Behaviors, Vol. 16, pp. 79-81, Primed in the USA. All rights reserved.
Addictive
1991
Copyright
0306-4603/91 $3.00 + .oO e 1991 Pergamon Press plc
BRIEF REPORT SMOKING IN HOSPITALISED PATIENTS RENEE BI’ITOUN,
MICHAEL
Smokers’ Clinic, Department
McMAHON,
of Thoracic
Medicine,
and DAVID H. BRYANT St. Vincent’s
Hospital,
Sydney
Abstract - A survey was conducted in a large inner-city hospital to examine the extent of overt and covert smoking being carried out by patients while they were in hospital. There were 311 patients studied. Twenty percent of all patients tested admitted to smoking during their admission, and another 8% showed expired carbon monoxide levels indicative of recent smoking, but denied they had smoked. The percentage of any one ward that were smoking varied from 4% to 41%. Patients with cardiac and respiratory disease were much more likely to lie about their smoking than those with other diseases. Smokers were more than twice as likely to be readmitted for the same condition than nonsmokers.
Tobacco smoking is still the most overwhelming cause of sickness and death in Australia and accounts for 81% of drug induced deaths (National Drug Abuse Data System, 1988). Studies have shown that patients will continue to smoke after laryngectomy (Himbury & West, 1985), myocardial infarction (Perkins & Dick, 1985), lung cancer and chronic respiratory disease (British Thoracic Society Committee, 1984). Although Australian federal and state Departments of Health are bringing about bans on smoking by hospital staff and patients, there is, however, to our knowledge, no available data verifying the extent of smoking among inpatients. Nicotine dependency is manifested by the persistent use of tobacco, despite the medical consequences (DSM-III, 1980). It is of interest to assess the amount of smoking being carried out by hospitalised patients during an admission, keeping in mind that patients may falsely deny smoking (Harber, Tashkin, Shimozaki, & Hathaway, 1988) so that appropriate strategies may be devised to help smokers quit. METHOD
A study was conducted in a large teaching hospital to determine the extent of overt and covert smoking carried out by inpatients. All consenting inpatients were asked a series of questions, and then an expired air sample was taken for immediate carbon monoxide (CO) analysis. They were not informed as to the reason for the air sample. There was no prior warning given to the wards, and the survey was conducted as quickly as possible to ensure that warning could not be passed on. Patient anonymity was maintained. The questions asked, in order, were as follows: Do you usually smoke? Have you smoked in the last 12 months? Have you smoked here in the hospital? Why are you in hospital? How many times have you been in hospital with this condition? Have you ever tried to quit smoking? All patients were asked to blow slowly into a portable Carbon Monoxide Analyser (Bedford Instruments) after a breath hold of 10 s. No conversation was entered into regarding the aim of the study, nor of the breathing test even if expired CO levels indicated recent smoking and the patient had responded otherwise. The criteria for recent (24-h) smoking was an expired CO of >5 parts per million (ppm) (Wald, Idle, Boreham, & Bailey, 1981). As Requests for reprints should be sent to Renee Bittoun, Smokers’ Clinic, Vincent’s Hospital, Victoria Street, Darlinghurst, NSW 2010, Australia. 79
Dept. of Thoracic
Medicine,
St.,
80
RENEE BI’ITOUN,
MICHAEL
McMAHON,
and DAVID H. BRYANT
Table 1. % Admitting to Smoking in Past 12 Months
% Admitting to Usual Smoking (at Home)
% Smoking in Hospital (Overt and Covert)
39
35
27
8
26 42 37
20 42 37
21 27 30
13 11 6
47 23
39 23
35 16
7 9
Total (n = 311) Disease category Cardiac (n = 61) Respiratory (n = 26) Others (n = 224) Sex Males (n = 182) Females (n = 129)
controls, 40 verified nonsmoking measured for expired CO.
% Smoking While Denying
health workers who were in the hospital environment
were
RESULTS
A total of 3 11 patients replied. Thirty-one were unable to reply because of the extreme nature of their hospitalisation, and only one refused. The mean age of the patients was 57 years (range 15-93, SD 19). Sixty-one (20%) admitted to smoking while in hospital, while 24 (8%) were found to have expired CO levels > 5 ppm but did not admit to recent smoking. Thus, 85 (27%) of the inpatient population were likely to have been smoking while in hospital. Smoking ranged from 4% to 41% of any given ward population. Table 1 shows the breakdown of smoking according to sex and disease categories. The mean expired CO of the 40 nonsmoking hospital health workers was 2.25 ppm (range 24 ppm, SD 0.75). The mean expired CO of all the inpatients was 5.7 ppm (range 149 ppm, SD 6.4). The mean expired CO for those inpatients reading >5 equalled 13.27 ppm (SD 9.3). The average frequency for which any patient had been hospitalised for the same condition was 2.2 (range O-50, SD 5.5). However, nonsmokers returned a mean of 1.6 times, whereas smokers returned a mean of 3.4 times for the same condition. Eleven percent (7/61) of those admitting to smoking in hospital said they had previously tried to stop smoking. DISCUSSION
Self-report of nonsmoking among previous smokers has shown to be unreliable (Harber et al., 1988) and there is widespread agreement on the need for biochemical validation. Carboxyhaemoglobin has a short half-life in sedentary subjects of 2.3 hr (Wald et al., 1981); therefore, elevated levels reflect very recent smoking. The use of the expired level of being >8 ppm as the criterion for current smoking has been discussed elsewhere (Irving, Clark, Crombie, & Smith, 1988); however, our experience at the Smokers’ Clinic has led to a drop in the established cutoff point to 5 ppm and is somewhat less than has been suggested in these studies from Britain and may be due to the higher levels of ambient CO in some British cities. Ambient CO levels, confirmed by the N.S.W. State Pollution Control Commission, throughout this study was zero, whereas the background levels in the British studies varied from 1.3 to 1.7 ppm and have been known to reach 5 ppm (Howard, Smith, & Bailey, 1975). The control nonsmokers had a mean expired CO of 2.25 ppm less than half the cutoff point, confirming the wide range between smoker and nonsmoker. However, notwithstanding the percentage of covert smoking being carried out in this large city hospital, it is surprising to note the degree of smoking being confessed to by the inpatients. In a recent survey of the
Smoking in hospitalised
patients
81
general population carried out by the Anti Cancer Council of Victoria (National Drug Abuse Data System, 1988), it was found that 32.9% of the adult male population and 28.5% of adult females smoked. Okene et al. (1985) have studied the factors that affect persistent smoking in patients with ischaemic heart disease. They found that 34% of patients admitted with a recurrent coronary event were still smoking once at home. Although many psychosocial parameters were measured in their study, they concluded that no personal asset had any significant effect on an individual’s ability to quit smoking after experiencing a cardiac event and those who persisted “seemed” to be more addicted. In our study, it appears that recurrent admission did not deter smokers either. At the time of the survey, most smokers used the “tea rooms” allocated for smokers. Smoking on the wards was prohibited as was smoking by personnel. Smoking has since been banned completely within the hospital grounds for patients, staff, and visitors, and a further survey is being carried out to ascertain whether this policy will induce more clandestine smoking. We conclude that there is a large proportion of smokers who evidently persist in smoking in hospital. Smokers may return repeatedly with diseases that are directly linked to their smoking. The disease may be treated, but more often than not the cause and dependency aspect is not addressed. The need to investigate further the dependent nature of their smoking and to find effective intervention strategies is paramount if preventative measures are to be taken seriously.
REFERENCES American Psychiatric Association. (1980). Diagnostic and sfaristical manual of mental disorders. Washington, DC: Author. British Thoracic Society Committee Report. (1984). Smoking withdrawal in hospital patients: Factors associated with outcome. Thorax, 39, 651-656. Harber, P., Tashkin, D., Shimozaki, S., & Hathaway, E. (1988). Veracity of disability claimants’ self-report of current smoking status. Chest, 93, 561-564. Himbury, S., & West, R. (1985). Smoking habits after laryngectomy. Brirish Medical Journal, 291, 514-515. Howard, S., Smith, P.J. & Bailey, A. (1975). Use of carboxyhaemoglobin levels to predict the development of diseases associated with cigarette smoking. Thorax, 30, 133-140. Irving, M.J., Clark, E.C., Crombie, I.K., & Smith, C.S. (1988). Evaluation of a portable measure of expired carbon monoxide. Prevenrative Medicine, 17, 109-l 15. Statistical Update. (1988). National Drug Abuse Data System, 4, l-2. Okene, J., Hosmer, D., Rippe, J., Williams, J., Goldberg, R., DeCosimo, D., Maher, P., & Dalen, D. (1985). Factors affecting cigarette smoking status in patients with Ischaemic heart disease. Journal of Chronic Diseases, 38, 985-994. Perkins, J., & Dick, T.B.S. (1985). Smoking and Myocardial infarction: Secondary prevention. Post Graduate Medical Journal, 61, 295-300. Wald, N., Idle, M., Boreham, J., & Bailey, A. (1981). Carbon monoxide in breath in relation to smoking and carboxyhaemoglobin levels. Thorax, 36, 366-369.
Addictive
1991
Copyright
0306-4603/91 $3.00 + .oO e 1991 Pergamon Press plc
BRIEF REPORT SMOKING IN HOSPITALISED PATIENTS RENEE BI’ITOUN,
MICHAEL
Smokers’ Clinic, Department
McMAHON,
of Thoracic
Medicine,
and DAVID H. BRYANT St. Vincent’s
Hospital,
Sydney
Abstract - A survey was conducted in a large inner-city hospital to examine the extent of overt and covert smoking being carried out by patients while they were in hospital. There were 311 patients studied. Twenty percent of all patients tested admitted to smoking during their admission, and another 8% showed expired carbon monoxide levels indicative of recent smoking, but denied they had smoked. The percentage of any one ward that were smoking varied from 4% to 41%. Patients with cardiac and respiratory disease were much more likely to lie about their smoking than those with other diseases. Smokers were more than twice as likely to be readmitted for the same condition than nonsmokers.
Tobacco smoking is still the most overwhelming cause of sickness and death in Australia and accounts for 81% of drug induced deaths (National Drug Abuse Data System, 1988). Studies have shown that patients will continue to smoke after laryngectomy (Himbury & West, 1985), myocardial infarction (Perkins & Dick, 1985), lung cancer and chronic respiratory disease (British Thoracic Society Committee, 1984). Although Australian federal and state Departments of Health are bringing about bans on smoking by hospital staff and patients, there is, however, to our knowledge, no available data verifying the extent of smoking among inpatients. Nicotine dependency is manifested by the persistent use of tobacco, despite the medical consequences (DSM-III, 1980). It is of interest to assess the amount of smoking being carried out by hospitalised patients during an admission, keeping in mind that patients may falsely deny smoking (Harber, Tashkin, Shimozaki, & Hathaway, 1988) so that appropriate strategies may be devised to help smokers quit. METHOD
A study was conducted in a large teaching hospital to determine the extent of overt and covert smoking carried out by inpatients. All consenting inpatients were asked a series of questions, and then an expired air sample was taken for immediate carbon monoxide (CO) analysis. They were not informed as to the reason for the air sample. There was no prior warning given to the wards, and the survey was conducted as quickly as possible to ensure that warning could not be passed on. Patient anonymity was maintained. The questions asked, in order, were as follows: Do you usually smoke? Have you smoked in the last 12 months? Have you smoked here in the hospital? Why are you in hospital? How many times have you been in hospital with this condition? Have you ever tried to quit smoking? All patients were asked to blow slowly into a portable Carbon Monoxide Analyser (Bedford Instruments) after a breath hold of 10 s. No conversation was entered into regarding the aim of the study, nor of the breathing test even if expired CO levels indicated recent smoking and the patient had responded otherwise. The criteria for recent (24-h) smoking was an expired CO of >5 parts per million (ppm) (Wald, Idle, Boreham, & Bailey, 1981). As Requests for reprints should be sent to Renee Bittoun, Smokers’ Clinic, Vincent’s Hospital, Victoria Street, Darlinghurst, NSW 2010, Australia. 79
Dept. of Thoracic
Medicine,
St.,
80
RENEE BI’ITOUN,
MICHAEL
McMAHON,
and DAVID H. BRYANT
Table 1. % Admitting to Smoking in Past 12 Months
% Admitting to Usual Smoking (at Home)
% Smoking in Hospital (Overt and Covert)
39
35
27
8
26 42 37
20 42 37
21 27 30
13 11 6
47 23
39 23
35 16
7 9
Total (n = 311) Disease category Cardiac (n = 61) Respiratory (n = 26) Others (n = 224) Sex Males (n = 182) Females (n = 129)
controls, 40 verified nonsmoking measured for expired CO.
% Smoking While Denying
health workers who were in the hospital environment
were
RESULTS
A total of 3 11 patients replied. Thirty-one were unable to reply because of the extreme nature of their hospitalisation, and only one refused. The mean age of the patients was 57 years (range 15-93, SD 19). Sixty-one (20%) admitted to smoking while in hospital, while 24 (8%) were found to have expired CO levels > 5 ppm but did not admit to recent smoking. Thus, 85 (27%) of the inpatient population were likely to have been smoking while in hospital. Smoking ranged from 4% to 41% of any given ward population. Table 1 shows the breakdown of smoking according to sex and disease categories. The mean expired CO of the 40 nonsmoking hospital health workers was 2.25 ppm (range 24 ppm, SD 0.75). The mean expired CO of all the inpatients was 5.7 ppm (range 149 ppm, SD 6.4). The mean expired CO for those inpatients reading >5 equalled 13.27 ppm (SD 9.3). The average frequency for which any patient had been hospitalised for the same condition was 2.2 (range O-50, SD 5.5). However, nonsmokers returned a mean of 1.6 times, whereas smokers returned a mean of 3.4 times for the same condition. Eleven percent (7/61) of those admitting to smoking in hospital said they had previously tried to stop smoking. DISCUSSION
Self-report of nonsmoking among previous smokers has shown to be unreliable (Harber et al., 1988) and there is widespread agreement on the need for biochemical validation. Carboxyhaemoglobin has a short half-life in sedentary subjects of 2.3 hr (Wald et al., 1981); therefore, elevated levels reflect very recent smoking. The use of the expired level of being >8 ppm as the criterion for current smoking has been discussed elsewhere (Irving, Clark, Crombie, & Smith, 1988); however, our experience at the Smokers’ Clinic has led to a drop in the established cutoff point to 5 ppm and is somewhat less than has been suggested in these studies from Britain and may be due to the higher levels of ambient CO in some British cities. Ambient CO levels, confirmed by the N.S.W. State Pollution Control Commission, throughout this study was zero, whereas the background levels in the British studies varied from 1.3 to 1.7 ppm and have been known to reach 5 ppm (Howard, Smith, & Bailey, 1975). The control nonsmokers had a mean expired CO of 2.25 ppm less than half the cutoff point, confirming the wide range between smoker and nonsmoker. However, notwithstanding the percentage of covert smoking being carried out in this large city hospital, it is surprising to note the degree of smoking being confessed to by the inpatients. In a recent survey of the
Smoking in hospitalised
patients
81
general population carried out by the Anti Cancer Council of Victoria (National Drug Abuse Data System, 1988), it was found that 32.9% of the adult male population and 28.5% of adult females smoked. Okene et al. (1985) have studied the factors that affect persistent smoking in patients with ischaemic heart disease. They found that 34% of patients admitted with a recurrent coronary event were still smoking once at home. Although many psychosocial parameters were measured in their study, they concluded that no personal asset had any significant effect on an individual’s ability to quit smoking after experiencing a cardiac event and those who persisted “seemed” to be more addicted. In our study, it appears that recurrent admission did not deter smokers either. At the time of the survey, most smokers used the “tea rooms” allocated for smokers. Smoking on the wards was prohibited as was smoking by personnel. Smoking has since been banned completely within the hospital grounds for patients, staff, and visitors, and a further survey is being carried out to ascertain whether this policy will induce more clandestine smoking. We conclude that there is a large proportion of smokers who evidently persist in smoking in hospital. Smokers may return repeatedly with diseases that are directly linked to their smoking. The disease may be treated, but more often than not the cause and dependency aspect is not addressed. The need to investigate further the dependent nature of their smoking and to find effective intervention strategies is paramount if preventative measures are to be taken seriously.
REFERENCES American Psychiatric Association. (1980). Diagnostic and sfaristical manual of mental disorders. Washington, DC: Author. British Thoracic Society Committee Report. (1984). Smoking withdrawal in hospital patients: Factors associated with outcome. Thorax, 39, 651-656. Harber, P., Tashkin, D., Shimozaki, S., & Hathaway, E. (1988). Veracity of disability claimants’ self-report of current smoking status. Chest, 93, 561-564. Himbury, S., & West, R. (1985). Smoking habits after laryngectomy. Brirish Medical Journal, 291, 514-515. Howard, S., Smith, P.J. & Bailey, A. (1975). Use of carboxyhaemoglobin levels to predict the development of diseases associated with cigarette smoking. Thorax, 30, 133-140. Irving, M.J., Clark, E.C., Crombie, I.K., & Smith, C.S. (1988). Evaluation of a portable measure of expired carbon monoxide. Prevenrative Medicine, 17, 109-l 15. Statistical Update. (1988). National Drug Abuse Data System, 4, l-2. Okene, J., Hosmer, D., Rippe, J., Williams, J., Goldberg, R., DeCosimo, D., Maher, P., & Dalen, D. (1985). Factors affecting cigarette smoking status in patients with Ischaemic heart disease. Journal of Chronic Diseases, 38, 985-994. Perkins, J., & Dick, T.B.S. (1985). Smoking and Myocardial infarction: Secondary prevention. Post Graduate Medical Journal, 61, 295-300. Wald, N., Idle, M., Boreham, J., & Bailey, A. (1981). Carbon monoxide in breath in relation to smoking and carboxyhaemoglobin levels. Thorax, 36, 366-369.
