When Nurses Smoked in Hospitals

In years past, there was an ashtray on every patient nightstand, nurses lit up in break rooms, and doctors and nurses were featured in cigarette ads

A group of female nurses in dresses and caps are smoking together

An attractive young woman in a crisp, white vintage nurse’s uniform and cap smiles up at the reader, dangling a lit cigarette between her fingers. Printed above her is a boldface slogan: “You like them FRESH? So do I!”

Although the copy for this 1932 print ad for Camel cigarettes doesn’t identify the model as an actual nurse, it would have been no surprise if she were. Once upon a time, many nurses, doctors and patients smoked, even inside hospitals.

Today, it’s hard to believe this was a fact and not just an urban myth. Years ago, smoking was glamorous and socially acceptable. Cigarettes were not generally viewed as harmful, addictive public health menaces, but as pleasurable indulgences enjoyed by most American adults.

Today, tobacco smoking is known to be addictive and a leading cause of cancer and respiratory diseases. As more hospitals, schools and businesses become “smoke-free” environments, smoking is rarely tolerated. In fact, new nurses who are smokers may find themselves to be unemployable.

“Those Were Different Times!”

On the Facebook page of the nursing group Show Me Your Stethoscope (SMYS), veteran nurses recently shared some of their past experiences with smoking in hospitals. Typical comments declared, “Those were different times! It was a different world. Everyone smoked.”

From the late 1800s until the early 1990s, tobacco was a routine part of the American hospital landscape. Doctors might smoke cigars or pipes while delivering a diagnosis or even while in the operating room. (One SMYS commenter recalls once being written up for refusing to fetch an ashtray for a doctor.)

Nurses routinely smoked in the nurse’s station, during report, while organizing their med carts and sometimes with their patients. Some hospitals had designated smoking lounges next to patient rooms. A compassionate nurse might hold up a cigarette to a dying patient’s tracheotomy tube so that they could take their last puff. Hospitals sometimes sold their patients cigarettes, which were taken into patient rooms on carts, along with chewing gum, toiletries and books. Charge nurses’ offices stocked plenty of ashtrays, often bearing the hospital logo.

Dan Carnithan, a respiratory therapist, says, “In the 1970s, there was an ashtray on every patient’s nightstand. The gift shop sold cigarettes with matches. … Sounds bizarre now, but that was the way it was back then!”

As late as the mid-80s, Jan Potter, RN, a former smoker, says that in state psychiatric hospitals, “the patients were allowed to smoke in the common areas — in fact, we provided ‘state tobacco’ for those that did not have money to buy their own. We even rolled cigarettes with one of those little machines for those who couldn’t roll their own.”

What About the Nurses?

Despite an official ban on staff smoking in common areas, Potter says, “We did it anyway during the swing shift.  …. Patients knew which staff regularly only partially smoked a cigarette and would gather around that person and ask for ‘shorts’ …. Makes me cringe now.”

Lois Albrecht-Anderson, RN, says some hospital departments used tobacco therapeutically. “On the rehab floor, every morning, the ‘quads’ would get a cup of coffee, a cigarette and then get put on the toilet,” she explains, “Quick and easy laxative!”

Smoking in hospitals was shockingly common even in situations where it directly put patients at risk. Donna Schultz, RN, says that a patient room in the respiratory ICU where she worked in the early ‘80s doubled as the staff break room and smoking lounge.

“Every 12-hour shift change, we would sit in that room and smoke during report,” Schultz recalls. “When we would open the door, a cloud of smoke would blow out into the unit. Even the nonsmokers stank. Most of our patients had trachs, were on vents or had lung cancer or COPD from smoking.”

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Pediatric patients weren’t spared either. “I was a kid on the pediatrics floor,” remembers Kathy Antos, RN. “They had to move me away from the nurses station because they smoked there and I have asthma.”

She adds, “I grew up to work at the hospital in the PICU and there was a little room you could smoke in. Luckily, we never blew up in the old days. Just a sign: ‘No smoking: oxygen in use.’”

Nurses and Doctors Once Advertised Cigarettes

Health concerns about cigarettes started to receive public attention as early as the 1930s. As consumers complained about “smoker’s cough” and “smoker’s hack,” researchers began to link cigarette smoke to cancer.

Tobacco companies fought back by promoting their cigarettes with keywords like “fresh,” “light,” “smooth” and “mild.” Advertising for brands like Lucky Strike implied that smoker’s cough was just a side effect of low-quality tobacco or inferior processing, which could be avoided by choosing the right cigarette brand.

The tobacco companies also recruited doctors and other healthcare providers, giving out free cigarettes at medical conferences and compiling favorable research like the studies produced by R.J. Reynolds Tobacco Co.’s “Medical Relations Division.” Doctors, nurses and dentists appeared in tobacco ads, trumpeting the company’s medical claims or the provider’s own brand preferences. “More Doctors smoke Camels than any other cigarette!” declared one long-running ad slogan.

These ads appeared in newspapers, magazines and radio programs, but New York Academy of Medicine librarians Johanna Goldberg and Andrew Gordon note that in the ‘30s and ‘40s, even prestigious journals like the New England Journal of Medicine often ran tobacco advertising. So did the American Journal of Nursing.

Nurses Smoking in the Media

For a study published in Nursing Outlook in 2012, UCSF School of Nursing Associate Professor Stella A. Bialous, RN, M.N., DPH, FAAN, and UCLA School of Nursing Interim Dean Linda Sarna, RN, Ph.D., FAAN, scoured digital archives for images associating nurses and smoking. The search found more than 10,000 images.

One example: An item in the Dec. 4, 1939, issue of LIFE magazine about Florence E. Linden, a registered nurse (and a nonsmoker) whom Philip Morris & Co. hired to lecture women’s groups and female professionals about the importance of avoiding uncouth smoking habits. Linden’s talks did address one safety issue: the need to properly extinguish cigarettes when smoking in bed.

In 1957, Surgeon General Leroy E. Burney, M.D., MPH, officially declared that there was a causal relationship between smoking cigarettes and lung cancer. The tobacco industry only beefed up their marketing efforts, despite mandatory surgeon general’s warnings and a ban later on TV and radio advertising.

New campaigns took aim at American personnel serving in the war in Vietnam and then at the women’s liberation movement, with slogans like the famous Virginia Slims tagline, “You’ve come a long way, baby!” In the ‘60s and ‘70s, the percentage of women — and female nurses — who smoked grew significantly.

In the ‘70s and ‘80s, medical TV shows like “Emergency” and “M.A.S.H.” showed doctors and nurses smoking while on duty. In one episode of the ‘80s British comedy “Blackadder,” a nurse tells a soldier, “A man should smoke — it acts as an expectorant and gives his voice a deep, gravely, masculine tone.” The soldier responds, “God, I love nurses! They are so disgustingly clinical.”

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Nonsmokers Were the Outcasts

Today, smokers often complain about being stigmatized, but back then, it was nonsmokers who were chastised as troublemakers. Nurses who smoked made fun of patients who asked for a nonsmoking room, viewing them as finicky and “difficult.”

Conflicts between smoking and nonsmoking nurses could lead to petty retaliation on both sides. On the SMYS Facebook page, one nurse recalled a nonsmoker who would pour coffee onto a cigarette left lit on an ashtray. The smoker then returned the favor by putting out her cigarette in the nonsmoker’s coffee.

Peer pressure probably contributed to the high percentages of nurses who smoked.  Several of the nurses who commented on the SMYS Facebook page said they started to smoke because everyone else in the hospital was smoking. Other contributing factors included job dissatisfaction and stress.

A study conducted by Renata Tagliacozzo, DrNatSci, and Sally Vaughn, M.A., in the late ‘70s, published in 1982 in the American Journal of Public Health, found that nurses who experienced high levels of job-related stress were more likely to smoke.

It was no wonder that smoking became the social norm in hospitals, even for nurses who didn’t light up in nursing school. “I was working in a ‘smoking’ hospital as a nonsmoker,” recalls Susan Tate, RN, “but later started to smoke and continue to battle that addiction to this day!”

The Tobacco Free Nurses Initiative

“Smoking is not a habit. It’s an addiction!” declares Linda Sarna. “Research shows that nicotine is hard to quit and changes the brain chemistry of the smoker. Many people do not understand the power of addiction or the role of the tobacco industry manipulating science.”

Sarna vividly remembers one of her professors at UCLA School of Nursing smoking during her lectures while carrying a miniature ashtray that she perched on the tip of her pinky finger. Like many new graduate nurses in the early ‘70s, Sarna also started smoking, although she quit after only a year because her boyfriend, a physician and a nonsmoker, did not approve.

After returning to UCLA to pursue her MSN in oncology nursing in the mid-70s, Sarna became interested in patients who were dying of cancer due to smoking. She continued to pursue that research into the ‘80s, completing her doctorate at UCSF in 1989. Four years later, The Joint Commission enacted new accreditation rules that effectively banned smoking in U.S. hospitals.

Sarna and Stella Bialous, her colleague from UCSF, later traveled to London to present their research on the impact smoking has on nurses and the nursing profession to the International Council of Nurses. Although the event was well-publicized, Sarna laments, “No one attended the presentation but the husbands of the presenters.”

That setback did not deter Sarna or Bialous. They set up a meeting with the Robert Wood Johnson Foundation (RWJF) to make the case for stronger anti-tobacco leadership, citing research showing that nurses’ smoking had a negative impact on patient care. Through those efforts, the Tobacco Free Nurses (TFN) initiative was born in 2003, funded by RWJF.

In 2007, Sarna and her colleagues furthered their efforts with the “Helping Smokers Quit” study, a CDC-funded, web-based intervention aimed at “improving nurses’ performance in tobacco dependence treatment.” Nurses from 30 hospitals in three states (including California, Indiana and West Virginia) participated in the study, which had good results.

Sarna later spearheaded an ambitious campaign closer to home: a new UCLA policy that made the campus completely tobacco-free (including chewing tobacco and e-cigarettes) as of April 22, 2013. She is also going global, with nursing-related studies in China, the Czech Republic, Hungary, Poland, Romania, Slovakia and Slovenia as well as in the U.S. One of her doctoral students is also researching the popularity of hookah smoking among young people.

Smoke-Free Hospitals

Compared to the ’60s or even the early ‘90s, we are living in a totally different world. A new state law enacted June 2016 prohibits smoking in any enclosed space of a public venue or business of any size. That means that in California, smoking is no longer allowed even in hospital break rooms or enclosed parking garages, much less in patient rooms. As of June 2016, those restrictions include e-cigarettes and “vaping” too.

Certain hospitals are now refusing to hire nurses who smoke and are subjecting new hires to nicotine tests. This practice may run afoul of some states’ employment nondiscrimination laws, which is a question that will probably have to be settled in court sooner or later.

Either way, it looks like smoking in or around hospitals is a thing of the past, as are healthcare professionals who smoke. A study Sarna and Bialous published in JAMA in early 2014 found that the number of U.S. nurses who smoke dropped 36 percent between 2007 and 2011.

To paraphrase the old ad slogan, when it comes to cigarettes, the nursing world really has come a long way.

ERSILIA POMPILIO, RN, MSN, PNP, is a pediatric nurse practitioner, writer and theatrical director. She is the creator of “Nurses and Hypochondriacs,” a storytelling show about nurses and patients.

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