Prevalence and predictors of smoking by inpatients during a hospital stay

Informed consent in dermatology: a narrative review

Informed consent is a legal and ethical obligation of healthcare providers, and there are several steps that must be followed for informed consent to be obtained. Numerous challenges exist to obtaining informed consent including gaps in health literacy, language barriers, impaired decision-making capacity, and inadequacy of informed consent forms. Dermatologists must understand the importance and process for obtaining informed consent to protect patients as well as avoid litigation. This narrative review provides an overview of the process of obtaining informed consent, insight into the top challenges that clinicians may face with suggested recommendations, and a brief review of litigation from improper consent among dermatologists.

Perceptions of prevalence, consequences, and strategies for managing contraband substance use in an inpatient concurrent disorders program: A qualitative study of patient perspectives and survey of clinician perspectives

OBJECTIVE

Inpatient treatment programs for substance use disorders (SUDs) typically have an abstinence policy for patients, but unsanctioned substance use nonetheless takes place and can have significant negative clinical impacts. The current study sought to understand this problem from a patient perspective and to develop strategies for improved contraband substance management in an inpatient concurrent disorders sample.

METHODS

First, a qualitative study (n = 10; 60% female) was undertaken to ascertain perceived prevalence, impact, and patient-generated strategies. Second, an anonymous follow-up survey was conducted with unit staff clinicians to evaluate the suggested strategies.

RESULTS

Patients reported that contraband substance use was present and had significant negative consequences clinically. Recommendations from patients included more extensive urine drug screening, the use of drug-sniffing dogs, and direct contingencies for contraband use. Nineteen staff competed an anonymous follow-up questionnaire to evaluate the viability of these strategies, revealing variable perceptions of feasibility and effectiveness.

CONCLUSION

These findings emphasize the adverse consequences of contraband substance use in addiction treatment programs and identify patient-preferred strategies for managing this challenge.

Factors associated with receipt of the 5As model of brief intervention for smoking cessation among hospitalized patients

BACKGROUND AND AIMS

Guidelines recommend the 5As model of brief intervention for providing smoking cessation support in clinical settings. This study assessed patient and hospital characteristics associated with self-reported receipt of the 5As (ask, advise, assess, assist and arrange).

DESIGN

Multi-center cross-sectional study.

SETTING AND PARTICIPANTS

Adult inpatients (n = 1047) were randomly selected from 13 hospitals in the Barcelona province of Spain in 2014-2015.

MEASUREMENTS

We explored participants' receipt of the 5As through a questionnaire. Given the progressiveness of the 5As, we recoded the fulfillment of the intervention as: A₀ : no intervention; A₁ : ask; A₂ : ask and advise; A₃ : A₂ and assess; A₄ : A₃ and assist; and A₅ : A₄ and arrange a follow-up. We explored patient (e.g. age, sex, comorbidities) and hospital (e.g. type of hospital, unit) characteristics. We adjusted multi-level robust Poisson regression models to estimate the adjusted prevalence ratios (aPR) of the association between the recoded 5As intervention received.

FINDINGS

A total of 60.4% (n = 624) of patients had been asked (A₁ ) about their smoking status. Among smokers, 46.5% (n = 90) were advised (A₂ ), 26.6% (n = 48) assessed (A₃ ) and 4.6% (n = 10) received all the components of the 5As (A₅ ). Middle-aged smokers [aPR = 3.63; 95% confidence interval (CI) = 1.69-7.79] with a respiratory disease (aPR = 2.19; 95% CI = 1.11-4.34) were most likely to have been asked, advised and assessed (A₃ ). The cessation intervention was most frequently performed by physicians.

CONCLUSIONS

In the Barcelona province of Spain, it appears that fewer than half of hospitalized patients who smoke were advised to quit and few received the full 'five As' brief intervention for smoking cessation.

Comparative effectiveness of post-discharge strategies for hospitalized smokers: Study protocol for the Helping HAND 4 randomized controlled trial

BACKGROUND

Tobacco smoking remains the leading preventable cause of death in the US. A hospital admission provides smokers with a unique opportunity to stop smoking because it requires temporary tobacco abstinence while illness may enhance motivation to quit. Hospital interventions must continue post-discharge to increase tobacco abstinence long-term, but how best to accomplish this remains unclear. Building on two previous randomized controlled trials, each of which tested smoking cessation interventions that began in hospital and continued after discharge, this trial compares two interventions that provide sustained smoking cessation treatment after hospital discharge with the goal of improving long-term smoking cessation rates among hospitalized smokers.

METHODS/DESIGN

Helping HAND 4 is a three-site randomized controlled trial that compares the effectiveness of two active interventions for producing validated past 7-day tobacco abstinence 6 months after hospital discharge. Smokers who are admitted to three hospitals receive a standard in-hospital smoking intervention, and those who plan to quit smoking after discharge are recruited and randomly assigned to two interventions that begin at discharge, Personalized Tobacco Care Management (PTCM) or Quitline eReferral. Each lasts 3 months. At discharge, PTCM provides 8 weeks of free nicotine replacement (NRT; a participant's choice of patch, gum, lozenge, or a combination) and then proactive smoking cessation support using an automated communication platform and live contact with a tobacco treatment specialist who is based in the health care system. In the eReferral condition, a direct referral is made from the hospital electronic health record to a community-based resource, the state's telephone quitline. The quitline provides up to 8 weeks of free NRT and offers behavioral support via a series of phone calls from a trained coach. Outcomes are assessed at 1, 3, and 6 months after discharge. The study hypothesis is that PTCM will produce higher quit rates than eReferral.

DISCUSSION

Helping HAND 4 is a pragmatic trial that aims to evaluate interventions in real-world conditions. This project will give hospital systems critical evidence-based tools for meeting National Hospital Quality Measures for tobacco treatment and maximizing their ability to improve cessation rates and overall health for the millions of smokers hospitalized annually in the US.

TRIAL REGISTRATION

Prospectively registered prior to start of enrollment at Clinicaltrials.gov, NCT03603496 (July 27, 2018). https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S00084MJ&selectaction=Edit&uid=U00002G7&ts=2&cx=ff0oxn.

Tobacco Use and Subsequent Cessation Among Hospitalized Patients in Mumbai, India: A Longitudinal Study

INTRODUCTION

Hospitalization is an important setting to address tobacco use. Little is known about post-discharge cessation and treatment use in low- and middle-income countries. Our objective was to assess tobacco use after hospital discharge among patients in Mumbai, India.

METHODS

Longitudinal observational study of inpatients (≥15 years) admitted at one hospital from November 2015 to October 2016. Patients reporting current tobacco use were surveyed by telephone after discharge.

RESULTS

Of 2894 inpatients approached, 2776 participated and 15.7% (N = 437) reported current tobacco use, including 5.3% (N = 147) smokers, 9.1% (N = 252) smokeless tobacco (SLT) users, and 1.4% (N = 38) dual users. Excluding dual users, SLT users, compared to smokers, were less likely to report a plan to quit after discharge (42.6% vs. 54.2%, p = .04), a past-year quit attempt (38.1% vs. 52.7%, p = .004), to agree that tobacco has harmed them (57.9% vs. 70.3%, p = .02) or caused their hospitalization (43.4% vs. 61.4%, p < .001). After discharge, 77.6% of smokers and 78.6% of SLT users reported trying to quit (p = .81). Six-month continuous abstinence after discharge was reported by 27.2% of smokers and 24.6% of SLT users (p = .56). Nearly all relapses to tobacco use after discharge occurred within 30 days and did not differ by tobacco type (log-rank p = .08). Use of evidence-based cessation treatment was reported by 6.5% (N = 26).

CONCLUSIONS

Three-quarters of tobacco users in a Mumbai hospital attempted to quit after discharge. One-quarter reported continuous tobacco abstinence for 6 months despite little use of cessation treatment. Increasing post-discharge cessation support could further increase cessation rates and improve patient outcomes.

IMPLICATIONS

No prior study has measured the patterns of tobacco use and cessation among hospitalized tobacco users in India. Three-quarters of tobacco users admitted to a hospital in Mumbai attempted to quit after discharge, and one-quarter remained tobacco-free for 6 months, indicating that hospitalization may be an opportune time to offer a cessation intervention. Although smokers and SLT users differed in socioeconomic status, perceived risks and interest in quitting, they did not differ in their ability to stay abstinent after hospital discharge.

Patient perceptions of tobacco control after smoke-free hospital grounds legislation: Multi-center cross-sectional study

OBJECTIVE

To examine patient perceptions of the role of health care providers in tobacco control and tobacco-related services they should provide after the introduction of national smoke-free hospital grounds legislation in Spain.

DESIGN

Multi-center cross-sectional study.

SETTING

Thirteen hospitals in Barcelona province in 2014-2015.

PARTICIPANTS

A total of 1,047 adult hospital patients, with a stay ≥ 24 h were randomly selected.

METHOD

We explored participants' perceptions of the role of health professionals and hospitals in tobacco control by asking about their agreement with several statements after the introduction of national legislation on smoke-free hospital grounds: (i) health professionals "should set an example and not smoke" and "should provide smoking cessation support"; (ii) hospitals "should provide smoking cessation treatments" and are "role model organizations in compliance with the smoke-free legislation", and (iii) "hospitalization is a perfect moment to quit smoking". Responses were described overall and according to participant and hospital characteristics: patient sex and age, type of hospital unit, number of beds, and smoking prevalence among hospital staff.

RESULTS

The majority of participants considered that health professionals should be role models in tobacco cessation (75.3%), should provide smoking cessation support to patients (83.0%), and that hospitalization is a good opportunity for initiating an attempt to quit (71.5%). Inpatients admitted to general hospitals where smoking cessation was not given as part of their portfolio, with a low level of implementation in tobacco control, and who stayed in surgical units had higher expectations of receiving smoking cessation interventions.

CONCLUSIONS

Inpatients strongly support the role of hospitals and health professionals in tobacco control and expect to receive smoking cessation interventions during their hospital stay. Systematically providing smoking cessation services in hospitals may have a relevant impact on health outcomes among smokers and on health care system expenditures.

Which hospitalized smokers receive a prescription for quit-smoking medication at discharge? A secondary analysis of a smoking cessation randomized clinical trial

OBJECTIVE

To determine the prevalence and predictors of receiving a smoking cessation medication prescription at discharge.

METHODS

Retrospective analysis of ongoing Human Studies Committee-approved clinical trial data at large tertiary care center, The University of Kansas Medical Center. Patients included were smokers over 18, either Spanish or English speaking, those admitted between October 1, 2016 through May 31, 2018. Other eligibility criteria include access to a telephone or mobile phone, not currently be pregnant or breastfeeding, have no significant co-morbidity that precludes participation (acute, life-threatening illness, and communication barriers such as tracheal tube or altered mental status). Those included in this analysis were those randomized into the trial who expressed interest in receiving a smoking cessation medication prescription at discharge.

RESULTS

Two hundred fourteen patients were recommended a prescription by their smoking cessation counselor, 88 patients (41.12%) were approved a prescription at discharge. Out of those approved, 50.70 (14.05 SD) was the average age, 12.84 (8.47 SD) was the average number of cigarettes used per day, 47 patients (53.41%) were White, 49 patients (55.68%) were admitted through the emergency department, 55 patients (62.50%) had used smoking cessation medication in the past, 49 patients (55.68%) had used inpatient smoking cessation, 36 patients (40.91%) had Medicaid. A binary logistic regression determined to show insurance status (P = 0.042) and use of inpatient smoking cessation medication use (P < 0.001) as statistically significant predictors of receiving a prescription at discharge.

CONCLUSION

It was determined that among the population recommended for medication, 41.12% actually received a prescription at discharge. The variables of "health insurance status" and "use of inpatient smoking cessation medication" demonstrated to be predictors of receiving a prescription. It is important to further study this as many patients rely on a prescription to afford these medications that are useful in a quit attempt.

Leverage points to improve smoking cessation treatment in a large tertiary care hospital: a systems-based mixed methods study

OBJECTIVES

To generate system insights on patient and provider levers and strategies that must be activated to improve hospital-based smoking cessation treatment.

DESIGN

Mixed methods study including a series of in-depth group model building sessions, which informed the design of an online survey completed by healthcare providers and a structured interview protocol administered at the bedside to patients who smoke.

SETTING

Large, tertiary care hospital in the Midwestern United States.

PARTICIPANTS

Group model building: 28 healthcare providers and 22 previously-hospitalised patients; Online survey: 308 healthcare providers; Bedside interviews: 205 hospitalised patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

Hypothesis-generating, participatory qualitative methods informed the examination of the following quantitative outcomes: patient interest versus provider perception of patient interest in smoking cessation and treatment; patient-reported receipt versus provider-reported offering of inpatient smoking cessation interventions; and priority ratings of importance and feasibility of strategies to improve treatment.

RESULTS

System insights included patients frequently leaving the floor to smoke, which created major workflow disruption. Leverage points included interventions to reduce withdrawal symptoms, and action ideas included nurse-driven protocols for timely administration of nicotine replacement therapy. Quantitative data corroborated system insights; for instance, 80% of providers reported that patients frequently leave the floor to smoke, leading to safety risks, missed assessments and inefficient use of staff time. Patients reported significantly lower rates of receiving any smoking cessation interventions, compared with provider reports (mean difference=17.4%-33.7%, p<0.001). Although 92% of providers cited patient interest as a key barrier, only 4% of patients indicated no interest in quitting or reducing smoking.

CONCLUSIONS

Engaging hospital providers and patients in participatory approaches to develop an implementation strategy revealed discrepant perceptions of patient interest and frequency of hospital-based treatment for smoking. These findings spurred adoption of standardised point-of-care treatment for cigarette smoking, which remains highly prevalent yet undertreated among hospitalised patients.

Smoking and hospitalisation: harnessing medical ethics and harm reduction

As resident physicians practicing Internal Medicine in hospitals within the USA, we are confronted on a daily basis with patients who wish to leave the hospital floor to smoke a cigarette. While many physicians argue that hospitals should do everything in their power to prevent patients from smoking, we argue that a more comprehensive and nuanced approach is needed. In part 1 of this perspective piece, we outline the various forms of smoking bans in hospital settings, applauding the development of indoor smoking bans while questioning the move towards stricter, campus-wide smoking bans. In part 2, we turn to traditional biomedical ethics to guide our approach to the hospitalised patient who smokes. This approach, which is informed by our backgrounds in harm reduction and medical anthropology, takes into account the lived realities of patients and acknowledges the complicated sociohistorical contexts of tobacco use.

Rapid relapse to smoking following hospital discharge

Many of nearly 7 million smokers who are hospitalized each year plan to stay quit after they leave the hospital. Most, however, relapse after discharge. This is a secondary analysis of a large Midwestern hospital-based smoking cessation trial that occurred between July 2011 and May 2013 to better understand how quickly smokers relapse and the predictors of rapid relapse. Of 942 participants who completed follow up, 25% returned to smoking within a day after hospital discharge. Among these rapid relapses, 36.6% relapsed within one-hour of leaving the hospital, 35.3% between one and 24 h, and 28.1% relapsed one-day post-discharge. Predictors with the highest odds for rapid relapse (within a day of hospital discharge) included tobacco use during hospitalization (OR, 7.37, [95% CI, 3.85–14.13], P < 0.01); low confidence for quitting (OR, 2.07, [95% CI, 1.49–2.88], P < 0.01); and not setting a quit date (OR, 1.76, [95% CI, 1.25–2.48], P < 0.01). Other significant predictors included higher nicotine dependence, shorter length of stay, and depression. Patients who are vulnerable to rapid relapse may benefit from policies that discourage leaving the hospital to smoke. In addition, hospital interventions that target smokers' confidence in quitting, encourage setting a quit date, and addressing nicotine dependence and depression may also be effective at supporting smoker's intentions to make their pre-admission cigarette their last.

Clinical Trials Registration NCT01305928

Tobacco Use Prevalence and Smoking Cessation Pharmacotherapy Prescription Patterns Among Hospitalized Patients by Medical Specialty

INTRODUCTION

Effective smoking cessation medications are readily available but may be underutilized in hospital settings. In our large, tertiary care hospital, we aimed to (1) characterize patient tobacco use prevalence across medical specialties, (2) determine smoking cessation pharmacotherapy prescription variation across specialties, and (3) identify opportunities for improvement in practice.

METHODS

Using electronic health records at Barnes Jewish Hospital, we gathered demographic data, admitting service, admission route, length of stay, self-reported tobacco use, and smoking cessation prescriptions over a 6-year period, from 2010 to 2016. We then compared tobacco use prevalence and smoking cessation prescriptions across medical specialties using a cross-sectional, retrospective design.

RESULTS

Past 12-month tobacco use was reported by patients in 27.9% of inpatient admissions; prescriptions for smoking cessation pharmacotherapy were provided during 21.5% of these hospitalizations. The proportion of patients reporting tobacco use was highest in psychiatry (55.3%) and lowest in orthopedic surgery (17.1%). Psychiatric patients who reported tobacco use were most likely to receive pharmacotherapy (71.8% of admissions), and plastic surgery patients were least likely (4.7% of admissions). Compared with Caucasian tobacco users, African American patients who used tobacco products were less likely to receive smoking cessation medications (adjusted odds ratio [aOR] = 0.65; 95% confidence interval [CI] = 0.62 to 0.68).

CONCLUSIONS

Among hospitalized tobacco users, safe and cost-effective pharmacotherapies are under-prescribed. We identified substantial variation in prescribing practices across different medical specialties and demographic groups, suggesting the need for an electronic medical record protocol that facilitates consistent tobacco use cessation pharmacotherapy treatment.

IMPLICATIONS

Tobacco use cessation pharmacotherapy is underutilized during hospitalization, and prescription rates vary greatly across medical specialties and patient characteristics. Hospitals may benefit from implementing policies and practices that standardize and automate the offer of smoking pharmacotherapy for all hospitalized patients who use tobacco.

Influence of gender and peer tobacco use on tobacco use intentions after a period of involuntary tobacco abstinence among U.S. Air Force trainees

This study examined gender, prior tobacco use, and social-environmental factors as predictors of intentions to use tobacco (cigarette smoking and/or smokeless tobacco [ST]) after a forced period of abstinence among U.S. Air Force (USAF) trainees. Trainees completed 8½ weeks of basic military training (BMT), then 4 weeks of Technical Training; both required abstinence from tobacco. A cross-sectional survey of 13,514 USAF trainees (73% male, 90% age 18–24, 43% prior tobacco use) was conducted at the beginning of the 4-week Technical Training period. Overall, 17% of the sample reported future tobacco use intentions. Intentions for future tobacco use were less prevalent among non-tobacco users before BMT (1%) than those reporting any tobacco use (37%). From a multivariable logistic regression model predicting intentions to use any tobacco after Technical Training, significant two-way interaction effects were detected between gender, and tobacco use prior to BMT (p = 0.0001), and number of close friends who smoked cigarettes (p = 0.018), and number of close friends who used ST (p = 0.029). Among non-tobacco users before BMT, females were more than twice as likely as males to report tobacco intentions (Odds Ratio = 2.2, Bonferroni corrected 95% CI: 1.14.4, p = 0.011); no gender differences were detected among tobacco users. For females, but not males, having more friends who smoked was associated with greater likelihood of tobacco intentions (Bonferroni corrected p ≤ 0.05). In contrast, for males, but not females, having more friends using ST was associated with greater likelihood of tobacco intentions (Bonferroni corrected p < 0.05). In this sample of USAF trainees, the study provides novel findings on how males and females are influenced differently by their prior tobacco use and peers' tobacco use in predicting tobacco intentions. Prevention efforts focused on uptake and resumption of tobacco use, along with gender-specific strategies, may be warranted.

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Prior tobacco use predicts tobacco use intentions among U.S. Air Force trainees.

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Male and female trainees are influenced differently by their peers' tobacco use.

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Gender-specific strategies targeting social norms about tobacco may be warranted.

Evaluation of smoking cessation treatment initiated during hospitalization in patients with heart disease or respiratory disease

Objective:

To evaluate the effectiveness of a smoking cessation program, delivered by trained health care professionals, in patients hospitalized for acute respiratory disease (RD) or heart disease (HD).

Methods:

Of a total of 393 patients evaluated, we included 227 (146 and 81 active smokers hospitalized for HD and RD, respectively). All participants received smoking cessation treatment during hospitalization and were followed in a cognitive-behavioral smoking cessation program for six months after hospital discharge.

Results:

There were significant differences between the HD group and the RD group regarding participation in the cognitive-behavioral program after hospital discharge (13.0% vs. 35.8%; p = 0.003); smoking cessation at the end of follow-up (29% vs. 31%; p < 0.001); and the use of nicotine replacement therapy (3.4% vs. 33.3%; p < 0.001). No differences were found between the HD group and the RD group regarding the use of bupropion (11.0% vs. 12.3%; p = 0.92). Varenicline was used by only 0.7% of the patients in the HD group.

Conclusions:

In our sample, smoking cessation rates at six months after hospital discharge were higher among the patients with RD than among those with HD, as were treatment adherence rates. The implementation of smoking cessation programs for hospitalized patients with different diseases, delivered by the health care teams that treat these patients, is necessary for greater effectiveness in smoking cessation.

Smoking among hospitalized patients: A multi-hospital cross-sectional study of a widely neglected problem

INTRODUCTION

A comprehensive smoking ban was recently enacted for acute-care hospital campuses in Spain. The aim of this study was to assess the prevalence and patterns of smoking among inpatients before and during hospitalization.

METHODS

Multi-center cross-sectional study was conducted in 13 hospitals in the province of Barcelona, Spain from May 2014 to May 2015. Participants were adults who provided informed consent. The sample size was calculated to be representative of each hospital (prevalence 29.4%, precision ± 5%, error 5%). We approached 1228 subjects, 888 accepted to participate and 170 were replaced (were not available or declined to participate). Final sample comprised 1047 subjects. We used a computer-assisted personal interview system to collect data, including sociodemographic variables and use of tobacco before and during hospitalization. Smoking status was validated with exhaled carbon monoxide. We calculated overall tobacco prevalence and investigated associations with participant and center characteristics. We performed multiple polytomous and multilevel logistic regression analyses to estimate odds ratios (ORs) and 95% confidence intervals (CIs), with adjustments for potential confounders.

RESULTS

In all, 20.5% (95% CI: 18.1–23.0) of hospitalized patients were smokers. Smoking was most common among men (aOR=7.47; 95% CI: 4.88–11.43), young age groups (18–64 years), and individuals with primary or less than primary education (aOR=2.76; 95% CI: 1.44–5.28). Of the smokers, 97.2% were daily consumers of whom 44.9% had medium nicotine dependence. Of all smokers, three-quarters expressed a wish to quit, and one-quarter admitted to consuming tobacco during hospitalization.

CONCLUSIONS

Our findings indicate the need to offer smoking cessation interventions among hospitalized patients in all units and service areas, to avoid infringements and increase patient safety, hospital efficiency, and improve clinical outcomes. Hospitalization represents a promising window for initiating smoking interventions addressed to all patients admitted to smoke-free hospitals, specially after applying a smoke-free campus ban.

Using Bioinformatics to Treat Hospitalized Smokers: Successes and Challenges of a Tobacco Treatment Service

BACKGROUND

Hospitals face increasing regulations to provide and document inpatient tobacco treatment, yet few blueprint data exist to implement a tobacco treatment service (TTS).

METHODS

A hospitalwide, opt-out TTS with three full-time certified counselors was developed in a large tertiary care hospital to proactively treat smokers according to Chronic Care Model principles and national treatment guidelines. A bioinformatics platform facilitated integration into the electronic health record to meet evolving Centers for Medicare & Medicaid Services meaningful use and Joint Commission standards. TTS counselors visited smokers at the bedside and offered counseling, recommended smoking cessation medication to be ordered by the primary clinical service, and arranged for postdischarge resources.

RESULTS

During a 3.5-year span, 21,229 smokers (31,778 admissions) were identified; TTS specialists reached 37.4% (7,943), and 33.3% (5,888) of daily smokers received a smoking cessation medication order. Adjusted odds ratios (AORs) of receiving a chart order for smoking cessation medication during the hospital stay and at discharge were higher among patients the TTS counseled > 3 minutes and recommended medication: inpatient AOR = 7.15 (95% confidence interval [CI] = 6.59-7.75); discharge AOR = 5.3 (95% CI = 4.71-5.97). As implementation progressed, TTS counseling reach and medication orders increased. To assess smoking status ≤ 1 month postdischarge, three methods were piloted, all of which were limited by low follow-up rates (4.5%-28.6%).

CONCLUSION

The TTS counseled approximately 3,000 patients annually, with increases over time for reach and implementation. Remaining challenges include the development of strategies to engage inpatient care teams to follow TTS recommendations, and patients postdischarge in order to optimize postdischarge smoking cessation.

Increasing smoking cessation care across a network of hospitals: an implementation study

BACKGROUND

Despite clinical practice guidelines recommending the provision of smoking cessation care to all smokers in hospital, the provision of such care can be sub-optimal. A study was conducted to assess the impact of an intervention on the provision of smoking cessation care to nicotine-dependent smokers across a network of hospitals.

METHODS

A 4-year interrupted time series study was undertaken in a single health district in New South Wales, Australia. A multi-component intervention was implemented over a 2-year period in all 37 public general hospitals. Outcome data were collected from eight randomly selected hospitals via medical record audit. Logistic regression analyses assessed differences between baseline, intervention and follow-up periods in the provision of seven measures of care: brief advice, offer and provision of inpatient and discharge nicotine replacement therapy, and offer and acceptance of referral to a Quitline.

RESULTS

Approximately 164,250 patients were discharged from the hospitals during the study, 16 % of whom were smokers. Of the selected smokers, 56.12 % (n = 2072) were nicotine-dependent. The prevalence of smoking cessation care increased significantly for all seven measures between baseline and intervention periods, and for six of the seven measures between the baseline and follow-up periods. The odds of receiving care at follow-up were between 1.7 (CI 1.18-2.58, p = 0.0004) and 6.2 (CI 2.84-13.85, p < 0.0001) times greater than at baseline. At follow-up, 53, 16 and 7 of smokers were offered inpatient NRT, discharge NRT and a Quitline referral, respectively.

CONCLUSIONS

Significant gains in the provision of smoking cessation care were indicated. However, at best, slightly more than half of the patients received smoking cessation care. Additional care enhancement strategies are required if all smokers are to obtain the intended benefits of smoking cessation care guidelines.

Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment

The implementation of smoke-free policies in inpatient psychiatric facilities, including patient adherence, mental health nursing staff support, and provision of nicotine-dependence treatment to patients, has been reported to be poor. The extent to which the quality of smoke-free policy implementation is associated with patient views of a policy is unknown. We conducted a cross-sectional survey of 181 patients (53.6%, n = 97 smokers; and 46.4%, n = 84 non-smokers) in an Australian inpatient psychiatric facility with a total smoke-free policy. Smokers' adherence to the policy was poor (83.5% smoked). Only half (53.6%) perceived staff to be supportive of the policy. Most smokers used nicotine-replacement therapy (75.3%); although few received optimal nicotine-dependence treatment (19.6%). Overall, 45.9% of patients viewed the smoke-free policy in the unit as positive (29.9% smokers; 64.3% non-smokers). For smokers, adhering to the ban, perceiving staff to be supportive, and reporting that the nicotine-replacement therapy reduced cravings to smoke were associated with a more positive view towards the smoke-free policy. These findings support the importance of patient adherence, mental health nursing staff support, and adequate provision of nicotine-dependence treatment in strengthening smoke-free policy implementation in inpatient psychiatric settings.

Results of an inpatient smoking cessation program: 3-month cessation rate and predictors of success

Background

Hospitalization presents smokers with an opportunity to initiate smoking cessation. We studied the effect of inpatient counseling and follow-up after discharge on smoking cessation and assessed predictors of successful cessation.

Methods

This study included a total of 125 patients (118 male and 7 female) who were admitted to departments of neurology, cardiology, and pulmonology. They were referred to the smoking cessation clinic, and participated between September 2011 and February 2013. A counseling service lasting about thirty minutes was provided by the third-year family medicine residents during hospitalization. The follow-up counseling services, which were either by telephone or in-person physician counseling were provided at 1 week, 4 weeks, and 3 months. Smoking habits and nicotine dependency data were gathered using questionnaires, and patient information was collected from electronic medical records.

Results

The average age in the study was 57.9 ± 10.2 years and duration of smoking was 35.9 ± 11.7 years. Daily tobacco consumption was 23.5 ± 13.2 cigarettes. The smoking cessation rate after 3 months was 42.4%. The only differences between patients in the successful cessation and failed groups were cause of admission (P = 0.039) and total number of counseling sessions after discharge (P < 0.001). In a multivariate analysis, smoking cessation was more likely when patients experienced more instances of follow-up after discharge (1-2 visits: odds ratio [OR], 8.186; 95% confidence interval [CI], 1.060 to 63.239; ≥3 visits: OR, 121.873; 95% CI, 14.462 to 1,027.055).

Conclusion

Smoking cessation counseling during hospitalization and further follow-up by telephone or outpatient counseling after discharge contributed to an increased smoking cessation rate. The smoking cessation rate also tended to increase with total counseling numbers.

Observation of the extent of smoking in a mental health inpatient facility with a smoke-free policy

BACKGROUND

People with a mental illness experience a higher burden of smoking-related disease. Smoke-free policies in mental health facilities provide an opportunity to reduce smoking-related harms for patients and staff alike. Limited evidence regarding the effect of such policies on preventing smoking in mental health facilities has been reported. The aims of this study are to describe the extent of smoking and the provision of nicotine replacement therapy (NRT) to patients in a mental health facility with a smoke-free policy.

METHODS

Cross-sectional studies of smoking (cigarette butt count and observed smoking) and nicotine dependence treatment (patient record audit) were undertaken over 9 consecutive weekdays in one mental health facility in Australia. A smoke-free policy incorporating a total smoking ban and guidelines for treating nicotine dependence among patients was implemented in the facility 4 years prior to the study.

RESULTS

Two thousand one hundred and thirty seven cigarette butts were collected and 152 occasions of people smoking were observed. Staff members were observed to enforce the policy on 66% of occasions. Use of NRT was recorded for 53% of patients who were smokers.

CONCLUSION

Implementation of the smoke-free policy was less than optimal and as a consequence ineffective in eliminating smoking and in optimising the provision of NRT. Additional strategies to improve the provision of nicotine dependence treatment to patients and the monitoring of adherence are needed to ensure the intended benefits of smoke-free policies are realised.

A conceptual model of verbal exchange health literacy

OBJECTIVE

To address a gap in understanding of verbal exchange (oral and aural) health literacy by describing the systematic development of a verbal exchange health literacy (VEHL) definition and model which hypothesizes the role of VEHL in health outcomes.

METHODS

Current health literacy and communication literature was systematically reviewed and combined with qualitative patient and provider data that were analyzed using a grounded theory approach.

RESULTS

Analyses of current literature and formative data indicated the importance of verbal exchange in the clinical setting and revealed various factors associated with the patient-provider relationship and their characteristics that influence decision making and health behaviors. VEHL is defined as the ability to speak and listen that facilitates exchanging, understanding, and interpreting of health information for health-decision making, disease management and navigation of the healthcare system. A model depiction of mediating and influenced factors is presented.

CONCLUSION

A definition and model of VEHL is a step toward addressing a gap in health literacy knowledge and provides a foundation for examining the influence of VEHL on health outcomes.

PRACTICE IMPLICATIONS

VEHL is an extension of current descriptions of health literacy and has implications for patient-provider communication and health decision making.

Smoking behavior among patients and staff: a snapshot from a major metropolitan hospital in Melbourne, Australia

Background

A cross-sectional study was conducted to provide a snapshot of smoking behavior among staff and patients at a major metropolitan hospital in Melbourne.

Methods

Patients and staff were surveyed using a questionnaire exploring demographics, nicotine dependence (Fagerstrom test), readiness to quit, and preference for smoking cessation options.

Results

A total of 1496 people were screened within 2 hours; 1,301 participated (1,100 staff, 199 patients). Mean age was 42 years, 68% were female. There were 113 (9%) current smokers and 326 (25%) ex-smokers. Seven percent of the staff were current smokers compared with 19% of the patients. The Fagerstrom test showed that 47% of patients who smoked were moderately nicotine dependent compared with 21% of staff. A third of the staff who smoked did not anticipate health problems related to smoking. Most patients (79%) who smoked disagreed that their current health problems were related to smoking. Although more than half of the current smokers preferred pharmacotherapy, one in two of them did not prefer behavior counseling; with consistent results among staff and patients. Multivariate analyses showed that patients were three times more likely (odds ratio 3.0, 95% confidence interval 1.9–4.7) to smoke than staff.

Conclusion

This study reports lower prevalence of smoking among hospital staff compared with national data. It also indicates an under-appreciation of health effects of smoking, and a preference not to use conventional methods of quitting.