Smoking policy in long-term care: a survey of administrators in San Francisco

Despite the fact that smoking is a ubiquitous yet potentially hazardous behavior in long-term care settings, little previous investigation has been made into the construction or implementation of policy to manage smoking by elderly residents. This survey of administrators in long-term care facilities in San Francisco city and county reveals that fire and safety issues were the prime forces motivating smoking policy, which operated through control of behavior rather than by other available means, such as the use of fire retardant aprons. Although all facilities permitted smoking, a hierarchy of limit setting strategies was adopted, strategies which successively and evermore intrusively overrode the resident's autonomy and turned smoking policy from beneficent philosophy into a coercive moral statement. Arranged in order of frequency of occurrence and increasing degree of restriction, these strategies were: (a) designating appropriate locations; (b) controlling smoking opportunities and materials; (c) requiring staff supervision or help; (d) limiting the availability of staff help; and (e) writing Doctor's orders. By acknowledging the tensions between ambivalent goals inherent in smoking in long-term care, administrators could devise policies and procedures that are both supportive of collective rights and less corrosive of individual ones.