Can smokers switch from a hospital-based to a community-based stop smoking service? an open-label, randomized trial comparing three referral schemes

Considerations for a head and neck smoking cessation support programme; A qualitative study of the challenges in quitting smoking after treatment for head and neck cancer

PURPOSE

Smoking is a major cause of head and neck squamous cell carcinoma (HNSCC), yet many patients who receive a diagnosis continue to smoke. This has an adverse effect on treatment and recovery, and leads to increased risks of recurrence and second cancers. There is evidence that stopping smoking after diagnosis can lead to better outcomes and reversal of risks. However, there is limited evidence for effective smoking cessation interventions in this population, and little about patient opinions regarding quitting smoking and support provided by healthcare professionals.

METHODS

This qualitative study was conducted as part of a larger project with the objective of developing a smoking cessation support programme. Eleven patients who had completed head and neck cancer (HNC) treatment were interviewed about smoking and quitting attempts. Interviews were semi-structured and took place face-to-face or over the phone.

RESULTS

Participants gave detailed accounts of their smoking journey. Thematic analysis of the data led to the identification of 2 overarching themes and four interlinking themes. Themes describe the 'guilty habit' of smoking, perceived 'barriers to quit', the 'teachable moment' of a diagnosis and the contrary 'social motivation' to both smoke and quit.

CONCLUSIONS

The results of this study highlight some missed needs for this group and major gaps in the support that is available. It is intended that the results will be used to develop a support programme for quitting smoking long term in a way that is useful and relevant to this complex population.

Treatment of tobacco dependence in UK hospitals: an observational study

Over a million smokers are admitted to hospitals in the UK each year. The extent to which tobacco dependence is identified and addressed in this population is unclear. Data on 14,750 patients from 146 hospitals collected for the British Thoracic Society smoking cessation audit were analysed to determine smoking prevalence, attempts to ask smokers about quitting, and referrals to smoking cessation services. Associations with hospital organisational factors were assessed by logistic regression. Overall hospital smoking prevalence was 25%. Only 28% of smokers were asked whether they would like to quit, and only one in 13 smokers was referred for treatment of tobacco dependence. There was a higher chance of smokers being asked about quitting in organisations with smoke-free sites, dedicated smoking cessation practitioners, regular staff training, and availability of advanced pharmacotherapy. Treatment of tobacco dependence in smokers attending UK hospitals is poor and could be associated with organisational factors.

Referring Hospitalized Smokers to Outpatient Quit Services: A Randomized Trial

INTRODUCTION

Linking outpatient cessation services to bedside counseling for hospitalized smokers can improve long-run quit rates. Adding an assisted referral (AR) offer to a tobacco treatment specialist consult service fits the team approach to care in U.S. hospitals.

DESIGN

A two-arm patient-randomized trial tested the effectiveness of adding an AR offer to outpatient smoking-cessation services and interactive voice recognition (AR+IVR) follow-up to a usual care (UC) tobacco-cessation consult for hospitalized smokers.

SETTING/PARTICIPANTS

Over 24 months (November 2011-November 2013), 898 hospitalized adult smokers interested in quitting smoking were recruited from three large hospitals in the Portland, Oregon, area: an integrated group model HMO (n=622), a community hospital (n=195), and an academic health center (n=81).

INTERVENTION

Tobacco treatment specialists identified smokers and provided an intensive bedside tobacco use assessment and cessation consultation (UC). AR+IVR recipients also received proactive ARs to available outpatient counseling programs and medications, and linked patients to a tailored IVR telephone follow-up system.

MAIN OUTCOME MEASURES

The primary outcome was self-reported 30-day abstinence at 6-month follow-up. Secondary outcomes included self-reported and continuous abstinence and biochemically confirmed 7-day abstinence at 6 months. Follow-up was completed in September 2014; data were analyzed in 2015.

RESULTS

A total of 597 and 301 hospitalized smokers were randomized to AR+IVR and UC, respectively. AR+IVR and UC recipients received 19.3 and 17.0 minutes of bedside counseling (p=0.372), respectively. Most (58%) AR+IVR patients accepted referrals for counseling, 43% accepted medications, and 28% accepted both. Self-reported 30-day abstinence for AR+IVR (17.9%) and UC (17.3%) were not statistically significant (p=0.569). Differences in 7-day, continuous, and biochemically confirmed abstinence by treatment group also were insignificant, overall and adjusting for site.

CONCLUSIONS

Adding an AR to outpatient counseling and medications did not increase cigarette abstinence at 6 months compared to UC alone.

Brief advice and active referral for smoking cessation services among community smokers: a study protocol for randomized controlled trial

Background

Most smokers do not use smoking cessation (SC) services although it increases successful quits. Passive referral providing SC information to smokers is commonly used in SC studies. Little was known about active referral in the community setting. This study aims to motivate community smokers to quit by brief SC advice using a validated AWARD model (Ask, Warn, Advise, Refer and Do-it-again) that adjunct with active referral of smokers to various SC services in Hong Kong.

Methods/Design

This is a single-blinded, parallel three-armed cluster randomized controlled trial (RCT) with two treatment groups of (1) brief SC advice using the AWARD model, active referral to SC services plus a referral card and a health warning leaflet (active referral group) and (2) brief SC advice using AWARD model and health warning leaflet (brief advice group) and a control group receives general very brief advice with a self-help booklet. A total of 1291 smokers will be recruited from 66 clusters (recruitment sessions) with 22 will be allocated to each of the two intervention and one control groups. SC ambassadors will be trained for delivering the interventions and conducting telephone follow-up. The primary outcomes are self-reported 7-days point prevalence (PP) abstinence at 3 and 6 months follow-up. Intention-to-treat principle and multi-level regressions will be used for data analysis.

Discussion

This is the first RCT on assessing a model combining brief advice and active referral to SC services among community smokers. The results will inform the practices of SC services and intervention studies.

Trial registration

NCT02539875 (ClinicalTrials.gov registry; registered retrospectively on 22 July 2015)

"Tobacco dependence treatment makes no sense because"…: rebuttal of commonly-heard arguments against providing tobacco dependence treatment in the hospital setting

BACKGROUND

The provision of tobacco dependence treatment in health care settings, particularly in countries lacking a history of strong tobacco control policy implementation, is limited by continued misconceptions on the part of health professionals and decision-makers regarding its worth and efficacy. In this paper, we rebut 9 arguments against the provision of tobacco dependence treatment that we have encountered in our experiences implementing and maintaining a dedicated smoking cessation service at a large university hospital in southern Germany.

DISCUSSION

Broadly, the arguments relate to the nature of addiction, the efficacy and safety of stop-smoking medication and behavioural support, and the benefits and challenges of quitting. They include: (a) If smokers really want to quit, they will be able to do it alone (without help); (b) You can't forbid patients from doing what they want; (c) Patients will be upset if you talk to them about their smoking; (d) Stop-smoking medication has side effects that are more dangerous than smoking; (e) You have to be well trained to help smokers to quit (otherwise you can do more harm than good); (f) If you smoke yourself, you lack credibility; (g) If you have cancer, it is too late to quit; (h) Nicotine withdrawal is dangerous for heavy smokers; and (i) Smokers die earlier, thus reducing costs to the health system.

SUMMARY

It is hoped that the counter-arguments presented here arm tobacco control advocates and practitioners working in health care settings, particularly in countries which have not prioritised tobacco control, to respond appropriately and convincingly to those opposed to the provision of tobacco dependence treatment.

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.

Implementation and effectiveness of a hospital smoking cessation service in Germany

OBJECTIVE

Hospitalized smokers are often highly motivated to quit and receptive to assistance. There are few published accounts of hospital-based smoking cessation programmes implemented outside of a trial setting, particularly outside North America. We describe the implementation and effectiveness of a dedicated smoking cessation service in Freiburg, Germany.

METHODS

Measures of implementation (e.g. number of patients referred and consenting to participate, receipt of post-discharge support) and effectiveness are presented.

RESULTS

In the first 2 years of the service, 1432 patients were referred. Over half (55.3%) of counselled smokers agreed to participate. Sustained abstinence for 6 months was achieved by 28.0% (missing cases coded as smokers), whereas 7-day point prevalence rates were between 30 and 35% at 3, 6 and 12 months. Those who received 4+ post-discharge calls were more likely to achieve sustained abstinence, as were older smokers, those with higher self-efficacy, and cardiovascular patients.

CONCLUSION

Hospitalized patients in Germany are receptive to the offer of bedside counselling and to phone support post-discharge, and success rates are comparable to those achieved in other countries.

PRACTICE IMPLICATIONS

The findings argue strongly for the routine identification of smokers upon hospital admission, and the availability of cessation support both during hospitalization and following discharge.

Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial

OBJECTIVES

To investigate the effectiveness of the systematic default provision of smoking cessation support to all adult smokers admitted to hospital, relative to usual care.

DESIGN

Open, cluster randomised controlled trial.

SETTING

Acute medical wards in one large teaching hospital in the United Kingdom.

PARTICIPANTS

264 patients randomised to intervention and 229 to usual care; primary outcome data were available at four weeks for 260 and 224 patients, respectively. All adult smokers and recent ex-smokers able to give informed consent were eligible for entry into the study.

INTERVENTIONS

The intervention comprised systematic smoking ascertainment and default provision of behavioural support and cessation pharmacotherapy for the duration of the hospital stay for all smokers and recent ex-smokers, with follow-up and referral to community services after discharge. Usual care comprised cessation support delivered at the initiative and discretion of clinical staff. All staff and patients were aware of group assignment.

MAIN OUTCOME MEASURES

Smoking cessation at four weeks, validated by measuring exhaled carbon monoxide. Secondary outcomes were uptake of inpatient behavioural support, use of cessation pharmacotherapy, referral to and uptake of community support after discharge, and validated smoking cessation at six months. Participants lost to follow-up were assumed to have reverted to smoking.

RESULTS

All patients in the intervention group received at least brief advice to quit smoking, compared to 106 (46%) patients in the usual care group. Cessation at four weeks was achieved by 38% (n=98) of intervention patients and 17% (n=37) of usual care patients (adjusted odds ratio 2.10 (95% confidence interval 0.96 to 4.61), P=0.06, number of patients needed to treat 8). Uptake of inpatient behavioural support, use of pharmacotherapy, and referral to and uptake of community support after discharge were all substantially and statistically significantly higher in the intervention group than in the usual care group. Cessation at six months was achieved by 19% (n=47) of intervention and 9% (n=19) of usual care patients, although this difference was not significant (adjusted odds ratio 1.53 (95% confidence interval 0.60 to 3.91); P=0.37).

CONCLUSIONS

Substantial improvements in smoking cessation among smokers admitted to hospital can be achieved by systematic ascertainment and delivery of cessation support in secondary care.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN25441641.

Health and economic effects from linking bedside and outpatient tobacco cessation services for hospitalized smokers in two large hospitals: study protocol for a randomized controlled trial

BACKGROUND

Extended smoking cessation follow-up after hospital discharge significantly increases abstinence. Hospital smoke-free policies create a period of 'forced abstinence' for smokers, thus providing an opportunity to integrate tobacco dependence treatment, and to support post-discharge maintenance of hospital-acquired abstinence. This study is funded by the National Heart, Lung, and Blood Institute (1U01HL1053231).

METHODS/DESIGN

The Inpatient Technology-Supported Assisted Referral study is a multi-center, randomized clinical effectiveness trial being conducted at Kaiser Permanente Northwest (KPNW) and at Oregon Health & Science University (OHSU) hospitals in Portland, Oregon. The study assesses the effectiveness and cost-effectiveness of linking a practical inpatient assisted referral to outpatient cessation services plus interactive voice recognition (AR + IVR) follow-up calls, compared to usual care inpatient counseling (UC). In November 2011, we began recruiting 900 hospital patients age ≥18 years who smoked ≥1 cigarettes in the past 30 days, willing to remain abstinent postdischarge, have a working phone, live within 50 miles of the hospital, speak English, and have no health-related barriers to participation. Each site will randomize 450 patients to AR + IVR or UC using a 2:1 assignment strategy. Participants in the AR + IVR arm will receive a brief inpatient cessation consult plus a referral to available outpatient cessation programs and medications, and four IVR follow-up calls over seven weeks postdischarge. Participants do not have to accept the referral. At KPNW, UC participants will receive brief inpatient counseling and encouragement to self-enroll in available outpatient services. The primary outcome is self-reported thirty-day smoking abstinence at six months postrandomization for AR + IVR participants compared to usual care. Additional outcomes include self-reported and biochemically confirmed seven-day abstinence at six months, self-reported seven-day, thirty-day, and continuous abstinence at twelve months, intervention dose response at six and twelve months for AR + IVR recipients, incremental cost-effectiveness of AR + IVR intervention compared to usual care at six and twelve months, and health-care utilization and expenditures at twelve months for AR + IVR recipients compared to UC.

DISCUSSION

This study will provide important evidence for the effectiveness and cost-effectiveness of linking hospital-based tobacco treatment specialists' services with discharge follow-up care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01236079.

Interventions for smoking cessation in hospitalised patients

BACKGROUND

Smoking contributes to reasons for hospitalisation, and the period of hospitalisation may be a good time to provide help with quitting.

OBJECTIVES

To determine the effectiveness of interventions for smoking cessation that are initiated for hospitalised patients.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group register which includes papers identified from CENTRAL, MEDLINE, EMBASE and PsycINFO in December 2011 for studies of interventions for smoking cessation in hospitalised patients, using terms including (hospital and patient*) or hospitali* or inpatient* or admission* or admitted.

SELECTION CRITERIA

Randomized and quasi-randomized trials of behavioural, pharmacological or multicomponent interventions to help patients stop smoking, conducted with hospitalised patients who were current smokers or recent quitters (defined as having quit more than one month before hospital admission). The intervention had to start in the hospital but could continue after hospital discharge. We excluded studies of patients admitted to facilities that primarily treat psychiatric disorders or substance abuse, studies that did not report abstinence rates and studies with follow-up of less than six months. Both acute care hospitals and rehabilitation hospitals were included in this update, with separate analyses done for each type of hospital.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently for each paper, with disagreements resolved by consensus.

MAIN RESULTS

Fifty trials met the inclusion criteria. Intensive counselling interventions that began during the hospital stay and continued with supportive contacts for at least one month after discharge increased smoking cessation rates after discharge (risk ratio (RR) 1.37, 95% confidence interval (CI) 1.27 to 1.48; 25 trials). A specific benefit for post-discharge contact compared with usual care was found in a subset of trials in which all participants received a counselling intervention in the hospital and were randomly assigned to post-discharge contact or usual care. No statistically significant benefit was found for less intensive counselling interventions. Adding nicotine replacement therapy (NRT) to an intensive counselling intervention increased smoking cessation rates compared with intensive counselling alone (RR 1.54, 95% CI 1.34 to 1.79, six trials). Adding varenicline to intensive counselling had a non-significant effect in two trials (RR 1.28, 95% CI 0.95 to 1.74). Adding bupropion did not produce a statistically significant increase in cessation over intensive counselling alone (RR 1.04, 95% CI 0.75 to 1.45, three trials). A similar pattern of results was observed in a subgroup of smokers admitted to hospital because of cardiovascular disease (CVD). In this subgroup, intensive intervention with follow-up support increased the rate of smoking cessation (RR 1.42, 95% CI 1.29 to 1.56), but less intensive interventions did not. One trial of intensive intervention including counselling and pharmacotherapy for smokers admitted with CVD assessed clinical and health care utilization endpoints, and found significant reductions in all-cause mortality and hospital readmission rates over a two-year follow-up period. These trials were all conducted in acute care hospitals. A comparable increase in smoking cessation rates was observed in a separate pooled analysis of intensive counselling interventions in rehabilitation hospitals (RR 1.71, 95% CI 1.37 to 2.14, three trials).

AUTHORS' CONCLUSIONS

High intensity behavioural interventions that begin during a hospital stay and include at least one month of supportive contact after discharge promote smoking cessation among hospitalised patients. The effect of these interventions was independent of the patient's admitting diagnosis and was found in rehabilitation settings as well as acute care hospitals. There was no evidence of effect for interventions of lower intensity or shorter duration. This update found that adding NRT to intensive counselling significantly increases cessation rates over counselling alone. There is insufficient direct evidence to conclude that adding bupropion or varenicline to intensive counselling increases cessation rates over what is achieved by counselling alone.