Smoking bans have helped dramatically reduce fires in an array of health care facilities—but they can’t extinguish the problem completely
NFPA Journal®, January/February 2010
By Marty Ahrens
When I was a social worker in a chronic disease hospital in the early 1980s, one of my tasks was to help a patient, a woman who was unable to use her hands or arms, have a cigarette. I would put the cigarette in a holder on its metal ashtray and insert the mouthpiece at the end of the attached tube in her mouth. We would chat while she smoked. In that place and time, smoking was the norm. Even the respiratory therapists smoked.
Times have changed. In the decades since, concern about the effects of smoking on the smokers and the people around them prompted health facilities and related organizations to call for increasingly tight restrictions against smoking in hospitals or on hospital campuses. In 1980–1984, U.S. fire departments responded to an average of 3,300 structure fires per year started by smoking materials, chiefly cigarettes, in hospitals, doctors’ offices, clinics, and related properties. Nearly half (47 percent) of these fires started in patient rooms or other bedrooms on the premises. Eleven percent began in the lounge area, another 9 percent started in the hallway or corridor, and 7 percent started in the lavatory, coatroom, or locker room. Almost one-third (30 percent) of all reported structure fires at these properties were started by smoking materials.
By comparison, in 2003–2007, fire departments responded to an average of 100 structure fires per year started by smoking materials on these properties. (The figure has remained around 100 to 200 annually since the late 1990s.) These fires accounted for only 5 percent of the reported structure fires in hospitals, clinics, and doctors’ offices. The areas of origin have changed as well. Only 12 percent of the smoking material fires reported in 2003–2007 started in patient rooms or bedrooms. In 1980–1984, less than 1 percent of the smoking material fires in or at hospital or doctors’ offices started in or on exterior balconies or unenclosed porches, or in courtyards, terraces, or patios. In 2003–2007, 7 percent of the smoking material fires started in exterior balconies or unenclosed porches, and 6 percent started in courtyards, terraces, or patios. The share of smoking material fires originating in trash or rubbish areas increased from 4 percent to 9 percent. The percentage of fires starting in lavatories, locker rooms, or check rooms increased from 8 percent to 11 percent.
In his 1993 Chest article on recent smoking restrictions in Boston-area hospitals, author Stefanos N. Kales tracked some of the changes in smoking policies in the health care environment. These changes contributed to the precipitous decline in smoking-material fires. In 1984, for example, the American Medical Association called on hospitals to restrict smoking to certain areas and to stop selling cigarettes on hospital property. Hospitals participating in Medicare were urged to go smoke-free in 1988. In 1992, the Joint Commission on Accreditation of Healthcare Organizations required hospitals to either have and enforce policies banning smoking throughout the building, or to have a plan to do so by the end of 1993. In their 2009 Tobacco Control article on the adoption of smoke-free hospital campuses in the United States, Scott Williams and his colleagues reported that the percentage of hospitals accredited by the Joint Commission that had smoke-free policies for the entire campus had increased from 3 percent in 1992 to 45 percent in 2008.
In a 1989 JAMA article on the impact of a total ban on smoking in the Johns Hopkins Children’s Center implemented in July 1987, Becker, Connor, Waranch, Stillman, Pennington, Lees, and Oski noted that the number of cigarette butts counted in an elevator lobby dropped from an average of 940 a day before the ban to 19 a day six months after the ban had taken effect. In a 1990 JAMA article on ending smoking at the Johns Hopkins medical institutions, Becker and her colleagues described findings from observations of behavior in public areas. A large drop was seen in the number of cigarette butts in ashtrays in all parts of the hospital except the lavatories, which smokers used to avoid the smoking restrictions. Before the ban, Johns Hopkins medical institutions experienced an average of roughly 20 fires per year known to be caused by smoking. This dropped to zero after the ban.
The United Kingdom’s National Health Service required hospitals to be smoke-free by 2006, but in a 2009 Bio Med Central article, Parks, Wilson, Turner, and Chin note that compliance with the policy can be inconsistent. Questionnaire results from 704 staff members, including 101 smokers, at a Cambridge hospital were analyzed. Thirty-two smokers reported smoking at least once a month while working at the hospital. Non-compliant smokers were more likely to report that the non-smoking policy was adequately enforced than were non-smokers and smokers who complied with the smoking ban. The authors also noted that those who smoked despite the ban were more likely to report habit as the reason they smoked than were those smokers who complied.
Parallels with national statistics
These studies suggest that smoking bans reduce but do not eliminate smoking. In some cases, smoking has moved outside or to unsupervised areas. These findings are consistent with national fire statistics.
Similar changes are seen in reported home structure fires started by smoking materials as the percentage of the population smoking has fallen, and as the number of smokers with limits or bans on indoor smoking at home has increased. In 1980–1984, U.S. fire departments responded to an annual average of roughly 56,000 home structure fires started by smoking materials. In 2003–2007, that average had fallen to fewer than 17,000 a year.
The U.S. Census Bureau, referencing data from the National Center for Health Statistics, has noted that, as of 2006, 24 percent of men and 18 percent of women, or 21 percent of all U.S. adults, smoke. In 1985, 33 percent of U.S. men and 28 percent of U.S. women smoked.
Attitudes about smoking have changed among non-smokers and smokers alike. In a 2007 article in MMWR, Trosclair, Babb, and other researchers from the Center for Disease Control and Prevention’s Office on Smoking and Health reported that the percentage of households that banned or restricted the location of indoor smoking jumped from 43 percent in 1992–1993 to 72 percent in 2003. Borland, Yong, Cummings, Hyland, Anderson, and Fong surveyed smokers in the United States, Canada, the United Kingdom, and Australia about their policies on smoking in the home in late 2002, and again roughly seven months later in 2003, for a study published by Tobacco Control in 2006. In 2003, 28 percent of the U.S. smokers reported that smoking was never allowed anywhere in their homes, 32 percent had some restrictions on where smoking was allowed, and no restrictions were present in 40 percent of the homes. The percentage of smokers with smoke-free homes increased in all four countries from 2002 to 2003.
The trends in area of origin for smoking-materials fires in the home also resemble those of health care facility fires. While the bedroom remains the leading area of origin for home fires started by smoking materials, the percentage of home smoking materials starting there was cut nearly in half, from 39 percent in 1980–1984 to 22 percent in 2003–2007. The share of fires starting on an exterior balcony or open porch, meanwhile, jumped from 1 percent to 11 percent. The percentage of fires starting in the living from, family room, or den fell from 28 percent to 10 percent. Fewer than 1 percent of the smoking material fires started on either a courtyard, terrace, or patio or on an exterior wall surface in 1980–1984, but the percentages increased to 4 percent and 3 percent, respectively, in 2003–2007.
While flammability requirements for upholstered furniture, mattresses, and bedding have contributed to the shift in areas of origin, it is likely that changes in behavior also account for a substantial share of the change. In a 2006 report on behavioral mitigation of smoking fires, NFPA and the U.S. Fire Administration advised, “If you smoke, smoke outside.” The risk of serious fire is lower when people smoke outside than when they smoke indoors. However, the risk does not disappear; fire safety precautions must be followed outside as well as inside. If smoking is allowed, safe ashtrays or other containers for the butts must be used. A discarded cigarette in the yard, mulch, or potted plant can start a fire.
Two other recommendations from the NFPA/USFA study are also important: “Wherever you smoke, use deep, sturdy, ashtrays,” and “Before you throw out butts and ashes, make sure they are out… Dowsing in water or sand is the best way to do that.” Finally, another recommendation of the smoker behavior mitigation study was “If you smoke, choose fire-safe cigarettes.” This safer technology has now been legislated in nearly every state, though the requirements have not yet taken effect in some states. In addition to the changes and behavioral strategies already cited, this fundamental change to the ignition strength of commercially available cigarettes will greatly reduce the risk of fatal cigarette fires in U.S. health care facilities, as well as everyhwere else smokers light up.
Marty Ahrens is manager of NFPA’s Fire Analysis Services.
Case examples of fatal hospital fires started by smoking materials taken from NFPA files
California, 1986: Five deaths
A fire began when a patient decided to smoke in bed after making an unsuccessful attempt to shut off the medical oxygen. A nurse pulled the severely burned patient from the room, but the fire was too intense to close the door. The patient later died of the injuries. Smoke inhalation was a contributing factor in the deaths of four other patients on the same unit. Flame damage was limited to the room of origin, but five patient rooms, the nurses’ station, and corridors in the area of origin sustained heavy heat and smoke damage. Smoking was prohibited in areas where combustibles were stored, where oxygen was used, or by patients in bed.
Virginia, 1994: Five deaths
Smoking materials in a patient’s room ignited bedding, including bedding made of foam plastic. A nurse was unable to move the patient, and the room’s door was left open. The oxygen regulator was damaged, and oxygen was released until a maintenance person shut off a zone valve before firefighters arrived. The suspended ceiling in the room of origin collapsed. The patient died of her burns, and four other patients died of smoke inhalation. As a result of this fire, Virginia required sprinklers to be installed in new and existing patient rooms by January 1, 1997.
Missouri, 1986: Two deaths
Fire officials confirmed the fire was unintentional and believed it was caused by smoking materials discarded in a trash container near a patient who was restrained in a chair. The resulting fire spread to the patient and chair, and throughout the room. The oxygen flow meter was damaged, causing oxygen to be released, intensifying the blaze. A nurse was able to remove the original patient from the room but could not rescue the patient’s roommate, who was unconscious before the fire. The first patient died six weeks later of severe burns; the roommate was pronounced dead at the scene. The first nurse suffered second- and third-degree burns, and six other staffers were treated for minor smoke inhalation. One firefighter was also injured. No sprinklers were present, and the patient’s room did not have smoke detection equipment.
North Carolina, 1999: One death
A patient who was passively restrained in a chair in his room started a fire when his cigarette ignited the chair. Fire spread to his clothing, and he threw his burning coat, used as a blanket, across the room, where it ignited a wheelchair. He verbally alerted staff, who began emergency procedures and used fire extinguishers to put out the fires. Several staffers suffered smoke inhalation injuries as they rescued patients and fought the fire. The 38-year-old patient died of his injuries. Smoking was not permitted in the hospital.