Smoke free hospitals

Editor—With reference to the editorial by McKee et al on smoke free hospitals,¹ to bar smoking for inpatients with smoking related disease seems reasonable.

To coerce smokers who happen to be in hospital with an unrelated condition into accepting smoke free behaviour as a condition of their care may be questionable.

When patients have no prospect of benefit from smoking cessation, and enforced abstention aggravates their existing distress, they are being managed unethically. Their best interests as a patient (which should be the medical profession's prime concern) are being subjugated to a broader policy that does them harm.

I have been asked by relatives to prescribe nicotine replacement for a terminally ill patient, whose last days in hospital were made worse for nicotine withdrawal. Also one of my patients with extensive stroke related brain damage and end stage peripheral vascular disease declined admission for adequate nursing care and analgesic adjustment because he would have to give up “his one remaining pleasure.”

Such cases should not blunt the public health message. Both patients were dying of smoking related disease. But making their last days more distressing than they would otherwise have been reflects an uncritical policy enforcement that adds a cruel and condescending twist to how doctors and health managers as much as the international tobacco industry are able to create smoking related suffering.