Tobacco Treatment Program Models in US Hospitals and Outpatient Centers on Behalf of the SRNT Treatment Network

Sustainability of an Opt-Out Electronic-Health Record-Based Tobacco Treatment Consult Service at a Large Safety-Net Hospital: A 6-Year Analysis

INTRODUCTION

Our safety-net hospital implemented a hospital-based tobacco treatment intervention in 2016. We previously showed the intervention, an "opt-out" Electronic Health Record (EHR)-based Best Practice Alert (BPA)+ order-set that triggers consultation to an inpatient Tobacco Treatment Consult (TTC) service for all patients who smoke, improves smoking abstinence. We now report on sustainability, 6 years after inception.

AIMS AND METHODS

We analyzed data collected between July 2016-June 2022 of patients documented as "currently smoking" in the EHR. Across the 6 years, we used Pearson's correlation analysis to compare Adoption (clinician acceptance of the BPA+ order-set, thus generating consultation to the TTC service); Reach (number of consultations completed by the TTC service); and Effectiveness (receipt of pharmacotherapy orders between patients receiving and not receiving consultations).

RESULTS

Among 39 558 adult admissions (July 2016-June 2022) with "currently smoking" status in the EHR for whom the BPA triggered, clinicians accepted the TTC order set on 50.4% (19 932/39 558), though acceptance varied across services (eg, Cardiology [71%] and Obstetrics-Gynecology 12%]). The TTC service consulted on 17% (6779/39 558) of patients due to staffing constraints. Consultations ordered (r = -0.28, p = .59) and completed (r = 0.45, p = .37) remained stable over 6-years. Compared to patients not receiving consultations, patients receiving consultations were more likely to receive pharmacotherapy orders overall (inpatient: 50.8% vs. 35.1%, p < .0001; at discharge: 27.1% vs. 10%, p < .0001) and in each year.

CONCLUSIONS

The "opt-out" EHR-based TTC service is sustainable, though many did not receive consultations due to resource constraints. Health care systems should elevate the priority of hospital-based tobacco treatment programs to increase reach to underserved populations.

IMPLICATIONS

Our study shows that opt-out approaches that utilize the EHR are a sustainable approach to providing evidence-based tobacco treatment to all hospitalized individuals who smoke, regardless of readiness to stop smoking and clinical condition.

Enabling tobacco treatment for gastroenterology patients via a novel low-burden point-of-care model

BACKGROUND & AIM

Smoking is a major risk factor for multiple gastrointestinal cancers, and adversely affects peptic ulcer disease, gastroesophageal reflux, pancreatitis and Crohn's disease. Despite key recommendations for diagnosing and treating tobacco use disorder in healthcare settings, the degree to which this is implemented in Gastroenterology (GI) clinics is unknown. We aimed to assess our providers' practices, identify barriers for implementing evidence-based smoking cessation treatments, and address these barriers by implementing a novel low-burden point of care Electronic health record-enabled evidence-based tobacco treatment (ELEVATE), in GI clinics.

METHODS

An online survey was distributed to clinic gastroenterologists. ELEVATE module training was implemented in 1/2021. Data were evaluated during pre (7/2020-12/2020) and post (1/2021-12/2021) implementation periods to evaluate the reach and effectiveness of ELEVATE. Generalized estimating equations (GEE) were used to generate rate ratios (RR) to evaluate the intervention.

RESULTS

91% (20/22) of GI physicians responded to our survey, and only 20% often assisted patients who smoke with counseling. Lack of a systematic program to offer help to patients was reported by 80% of providers as an extremely/very important barrier limiting their smoking cessation practices. The proportion of current patients who smoke receiving cessation treatment increased from pre-ELEVATE to post-ELEVATE (14.36-27.47%, RR = 1.90, 95% CI 1.60-2.26, p < .001). Post-ELEVATE, 14.4% (38/264) of patients with treatment quit smoking, compared to 7.9% (55/697) of patients without treatment (RR = 1.89, 95% CI 1.26-2.82, p = .0021).

CONCLUSION

Smoking practices are frequently assessed in GI clinics but barriers limiting cessation treatment exist. The use of a low burden point of care EHR enabled smoking cessation treatment module has led to a significant improvement in the treatment of smoking and subsequent cessation in our clinics. This study sheds light on an often under-recognized source of morbidity in GI patients and identifies an efficient, effective, and scalable strategy to combat tobacco use and improve clinical outcomes in our patients.

Implementation of an "opt-out" tobacco treatment program in six hospitals in South Carolina

OBJECTIVE

Describe the screening, referral, and treatment delivery associated with an opt-out tobacco treatment program (TTP) implemented in six hospitals varying in size, rurality and patient populations.

METHODS

Between March 6, 2021 and December 17, 2021, adult patients (≥ 18 years) admitted to six hospitals affiliated with the Medical University of South Carolina were screened for smoking status. The hospitals ranged in size from 82 to 715 beds. Those currently smoking were automatically referred to one of two tobacco treatment options: 1) Enhanced care (EC) where patients could receive a bedside consult by a trained tobacco treatment specialist plus an automated post-discharge follow-up call designed to connect those smoking to the South Carolina Quitline (SCQL); or 2) Basic care (BC) consisting of the post-discharge follow-up call only. An attempt was made to survey patients at 6-weeks after hospitalization to assess smoking status.

RESULTS

Smoking prevalence ranged from 14 to 49% across the six hospitals; 6,000 patients were referred to the TTP.The delivery of the bedside consult varied across the hospitals with the lowest in the Charleston hospitals which had the highest caseload of referred patients per specialist. Among patients who received a consult visit during their hospitalization, 50% accepted the consult, 8% opted out, 3% claimed not to be current smokers, and 38% were unavailable at the time of the consult visit. Most of those enrolled in the TTP were long-term daily smokers.Forty-three percent of patients eligible for the automated post-discharge follow-up call answered the call, of those, 61% reported smoking in the past seven days, and of those, 34% accepted the referral to theSCQL. Among the 986 of patients surveyed at 6-weeks after hospitalization quit rates ranged from 20%-30% based on duration of reported cessation and were similar between hospitals and for patients assigned to EC versus BC intervention groups.

CONCLUSION

Findings demonstrate the broad reach of an opt-out TTP. Elements of treatment delivery can be improved by addressing patient-to-staffing ratios, improving systems to prescribe stop smoking medications for patients at discharge and linking patients to stop smoking services after hospital discharge.

Tobacco treatment in the setting of lung cancer screening

PURPOSE OF REVIEW

Lung cancer screening by low-dose CT is an increasingly implemented preventive medicine tool. Screening for lung cancer is incomplete without addressing problematic tobacco use, the greatest modifiable risk factor in the development of lung cancer. This review describes recent work related to lung cancer screening and treatment of tobacco use in that context.

RECENT FINDINGS

Implementation of lung cancer screening demonstrates socioeconomic disparities in terms of adherence to screening as well as likelihood of successful tobacco dependence treatment. Active tobacco dependence is a common comorbidity for patients undergoing lung cancer screening. The optimal implementation of tobacco dependence treatment in the context of lung cancer screening is still an area of active investigation.

SUMMARY

Treatment of tobacco dependence at time of lung cancer screening is a major opportunity for clinicians to intervene to reduce the major modifiable risk factor for lung cancer, tobacco use. Providing comprehensive tobacco dependence treatment is most effective using combination pharmacologic and behavioral interventions. Practices providing comprehensive treatment will benefit from accurate documentation for billing and coding and supplementing with external resources such as state Quit Lines.

Nicotine replacement therapy for vaping cessation among mono and dual users: A mixed methods preliminary study

Many adults express interest in e-cigarette cessation; however, there are few empirically tested interventions for quitting vaping. This study seeks to (1) evaluate reasons for quitting e-cigarettes in treatment-seeking adults, and (2) assess the feasibility and acceptability of nicotine replacement therapy (NRT) for e-cigarette cessation. Adult daily e-cigarette users completed qualitative interviews about quitting e-cigarettes, then were randomized to either 28-day supply of combination NRT (21 mg patches, 4 mg lozenges) + supportive booklet or Quitline referral. Primary aims were feasibility (number who enrolled) and acceptability (NRT use, adverse side effects). Exploratory aims evaluated abstinence (7-day point-prevalence) at end of treatment. Of the 30 participants who were enrolled, 50 % (n = 15) were dual users, and 50 % (n = 15) were mono-vapers, 26.6 % (n = 8) of whom were former smokers. Participants reported seeking treatment due to health concerns, dependence, stigma, and cost. Anticipated challenges of quitting vaping were withdrawal, negative mood, sensorimotor habits, and convenience. Most completed the end of treatment survey (n = 24; 80 %). Participants who received NRT reported using the patch M = 10.89 days and lozenges M = 6.39 days, with few days of adverse effects (M = 2.67). At end of treatment, 6/18 (33.3 %; 6 mono and 0 dual users) in the intervention group reported abstinence from vaping, compared to 0 in the control group (Fisher = 5.00, p =.057). In conclusion, adults are interested in quitting e-cigarettes due to negative consequences of use and are willing to use pharmacotherapy. Future research should confirm these results in a larger trial, address cigarette smoking in dual users, and aim to disseminate treatments.

Tobacco Treatment Outcomes for Hospital Patients With and Without Mental Health Diagnoses

BACKGROUND

The prevalence of mental health conditions is higher in cigarette smokers than nonsmokers. However, those with diagnosed mental health disorders are understudied within general inpatient hospital settings. This study seeks to evaluate how having a mental health diagnosis influences response to a brief opt-out inpatient tobacco treatment intervention.

METHODS

Data included 4,153 admitted patients who completed a tobacco treatment visit. Post-discharge self-reported abstinence was obtained via response to an automated call 1-month after discharge. Mental health co-morbidities were assessed by reviewing electronic medical records. Logistic regression was used to assess associations between having a mental health diagnosis and patients' smoking history, interest in quitting smoking, and post-discharge abstinence.

RESULTS

Overall 34.1% of patients were diagnosed with mental health disorders, most commonly depression or substance use disorders. Patients with a diagnosed mental health disorder were more likely to report a history of long-term heavy smoking and were less likely to express an interesting in remaining abstinent from smoking after hospitalization. An intent-to-treat analysis using logistic regression analysis found lower rates of self-reported smoking abstinence in those with a mental health disorder compared to those without (9 vs. 13.2%, p < 0.001).

CONCLUSIONS

Patients with a history of mental health diagnoses, such as depression or substance use disorders, was associated with lower rates of smoking abstinence in patients after hospitalization. Hospital based opt-out smoking cessation programs have shown to be generally effective and efficient. However, certain subpopulations may require tailored intervention in order to improve treatment outcomes. Future research is needed to develop brief, effective tobacco treatment for hospital patients with comorbid mental health diagnoses.