Smoke free hospitals

Editor—McKee et al criticised our decision to provide smoking rooms for patients' use.¹ We have also trained a substantial number of clinical staff to offer opportunistic advice about smoking cessation, offering nicotine replacement to all smokers who are admitted.

Jarvis et al drew attention to the prevalence of “hardcore” smoking in England and its links with age and socioeconomic deprivation.² Most patients in the Royal Victoria Hospital are elderly, and many come from deprived areas. Even among pregnant women, who are more motivated to stop smoking, complex interventions are required.³

Change in smoking behaviour is a process, not an all or nothing event. High intensity behavioural interventions with follow up such as we proposed are effective in promoting smoking cessation in hospital patients. Interventions delivered only during the hospital stay are, however, ineffective.⁴ In all, 70% of our admissions are non-elective, with no opportunity for pre-assessment and intervention. Smoking cessation can be addressed in the population only with a strategy and service that links community with primary and secondary care. Without these, introducing a smoking ban in hospitals with the sole aim of sending a consistent message will be ineffective.

A ban on patient smoking is also impractical. For safety reasons we are unwilling to insist that patients who wish to smoke should leave the hospital building. Neither do we want smoking to take place in uncontrolled areas, which will expose others to secondhand smoke and increase the risk of fire. We also recognise the distress of terminally ill patients and relatives who may be smokers.

In these circumstances acute hospitals should provide limited and controlled smoking facilities for patients. Up to four rooms in a seven storey building will be made available at a cost of £390 000. We aspire to achieve a smoke free hospital, but we also have to recognise that patients don't leave their cigarettes and matches at home.