Smoking by patients in a smoke-free hospital: prevalence, predictors, and implications

Background: No-smoking policies are now mandated in all U.S. hospitals. They require hospitalized smokers to abstain temporarily from tobacco. Little is known about patients' compliance with these policies or about their effects on patients' comfort and subsequent smoking behavior. Hospitalization in a smoke-free hospital might precipitate nicotine withdrawal in smokers, but it might also offer smokers an opportunity to stop smoking.

Methods: To assess the prevalence, predictors, and implications of smoking during hospitalization, we analyzed data from a cohort of 650 adult smokers who were admitted to an urban teaching hospital and participating in a smoking intervention trial. We measured nicotine withdrawal symptoms at study entry (24-48 h after admission) and patients' self-reports of smoking while hospitalized, compliance with the hospital no-smoking policy (smoking prohibited indoors but permitted outdoors), and smoking status 1 and 6 months after discharge.

Results: One-quarter of smokers admitted to a smoke-free hospital reported smoking during their hospital stay, although only 4% of smokers admitted violating policy by smoking indoors. Within 48 h of admission, 55% of smokers reported cigarette cravings and 29% of smokers reported difficulty refraining from smoking. Smokers with cigarette cravings were more likely to smoke while hospitalized (OR 3.6; 95% CI: 1.9-6.7). Those with nicotine withdrawal symptoms were more likely to violate the hospital no-smoking policy (OR 6.8; 95% CI: 5.3-8.3). Abstaining from tobacco use while hospitalized was a strong independent predictor of continued abstinence after discharge (OR 3.8; 95% CI: 1.4-10.3).

Conclusions: Smoking by patients in a smoke-free hospital was common. Craving for cigarettes and symptoms consistent with nicotine withdrawal occurred frequently in hospitalized smokers and were associated with smoking during hospitalization, which was itself strongly linked with continuing to smoke after discharge. Pharmacologic treatment of cigarette cravings in hospitalized smokers could potentially improve patient comfort, increase compliance with hospital no-smoking policies, and promote smoking cessation after hospital discharge. This approach deserves further study.