Smoke Break

An inconvenient puff: Smokers must walk off campus to indulge their habit. Megan Morr

Out on the sidewalk, Cheryl Pritchard lights up and takes a quick drag on her cigarette. She exhales a small cloud of smoke and lets her arm, crooked at the elbow, fall a bit. She watches as a line of cars pull to a stop, one by one, just in front of her.

Pritchard's life partner has stage-four melanoma. He's receiving treatment at the cancer wing of Duke Hospital, and she's here visiting him. It's a stressful time for her, and as at other stressful times, she finds a cigarette takes the edge off a little bit, lets her relax.

The only problem is, Duke Health System has recently extended a smoking ban that once applied only inside its facilities to its grounds as well. Not twenty feet from Pritchard is a sign, one of many that have been placed around the perimeter of the health system's property on campus and elsewhere. The sign features a blue box filled by a white H, reminiscent of Hospital signs posted along the highway. But if you look closely, you notice that one of the H's legs is actually a cigarette butt being mashed into the ground. "Duke Medicine is 100% tobacco-free," it reads, in small print at the bottom. "INSIDE AND OUT."

So Pritchard and other smokers in Duke North must abandon their old haunts—doorways, overhangs, the smoking hut located near the centrally located cafeteria—and hump it out here to Erwin Road, Durham property. Smokers in Duke South and in the medical center's research building hike across Research Drive onto the academic campus (where smoking is still permitted), out the doors of Davison onto the main quad, or into fringe of the Sarah P. Duke Gardens.

Throughout the day, the Durham bus stop located directly in front of Duke North, as well as the adjacent sidewalk and lawn, plays host to a never-ending parade of smokers: visitors in shorts and T-shirts, researchers and hospital staff members in scrubs, even patients in hospital gowns hooked up to IVs or in wheelchairs.

Pritchard is miffed by the new policy, which went into effect July 4, extending her one-way walk to a smoking area to ten minutes. Her partner, she says, is often up late into the night, and she plans to be here visiting him, but worries about the safety of trekking out to the bus stop after dark. "It's pretty scary," she says. "I don't know what I'm going to do. Maybe get some mace or something." She lights up a second cigarette.

Many visitors and staff members echo Pritchard's complaint about the longer walk. They spread rumors that being caught smoking on hospital property results in a huge fine—rumors that turn out to be untrue. They also point out the irony that Duke would outlaw the byproducts of the very crop on which it was built and question the true impact of the new policy on Duke's image.

"I don't like standing out in the middle of the street," says a housekeeper sitting on the bus-stop bench, wearing green scrubs, cigarette in hand. She's joined by three fellow smokers in scrubs: royal blue, dark blue, and maroon—like a rainbow starting to catch fire.

"It's just awful, and it looks stupid," says Royal Blue, who works in sterile processing. "They're worried about how smokers represent Duke and the hospital. But we still represent Duke when we're sitting out here." It's ugly, she says, gesturing to the nearby crowd and to the cigarette butts littering the lawn.

Maroon: "Plus, it's going to get cold in the winter."

Green: "Too hot in summertime, too cold in winter."

Royal Blue shrugs. "Put that coat on."

Others' responses are more measured. "It's better than having patients come in and out through a cloud of smoke," says visitor Jimmy Jacobs, as he himself takes a puff on a cigarette.

"I think it's a good idea," says T.J. Barnaby, crouching in the shade of a tree about fifty yards down the road. Barnaby's son is undergoing surgery. "Half the people in there are in there from smoking.

"It's the way the world's going. Restaurants, bars…. Where I'm from originally [in Massachusetts], you can't smoke anywhere. I can't smoke if I go to see my kid at school. It makes it inconvenient for smokers. It's not a bad idea."

At 11:30 a.m. Jackie Caldwell, who works for a construction subcontractor, is out on the lawn sipping a cold Mountain Dew and having a smoke. His first, he says, since 6:30 a.m. He smokes less now than he did when the ban went into effect, in part because his fifteen-minute breaks don't always give him time to get off medical center property, and in part because he can no longer smoke when he's working outdoors, on the loading dock. He acknowledges that smoking less is a good thing. "I'd like to quit," he says. "But I want to quit because I want to, not because the university's forcing me."

His story is not uncommon. For all their complaints, the majority of those visiting the bus stop acknowledge that the new restrictions have cut down on their smoking, not an undesirable development in and of itself. It's just that they feel their freedoms have been chipped away a bit more.

The shift toward smoke-free environments, both nationwide and at Duke, has been a gradual one, though in recent years, as many cities and towns have begun instituting bans on smoke in bars and restaurants—even against business owners' complaints that they will curb business—it seems to have picked up some steam.

Duke Medical Center first banned the sale of cigarettes and tobacco products in 1987. (Its six cigarette machines were "used to replace outdated machines elsewhere on campus," read a quote in The Chronicle.) In 1989, the medical center went smoke-free indoors, following a growing trend, but also giving it weight as the largest employer in the county. Duke's early smoke-free initiatives were led by Steve Herman, then director of the medical center's Quit Smoking Consult Service and an assistant professor of medical psychology.

In almost every case, the medical center faced challenges from smokers arguing that their rights were being violated. Herman's papers, housed in the medical center archives, include a lengthy 1988 correspondence with a faculty member who argued that surveys favoring the indoor ban were unscientific; that the grant money she brought into the university effectively paid her rent and that her space was her responsibility; that patients, as consumers, might choose to go to another hospital where smoking was allowed; and that the new rules would create "supervisory nightmares."

These issues remain salient today. They were mulled extensively by the fifty-member committee that oversaw the most recent tobacco-free initiative. The announcement that the health system would be going smoke-free—in concert with neighboring UNC Hospitals, Rex Healthcare, and WakeMed—was made last October. In subsequent months, the committee developed a public-relations campaign to promote the new policy, put together an instruction manual for staff managers on implementing and enforcing the policy, and highlighted Duke smoking cessation programs available to faculty and staff members.

The central issue that inspired the effort, says Stephen Smith, chief human-resources officer for the health system and head of the committee, was "the hypocrisy of a health organization like a hospital not taking a more firm stand" on smoking, long accepted as a leading cause of cancer.

"My wife and I were in Ireland on vacation," he says. "All of the pubs there are smoke-free. If they can pull it off in Irish pubs, we can do it with hospitals."

As for the extensive planning process, Smith says, Victor Dzau, chancellor for health affairs and CEO of the health system, "could have simply decreed it, and we all would have wondered why it didn't work."

So on the week of July 4, the grounds crews usually charged with emptying and cleaning large cement ashtrays were loading them onto a truck and driving them off. A team from the hospital's engineering-and-operations department was demolishing the metal and glass smoking hut, near the cafeteria, and taking the parts to an off-campus storage unit. The medical center's sign shop was turning out freshly minted signs declaring the property tobacco-free. And smokers were tracking new routes.

Some smokers fumed at the inconvenience. But talking to Smith, you get the sense that the inconvenience might not be unintentional. "We are trying to help people break a habit that's detrimental to their health," he says of the new policy. "That's what a hospital should be doing."

Now, "When people ask me where they can smoke, I say, ‘I'll tell you where you can't smoke.' "