It’s a sunny day at Calgary’s busy Foothills hospital. Walk onto the grounds from the main road and large billboards declare this to be a non-smoking property.
Yet, turn the corner and across the road from the main entrance and emergency doors, a dozen or so patients and visitors are smoking undeterred in a pleasant outdoor area with benches and modern butt receptacles. I’d heard there was an innovation here – and a hospital staffer confirms this is it: a designated smoking area.
There is no signage, indicating perhaps the tensions behind the hospital’s no smoking policy. While hospitals have banned smoking on their grounds across Canada and worldwide, the pendulum here seems to have swung back a bit since the Calgary health region became the first in Canada to have smoke-free hospital grounds in 2000. The rules produced by a well-meaning medical establishment have met an even tougher foe: highly addicted patients, visitors and staff, often smoking because of stress.
“The complaints or concerns that we most commonly hear from patients wanting to access our facilities are having to travel through a small group of smokers in order to get service,” says Dr. Brent Friesen, Alberta’s lead for tobacco reduction.
Indeed, when Manitoba nursing professor Annette Schultz undertook studies of smoke-free hospital sites in three provinces, she found patients said they smoked within smoke-free zones, both inside and outside the hospital, and that “mostly smoking occurred close to entrances, near emergency doors…” Her research revealed a cauldron of competing values: people who thought they had a right to smoke, nursing staff who didn’t want to police tobacco and let patients smoke in rooms and, in some cases, security that stopped enforcing the non-smoking policy altogether.
It’s not just a Canadian issue. A 2008 British study found most nursing and medical staff would not enforce the no-smoking policy with patients for fear of aggression while a 2017 Australian study similarly found self-reported enforcement of hospital smoke-free policy by medical, nursing and other health staff was low (60.9 per cent). The conclusion: both enforcement and compliance were low.
Back in Alberta, the unpleasant nature of enforcing no-smoking rules led Medicine Hat hospital security to even offer a coffee card to on-site smokers when informing them of the smoke-free policy to lessen confrontations. Currently, a script even directs hospital security in Alberta on how best to direct smokers offsite to smoke.
A telling recommendation from patients, visitors and medical staff interviewed by Schultz and her team was to create designated smoking areas, even smoking enclosed areas.
Today at the Foothills Medical Centre, which is experiencing a COVID-19 outbreak on several units, this smoking area seems like a bit of a detente – even as Alberta awaits proclamation of a law (Bill 19) at some point this fall similar to those in Ontario, New Brunswick, P.E.I., Northwest Territories and Nunavut that makes smoking illegal on hospital grounds rather than a matter of policy. “Having a law matters,” says Rob Cunningham, Policy Analyst with the Canadian Cancer Society. “It has more teeth than just a policy.”
Indeed, Alberta Health Services lobbied for legislation with more serious fines. The new law specifies “No person shall smoke or vape on a hospital property, including the building, grounds, and parking areas used in relation to the hospital property” and raises fines to $1,000 for a first offence and $5,000 for a second. But even with these new provisions, it’s unclear how authorities will move beyond a desire to avoid confrontation, not discourage smoker patients from seeking health care.
Non smokers continue to speak out against lack of enforcement at the Foothills site. “If I have to walk through that person who is smoking, that puts me in a vulnerable state,” cancer patient Tim Allsopp told Global News.
Similarly, I’d written to Friesen in 2016 as a patient who’d had it with inhaling smoke while accessing medical care at various Calgary public hospitals and clinics. A respiratory therapist summed up to me: “I hold my breath and run in the doors to work.” So this new smoking area away from hospital doors seems to make practical sense. Indeed, there’s no example of a smoke-free hospital site anywhere in the literature that is actually smoke free and many studies have found that enforcement can bring harm to patients.
“We did an AHS audit and identified at least 35 patients that have suffered death or serious injury as a result of smoking while using oxygen,” said Friesen, adding that there was also property damage.
In response, a hospital committee of medical personnel and staff agreed to try a new smoking-area pilot project beginning in August 2019 as new parkade construction meant there’d be space for a smoking area across from the main doors. The committee gained special Alberta Health Services approval to work outside the tobacco and smoke free policy with the idea the smoking area would be for patients and that there would be education and evaluation, according to Friesen.
But there would be no signage.
“Partly, it was not to undermine the overall policy measures on our sites that are smoke-free,” Friesen said.
Until the pandemic, evaluation of the pilot project was supposed to happen this summer and consider perceptions of staff, physicians and volunteers; those of users of the smoking area; air quality assessments; and a review of patient concerns.
Another view comes from Dr. Gaston Ostiguy, who told a parliamentary committee each hospital should have a good smoking cessation clinic that can address cases of hardcore, addicted smokers. The retired chest physician said recently that he firmly believes vaping should be allowed on hospital grounds as an effective smoking cessation tool.
“It’s a big hammer to put vaping and smoking on the same level,” Ostiguy said, speaking from his Quebec home. The retired director of McGill University medical system’s smoking cessation clinic says he’s seen “magnificent stories” of health improvement with vaping including better health, reduced hospitalization and ability of patients to come off some respiratory medications.
“In Quebec, we need to respect smoking nine metres away from the hospital doors. It’s a shame to see the number of butts lying on the ground there anyway. Why not allow people to vape without any problem?”
Smoking addiction – especially with mental health patients – is complex.
“I have some colleagues who are proud to say they prohibit vaping and smoking within psychiatric hospital when we know it helps them (patients),” said Ostiguy, adding that smoking cessation is a complex, time-consuming process that needs compassionate medical support.
“I think vaping should be limited to a certain area (on the hospital grounds) but I don’t think smoking should be allowed within hospital grounds. Smoking is bad for your health.”
The Canadian Cancer Society’s Cunningham takes heart in declining smoking rates amongst Canadians (from 26 per cent to 15 per cent over two decades). Like Ostiguy, he said he thinks more of the tobacco tax should be directed back to helping smokers.
“Very little of tobacco tax goes into smoking cessation programs,” Cunningham notes.
He is not a fan of smoking on hospital grounds: “Being hospitalized with a smoking-related illness is a real teachable moment. Within the hospital there should be very proactive efforts to get people to quit and provide RT (replacement therapy) products.”
Further, smoke-free employment grounds help encourage smokers to quit, he said.
As winter looms and a non-smoking law awaits proclamation in Alberta, the smoking area at Calgary’s Foothills Medical Centre remains, pending evaluation by Alberta’s health authorities and perhaps others looking for solutions to a stubborn problem.