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