients would make more sense here than in othopaedic or psychiatric patients for example. If you see no distinction, then this invites the prospect of health authorities swooping on smokers in all sorts of contexts, all for their own good.

  Your third argument is just a more florid recitation of your first: banning smoking is good for people's health, so let's do it! I'm afraid I see life as being a bit more complicated than that.

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  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  Smoking restrictions in confined outdoor areas are justified

  • Margo Goodin, public servant

  In researching passive smoking issues for a suggested 'best practice' model in Australia, I was asked -- no, urged -- by normally sedate and conservative tobacco control bureaucrats a number of jurisdictions (which had no legislation to limit smoking in indoor areas) to consider the issue of smoking in outdoor places of public assembly. This was clearly an Issue of Public Importance.

  My own experience in the Aus...

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  In researching passive smoking issues for a suggested 'best practice' model in Australia, I was asked -- no, urged -- by normally sedate and conservative tobacco control bureaucrats a number of jurisdictions (which had no legislation to limit smoking in indoor areas) to consider the issue of smoking in outdoor places of public assembly. This was clearly an Issue of Public Importance.

  My own experience in the Australian Capital Territory -- where smokefree indoor air legislation has been in effect since 1994 -- was also that the public is unhappy about ETS exposure when they attend events at outdoor venues. I was aware of moves in the USA to prohibit smoking at such venues, promoted by statement such as, 'We wanted to make this the best family venue in California.' But in the 'evidence-based policy' environment of Australia, did this mean that prohibiting or restricting smoking at these venues is justified on health grounds?

  I believe that there is evidence to support the view that, although people's ETS exposure in venues which are substantially or entirely unenclosed will normally be less than in enclosed spaces, tobacco smoke exposure in these circumstances can product symptoms of ill health. These can be a particular concern for vulnerable individuals such as young children, pregnant women and people who suffer from allergies and pre- existing respiratory or cardiovascular conditions.

  Particularly in places where smoking in indoor environments is subject to legislative control, the community accepts (and expects) that they have a right to be protected from ETS exposure in confined areas. If this is protection is not provided as a matter of venue policy, there is no reason that it should not be included in smokefree public places legislation. Such a provision could refer to restricting or prohibiting smoking in a place or part of a place where, during an event to which members of the public are invited or permitted to attend, persons sit or stand in immediate proximity to each other.

  If such legislation also has provisions which require reasonable steps to be taken to prevent tobacco smoke from penetrating non-smoking areas, then this should motivate building managers to ensure that outdoor smoking areas are located well away from building entrances and air intakes.

  Margo Goodin Director, Tobacco Control Program ACT Department of Health and Community Care Canberra

  The views expressed are the views of the author and should not be taken as representatives of the Department or of the ACT Government.

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  Conflict of Interest:
  None declared.

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