Referring Hospitalized Smokers to Outpatient Quit Services: A Randomized Trial

Interactive voice response (IVR) for tobacco cessation: a systematic review

OBJECTIVE

To summarise the uses, outcomes and implementation of interactive voice response (IVR) as a tobacco cessation intervention.

DATA SOURCES

A systematic review was conducted. Searches were performed on 3 May 2023. The strategies used keywords such as "tobacco cessation", "smoking reduction" and "interactive voice recording". Ovid MEDLINE ALL, Embase, APA PsycINFO, CINAHL, Cochrane Library and Web of Science were searched. Grey literature searches were also conducted.

STUDY SELECTION

Titles and abstracts were assessed by two independent reviewers. Studies were included if IVR was an intervention for tobacco cessation for adults; any outcomes were reported and study design was comparative. Any abstract included by either reviewer proceeded to full-text review. Full texts were reviewed by two independent reviewers.

DATA EXTRACTION

Data were independently extracted by two reviewers using a standardised form. The Risk of Bias Tool for Randomised Trials and the Risk of Bias in Non-Randomised Studies of Interventions tools were used to assess study quality.

DATA SYNTHESIS

Of 308 identified abstracts, 20 moderate-quality to low-quality studies were included. IVR was used standalone or adjunctly as a treatment, follow-up or risk-assessment tool across populations including general smokers, hospitalised patients, quitline users, perinatal women, patients with cancer and veteran smokers. Effective studies found that IVR was delivered more frequently with shorter follow-up times. Significant gaps in the literature include a lack of population diversity, limited implementation settings and delivery schedules, and limited patient and provider perspectives.

CONCLUSIONS

While the evidence is weak, IVR appears to be a promising intervention for tobacco cessation. However, pilot programmes and research addressing literature gaps are necessary.

Hospital-Initiated Smoking Cessation Among Patients Admitted with Behavioral Health Conditions

BACKGROUND

Smoking rates among people living with behavioral health conditions (BHC) range from 30 to 65% and are 2-4 times higher than rates found in the general population. Starting tobacco treatment during a hospital stay is effective for smoking cessation, but little is known regarding treatment response among inpatients with BHC.

OBJECTIVE

This study pooled data across multiple clinical trials to determine the relative success in quitting among participants with BHC compared to other study participants.

PARTICIPANTS

Adults who smoke (≥ 18 years old) from five hospital-based smoking cessation randomized clinical trials.

DESIGN

A retrospective analysis using data from the electronic health record to identify participants with primary diagnoses related to BHC. Recruitment and data analysis were conducted from 2011 to 2016. We used propensity score matching to pair patients with BHC to those with similar characteristics and logistic regression to determine differences between groups.

MEASURES

The main outcome was self-reported 30-day abstinence 6 months post-discharge.

RESULTS

Of 6612 participants, 798 patients had a BHC-related primary diagnosis. The matched sample included 642 pairs. Nearly 1 in 3 reported using tobacco medications after hospitalization, with no significant difference between patients with and without BHC (29.3% vs. 31.5%; OR (95% CI) = 0.90 (0.71, 1.14), p = 0.40). Nearly 1 in 5 patients with BHC reported abstinence at 6 months; however, their odds of abstinence were 30% lower than among people without BHC (OR (95% CI) = 0.70 (0.53,0.92), p = 0.01).

CONCLUSION

When offered tobacco treatment, hospitalized patients with BHC were as likely as people without BHC to accept and engage in treatment. However, patients with BHC were less likely to report abstinence compared to those without BHC. Hospitals are a feasible and promising venue for tobacco treatment among inpatients with BHC. More studies are needed to identify treatment approaches that help people with BHC achieve long-term abstinence.

Interventions for smoking cessation in hospitalised patients

BACKGROUND

In 2020, 32.6% of the world's population used tobacco. Smoking contributes to many illnesses that require hospitalisation. A hospital admission may prompt a quit attempt. Initiating smoking cessation treatment, such as pharmacotherapy and/or counselling, in hospitals may be an effective preventive health strategy. Pharmacotherapies work to reduce withdrawal/craving and counselling provides behavioural skills for quitting smoking. This review updates the evidence on interventions for smoking cessation in hospitalised patients, to understand the most effective smoking cessation treatment methods for hospitalised smokers.

OBJECTIVES

To assess the effects of any type of smoking cessation programme for patients admitted to an acute care hospital.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 7 September 2022.

SELECTION CRITERIA

We included randomised and quasi-randomised studies of behavioural, pharmacological or multicomponent interventions to help patients admitted to hospital quit. Interventions had to start in the hospital (including at discharge), and people had to have smoked within the last month. We excluded studies in psychiatric, substance and rehabilitation centres, as well as studies that did not measure abstinence at six months or longer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was abstinence from smoking assessed at least six months after discharge or the start of the intervention. We used the most rigorous definition of abstinence, preferring biochemically-validated rates where reported. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 82 studies (74 RCTs) that included 42,273 participants in the review (71 studies, 37,237 participants included in the meta-analyses); 36 studies are new to this update. We rated 10 studies as being at low risk of bias overall (low risk in all domains assessed), 48 at high risk of bias overall (high risk in at least one domain), and the remaining 24 at unclear risk. Cessation counselling versus no counselling, grouped by intensity of intervention Hospitalised patients who received smoking cessation counselling that began in the hospital and continued for more than a month after discharge had higher quit rates than patients who received no counselling in the hospital or following hospitalisation (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.24 to 1.49; 28 studies, 8234 participants; high-certainty evidence). In absolute terms, this might account for an additional 76 quitters in every 1000 participants (95% CI 51 to 103). The evidence was uncertain (very low-certainty) about the effects of counselling interventions of less intensity or shorter duration (in-hospital only counselling ≤ 15 minutes: RR 1.52, 95% CI 0.80 to 2.89; 2 studies, 1417 participants; and in-hospital contact plus follow-up counselling support for ≤ 1 month: RR 1.04, 95% CI 0.90 to 1.20; 7 studies, 4627 participants) versus no counselling. There was moderate-certainty evidence, limited by imprecision, that smoking cessation counselling for at least 15 minutes in the hospital without post-discharge support led to higher quit rates than no counselling in the hospital (RR 1.27, 95% CI 1.02 to 1.58; 12 studies, 4432 participants). Pharmacotherapy versus placebo or no pharmacotherapy Nicotine replacement therapy helped more patients to quit than placebo or no pharmacotherapy (RR 1.33, 95% CI 1.05 to 1.67; 8 studies, 3838 participants; high-certainty evidence). In absolute terms, this might equate to an additional 62 quitters per 1000 participants (95% CI 9 to 126). There was moderate-certainty evidence, limited by imprecision (as CI encompassed the possibility of no difference), that varenicline helped more hospitalised patients to quit than placebo or no pharmacotherapy (RR 1.29, 95% CI 0.96 to 1.75; 4 studies, 829 participants). Evidence for bupropion was low-certainty; the point estimate indicated a modest benefit at best, but CIs were wide and incorporated clinically significant harm and clinically significant benefit (RR 1.11, 95% CI 0.86 to 1.43, 4 studies, 872 participants). Hospital-only intervention versus intervention that continues after hospital discharge Patients offered both smoking cessation counselling and pharmacotherapy after discharge had higher quit rates than patients offered counselling in hospital but not offered post-discharge support (RR 1.23, 95% CI 1.09 to 1.38; 7 studies, 5610 participants; high-certainty evidence). In absolute terms, this might equate to an additional 34 quitters per 1000 participants (95% CI 13 to 55). Post-discharge interventions offering real-time counselling without pharmacotherapy (RR 1.23, 95% CI 0.95 to 1.60, 8 studies, 2299 participants; low certainty-evidence) and those offering unscheduled counselling without pharmacotherapy (RR 0.97, 95% CI 0.83 to 1.14; 2 studies, 1598 participants; very low-certainty evidence) may have little to no effect on quit rates compared to control. Telephone quitlines versus control To provide post-discharge support, hospitals may refer patients to community-based telephone quitlines. Both comparisons relating to these interventions had wide CIs encompassing both possible harm and possible benefit, and were judged to be of very low certainty due to imprecision, inconsistency, and risk of bias (post-discharge telephone counselling versus quitline referral: RR 1.23, 95% CI 1.00 to 1.51; 3 studies, 3260 participants; quitline referral versus control: RR 1.17, 95% CI 0.70 to 1.96; 2 studies, 1870 participants).

AUTHORS' CONCLUSIONS

Offering hospitalised patients smoking cessation counselling beginning in hospital and continuing for over one month after discharge increases quit rates, compared to no hospital intervention. Counselling provided only in hospital, without post-discharge support, may have a modest impact on quit rates, but evidence is less certain. When all patients receive counselling in the hospital, high-certainty evidence indicates that providing both counselling and pharmacotherapy after discharge increases quit rates compared to no post-discharge intervention. Starting nicotine replacement or varenicline in hospitalised patients helps more patients to quit smoking than a placebo or no medication, though evidence for varenicline is only moderate-certainty due to imprecision. There is less evidence of benefit for bupropion in this setting. Some of our evidence was limited by imprecision (bupropion versus placebo and varenicline versus placebo), risk of bias, and inconsistency related to heterogeneity. Future research is needed to identify effective strategies to implement, disseminate, and sustain interventions, and to ensure cessation counselling and pharmacotherapy initiated in the hospital is sustained after discharge.

[Smoking cessation in hospitalised patients - Initiate among inpatients, continue when outpatients - A Position Paper by the German Respiratory Society (DGP) Taskforce for Smoking Cessation]

Tobacco smoking is the greatest preventable health risk. The effects are serious, both individually and societal. Nevertheless, the current prevalence of tobacco smokers in Germany is still high at around 35 %. A recent strong increase in actively smoking adolescents (14- to 17-year-olds, current prevalence approx. 16 %) and young adults (18- to 24-year-olds, current prevalence approx. 41 %) is also a cause for concern. About a third of all inpatients continue smoking while being treated. The hospitalization of active smokers in acute and rehabilitation hospitals serves as a "teachable moment" for initiation of cessation offers. An intervention that begins in hospital and continues for at least a month after discharge results in about 40 % additional smokefree patients. It is scientifically well-researched, effective and cost-efficient. After initiation in hospital these measures can be continued via ambulatory cessation programs, rehabilitation facilities, an Internet or telephone service. In Germany, there are structured and quality-assured cessation offers, both for the inpatient and for the outpatient area. The biggest obstacle to broad establishment of such offers is the lack of reimbursement. Two feasible ways to change this would be the remuneration of the existing OPS 9-501 "Multimodal inpatient treatment for smoking cessation" and the establishment of quality contracts according to § 110a SGB V. An expansion of tobacco cessation measures in healthcare facilities would reduce smoking prevalence, associated burden of disease and consecutive costs.

Text messaging interventions to support smoking cessation among hospitalized patients in Brazil: a randomized comparative effectiveness clinical trial

OBJECTIVE

A clinical trial carried out in patients hospitalized for clinical and surgical conditions. This study evaluated the effectiveness of text messaging interventions (TM) versus telephone counseling (TC) to promote smoking cessation among hospitalized smokers in a middle-income country. Seven-day abstinence was measured during follow-up phone calls one month after discharge. The comparative cost of the two interventions considered the cost of calls, time spent on phone calls and sending SMS and cost of the professional involved in the approaches.

RESULTS

Past 7-day tobacco abstinence was not statistically different between groups (30.5% in TM group and 26% in TC, p = 0.318). Costs were significantly lower in the TM group (U$9.28 × U$19.45- p < 0,001). Continuous abstinence was reported by 26% of TM participants and 24.5% of TC participants (p = 0.730). In the 3-month follow-up, 7-day abstinence was 23% in the TMI and 27% in the TC (p = 0.356) group. Continuous abstinence was reported by 20% of TM participants and 24% of TC participants (p = 0.334).

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03237949 Registred on: 30th May 2017.

Evaluation of a Systems-Based Tobacco Cessation Program Using Bedside Volunteers

INTRODUCTION

Hospitalization and post-discharge provide an opportune time for tobacco cessation. This study tested the feasibility, uptake, and cessation outcomes of a hospital-based tobacco cessation program, delivered by volunteers to the bedside with post-discharge referral to Quitline services. Patient characteristics associated with Quitline uptake and cessation were assessed.

METHODS

Between February and November 2016, trained hospital volunteers approached inpatient tobacco users on six pilot units. Volunteers shared a cessation brochure and used the ASK-ADVISE-CONNECT model to connect ready to quit patients to the Delaware Quitline via fax-referral. Volunteers administered a follow-up survey to all admitted tobacco users via telephone or email at 3-months post-discharge.

RESULTS

Of the 743 admitted tobacco users, 531 (72%) were visited by a volunteer, and 97% (531/547) of those approached, accepted the visit. Over one-third (201/531; 38%) were ready to quit and fax-referred to the Quitline, and 36% of those referred accepted Quitline services. At 3 months post-discharge, 37% (135/368) reported not using tobacco in the last 30 days; intent-to-treat cessation rate was 18% (135/743). In a multivariable regression model of Quitline fax-referral completion, receiving nicotine replacement therapy (NRT) during hospitalization was the strongest predictor (odds ratios [OR] = 1.97; 95% confidence interval [CI] = 1.34 to 2.90). In a model of 3-month cessation, receiving Quitline services (OR = 3.21, 95% CI = 1.35 to 7.68) and having coronary artery disease (OR = 2.28; 95% CI = 1.11 to 4.68) were associated with tobacco cessation, but a volunteer visit was not.

CONCLUSIONS

An "opt-out" tobacco cessation service using trained volunteers is feasible for connecting patients to Quitline services.

IMPLICATIONS

This study demonstrates the feasibility of a systems-based approach to link inpatients to evidence-based treatment for tobacco use. This model used trained bedside volunteers to connect inpatients to a state-funded Quitline after discharge that offers free cessation treatment of telephone coaching and cessation medications. Receiving NRT during hospitalization positively impacted Quitline referral, and engagement with Quitline resources was critical to tobacco abstinence post-discharge. Future work is needed to evaluate the cost-effectiveness and sustainability of this volunteer model.

Promoting cessation in hospitalized smoking patients: a systematic review

OBJECTIVES The objective of this review was to evaluate high intensity post-discharge follow-up strategies to promote smoking cessation in hospitalized patients. METHODS A systematic review was performed, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA - P) protocol. The databases used for research were: PubMed, LILACS/BIREME, Scopus, Web of Science, Cochrane and Scielo. The included articles were randomized clinical trials, published from 1990 to 2018, which evaluated in-hospital and post-discharge intervention, and provided a minimum of 30-day care post discharge. The studies aimed to evaluate tobacco cessation. RESULTS Fourteen studies were selected for analysis. Across studies, pharmacotherapy was consistently effective for smoking cessation. Communication technologies likewise were consistently effective for cessation and post-discharge access. CONCLUSION Effective strategies exist. The challenge for future trials is to determine the best approaches for different clinical contexts, to promote cessation.

Effects of post-discharge counseling and medication utilization on short and long-term smoking cessation among hospitalized patients

Numerous studies have tested the effect of multicomponent post-discharge smoking cessation interventions on post-discharge smoking cessation, and many are effective. However, little is known regarding the relative efficacy of the different intervention components on short or long-term cessation. The present study is a secondary analysis (n = 984) of a randomized controlled trial for hospitalized smokers that took place at two large hospitals in Kansas from 2011 to 2014. All study participants were offered post-discharge quitline services. Pharmacotherapy was recommended during bedside tobacco treatment. The study outcomes were self-reported cessation at 1-month and biochemically verified cessation at 6-months post-randomization. During the post-discharge period, 69% of participants completed at least one quitline call and 28% of participants reported using cessation pharmacotherapy. After controlling for known predictors of cessation among hospitalized smokers, both the number of total quitline calls completed post-discharge and use of cessation pharmacotherapy post-discharge were predictive of cessation at 1-month. After accounting for predictors of cessation and quitting at 1-month, total post-discharge quitline calls was associated with cessation at 6-months (OR [95% CI] = 1.23 [1.12, 1.35], p < 0.001) while post-discharge cessation pharmacotherapy use was not. The results suggest that both engagement in quitline services and use pharmacotherapy independently facilitate cessation beyond the influence of known clinical characteristics associated with cessation. Over the longer term, the effect of engaging in quitline services persists while the effect of pharmacotherapy diminishes. To optimize outcomes, future research should investigate methods to increase utilization of medications and promote sustained counseling engagement in order to sustain the effects of treatment during the post-discharge period.

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Counseling and pharmacotherapy are effective interventions for helping hospitalized smokers quit smoking, but the relative contribution of each intervention component to short or long-term abstinence is not well understood

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This secondary analysis of a large clinical trial found that quitline counseling and pharmacotherapy – when used after hospital discharge - were associated with increased odds of quitting smoking at 1-month follow up

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Controlling for early abstinence at 1 month, only post-discharge quitline counseling remained predictive of cessation at 6-months follow-up

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Pharmacotherapy and quitline counseling independently facilitate short-term abstinence, while long-term abstinence is facilitated by engagement in quitline counseling services

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Hospitals could work directly with state quitlines to integrate counseling into post-discharge care

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I2 statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I2 = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I2 = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I2 = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.