Smoking: A Catch-22 for providers

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Elizabeth Newman
Elizabeth Newman

Journey with me, children, back to 2003, when yours truly hung out with smokers.

That's because almost all of my fellow newspaper journalist friends — all college-educated, and I'll tell you why that matters in a second — hung out outside the newsroom. With the editor, who also smoked. Apart from a brief fling with smoking in college, I didn't join in, but that environment — complete with secondhand smoke — was where all the good dirt was shared. Keep in mind newsrooms, back in the day, had burned-out journalists who smoked at their desk, surrounded by old newspapers next to their bottles of whiskey. It's amazing, in hindsight, that more newspapermen didn't regularly burst into flames.

Fast-forward to 2017, and a new study shows that smoking rates are at an all-time low — except among the poor, the uneducated and those in rural areas. The rate of smoking among those with a college degree has dropped 83% since 1966. For those with a high school degree, it's dropped by 39%.

Among adults today with an undergraduate college degree, 7.4% smoke, with about half that number among graduate-degree holders. Among those who do not have a high school diploma, the rate is more than three times as much, at 24.2%. That's a similar rate for those adults who smoke who live below the poverty line.

Smoking used to be a cool thing rich people did, and now it's a habit for the most vulnerable members of our country. All of that is creating situations that keep you up at night, because nursing homes are in a Catch-22 with smoking.

A nursing home provider said during the LeadingAge PEAK conference this spring that they tried to discharge a resident who was consistently smoking and putting others in danger, but they were told by government officials that she couldn't be kicked out. Another Centers for Medicare & Medicaid Services official indicated to me he believed providers can't deny admission for someone who refuses to stop smoking. Janet K. Feldkamp, a nurse-attorney in Ohio, however, said it can be a condition stated up-front.

“If your admission agreement says you are a non-smoking building, you can set that as a condition of admission,” she told me during a break at the AADNS conference in Leesburg, VA. That may include, for a smoker, an agreement to wear a nicotine patch.

It's not just about cigarettes, either. As baby boomers age and move into long-term care, many are reluctant to give up marijuana, or cocaine, she noted.

“People believe they can continue their lifestyle, and they have a right to continue to smoke or not smoke, but the building has to be consistent.”

The big problems often arise when a resident leaves and returns with a lighter or other paraphernalia. The monitoring is a “nightmare,” Feldkamp said.

Another AADNS nurse told me a story about a resident who kept insisting on smoking, leaving cigarettes everywhere, from her mattress to the trash. The facility kept giving options, from medication to a patch, and the resident would say she'd try to quit. Ultimately, the facility was able to move her to a smoking facility, a process that took four months.

No matter what, nursing homes need to follow their policies, which includes reporting illegal substances to police, Feldkamp reminds. She also said that part of a resident assessment may show signs such as injection sites or a damaged septum that can indicate drug use. Supervision and assistance, aprons and a fire blanket all should  be on hand.

The same nurse who told me about the fire-breathing resident also mentioned how supervision is tricky. You can't ask a non-smoking employee to be around secondhand smoke constantly as a monitor, she said, so some facilities have designed observation areas where a staff member can watch through a window.

As for sending in an employee who smokes to monitor smoking residents, forget it.

“You lose them,” she said.

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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Marty Stempniak.