Smoke and Mirrors

For decades now, cigarettes and hospitals have not mixed. Long before any clean-air act or tobacco settlement, there were islands of exiles—many of them standing sheepishly in scrubs—outside the whispering doors of the ER. Paradoxically, smoking persists in one place inside the hospital: the psych ward. There are reasons. When smoking is banned in psychiatric units, there frequently are outbursts of violence, anger, and resentment.

John Gray is the nursing supervisor for inpatient psychiatry at Hennepin County Medical Center. His unit provides patients with a smoking room, which is more or less a well-ventilated closet. Gray is old enough to remember a time not too long ago when it was common for a doctor to light up with a patient during a psychiatric interview. He also remembers the dark days when his unit adopted a strict nonsmoking policy, in 1994. The results were nerve-racking, to say the least. “During that year, the doctors were all for the non-smoking policy,” Gray said. “And the same doctors decided it wasn’t a good idea after dealing with the patients.” An exemption was granted.

On the whole, people are comfortable with the current policy, which allows smoking in designated areas during restricted times. It is a singular liberty and a comfort to troubled souls. Gray has received only one complaint from the family of a patient, but has received quite a bit of appreciative feedback. In fact, one family whose son was a patient shows its appreciation by donating cartons of cigarettes a few times a year. Not a smoker himself, Gray is careful to clarify that the unit does not endorse smoking. It’s a hospital, after all, and alternatives are available. “We have offered tobacco cessation. But it’s a rare patient that has any interest.”

From her comfortable office over on Nicollet Mall, Dr. Maureen Hackett disagreed. She is a forensic psychiatrist in private practice, who specializes in legal issues in psychiatry. She teaches classes at William Mitchell College of Law. Hackett believes that most people who smoke want to quit and that it’s medically irresponsible to allow smoking in any health care facility. As a result of her convictions, she launched what she called a “one-person campaign” seeking legislation that would explicitly require all health-care facilities, including psychiatric units, to be smoke-free. With the support of the Minnesota Medical Association, her efforts were successful. “A bill was signed and is going into action in 2004 that will eliminate smoking on hospital grounds,” she said. According to Hackett, this will include the HCMC psychiatric unit. She anticipates grumbling from both the staff and the patients, but feels education will change the minds of many health-care workers. “These nurses are clueless,” said Dr. Hackett. “And I’m not being disrespectful, because I was clueless too. There is a perception on the part of the staff that hostility is going to grow, and really it lessens.” There are plenty of studies, she said, where this has been shown. “I think the unit needs to offer other options. The smoking room could be turned into a place that offers time out, maybe with running water, a fountain, or mood music.” Perhaps they’ll also consider punching bags.—Sarah Sawyer