Smoking cessation. 3: Needed healthcare policy changes

Patients' and healthcare professionals' views on a specialist smoking cessation service delivered in a United Kingdom hospital: a qualitative study

BACKGROUND

Hospital admission provides a powerful opportunity to promote smoking cessation. We explored patients' and healthcare professionals' (HCP) views of a specialist smoking cessation service comprising systematic smoking ascertainment, default provision of pharmacotherapy and behavioural counselling at the bedside, and post-discharge follow-up, in a clinical trial in a United Kingdom teaching hospital.

METHODS

Semi-structured interviews with 30 patients who were offered the intervention, and 27 HCPs working on intervention wards, were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

The shock of being admitted, and awareness that smoking may have contributed to the need for hospital admission, caused many patients to reassess their quit intentions. Most patients felt the service was too good an opportunity to pass up, because having long-term support and progress monitored was more likely to result in abstinence than trying alone. Had they not been approached, many patients reported that they would have attempted to quit alone, though some would have been discouraged from doing so by pharmacotherapy costs. Service delivery by a specialist advisor was favoured by patients and HCPs, largely because HCPs lacked time and expertise to intervene. HCPs reported that in usual practice, discussions about smoking were usually limited to ascertainment of smoking status. Timing of service delivery and improved co-ordination between service staff and inpatient ward staff were matters to address.

CONCLUSIONS

A hospital-based specialist smoking cessation service designed to identify smokers and initiate cessation support at the bedside was deemed appropriate by patients and HCPs.

TRIAL REGISTRATION

Trial registration: ISRCTN25441641.

Helping hospital patients quit: what the evidence supports and what guidelines recommend

OBJECTIVE

The study aimed to critically appraise the extent and strength of systematic review evidence for, and guideline recommendations regarding hospital smoking cessation interventions.

METHODS

Systematic reviews of smoking cessation interventions were identified via an electronic search of the Cochrane Library. Meta-analyses from Cochrane reviews were categorised as those that incorporated only studies of hospital based interventions, and those which incorporated interventions which were not hospital based. Smoking cessation guidelines for hospital health professionals were identified via a search of the World Wide Web.

RESULTS

The review found that evidence from meta-analyses restricted to hospital studies was insufficient to evaluate a number of specific intervention strategies and at times conflicted with the findings of meta-analyses without such restrictions. The majority of guidelines recommended the provision of brief advice, counseling, nicotine replacement therapy despite the absence of clear supporting evidence.

CONCLUSIONS

Further hospital-based research addressing specific cessation strategies is required. Furthermore, smoking cessation guidelines for hospital based health professionals should more specifically reflect evidence from this setting.

Computerized assessment of surgical patients for tobacco use: accuracy and acceptability

BACKGROUND

Despite increased risks of postoperative complications among patients who use tobacco, a number of barriers hinder the systematic identification of surgical patients who smoke. The study investigated the accuracy and acceptability of a patient-completed touchscreen computer program, which assessed patient smoking status during attendance at a surgical pre-operative clinic.

METHODS

One thousand and four patients participated in the study and completed a touchscreen computer smoking assessment program.

RESULTS

The sensitivity and specificity measures of the computerized assessment were 93% and 95% respectively. Patients, and clinic receptionists, nurses and anaesthetists found the touchscreen computer-based assessment acceptable.

CONCLUSIONS

The findings suggest that computerized assessment of smoking status is an accurate and acceptable way to identify tobacco users in a pre-operative clinic setting.

Increasing smoking cessation care in a preoperative clinic: a randomized controlled trial

BACKGROUND

Evidence suggests that preoperative clinics, like other hospital outpatient clinics and inpatient wards, fail to systematically provide smoking cessation care to patients having planned surgery.

METHODS

The aim of the study was to assess the efficacy, acceptability, and cost of a multifaceted intervention to facilitate the provision of comprehensive smoking cessation care to patients attending a preoperative clinic. Two hundred ten smoking patients attending a preoperative clinic at a major teaching hospital in Australia took part in the study. One hundred twenty-four patients were randomly assigned to an experimental group and 86 patients to a usual cessation care group. A multifaceted intervention was developed that included the use of opinion leaders, consensus processes, computer-delivered cessation care, computer-generated prompts for care provision by clinic staff, staff training, and performance feedback.

RESULTS

Ninety-six percent of experimental group patients received behavioral counseling and tailored self-help material. Experimental group patients were significantly more likely than usual care patients to report receiving brief advice by nursing (79% vs. 47%; P < 0.01) and anaesthetic (60% vs. 39%; P < 0.01) staff. Experimental group patients who were nicotine dependent were also more likely to be offered preoperative nicotine replacement therapy (NRT) (82% vs. 8%; P < 0.01) and be prescribed postoperative NRT (86% vs. 0%; P < 0.01). The multifaceted intervention was found to be acceptable by staff.

CONCLUSION

A multifaceted clinical practice change intervention may be effective in improving the delivery of smoking cessation care to preoperative surgical patients.

Smoking care provision in smoke-free hospitals in Australia

BACKGROUND

The study aimed to (1) determine the current routine smoking care that smoke-free public hospitals in New South Wales (NSW), Australia, provide to inpatients who are smokers; (2) determine current strategies supporting such care; and (3) examine the association between smoking care provision and hospital characteristics and support strategies.

METHOD

A cross-sectional survey of 169 senior hospital managers was undertaken. Survey items included smoking care practices such as identification of smoking status and provision of nicotine replacement therapy as well as hospital activities such as existence of policies and staff training. Hospital characteristics such as size and geographic location were also collected.

RESULTS

Twenty percent of respondents reported provision of minimally 'adequate' smoking care, defined as providing five or more smoking care items to 80% or more of patients. Larger hospitals were significantly less likely to provide adequate smoking care. Nurse training, the existence of signs indicating a smoke-free site and signs indicating location of designated smoking areas were also associated with smoking care provision. The existence of three or more support strategies was associated with smoking care provision.

CONCLUSION

Even in the context of a smoke-free hospital site, the majority of inpatients who are smokers receive inadequate smoking care. Considered investment is required for hospitals to implement strategies to institutionalise the routine provision of appropriate smoking care.

Novel strategy to stop cigarette smoking by surgical patients: Pilot study in a preadmission clinic

BACKGROUND

Evidence-based guidelines suggest that all services, wards and clinics within hospitals consider smoking status a vital sign and routinely provide cessation care. Despite this, such opportunities are currently under-utilized. The aim of the present pilot study was to determine the potential effectiveness, feasibility and acceptability of computer delivery of smoking cessation advice to surgical preadmission patients.

METHODS

All smokers attending a non-cardiac surgical preadmission clinic at the John Hunter Hospital, New South Wales, completed a brief computerized smoking cessation intervention programme. Nine months following completion of the programme, patients completed a follow-up telephone interview that assessed their smoking status and the acceptability of the programme.

RESULTS

At follow up, 22 of the 37 participants (60.0%) reported that they had stopped smoking prior to their surgery 9 months previously. Of the 37 participants at follow up, five reported that they were no longer smokers at that time, a cessation rate of 13.5%. Among those patients still smoking, a trend toward smoking fewer cigarettes was evident. Of the 56 smokers at baseline, all completed the computerized smoking cessation programme, with an average completion time of 21 min. A large majority of the smokers (80%) and non-smokers (88%) found that the provision of smoking cessation advice by the computer was appropriate and acceptable. Extrapolation of the results to a full year suggests a cost per quitter of $443.

CONCLUSIONS

An interactive computerized smoking cessation programme is an acceptable and feasible method of routinely encouraging surgical preadmission clinic patients to stop or reduce their smoking. Further development and testing of the efficacy of this approach is required.

Social ecology and behavioral medicine: implications for training, practice, and policy

Social ecology offers a conceptual framework for understanding the etiology of multiple health problems and a basis for designing broad-gauge educational, therapeutic, and policy interventions to enhance personal and community well-being. Implications of social ecology for behavioral medicine are considered in relation to the development of diagnostic and therapeutic practices, professional training programs, and health policies implemented at municipal, state, and national levels. By influencing the training and practices of healthcare professionals and the decisions of corporate and community leaders, behavioral medicine can expand the scope and impact of future interventions beyond the health gains achievable through provision of direct services to patient populations. Potential barriers to establishing ecologically based health programs and policies and directions for research at the interface of behavioral medicine, social ecology, and public health are discussed.

Smoking cessation in the hospitalized patient using the transtheoretical model of behavior change

Tobacco use continues to be the most prevalent cause of preventable morbidity and mortality in the United States, causing more than 430,000 deaths each year, or 1 in every 5 deaths. In addition, many health care providers employed in critical care settings deal with patients who have experienced a near-death event that has led them to consider smoking cessation. The smoking cessation rate 1 year after a myocardial infarction is approximately 70% in those patients who receive a smoking cessation intervention. Theory-based smoking cessation interventions have been found to be effective. The purpose of this article is to present the transtheoretical model as basis for developing a hospital-based smoking cessation intervention. In addition, symptom management options will be discussed.

Reducing the addictiveness of cigarettes. Council on Scientific Affairs, American Medical Association

OBJECTIVE

To assess the feasibility of reducing tobacco-caused disease by gradually removing nicotine from cigarettes until they would not be effective causes of nicotine addiction.

DATA SOURCES

Issues posed by such an approach, and potential solutions, were identified from analysis of literature published by the US Food and Drug Administration (FDA) in its 1996 Tobacco Rule, comments of the tobacco industry and other institutions and individuals on the rule, review of the reference lists of relevant journal articles, other government publications, and presentations made at scientific conferences.

DATA SYNTHESIS

The role of nicotine in causing and sustaining tobacco use was evaluated to project the impact of a nicotine reduction strategy on initiation and maintenance of, and relapse to, tobacco use. A range of potential concerns and barriers was addressed, including the technical feasibility of reducing cigarette nicotine content to non-addictive levels, the possibility that compensatory smoking would reduce potential health benefits, and whether such an approach would foster illicit ("black market") tobacco sales. Education, treatment, and research needs to enable a nicotine reduction strategy were also addressed. The Council on Scientific Affairs came to the following conclusions: (a) gradually eliminating nicotine from cigarettes is technically feasible; (b) a nicotine reduction strategy holds great promise in preventing adolescent tobacco addiction and assisting the millions of current cigarette smokers in their efforts to quit using tobacco products; (c) potential problems such as compensatory over-smoking of denicotinised cigarettes and black market sales could be minimised by providing alternate forms of nicotine delivery with less or little risk to health, as part of expanded access to treatment; and (d) such a strategy would need to be accompanied by relevant research and increased efforts to educate consumers and health professionals about tobacco and health.

CONCLUSIONS

The council recommends the following: (a) that cessation of tobacco use should be the goal for all tobacco users; (b) that the American Medical Association continue to support FDA authority over tobacco products, and FDA classification of nicotine as a drug and tobacco products as drug-delivery devices; (c) that research be encouraged on cigarette modifications that may result in less addicting cigarettes; (d) that the FDA require that the addictiveness of cigarettes be reduced within 5-10 years; (e) expanded surveillance to monitor trends in the use of tobacco products and other nicotine-containing products; (f) expanded access to smoking cessation treatment, and strengthening of the treatment infrastructure; and (g) more accurate labelling of tobacco products, including a more meaningful and understandable indication of nicotine content.