Habit or addiction: the critical tension in deciding who should enforce hospital smoke-free policies.

ventable cause of disease, disability and death. Most recently, the US Surgeon General has affirmed that there is no safe level of exposure to environmental tobacco smoke. The adverse affects of smoking and exposure to tobacco smoke on health pervade multiple areas of life. For these reasons, many countries have introduced smoke-free policies in a variety of community, workplace and service settings. Hospitals, in particular, are a focus of smokefree policy because their primary goal is to promote health by attending to acute health crises or serious exacerbations of chronic conditions, many of which have direct or indirect links to smoking. Hospital staff see people with smoking-related diseases every day. In a study of health care use by 20 831 employees of a large company, the American Cancer Society found that employees who smoked had more admissions to hospital (124 per 1000 v. 76 per 1000), had a longer average length of stay in hospital (6.47 v. 5.03 d), and made six more visits to health care facilities per year than employees who did not smoke. Smoking-related diseases account for a high proportion of admissions to hospital and deaths across the population. The effectiveness of smokefree policies in reducing admissions to hospital and deaths from smoking has been supported and questioned, but hospitals play only a limited role in the journey to ill health a person takes as a result of smoking, and such reports may underestimate the range of measures needed to address the harms of smoking in the general population. As evidence of the harms of smoking mounts, hospital administrators have clear responsibilities to provide an environment that does not undermine the health of patients and employees, and clinical staff have a clear mandate to address smoking and its affects with their patients. These tasks are far from straightforward; they involve substantial structural, practical and cultural change. Knowing what is good for us and changing our unhealthy behaviour, or convincing others to do so, are two quite different things for patients and employees. The paper by Schultz and colleagues provides a rich description of the complexity of attempts to address smoking cessation and to enforce smoke-free policies in two large Canadian general hospitals. Central to the authors’ findings is a description of how staff act, or fail to act, when patients’ nicotine dependence is viewed as a habit rather than as an addiction, and the adverse consequences this perception has for the success of smoke-free po licies. Schultz and colleagues provide us with a unique look at how hospital staff attempt to navigate the ethical, legal, moral and clinical debates over smoking and the enforcement of smoke-free policies on hospital grounds. The comments made by staff, although sometimes alarming, capture the tension between their opinions as public citizens, shaped by the policies and social norms of their society, and their knowledge as clinicians demanding a response (or not) to the clear evidence of the harms of smoking to the health of their patients. Perhaps something can be learned from the many studies of smoking and smoke-free policies applied to a particularly vulnerable population — people with mental illness. Such studies lay bare the values, attitudes and contradictions that often underpin how patients and staff behave toward each other in psychiatric settings regarding the issue of smoking. In such settings, we have the privilege of seeing many of the same at titudes, behaviours and challenges described by Schultz and colleagues in their starkest view — Habit or addiction: the critical tension in deciding who should enforce hospital smoke-free policies