1. A survey of smoking in WELSH palliaTIve care units
Nicotine addiction in palliative care inpatients
A survey of smoking in WELSH palliaTIve care units
Dr Rhian Davies
Dr Fiona Rawlinson
Y Bwthyn Newydd, Bridgend

2. Introduction Background on smoking law Results of a survey on smoking
Exploring issues related to palliative care

3. Background - smoking
21% of the population aged over 16 in GB are smokers
Only 66% of smokers want to give up – so 33% wish to continue smoking
17% of smokers light up within 5 minutes of waking
Source: Office for national statistics. Smoking. Pub 11 March 09. <

4. “The smoking ban”
Smoke-free legislation came into force in Wales on 2nd April 2007, ending smoking in enclosed and substantially enclosed public places
On July 1st 2007, England also introduced a new law.

5. Smoke-free legislation
“In certain types of accommodation, a balance is needed between allowing people to smoke in their own residential spaces, and protecting others - including other residents and staff - from exposure to second-hand smoke”
‘Designated rooms’ will be permitted in the following premises in Wales:
Care homes
A hospice for adults
A mental health unit

6. Provision for smoking
No legal obligation for care homes, hospices or mental health units to offer designated smoking rooms if they do not wish to do so.
Smoking room:
Designated in writing by the person in charge of the establishment as a room in which smoking is permitted
Clearly marked as a smoking room.
Other guidance also on room specifications

7. Survey
Aim
To assess the provisions made for smoking in patients with terminal illness in the last stages of life.
Method
A telephone-based survey
Conducted in September 2009
15 adult inpatient palliative care units in Wales.

8. Questions asked Are there formal provisions for smoking?
Any informal provisions?
Where do patients go to smoke? (incl. informally)
Has smoking been an issue?

9. Results 15 units surveyed: 6 had formal provisions for smoking
7 had no formal provisions
2 gave no response

10. Results: Where patients smoke
Units with formal provisions:
1 had a sheltered outside area for smoking
5 had a smoking room
Units without formal provisions:
In 6 units, patients ‘unofficially’ smoked on site
1 gave no response

11. Results: Is smoking an issue?
Yes: 4
No: 8
Of which:
6 had formal provision
1 had an unofficial arrangement which worked well
1 said nicotine replacement meant it wasn’t an issue
No answer: 3

12. Results: Is smoking an issue?
Issues:
Relatives smoking on the ward
Staff having to “turn a blind eye”
Immobile patients that can’t go outside unaided
Patients who can’t make it to smoke outside smoking on the ward

13. Discussion Questions that need to be addressed:
Is it fair expecting staff to ‘turn a blind eye’?
If at discretion of trust why varying provision within trusts?
Nicotine replacement; but is this really the issue?
The ‘act of smoking’ - a distraction at time of distress?

14. Nicotine withdrawal symptoms
An intense craving for nicotine
Aim is symptom control in terminal illness
Not secondary prevention of other diseases
DSM IV criteria: Nicotine withdrawal
Dysphoric/depressed mood
Insomnia
Irritability, frustration or anger
Anxiety
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
Source: American Psychiatric Association:
Diagnostic and Statistical Manual of Mental Disorders (DSM)

15. How the WHO defines our role

16. “freedom to determine one’s own actions and behaviour”
Autonomy
“freedom to determine one’s own actions and behaviour”

17. Conclusion
Attempts should be made to minimise distress and discomfort in last stages of life
Take smoking into account
Issues that need addressing
Consider the need for uniformity
Consider the need for formal provisions