Q. Hello Dr. C. My name is Becky and I live in Savannah. I am an administrator for a medical practice at which the physician has posted signs inside and outside of the office that state: This is a No Smoking Property. As I drove into the parking area recently I noticed a person sitting on the curb in the parking lot smoking a cigarette. I politely asked her to refrain from smoking on the office grounds. The smoker responded with the four-letter expletive plus off. In addition to being surprised and angry, I concluded I had done my about all my employer would expect, returned to the office, and eventually reported the event to my physician/employer. What do you think about medical office and hospital policies of having No Smoking anywhere near the facilities. It is difficult to enforce and I am not sure it serves much purpose. It certainly upset my day. R. Well Becky, you did your job as the practice administrator and there is not much else you could be expected to do. If the smoker in this case is rude, surly, and uncooperative in addition to being unconcerned about her health, there is not much one can do. I dont think your boss would have wanted you to have put out her cigarette with a fire hose or have washed her mouth out with soap. These would have been inappropriate responses to an inappropriate situation. On the other hand, the signs and the policies are not only reasonable but are essential in getting the message across. What message? TOBACCO IS THE LEADING AVOIDABLE CAUSE OF DEATH IN AMERICA, RESPONSIBLE FOR 500 THOUSAND DEATHS ANNUALLY. The message is that for all the visits people make to the doctor, all the money they spend, all the pain and suffering they show, cigarettes cause the bulk of the problem. Heart attacks, strokes, pneumonia, emphysema, cancer, you name it, and cigarettes play a role. I have considered other signs. How about this: The doctor can only do so much, how about seriously accepting some responsibility for your health by stopping smoking. Too harsh? How about comparing that sign to: I am sorry sir but you only have six months to live. Doctors and hospitals are trying to find ways to be serious about the risks of smoking as they relate to what they do. Certainly employers are getting tougher. Recently, large companies are refusing to give group insurance to smoking employees. These employees are more likely to get sick, incur hospital costs, and miss work. Speaking of employers, your doctor-boss and other doctors can do a great deal more to help the smoker recognize the role of smoking in their health, but more importantly provide an opportunity to assist the smoker in quitting. From your experience, the signs dont seem to help very much as you quite correctly pointed out. Doctors can assist patients who are about to undergo elective surgery by using that event as a focus for smoking cessation. The medical merit for the patient is both immediate and long-lasting. In 2006 an estimated eight million smokers will undergo some relatively elective surgical procedures. These would include lung resections, heart surgery, gallbladder removal, cosmetic, and other plastic surgery, hernia repairs, vascular aneurysm repairs, urologic and orthopedic procedures, all under general anesthesia. Doctors could tell patients that they have a higher chance of post-operative pneumonia, heart-related complications, slowed wound healing, and infections of all types if they smoke in the weeks before and after surgery. There is good data to show that with only a two-month pre-operative smoke-free period, these complications and the prolonged hospital stay, costs, pain, and scarring can be reduced to the level of incidence of the nonsmoker. That is the short-term benefit. What is incredibly encouraging is that while the general rate of smoking cessation is only 3% per year, the surgical patient is much more motivated. Heart and lung surgery patients stop at a 50% rate. Other surgical patients stop at a rate of 10% in the year after surgery. If doctors had more courage (not afraid to lose the elective case to another surgeon), they should require that smoking patients stop for perhaps two months before surgery. Hospitals and anesthesiologists should refuse to admit smokers into the operating rooms for elective procedures without a smoke and carbon monoxide washout. The doctors and hospitals that take these steps will enjoy and can certainly report--lower post-operative complication rates and likely shorter hospital stays and lower costs. Family physicians can help by offering medications and support before and after surgery. In this regard, it is of interest that in this setting, success is much higher and the withdrawal symptoms are much less for the pre-operative smoker trying to quit. Of additional scientific interest is that smokers who go cold-turkey and those who use the nicotine patch before surgery have less post-operative wound infections than smokers who do not refrain from smoking before surgery. These results indicate that nicotine patches should be promoted pre  and post-op since it appears that nicotine is not the specific toxin to the post-operative recovery phase. To answer your question, signs promote but probably do not produce better health. What would be of real help and a measured dose of responsibility for the smoker would be for the doctor, the hospital, and the insurance company collectively to tell the smoker requesting elective surgery to do exactly what that smoker in the parking lot told you to do! That should at least make you feel better. The smoker turned ex-smoker during elective surgery will both feel better and live longer. Seems reasonable to me. Finally, the medical community could take a lesson from you by showing some courage with professional behavior that will produce results.

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