01/01/11

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Dear Dr. Jeff: Whenever I drive up to our nursing home, I see a group of residents sitting in front smoking cigarettes. I think this looks terrible and sends the wrong message. If my husband's office can be smoke free, shouldn't our health care facility do as much? Don't you think that all nursing homes should ban smoking?

Dr. Jeff responds: It is almost 50 years since the U.S. surgeon general confirmed what most physicians knew already – that cigarettes are bad for your health. In the years since 1964, research has confirmed the connection between tobacco smoke and a long list of diseases, from multiple forms of cancer to heart disease, stroke, peripheral vascular disease, and peptic ulcer disease.

For most of these, tobacco smoke is the major reversible risk factor. Documentation regarding counseling on smoking cessation is considered a quality indicator in primary care, and multiple assistive modalities from nicotine patches and gums to various Food and Drug Administration–approved medications may be used to help smokers to break the habit.

Unfortunately, tobacco use persists. Because tobacco is addicting, many seniors who started smoking before the dangers were documented – or when the tobacco companies were still trying to persuade their victims that smoking could be safe and even glamorous – continue to smoke in old age. Because smokers are at risk of multiple debilitating illnesses, they are also likely to be placed in long-term care facilities.

As knowledge of the dangers of secondhand smoke has also grown and public opinion has shifted against the use of tobacco products, smoking has been banned from an increasing number of public places including airplanes and trains, most mass transit, and many work environments, stores, public buildings, restaurants, and bars.

New York City has recently proposed banning smoking in public parks and on beaches. But there has been no national movement to outlaw smoking completely. Smokers continue to have the right to destroy their health in the privacy of their own homes.

 

 

Free to Be Self-Destructive

This issue highlights the basic contradiction in nursing home care. On the one hand, we are like hospitals, with a clear mission to promote health and relieve suffering. Just as hospitals were among the first institutions to ban smoking – and smoking prohibitions are strictly enforced by the Joint Commission accrediting body – we might expect long-term care facilities to be smoke free.

On the other hand, we are homes for individuals who are called “residents” rather than “patients.” These residents should be entitled to the freedoms that they would enjoy in their own homes.

It is ironic that the national antismoking movement is achieving its greatest successes at the same time that the long-term care community is trying to reshape facilities for “person-centered” care and the new federally mandated survey process is increasingly focused on quality of life and resident choice.

Just as many lifetime smokers continue to smoke after being diagnosed with lung cancer (“I've already got cancer so why stop now?”), many elderly nursing home residents do not see the health risks from smoking as terribly threatening, compared with either the pleasure they receive from continuing tobacco abuse or the potential discomfort of attempting to stop.

Many families and, indeed, some physicians see very little purpose in preaching against tobacco to the old and frail. I once had a patient who was 105 years old. She enjoyed chewing tobacco and spitting the tobacco-stained saliva into an old coffee can. Her 80-year-old daughter asked me to try to convince her to stop. “Doesn't she know it's bad for her health?” I confess that I had some difficulty formulating the argument.

Facing the obvious contradiction between resident choices and best interest, different states have chosen different paths. Some have encouraged facilities to go smoke free while others have cited facilities for resident rights violations when they attempted to eliminate smoking. Some states have a mixture of facilities that allow unlimited tobacco use with others where tobacco is highly restricted and yet others where it is forbidden.

My elderly tobacco chewer lived at home. Even in the home care setting, smoking may be an issue. Many home health aides object to having to spend long hours at work in a place filled with tobacco smoke, potentially risking their own health to care for a homebound chain smoker. Even when the patient agrees not to smoke when the home care worker is present, there is no mistaking the reek that hangs in the clothing and furniture in a house with a regular tobacco user.

Nevertheless, few would argue with the right of an elderly smoker to continue his or her habit – although some have argued that it is wrong to force society to pay for the consequences of individual risky behaviors.

Nursing homes and assisted living facilities are, in the end, neither purely health care institutions nor collections of the individual homes of frail people with self-care deficits. They are also communities where people live together and with staff who spend long ours with them and are expected to “care” for them in both meanings of the word.

The model of autonomous adults making life choices for themselves in a facility designed to facilitate these choices doesn't really apply, regardless of what some medical ethicists or state surveyors may believe. Smoking presents significant risks to other members of the community which they should not have to accept, even though the smoker may choose to accept them.

 

 

And a Burning Issue

One risk of having cigarette smoking in or near a health care facility is the risk of fire. The recent fire with multiple fatalities in a Connecticut nursing home is believed to have been caused by a resident smoking in her room. Physically and cognitively impaired smokers are a risk to themselves and to others. Even when smoking in resident rooms is forbidden, memory-impaired smokers may forget the rules, while tobacco addicts may hide cigarettes and matches in their rooms instead of having to get dressed and move down a hallway to indulge their habit.

One resident at a facility where I worked set her purse on fire trying to hide a cigarette when the nurse came in on rounds. Fortunately, that resident did not lose too much besides a few dollars and a pack of tissues, but unsafe smoking is a recurrent problem in long-term care facilities. The resident who is willing to accept the risk of setting his or her own mattress on fire, risking burns and death, cannot accept that risk for the other residents of the home.

Even in apartment buildings, the odor of a nearby smoker seeps into the hallways and adjacent apartments. But nursing homes frequently have residents sharing bedrooms and room doors are frequently open. Even specially constructed smoking rooms with external ventilation allow smoky air back into the general environment when doors are opened for prolonged periods to allow walkers and wheelchairs to enter and exit.

Nursing home staff must assist residents in the smoking areas and will inevitably be exposed to smoke. Ultimately, the decision of a single individual to smoke within the facility becomes a community decision, one in which other residents and staff are forced to accept health risks and unpleasant odors to allow a resident to indulge a habit.

As a compromise, some facilities will allow residents to smoke outside on the grounds. This may be what you are witnessing as you drive up.

Such policies obviously decrease the concerns for secondhand smoke and building fire, although neither concern is completely eliminated. I would suggest that, if your facility has chosen this course, a staff member be assigned to observe the residents while they smoke. Given the frailty of our current resident populations, those who chose to smoke still need to be protected against setting themselves on fire.

In the short run, I would encourage you to find a different location for any sanctioned tobacco use.

Since the front entrance tends to be a popular location in any building, as it allows the residents to be part of the action by reviewing everyone who enters and leaves, you have created a social situation which encourages your residents to sit and socialize as they smoke. Perhaps a side entrance with a view of the compactor might be more appropriate. Allowing smoking is not the same as encouraging it.

The antismoking campaign has been a gradual, but amazing, public health success. In the long run, I believe that the interests of the community outweigh the desires of a small number of residents, where smoking is concerned.

As tobacco use gradually disappears, we all become healthier. Although it may be problematic to deny current residents a right that they enjoyed when they were admitted to the facility, it is surely possible to add a section to the admissions agreement specifying that no new resident will be allowed to smoke.

As the number of smokers declines in your facility and the persistent smokers become more confused and frail, the social attraction of smoking will decline. Given the shortened life expectancy of tobacco users, your facility will become smoke free in a short period of time and your entryway can return to what your architect envisioned.