Smoking cessation post-discharge following nicotine replacement therapy use during an inpatient admission

Is hospitalization a missed opportunity to intervene on tobacco cessation?

BACKGROUND

Although tobacco use is associated with elevated morbidity and mortality, its use remains widespread among adults within the United States. Nicotine Replacement Therapy (NRT) products are effective aids that improve rates of tobacco cessation. Many smokers interact with the medical system, such as during hospitalization, without their tobacco use addressed. Hospitalization is a teachable moment for patients to make health-related changes, including tobacco cessation.

METHODS

Retrospective cohort study of adult patients in a university-based patient-centered medical home from 2012 to 2021 evaluating the proportion of adults who smoke who received at least one prescription for NRT. Logistic regression models were used to analyze the association of being hospitalized and receipt of a NRT prescription.

RESULTS

Of the 4,072 current smokers identified, 1,182 (29%) received at least one prescription for NRT during the study period. Hospitalization was associated with increased odds of receiving a NRT prescription (OR 1.68). Of 1,844 current smokers with a hospitalization during the study period, 1,078 (58%) never received a prescription for NRT at any point. Only 87 (5%) of the smokers received a prescription for NRT during hospitalization or at the time of hospital discharge.

CONCLUSIONS

Despite hospitalization being associated with NRT prescribing, most patients who use tobacco and are hospitalized are not prescribed NRT. Hospitalization is an underutilized opportunity for both hospitalists and primary care physicians to intervene on smoking cessation through education and prescription of tobacco cessation aids.

Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes.

OBJECTIVES

To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes.

DESIGN

Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results.

SETTING

Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes.

PARTICIPANTS

Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes.

INTERVENTIONS

Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies.

MAIN OUTCOME MEASURES

Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events.

DATA SOURCES

Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019.

REVIEW METHODS

Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model.

RESULTS

Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard.

LIMITATIONS

Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified.

CONCLUSIONS

Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK.

FUTURE WORK

Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041302.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 59. See the NIHR Journals Library website for further project information.

Cessation classification likelihood increases with higher expired-air carbon monoxide cutoffs: a meta-analysis

BACKGROUND

Expired-air carbon monoxide (CO) is commonly used to biochemically verify smoking status. The CO cutoff and CO monitor brand may affect the probability of classifying smokers as abstinent, thus influencing conclusions about the efficacy of cessation trials. No systematic reviews have tested this hypothesis. Therefore, we performed a meta-analysis examining whether the likelihood of smoking cessation classification varied due to CO cutoff and monitor brand.

METHODS

Eligible studies (k = 122) longitudinally assessed CO-verified cessation in adult smokers in randomized trials. Primary meta-regressions separately assessed differences in quit classification likelihood due to continuous and categorical CO cutoffs (Low, 3-4 parts per million [ppm]; [SRNT] Recommended, 5-6 ppm; Moderate, 7-8 ppm; and High, 9-10 ppm); exploratory analyses compared likelihood outcomes between monitor brands: Bedfont and Vitalograph.

RESULTS

The likelihood of quit classification increased 18% with each 1 ppm increase above the lowest cutoff (3 ppm). Odds of classification as quit significantly increased between each cutoff category and High: 261% increase from Low; 162% increase from Recommended; and 150% increase from Moderate. There were no differences in cessation classification between monitor brands.

CONCLUSIONS

As expected, higher CO cutoffs were associated with greater likelihood of cessation classification. The lack of CO monitor brand differences may have been due to model-level variance not able to be followed up in the present dataset. Researchers are advised to report outcomes using a range of cutoffs-including the recommended range (5-6 ppm)-and the CO monitor brand/model used. Using higher CO cutoffs significantly increases likelihood of quit classification, possibly artificially elevating treatment strategies.

Evaluating the utility of a Smoking Cessation Clinical Pathway tool to promote nicotine prescribing and use among inpatients of a tertiary hospital in Brisbane, Australia

Introduction

Due to the burden of tobacco-related illnesses among hospital inpatients, an evidence-based smoking cessation brief intervention tool was developed for clinicians working in hospitals in Queensland, Australia. The tool, called the Smoking Cessation Clinical Pathway (SCCP), is used by clinicians to support inpatient smoking cessation and manage nicotine withdrawal in hospital.

Aims

To investigate the impact of completed SCCP on nicotine replacement therapy (NRT) prescribing and use, and to explore clinician involvement in smoking cessation interventions.

Methods

A retrospective review was conducted to examine data regarding SCCP responses and NRT offering, prescribing and use. The statistical significance of the results was assessed using chi-squared and Fisher's exact tests.

Results

Patients with a completed SCCP were more likely to be offered NRT (P < 0.0001). NRT prescribing on admission and discharge was higher in patients with a completed SCCP (P = 0.001 and P = 0.027). Intention to quit had no effect on whether NRT was offered (P = 0.276) and NRT acceptance was higher for patients that intended to quit smoking (P < 0.0001).

Conclusions

The SCCP prompted clinicians to offer NRT to patients, leading to increased NRT prescribing and use. These findings demonstrate the utility of the SCCP to assist clinicians to promote smoking cessation among hospital inpatients.

Efficacy of a universal smoking cessation intervention initiated in inpatient psychiatry and continued post-discharge: A randomised controlled trial

OBJECTIVE

Interventions are required to redress the disproportionate tobacco-related health burden experienced by persons with a mental illness. This study aimed to assess the efficacy of a universal smoking cessation intervention initiated within an acute psychiatric inpatient setting and continued post-discharge in reducing smoking prevalence and increasing quitting behaviours.

METHOD

A randomised controlled trial was undertaken across four psychiatric inpatient facilities in Australia. Participants ( N = 754) were randomised to receive either usual care ( n = 375) or an intervention comprising a brief motivational interview and self-help material while in hospital, followed by a 4-month pharmacological and psychosocial intervention ( n = 379) upon discharge. Primary outcomes assessed at 6 and 12 months post-discharge were 7-day point prevalence and 1-month prolonged smoking abstinence. A number of secondary smoking-related outcomes were also assessed. Subgroup analyses were conducted based on psychiatric diagnosis, baseline readiness to quit and nicotine dependence.

RESULTS

Seven-day point prevalence abstinence was higher for intervention participants (15.8%) than controls (9.3%) at 6 months post-discharge (odds ratio = 1.07, p = 0.04), but not at 12 months (13.4% and 10.0%, respectively; odds ratio = 1.03, p = 0.25). Significant intervention effects were not found on measures of prolonged abstinence at either 6 or 12 months post-discharge. Differential intervention effects for the primary outcomes were not detected for any subgroups. At both 6 and 12 months post-discharge, intervention group participants were significantly more likely to smoke fewer cigarettes per day, have reduced cigarette consumption by ⩾50% and to have made at least one quit attempt, relative to controls.

CONCLUSIONS

Universal smoking cessation treatment initiated in inpatient psychiatry and continued post-discharge was efficacious in increasing 7-day point prevalence smoking cessation rates and related quitting behaviours at 6 months post-discharge, with sustained effects on quitting behaviour at 12 months. Further research is required to identify strategies for achieving longer term smoking cessation.

A Reasonable Alternative to Clozapine in the Chronically Relapsing Smoking Patient? A Retrospective Analysis

Background: Clozapine levels are severely decreased by cigarette smoke hydrocarbons. A new agent that is unaffected by smoking is paliperidone palmitate. Objective: The purpose of this study is to retrospectively evaluate hospital readmission and time until readmission for patients prescribed paliperidone palmitate intramuscular injection (PP) as an alternative to oral clozapine for patients with severe schizophrenia who resume smoking following discharge. A secondary analysis was performed to determine whether smoking status alone affects hospital readmission rates in both smoking and nonsmoking clozapine-treated patients. Methods: This was a retrospective analysis of all patients who were positive for smoking at admission and readmission who were prescribed clozapine and PP. Smokers were identified by concurrent orders for nicotine replacement. Readmission rates and time until readmission were determined. Data were analyzed utilizing nonparametric statistical methods. Results: A total of 133 subjects were identified, including 108 smokers in PP group, 18 smokers in clozapine group, and 7 nonsmoking clozapine patients. Readmission rates were statistically significant between smokers in the clozapine and PP groups, with significantly lower readmission rates in the PP group (p = .004). In the sub-analysis, hospital readmissions between smokers and nonsmokers in the clozapine group were statistically significant (p = .027). Results may be influenced by use of a single hospital site, limits of a retrospective analysis, and variation in pharmaceutical preparation. Conclusion: PP may be a reasonable alternative to clozapine in severe schizophrenia for patients who continually resume smoking following discharge. Smoking may also be an important predictor of decompensation in smokers prescribed clozapine. A further prospective study is warranted.

The impact of a smoke-free psychiatric hospitalization on patient smoking outcomes: a systematic review

OBJECTIVE

Smoke-free policies have been introduced in inpatient psychiatric facilities in most developed nations. Such a period of supported abstinence during hospitalization may impact smoking behaviours post discharge, yet little quantitative evidence exists. The aim of this review was to provide the first synthesis of the research evidence examining the impact of a smoke-free psychiatric hospitalization on patients' smoking-related behaviours, motivation, and beliefs.

METHODS

We conducted a systematic review of electronic databases PubMed, MEDLINE, PsycINFO, and EMBASE from inception to June 2013. Studies were included if they were conducted in an inpatient psychiatric facility with a smoke-free policy and if they examined any change in patients' smoking-related behaviours, motivation, or beliefs either during admission, post discharge, or both. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool.

RESULTS

Fourteen studies were included in the review. Of the four studies that assessed change in smoking from admission to post discharge, two indicated a significant decline in cigarette consumption up to 3 months post discharge. Positive changes in motivation to quit and beliefs about quitting ability were identified in two studies. One study reported an increase in the rate of quit attempts and one reported a decline in nicotine dependence levels.

CONCLUSIONS

A smoke-free psychiatric hospitalization may have a positive impact on patients' smoking-related behaviours, motivation, and beliefs, both during admission and up to 3 months post discharge. Further controlled studies with more rigorous designs are required to confirm this potential.

A randomised controlled trial linking mental health inpatients to community smoking cessation supports: a study protocol

BACKGROUND

Mental health inpatients smoke at higher rates than the general population and are disproportionately affected by tobacco dependence. Despite the advent of smoke free policies within mental health hospitals, limited systems are in place to support a cessation attempt post hospitalisation, and international evidence suggests that most smokers return to pre-admission smoking levels following discharge. This protocol describes a randomised controlled trial that will test the feasibility, acceptability and efficacy of linking inpatient smoking care with ongoing community cessation support for smokers with a mental illness.

METHODS/DESIGN

This study will be conducted as a randomised controlled trial. 200 smokers with an acute mental illness will be recruited from a large inpatient mental health facility. Participants will complete a baseline survey and will be randomised to either a multimodal smoking cessation intervention or provided with hospital smoking care only. Randomisation will be stratified by diagnosis (psychotic, non-psychotic). Intervention participants will be provided with a brief motivational interview in the inpatient setting and options of ongoing smoking cessation support post discharge: nicotine replacement therapy (NRT); referral to Quitline; smoking cessation groups; and fortnightly telephone support. Outcome data, including cigarettes smoked per day, quit attempts, and self-reported 7-day point prevalence abstinence (validated by exhaled carbon monoxide), will be collected via blind interview at one week, two months, four months and six months post discharge. Process information will also be collected, including the use of cessation supports and cost of the intervention.

DISCUSSION

This study will provide comprehensive data on the potential of an integrated, multimodal smoking cessation intervention for persons with an acute mental illness, linking inpatient with community cessation support.