Any smokers on your staff? Then you know how a five-minute bathroom break can turn into a 15-minute puff party and how the slightest lull in the OR is reason enough for them to step outside and light up. You also know how this steams your non-smokers, who are forced to pick up the slack while their colleagues are on their tar-and-nicotine timeouts. Here's advice on how to handle this situation.

I'll be right back
The reasoning (or excuses) smokers use for taking multiple breaks during the day is the same everywhere. "If I don't get my smoke, I can't think straight," they say. "What's the big deal? I'm only gone a few minutes."

If only that were the case. I've been around long enough to realize that a smoker's definition of a few minutes is more like 15 minutes to the rest of us. Most surgical facilities allow a morning and afternoon break - depending, of course, on patient volume and the day's schedule (you may be laughing, thinking you're lucky to get a break at all). Most smokers believe they play by different rules, blaming - or relying on - their habit to excuse themselves between cases. Instead of taking only two breaks a day, smokers often take many more. And what happens? The non-smokers are left behind to cover patients. And smoking is seldom a private affair. Smokers typically bond with other smokers; when one heads for the parking lot, others follow. Lighting up is as much about socializing as it is about getting a nicotine fix.

Kicking the habit
Of all the negative habits staff bring to your center, smoking is by far the hardest to deal with. You'll face little resistance in maintaining a smoke-free facility, but physician-owners and administrators may balk at creating a smoke-free campus. Why? Mostly to accommodate the families of patients who need a nicotine hit to deal with the stress of waiting for loved ones to return from surgery. In the end, the smoking status of your facility or campus is irrelevant because smokers will always find ways to sneak a few drags - in their car, for instance - and you'll face a staff split over the habit's fallout.

So what do you do when smokers abuse their break privileges? The biggest mistake is ignoring the problem, which I know many of you do. Dealing with smokers is a challenge many administrators don't want to tackle. It's a difficult undertaking. But ignoring the problem won't make it go away and will undermine your authority in other areas.

Follow the protocol outlined in your employee handbook for performance management. Document the number of breaks smokers take beyond what is allowed for all employees, counsel the employee and set a time frame for changing her behavior. Beyond disciplinary action, offering help to smokers who want to kick the habit is a decision left up to individual centers. It's a good idea to offer some sort of assistance to those who are serious about quitting. For those who want to quit - and demonstrate their seriousness - be firm, but fair.

But be careful with how much you give or allow. The non-smokers in your facility may question your actions and see benefits bestowed on smokers as a benefit that non-smokers don't receive. Some may be supportive of the smoker who seeks help and will understand the potential long-term benefit to the entire staff if they quit; others may resent what they perceive as preferential treatment. It's a delicate balance.

One of my former business office managers was a constant smoker and said she couldn't quit in part because she couldn't afford nicotine patches and gum. Should the center help pick up the tab? To what expense should the center go? And does that open up the possibility of paying for the treatment of those with alcohol and drug problems? The efforts and means you give to help a person break an addiction is a slippery slope. Establish a consistent policy and stick to it.

High stakes
To avoid problems associated with smokers, consider weeding them out when looking for new hires. I'd avoid asking about smoking habits during the interview process, but there are ways to recognize a smoker. They often reek of smoke without realizing, they may chew gum to mask the smell or perhaps have a hacking cough during non-flu season. If I'm presented with two equal candidates with identical qualifications, and one is a smoker while the other isn't, I'll hire the non-smoker every time.

I'm not a smoker, and perhaps my tone suggests an underlying dislike of the habit. That may be true. My former employee who said she couldn't afford the patches or gum eventually succumbed to lung cancer. Smoking is dangerous to the smoker before anything else. I'm passionate about having employees kick the habit, and its disruptive nature to the staff is the least of my reasons.