Interventions for smoking cessation in hospitalised patients: a systematic review

[Manejo de la cesación tabáquica entre residentes de cardiología de Iberoamérica]

Introducción y objetivos:

Si bien los cardiólogos asisten cotidianamente a pacientes que sufren daño por el tabaquismo, no se conoce el grado de formación que reciben sobre esta problemática durante su residencia. Debido a ello nos propusimos evaluar las preferencias y prácticas de los residentes de cardiología para la cesación tabáquica de los pacientes que asisten.

Materiales y métodos:

Encuesta cerrada, prefijada, voluntaria y anónima entre médicos que realizaban la especialidad de cardiología en cinco países de Latinoamérica y España.

Resultados:

Se encuestaron 716 residentes: un 62.4% de Argentina, un 19% de México, un 6.8% de España, un 6.7% de Chile, un 3.2% de Uruguay y un 1.9% de Paraguay. Con respecto a la importancia que asignaban a esta problemática (empleando una escala de 1-10), el 85.8% le asignó a esta pregunta una puntuación de 8 o mayor. Mientras el 80.5% de los participantes expresó dar consejo breve antitabáquico sistemáticamente, solamente un 27.7% empleaban terapia farmacológica con este fin. Entre quienes no empleaban terapia farmacológica, el 58.3% manifestó que el motivo era no encontrarse familiarizados con los tratamientos. El 62.9% de los encuestados dijo no haber recibido ningún tipo de formación en esta problemática. Aquellos residentes que recibieron algún tipo de formación manifestaron sentirse más preparados (p < 0.0001).

Conclusión:

Encontramos un bajo conocimiento sobre el tratamiento farmacológico y relativamente poca seguridad por parte de los residentes de cardiología para brindar asistencia en cesación tabáquica. Consideramos esencial incluir este tópico en la formación de los futuros cardiólogos a fin de lograr una prevención cardiovascular más integral.

Effect of a Smoking Cessation Program on Inpatients in the Largest Hospital in Southern Iran

Background:

There is evidence that cessation programs can be effective for hospital inpatients. Hence, the aim of this study was to investigate the effects of such programs and factors that may affect success.

Methods:

This study was carried out on in-patient users of tobacco in Shiraz Hospital, Iran in 2015. After implementing the inclusion criteria, a study population was selected using a convenience sampling method. Participants were contacted monthly by study personnel concerning certain aspects of their tobacco cessation program. The study lasted 6 months. Data analyses involved survival analysis using Kaplan–Meier analysis, log-rank test, and multivariate Cox regression modeling.

Results:

The study included 425 in-patient smokers of which 328 (77.2%) were male. Median follow-up time was 96 days (interquartile range: 20–150). Cessation survival rates were 76% at 1 month, 63% at 2 months, and 61% at 3 months. From the 4^th month onward rates remained unchanged at 60%. Univariate analyses with variables such as time since last smoking, consumption type, interval between wake-up and consumption, the severity of dependence and interest in smoking cessation were statistically significant as to cessation survival rate (P < 0.05). After adjusting the confounding variables based on multivariable analyses, results indicated that consumption type, the severity of dependence and interest in smoking cessation were the most important predictors of cessation survival rates among in-patient smokers.

Conclusions:

Findings indicated that application of the cessation program among our group of inpatients appears to have been an effective intervention that produced an extended period of no smoking.

Comparison of two smoking cessation interventions for inpatients

Objective:

This study aimed to compare the effectiveness of two cognitive behavioral therapy-based smoking cessation interventions initiated during hospitalization and to evaluate the factors related to relapse after discharge.

Methods:

This was a prospective randomized study involving 90 smokers hospitalized in a university hospital. We collected data related to sociodemographic characteristics, reasons for admission, smoking-related diseases, smoking history, the degree of nicotine dependence (ND), and the level of craving. Patients were divided into two treatment groups: brief intervention (BrInter, n = 45); and intensive intervention with presentation of an educational video (InInterV, n=45). To assess relapse, all patients were assessed by telephone interview in the first, third, and sixth months after discharge. Abstinence was confirmed by measurement of exhaled carbon monoxide (eCO).

Results:

Of the 90 patients evaluated, 55 (61.1%) were male. The mean age was 51.1 ± 12.2 years. The degree of ND was elevated in 39 (43.4%), and withdrawal symptoms were present in 53 (58.9%). The mean eCO at baseline was 4.8 ± 4.5 ppm. The eCO correlated positively with the degree of ND (r = 0.244; p = 0.02) and negatively with the number of smoke-free days (r = −0.284; p = 0.006). There were no differences between the groups in terms of the variables related to socioeconomic status, smoking history, or hospitalization. Of the 81 patients evaluated at 6 months, 33 (40.7%) remained abstinent (9 and 24 BrInter and InInterV group patients, respectively; p = 0.001), and 48 (59.3%) had relapsed (31 and 17 BrInter and InInterV group patients, respectively; p= 0.001). Moderate or intense craving was a significant independent risk factor for relapse, with a relative risk of 4.0 (95% CI: 1.5-10.7; p < 0.00001).

Conclusions:

The inclusion of an educational video proved effective in reducing relapse rates. Craving is a significant risk factor for relapse.

Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme

Background

Electronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.

Objective

To evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.

Design

Epidemiological cohort, health informatics, health economics and ethnographic approaches were used.

Setting

230 NHS hospitals and 226 general practices in England and Wales.

Participants

Up to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.

Main outcome measures

Quality of care, fatal and non-fatal cardiovascular disease (CVD) events.

Data platform and methods

We created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.

Results

CALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.

Conclusions

Emerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.

Future work

The vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.

Study registration

CALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).

Warm Handoff Versus Fax Referral for Linking Hospitalized Smokers to Quitlines

INTRODUCTION

Few hospitals treat patients' tobacco dependence. To be effective, hospital-initiated cessation interventions must provide at least 1 month of supportive contact post-discharge.

STUDY DESIGN

Individually randomized clinical trial. Recruitment commenced July 2011; analyses were conducted October 2014-June 2015.

SETTING/PARTICIPANTS

The study was conducted in two large Midwestern hospitals. Participants included smokers who were aged ≥18 years, planned to stay quit after discharge, and spoke English or Spanish.

INTERVENTION

Hospital-based cessation counselors delivered the intervention. For patients randomized to warm handoff, staff immediately called the quitline from the bedside and handed the phone to participants for enrollment and counseling. Participants randomized to fax were referred on the day of hospital discharge.

MAIN OUTCOME MEASURES

Outcomes at 6 months included quitline enrollment/adherence, medication use, biochemically verified cessation, and cost effectiveness.

RESULTS

Significantly more warm handoff than fax participants enrolled in quitline (99.6% vs 59.6%; relative risk, 1.67; 95% CI=1.65, 1.68). One in four (25.4% warm handoff, 25.3% fax) were verified to be abstinent at 6-month follow-up; this did not differ significantly between groups (relative risk, 1.02; 95% CI=0.82, 1.24). Cessation medication use in the hospital and receipt of a prescription for medication at discharge did not differ between groups; however, significantly more fax participants reported using cessation medication post-discharge (32% vs 25%, p=0.01). The average incremental cost-effectiveness ratio of enrolling participants into warm handoff was $0.14. Hospital-borne costs were significantly lower in warm handoff than in fax ($5.77 vs $9.41, p<0.001).

CONCLUSIONS

One in four inpatient smokers referred to quitline by either method were abstinent at 6 months post-discharge. Among motivated smokers, fax referral and warm handoff are efficient and comparatively effective ways to link smokers with evidence-based care. For hospitals, warm handoff is a less expensive and more effective method for enrolling smokers in quitline services.

Smoking Cessation after Myocardial Revascularization Procedures

Introduction: Smoking is associated with the development of coronary artery disease and influences negatively the prognosis of patients undergoing myocardial revascularization procedures. However, the rate of smoking cessation after these procedures is not well established in the literature. We aimed to evaluate the rate of smoking cessation in patients undergoing revascularization procedures, immediately and after 12 months of follow-up.

Methods: We examined smoking patients from a unique cardiology center who underwent myocardial revascularization procedures between January 2010 and December 2011. These patients were allocated to two groups according to the revascularization procedure performed: Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Interventions (PCI). Data related to cessation or maintenance of smoking were obtained at subsequent clinical appointments or telephone calls.

Results: Among 173 patients selected, 118 (68.2%) underwent PCI and 55 (31.8%) underwent CABG. After revascularization procedures, the total rate of smoking cessation was 79.3%. Furthermore, there was no significant difference between the two groups (83.6% – CI 95%: 71.2–92.2% for CABG, and 79.3% – CI 95%: 70.8–86.3% for PCI). The maintenance of smoking cessation after one year was 53.2%, similar between groups (52.7% for CABG and 53.4% for PCI). Nevertheless, the average time of smoking cessation was significantly higher in the CABG group (6.9 months versus 4.5 months for PCI).

Conclusions: Coronary interventions add important value to smoking cessation, and the smoking cessation rates were similar, independent of the procedure executed.

Cardiovascular risks associated with smoking: a review for clinicians

The cardiovascular consequences of cigarette smoking may not be as readily recognized as the adverse respiratory consequences. Smoking results in sudden death, myocardial infarction, coronary heart disease, worsened outcomes after angioplasty or bypass surgery, cerebrovascular disease, aortic aneurysm, peripheral vascular disease, increased risk of complications of hypertension and impotence. Physicians should encourage and help all their smoking patients to quit. Pharmacotherapy for smoking cessation is one of the most cost-effective healthcare interventions and should be offered to all dependent smokers. Both nicotine replacement and bupropion have been shown to be well tolerated in populations with cardiovascular disease.

Using a Mobile App to Promote Smoking Cessation in Hospitalized Patients

Background

The potential of interactive health education for preventive health applications has been widely demonstrated. However, use of mobile apps to promote smoking cessation in hospitalized patients has not been systematically assessed.

Objective

This study was conducted to assess the feasibility of using a mobile app for the hazards of smoking education delivered via touch screen tablets to hospitalized smokers.

Methods

Fifty-five consecutive hospitalized smokers were recruited. Patient sociodemographics and smoking history was collected at baseline. The impact of the mobile app was assessed by measuring cognitive and behavioral factors shown to promote smoking cessation before and after the mobile app use including hazards of smoking knowledge score (KS), smoking attitudes, and stages of change.

Results

After the mobile app use, mean KS increased from 27(3) to 31(3) (P<0.0001). Proportion of patients who felt they “cannot quit smoking” reduced from 36% (20/55) to 18% (10/55) (P<0.03). Overall, 13% (7/55) of patients moved toward a more advanced stage of change with the proportion of patients in the preparation stage increased from 40% (22/55) to 51% (28/55). Multivariate regression analysis demonstrated that knowledge gains and mobile app acceptance did not depend on age, gender, race, computer skills, income, or education level. The main factors affecting knowledge gain were initial knowledge level (P<0.02), employment status (P<0.05), and high app acceptance (P<0.01). Knowledge gain was the main predictor of more favorable attitudes toward the mobile app (odds ratio (OR)=4.8; 95% confidence interval (CI) (1.1, 20.0)). Attitudinal surveys and qualitative interviews identified high acceptance of the mobile app by hospitalized smokers. Over 92% (51/55) of the study participants recommended the app for use by other hospitalized smokers and 98% (54/55) of the patients were willing to use such an app in the future.

Conclusions

Our results suggest that a mobile app promoting smoking cessation is well accepted by hospitalized smokers. The app can be used for interactive patient education and counseling during hospital stays. Development and evaluation of mobile apps engaging patients in their care during hospital stays is warranted.

Increased evidence-based tobacco treatment through Oklahoma hospital system changes

BACKGROUND

Oklahoma hospitals admit approximately 120,000 tobacco users each year, many for diseases resulting from tobacco use.

PURPOSE

To describe a unique partnership between the Oklahoma Hospital Association and Oklahoma Tobacco Settlement Endowment Trust to reach more tobacco users through the implementation of sustainable health system changes within hospitals and clinics to integrate an evidence-based tobacco treatment protocol for all tobacco-using patients.

METHODS

The Oklahoma Hospital Association tobacco-cessation model included (1) identifying all tobacco-using patients; (2) assessing addiction level and readiness to quit; (3) prescribing medications to manage withdrawal while in hospital; and (4) proactively faxing a referral to the Oklahoma Tobacco Helpline for all patients ready to quit. Helpline registration patterns and characteristics of fax-referred hospitalized patients were tracked for the 4 years of the initiative (2009-2013); data were analyzed in 2013.

RESULTS

Twenty-one hospitals and 12 clinics participated in the initiative. Fax referrals to the Helpline increased by >150% in the first year, from about 600 during the year prior to the implementation of the program (July 2009 to June 2010) to 1,581 from Oklahoma Hospital Association facilities alone in the first year following the launch of the initiative. Nearly 5,600 Oklahoma Hospital Association fax referrals were made during the 4-year study period. About 41% of these referrals resulted in Helpline enrollment (n=2,289).

CONCLUSIONS

Sustainable, evidence-based tobacco treatment interventions embedded in hospital systems can successfully identify tobacco users and provide effective treatment, including increased proactive Helpline referrals for quit coaching.

Differences in risk perception and quit rates among hospitalized veteran pipe smokers, cigarette smokers, and dual users

OBJECTIVE

This study examined differences in perception of risk, hospitalization quit rates, and 6-month quit rates between pipe smokers, cigarettes smokers, and those who smoke both in the Department of Veterans Affairs.

METHODS

Before implementing the Tobacco Tactics intervention (among 811 smokers), smoking quit rates were determined (among N = 465 patients with 6-month follow-up data available) in three Midwestern hospitals during 2006-2010.

RESULTS

Pipe smokers were less likely to believe that they needed to quit tobacco, that quitting would be difficult, and that quitting tobacco was important to their health. Eighty-five percent of pipe smokers remained tobacco free throughout their hospital stay compared with 59% of dual smokers and 60% of cigarette smokers (p < .10). Twenty-three percent of pipe smokers remained tobacco free at 6 months compared with 19% of dual users and 7% of cigarette smokers (p < .10).

CONCLUSION

Although pipe smokers had higher spontaneous quit rates than dual smokers and cigarette smokers, the perception of the risk of smoking was less among pipe smokers suggesting a need to expel the myths surrounding pipe smoking and increase cessation efforts.

Effective behaviour change techniques in smoking cessation interventions for people with chronic obstructive pulmonary disease: a meta-analysis

PURPOSE

The purpose of this study was to identify the behaviour change techniques (BCTs) that are associated with greater effectiveness in smoking cessation interventions for people with chronic obstructive pulmonary disease (COPD).

METHODS

A systematic review and meta-analysis was conducted. Web of Knowledge, CINAHL, EMBASE, PsycINFO, and MEDLINE were searched from the earliest date available to December 2012. Data were extracted and weighted average effect sizes calculated; BCTs used were coded according to an existing smoking cessation-specific BCT taxonomy.

RESULTS

Seventeen randomized controlled trials (RCTs) were identified that involved a total sample of 7446 people with COPD. The sample-weighted mean quit rate for all RCTs was 13.19%, and the overall sample-weighted effect size was d+ = 0.33. Thirty-seven BCTs were each used in at least three interventions. Four techniques were associated with significantly larger effect sizes: Facilitate action planning/develop treatment plan, Prompt self-recording, Advise on methods of weight control, and Advise on/facilitate use of social support. Three new COPD-specific BCTs were identified, and Linking COPD and smoking was found to result in significantly larger effect sizes.

CONCLUSIONS

Smoking cessation interventions aimed at people with COPD appear to benefit from using techniques focussed on forming detailed plans and self-monitoring. Additional RCTs that use standardized reporting of intervention components and BCTs would be valuable to corroborate findings from the present meta-analysis.

A randomized trial of a brief intervention to promote smoking cessation for parents during child hospitalization

BACKGROUND

Parental smoking significantly increases the risk of child hospitalization for multiple illnesses. Parenting smokers may not have easy access to smoking cessation services elsewhere and a few interventions with this population in the inpatient setting have shown promising results.

METHODS

We sought to evaluate the efficacy of a brief intervention with smoking parents on smoking cessation rates after child hospitalization with a randomized, controlled trial.

RESULTS

Sixty smoking parents participated in the study. The majority of study participants were uninsured women under age 30 who smoked approximately half of a pack per day. There were no statistically significant differences between control and intervention groups for our outcomes. However, 45% (CI: 33-57%) of all participants reported at least one quit attempt during the 2-month study period and 18% (CI: 10-30%) of participants were quit at study conclusion.

CONCLUSIONS

Willingness to quit smoking was much higher than expected in this population of parenting smokers.

Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial

BACKGROUND

Post-discharge support is a key component of effective treatment for hospitalized smokers, but few hospitals provide it. Many hospitals and care settings fax-refer smokers to quitlines for follow-up; however, less than half of fax-referred smokers are successfully contacted and enrolled in quitline services. "Warm handoff" is a novel approach to care transitions in which health care providers directly link patients with substance abuse problems with specialists, using face-to-face or phone transfer. Warm handoff achieves very high rates of treatment enrollment for these vulnerable groups.

METHODS

The aim of this study-"EQUIP" (Enhancing Quitline Utilization among In-Patients)-is to determine the effectiveness, and cost-effectiveness, of warm handoff versus fax referral for linking hospitalized smokers with tobacco quitlines. This study employs a two-arm, individually randomized design. It is set in two large Kansas hospitals that have dedicated tobacco treatment interventionists on staff. At each site, smokers who wish to remain abstinent after discharge will be randomly assigned to groups. For patients in the fax group, staff will provide standard in-hospital intervention and will fax-refer patients to the state tobacco quitline for counseling post-discharge. For patients in the warm handoff group, staff will provide brief in-hospital intervention and immediate warm handoff: staff will call the state quitline, notify them that a warm handoff inpatient from Kansas is on the line, then transfer the call to the patients' mobile or bedside hospital phone for quitline enrollment and an initial counseling session. Following the quitline session, hospital staff provides a brief check-back visit. Outcome measures will be assessed at 1, 6, and 12 months post enrollment. Costs are measured to support cost-effectiveness analyses. We hypothesize that warm handoff, compared to fax referral, will improve care transitions for tobacco treatment, enroll more participants in quitline services, and lead to higher quit rates. We also hypothesize that warm handoff will be more cost-effective from a societal perspective.

DISCUSSION

If successful, this project offers a low-cost solution for more efficiently linking millions of hospitalized smokers with effective outpatient treatment-smokers that might otherwise be lost in the transition to outpatient care.

TRIAL REGISTRATION

Clinical Trials Registration NCT01305928.

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.

Smoking Cessation Rates After a Nurse-Led Inpatient Smoking Cessation Intervention

Objective: To evaluate the effectiveness of inpatient brief counselling by a smoking cessation nurse compared to usual care (no advice). Methods: The subjects (n = 381, 245 men and 136 women) studied were in-patients, in four Flemish University Hospitals, who were daily smokers. Patients were randomised between 2005 and June 2006. Patients were allocated to an experimental group (EG) or to a control group (CG). Allocation and smoking cessation interventions of patients were stage-matched according to their stage of change as defined by Prochaska and Diclemente. Smoking cessation advice was administered by a qualified smoking cessation nurse. Results: The six-month self-reported continuous abstinence in the EG in 28/178 patients (15.7%) compared to the CG where 14/180 patients were abstinent (7.7%) was significantly better. The effect was most pronounced in the subgroup over 40 years old in the preparation and action stage. In this cohort in the EG, 44% of patients were abstinent at six months compared to 18%in the CG. All patients tended to smoke less after a hospitalisation. Conclusion: The intervention by a smoking cessation nurse during hospitalisation seems effective and is most rewarding in the smokers > 40 years old, and who were well motivated to stop.

Effect of smoking relapse on outcome after acute coronary syndromes

The aim of the present study was to evaluate the smoking relapse rate among smokers who had become abstinent during admission for acute coronary syndromes. The association between smoking relapse and mortality was also analyzed. A cohort of 1,294 consecutive active smokers who had interrupted smoking after admission for acute coronary syndromes (1,018 men and 276 women, mean age 59.7 ± 12.3 years) was followed up for 12 months after the index admission. All patients received a brief in-hospital smoking cessation intervention consisting of repeated counseling sessions. During follow-up, 813 patients (62.8%) resumed regular smoking (median interval to relapse 19 days, interquartile range 9 to 76). Increasing age (hazard ratio [HR] 1.034 per year, 95% confidence interval [CI] 1.028 to 1.039, p = 0.001) and female gender (HR 1.23, 95% CI 1.09 to 1.42, p = 0.03) were independent predictors of smoking relapse. Patients enrolled in a cardiac rehabilitation program (HR 0.74, 95% CI 0.51 to 0.91, p = 0.02) and those with diabetes (HR 0.79, 95% CI 0.68 to 0.94, p = 0.03) were more likely to remain abstinent. During follow-up, 97 patients died (1-year probability of death 0.075, 95% CI 0.061 to 0.090). Multivariate analysis with the Cox proportional hazard regression method, including smoking relapse as a time-dependent covariate, demonstrated that, after adjustment for patient demographics, the clinical history features and variables related to the index event, the resumption of smoking was an independent predictor of total mortality (HR 3.1, 95% CI 1.3 to 5.7, p = 0.004). In conclusion, smoking relapse after acute coronary syndromes is associated with increased mortality, and counseling interventions should be integrated into the postdischarge support to reduce the negative effects of smoking resumption.

Smoking among inpatients at a university hospital

OBJECTIVE

To determine the prevalence and characteristics of smoking among inpatients at a university hospital, as well as to evaluate their motivation, interest, and need for help in quitting smoking.

METHODS

A prospective study involving inpatients treated between May of 2008 and April of 2009 on the cardiovascular disease wards at the Antonio Pedro University Hospital, located in the city of Niterói, Brazil. All inpatients were asked to complete a questionnaire designed to collect data regarding demographics, reasons for admission, and smoking status. The smokers also responded to additional questions regarding their smoking habits. The level of nicotine dependence was determined with the Fagerström Test for Nicotine Dependence.

RESULTS

Of the 136 inpatients who participated in the study, 68 (50.0%) were male. The mean age was 60.7 years. The prevalence of smoking was 13.2%. Among the 49 patients with coronary disease, 36 (73.5%) were smokers or former smokers. The majority of the patients presented with a high level of nicotine dependence and reported withdrawal symptoms during hospitalization. Although most smokers were motivated to quit smoking, they admitted that they needed help to do so.

CONCLUSIONS

Because smoking is forbidden in the hospital environment and most inpatients who smoke are highly motivated to quit, health professionals should view the hospitalization period as an opportunity to promote smoking cessation.

Improving the quality of care for the hospitalized tobacco user--one institution's transformational journey

Hospitalization represents an ideal time to address tobacco cessation. For a variety of reasons, current users do not always receive appropriate support or treatment during the hospitalization. An improvement team was created to improve the care for the hospitalized tobacco user. The team's aim was to develop a standardized process to increase the assessment, documentation, and delivery of cessation counseling, and increase community referrals upon discharge. After implementation of the project, percentages of hospitalized patients who had their tobacco use status documented in the electronic medical record increased to 80-90%. The percentage of patients admitted with heart failure or pneumonia had their rates of tobacco cessation counseling improved to 82-96%. The care of the hospitalized tobacco user can be improved and sustained by utilizing community resources and creating a team of motivated care providers. This improvement work stimulated the creation of a smoke-free institution and other preventive health measures throughout the institution.

Effectiveness of pharmacotherapy and behavioral interventions for smoking cessation in actual clinical practice

OBJECTIVES

This study evaluated the effectiveness of behavioral interventions (brief counseling, nonspecific psychological support in groups - NSGS and cognitive behavioral group therapy - CBGT) in combination with bupropion SR for smoking cessation in the field, through a smoking cessation clinic.

METHODS

Two-hundred-and-five smokers were enrolled in a 19-week course during 2007/ 2008, and were randomly assigned to: bupropion SR combined with brief counseling (group A), bupropion SR combined with NSGS (group B), bupropion SR combined with CBGT (group C), or CBGT as the only approach (group D).

RESULTS

Continuous abstinence rates at the end of therapy were 53.2% for group A, 62.9% for group B, 50.0% for group C, and 22.2% (p < 0.05) for group D. Sustained abstinence rates in 12 months were 29.6%, 28.1%, 34.3% and 19.4% (p > 0.05), respectively.

CONCLUSIONS

Bupropion SR is an effective aid for smoking cessation in clinical practice. NSGT increased the chances for success at the end of therapy when combined with bupropion SR, while CBGT as monotherapy was less effective compared with the approaches including pharmacotherapy. It is suggested that smoking cessation interventions in real-life healthcare settings should be implemented through comprehensive programs using pharmacotherapy where applicable, combined with NSGT, and integrated by specialized healthcare professionals.

A before-after implementation trial of smoking cessation guidelines in hospitalized veterans

Background

Although most hospitalized smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. US Department of Veterans Affairs (VA) hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Few studies have applied the Chronic Care Model (CCM) to improve inpatient smoking cessation.

Specific objectives

The primary objective of this protocol is to determine the effect of a nurse-initiated intervention, which couples low-intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients. Key secondary aims are to determine the impact of the intervention on staff nurses' attitudes toward providing smoking cessation counseling; to identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals; and to determine the short-term cost-effectiveness of implementing the intervention.

Design

Pre-post study design in four VA hospitals

Participants

Hospitalized patients, aged 18 or older, who smoke at least one cigarette per day.

Intervention

The intervention will include: nurse training in delivery of bedside cessation counseling, electronic medical record tools (to streamline nursing assessment and documentation, to facilitate prescription of pharmacotherapy), computerized referral of motivated inpatients for proactive telephone counseling, and use of internal nursing facilitators to provide coaching to staff nurses practicing in non-critical care inpatient units.

Outcomes

The primary endpoint is seven-day point prevalence abstinence at six months following hospital admission and prolonged abstinence after a one-month grace period. To compare abstinence rates during the intervention and baseline periods, we will use random effects logistic regression models, which take the clustered nature of the data within nurses and hospitals into account. We will assess attitudes of staff nurses toward cessation counseling by questionnaire and will identify barriers and facilitators to implementation by using clinician focus groups. To determine the short-term incremental cost per quitter from the perspective of the VA health care system, we will calculate cessation-related costs incurred during the initial hospitalization and six-month follow-up period.

Trial number

NCT00816036

Smoking cessation treatment in a real-life setting: the Greek experience

OBJECTIVES

The aim of this study was to estimate the clinical efficacy of counseling combined with currently used pharmacotherapy for smoking cessation (bupropion SR and nicotine replacement therapy, NRT) in actual clinical practice, and to identify predictors of successful abstinence at the end of therapy, as well as predictors of sustained abstinence in one year.

METHODS

895 smokers, self-motivated to quit, received bupropion SR for 7 or 19 weeks and/or nicotine replacement therapy (NRT) (nicotine patch) for 9 weeks in combination with individual behavioural therapy. An intensive program including repetitive visits and telephone contacts during treatment and one year's follow-up period was available for supporting and motivating smokers to prevent relapse.

RESULTS

Post-treatment abstinence rates were 71.6% and 53.2% in bupropion SR groups for 7 and 19 weeks of treatment, respectively, (p < 0.001), 63.4% in bupropion SR plus nicotine patch group and 45% (p < 0.001) in nicotine patch group. One year's follow-up abstinence rates were 43.1%, 29.6%, 30.4% and 18.4% (p < 0.05), respectively. Predictors of successful abstinence at the end of therapy included (a) bupropion SR, (b) lower DSM IV symptom score, and (c) lower nicotine addiction, while predictors for sustained abstinence in one year included: (a) bupropion SR, (b) lower nicotine addiction, and (c) smoker's motivation.

CONCLUSIONS

Smoking cessation interventions implementing intensive multi-component programs and constant smokers' motivation in health care settings of actual practice seem promising for increasing short and long-term abstinence rates.

Tabagismo em pacientes internados em um hospital geral

OBJETIVO: Determinar a freqüência do tabagismo em pacientes internados em um hospital geral, e caracterizar o perfil dos fumantes hospitalizados. MÉTODOS: Foi avaliada uma amostra representativa e aleatória de 111 pacientes internados, classificados como não-fumantes, ex-fumantes e fumantes. Nos fumantes foi aplicado o questionário de Fagerström e obtidas medidas de monóxido de carbono no ar expirado. Valores acima de 6 ppm de monóxido de carbono no ar expirado foram considerados significantes para tabagismo recente. RESULTADOS: Dos 111 pacientes, 60 (54%) eram do sexo feminino. A média de idade foi de 70 anos. Do total, 56 pacientes (51%) nunca fumaram, 36 (32%) eram ex-fumantes e 19 (17%) eram fumantes atuais. Todos os fumantes eram do sexo masculino. Os fumantes tinham menor idade (58 ± 17 anos), em comparação aos não-fumantes (68 ± 14 anos) e ex-fumantes (73 ± 14 anos)-ANOVA: F = 6,57 (p = 0,002). A carga tabágica média dos fumantes foi de 43 anos-maço. A média do escore de Fagerström foi de 5,0. Dos 19 fumantes, 11 (58%) tinham sintomas respiratórios, e 3 tinham sintomas de abstinência. A média de monóxido de carbono no ar expirado dos fumantes foi 5,0 ppm. Oito (42%) dos fumantes tinham níveis de monóxido de carbono no ar expirado acima de 6 ppm. Houve maior prevalência de tabagistas em algumas clinicas: 70% dos fumantes se encontravam em apenas cinco enfermarias. CONCLUSÕES: Em um grande hospital terciário, 17% dos pacientes internados eram fumantes e destes 7% fumaram nas últimas 8 horas. Os fumantes eram pacientes mais jovens do sexo masculino, internados em determinadas clínicas.

Diretrizes para cessação do tabagismo - 2008

Estas diretrizes constituem uma ferramenta atualizada e abrangente para auxiliar o profissional de saúde na abordagem do tabagista, recomendando atitudes baseadas em evidências clínicas como a melhor forma de conduzir cada caso. De forma reduzida e mais objetiva possível, o texto final foi agrupado em dois grandes itens: Avaliação e Tratamento. Os dois itens apresentam comentários e níveis de recomendação das referências utilizadas, bem como algumas propostas de abordagem, como por exemplo, redução de danos, em situações específicas ainda pouco exploradas, como recaídas, tabagismo passivo, tabagismo na categoria médica e uso de tabaco em ambientes específicos.

The role of health care systems in increased tobacco cessation

Health care delivery systems are critical components of tobacco cessation efforts. This review summarizes recent evidence in support of the health care system recommendations in the 2000 U.S. Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence. Measurable progress in addressing tobacco use through the health care system is summarized, including accountabilities for addressing tobacco in national health care reporting systems, increases in reported advice to quit smoking from health care providers, and wider availability of insurance coverage for tobacco cessation treatments. Despite progress, significant gaps remain between what is possible and what is done by health care systems to impact tobacco cessation. A four-point public policy agenda is outlined to help close these gaps.

A randomized, controlled trial of smoking cessation counseling provided during child hospitalization for respiratory illness

The impact of parental smoking on children is enormous. Injury and illness related to parental smoking result in 6,200 excess pediatric deaths per year, which places smoking as the leading preventable cause of death in US children. Parental smoking doubles the risk of child hospitalization for respiratory illness therefore pediatricians have frequent contact with smoking parents. A single study has previously investigated the effect of child hospitalization on parental smoking cessation. Smoking caregivers of children hospitalized for respiratory illness at the University of New Mexico were offered a smoking cessation intervention during the child's hospitalization. Participants were randomized to receive either a brief anti-smoking message or more extensive counseling based on current clinical practice guidelines. Forty-two parents enrolled in the study. Fourteen percent of participants in the counseling group and 5% in the brief message group were self-reported quitters at 6 months. A significant percentage of smoking parents of children hospitalized for respiratory illness are willing to receive smoking cessation counseling while their child is in the hospital. Abstinence rates appear similar to other pediatric office-based interventions. Child hospitalization should be considered an important opportunity to provide parents with smoking cessation services, particularly since many smoking parents will not have access to these services elsewhere.

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.

Interventions for smoking cessation in hospitalised patients

BACKGROUND

An admission to hospital provides an opportunity to help people stop smoking. Individuals may be more open to help at a time of perceived vulnerability, and may find it easier to quit in an environment where smoking is restricted or prohibited. Initiating smoking cessation services during hospitalisation may help more people to make and sustain a quit attempt.

OBJECTIVES

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

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group register which includes papers identified from CENTRAL, MEDLINE, EMBASE and PSYCINFO in January 2007, and CINAHL in August 2006 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 for psychiatric disorders or substance abuse, studies that did not report abstinence rates and studies with follow up of less than six months.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Thirty-three 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 (Odds Ratio (OR) 1.65, 95% confidence interval (CI) 1.44 to 1.90; 17 trials). No statistically significant benefit was found for less intensive counselling interventions. The one study that tested a single brief (<=15 minutes) in-hospital intervention did not find it to be effective (OR 1.16, 95% CI 0.80 to 1.67). Counselling of longer duration during the hospital stay was not associated with a higher quit rate (OR 1.08, 95% CI 0.89 to 1.29, eight trials). Even counselling that began in the hospital but had less than one month of supportive contact after discharge did not show significant benefit (OR 1.09, 95% CI 0.91 to 1.31, six trials). Adding nicotine replacement therapy (NRT) did not produce a statistically significant increase in cessation over what was achieved by intensive counselling alone (OR 1.47, 95% CI 0.92 to 2.35, five studies). The one study that tested the effect of adding bupropion to intensive counselling had a similar nonsignificant effect (OR 1.56, 95% CI 0.79 to 3.06). A similar pattern of results was observed in smokers admitted to hospital because of cardiovascular disease (CVD). In this subgroup, intensive intervention with follow-up support increased the odds of smoking cessation (OR 1.81, 95% CI 1.54 to 2.15, 11 trials), 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.

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. These interventions are effective regardless of the patient's admitting diagnosis. lnterventions of lower intensity or shorter duration have not been shown to be effective in this setting. There is insufficient direct evidence to conclude that adding NRT or bupropion to intensive counselling increases cessation rates over what is achieved by counselling alone, but the evidence of benefit for NRT has strengthened in this update and the point estimates are compatible with research in other settings showing that NRT and bupropion are effective.

An ethnographic study of tobacco control in hospital settings

BACKGROUND

Tobacco control in hospital settings is characterised by a focus on protection strategies and an increasing expectation that health practitioners provide cessation support to patients. While practitioners claim to have positive attitudes toward supporting patient cessation efforts, missed opportunities are the practice norm.

OBJECTIVE

To study hospital workplace culture relevant to tobacco use and control as part of a mixed-methods research project that investigated hospital-based registered nurses' integration of cessation interventions.

DESIGN

The study was conducted at two hospitals situated in British Columbia, Canada. Data collection included 135 hours of field work including observations of ward activities and designated smoking areas, 85 unstructured conversations with nurses, and the collection of patient-care documents on 16 adult in-patient wards.

RESULTS

The findings demonstrate that protection strategies (for example, smoking restrictions) were relatively well integrated into organisational culture and practice activities but the same was not true for cessation strategies. An analysis of resources and documentation relevant to tobacco revealed an absence of support for addressing tobacco use and cessation. Nurses framed patients' tobacco use as a relational issue, a risk to patient safety, and a burden. Furthermore, conversations revealed that nurses tended to possess only a vague awareness of nicotine dependence.

CONCLUSION

Overcoming challenges to extending tobacco control within hospitals could be enhanced by emphasising the value of addressing patients' tobacco use, raising awareness of nicotine dependence, and improving the availability of resources to address addiction issues.

[Feasibility of systematic screening for addictive behaviours of hospitalized patients]

BACKGROUND

The national policy against addiction led to the establishment of specialized units with liaison teams trained in addiction specifically to work with the in-patients. The aim of this study has been established within the context of the implementation of one of these addiction liaison units in a Parisian Hospital, the Georges Pompidou European Hospital (HEGP), that is namely to evaluate the feasibility of a systematic screening procedure concerning tobacco and alcohol dependence among inpatients in two of the hospital's specialization departments between December 6, 2001, and March 6, 2002.

METHODS

Self-administered questionnaires on addictive behaviours were distributed to each patient admitted to the vascular health department and to the hypertension department They included the Fagerström Test for Nicotine Dependence and the AUDIT for evaluating levels of alcohol abuse.

RESULTS

The response rate was 30.2% (110/364). Twenty-nine smokers were identified. Among them, 72.5% presented a low level of physical nicotine dependence. Nearly half of them (14/29) were not interested in participating in a smoking cessation intervention with the assistance of relevant hospital staff. Among eleven patients at risk of excessive alcohol abuse, only one accepted to be referred to a specialist.

CONCLUSION

This study highlights the difficulties of the systematic screening for addictive behaviours in hospitalized patients. Nevertheless, the obstacles faced in terms of the acceptability of the screening, but the patients as well as by the hospital staff, do not lean against the development of this trend or oppose this type of approach. New methods of individual screening for addictive behaviours should be explored.

Does smoking influence survival in cancer patients through effects on respiratory and vascular disease?

Patients with cancers caused by smoking may die because they continue to smoke even after diagnosis of a cancer caused by smoking. We investigated differences in cause-specific mortality between patients diagnosed with smoking-related and non-smoking-related cancers. The causes of death were classified as smoking-related cancer, non-smoking-related cancer, respiratory or vascular disease, and all other causes. We studied all 220 089 people diagnosed with cancer in Scotland between 1986 and 1996, aged between 20 and 85 years, with last follow-up on 31 December 1999. There was a moderate excess risk of dying from respiratory and vascular causes in those with smoking-related cancers, which did not fall with time since diagnosis, consistent with continued smoking by these patients. Mortality among cancer patients might fall if more assistance in stopping smoking was provided for patients who have smoking-related cancers.

Predictors of success in smoking cessation among hospitalized patients

OBJECTIVE

To determine the predictors of continued smoking abstinence in patients receiving smoking cessation intervention during and following hospital admission.

METHODOLOGY

A prospective cohort study was conducted in a university-affiliated hospital. A total of 248 smokers admitted with primary cardiac and respiratory conditions received verbal advice (lasting about 1 h) and standard booklets on smoking cessation from a dedicated nurse counsellor. After discharge, participants received follow-up telephone counselling calls every 2 weeks from the same smoking counsellor. The main outcome measure was continued abstinence at 2 months after hospital discharge, as determined by self-reporting and carbon monoxide breath testing. The following groups of covariates were analysed to determine the possible factors associated with smoking abstinence: demographics, smoking history, readiness to quit, and medical history.

RESULTS

At 2 months post-discharge, 108 (43.5%) patients remained abstinent. Low nicotine dependence score (odds ratio, 2.30; 95% CI, 1.25-4.26; P = 0.008), decision to quit by sudden cessation as compared to reduction of smoking (odds ratio, 7.19; 95% CI, 1.56-33.06; P = 0.011), and initial hospitalization for their medical condition (odds ratio, 6.37; 95% CI, 1.33-30.44; P = 0.020) were the main independent predictors for positive outcome.

CONCLUSION

Among this cohort of hospitalized patients receiving smoking cessation intervention, low dependence on tobacco, motivation to quit by sudden cessation, and initial hospitalization were the main independent predictors of smoking abstinence after discharge from hospital.

Multicomponent individualized smoking cessation intervention for patients with lung disease

AIMS

This paper reports a study examining the process and outcomes of a long-term, multicomponent smoking cessation intervention for patients with lung disease initiated while hospitalized and provided over 1-year postdischarge.

BACKGROUND

Successful smoking cessation interventions are of primary importance for people with lung disease. Initiation of such an intervention in hospital settings is particularly important as patients may be especially motivated to quit as a result of strong perceptions of vulnerability while hospitalized for a smoking-related disease. Tailoring the intervention to each person's needs is a promising approach to practice.

METHODS

All patients who smoked and were admitted to a pulmonary unit over 2 years were invited to participate in this quasi-experimental study (n = 85), and 69 continued beyond the first month. The intervention was shaped by the TransTheoretical Model and used nicotine replacement therapy, along with individual and group counselling and support grounded in the nurse-patient relationship. The intervention was provided during hospitalization and by telephone after discharge at 1 week, and 1, 3, 6 and 12 months.

RESULTS

At 12-months postdischarge, 39% of the patients reported continuous abstinence from smoking from the time they joined the programme and 52% were not smoking at that time. No relationship was found between abstinence and the number of quit attempts, readiness to quit, nicotine dependency and length of hospital stay. Readiness to quit had increased and nicotine dependency decreased significantly by the end of the programme. No gender differences were found for the main variables.

CONCLUSIONS

Comprehensive, individualized smoking cessation interventions for hospitalized patients having lung disease, with a 1-year follow-up, was successful. Abstinence was high in comparison with other studies. This may in part be explained by significantly enhanced motivation to quit during the smoking cessation programme.

Smoking Cessation: Techniques and Potential Benefits

Smokers have a significantly greater risk of complications during and after operations. Cigarette smoke has significant effects on cardiac function, circulation, and respiratory function. Preliminary studies suggest that smoking cessation for a minimum of 6 to 8 weeks before surgery is required to reduce the perioperative and postoperative risks of smoking. Smoking cessation programs that employ advice, support groups, nicotine replacement therapy, or some anti-depressants have been used successfully in many situations and should be used to discourage smoking preoperatively. Further research is needed, however, to clarify the best approach to smoking cessation for surgical patients.

Nursing and tobacco reduction: a review of the literature

Nurses have an instrumental role to play in tobacco reduction, which is one strategy used to address tobacco use; a primary source of preventable morbidity and mortality globally. The following review addresses activities by two groups of nurses: nursing governance bodies and nurse scientists, whom together provide vision and knowledge to support and shape nursing practice. While nursing governance bodies and scientists have contributed a great deal to tobacco reduction, there are also gaps. Areas that require strengthening are: support for tobacco dependent nurses, basic nursing education concerning tobacco dependency treatment, and integration of tobacco dependence treatment into nursing practice.

Clinical trial comparing nicotine replacement therapy (NRT) plus brief counselling, brief counselling alone, and minimal intervention on smoking cessation in hospital inpatients

BACKGROUND

Guidelines recommend that smoking cessation interventions are offered in all clinical settings to all smokers willing to make a quit attempt. Since the effectiveness of routine provision of behavioural counselling and nicotine replacement therapy (NRT) to smokers admitted to hospital has not been established, a randomised controlled trial of these interventions given together compared with counselling alone or minimal intervention was performed in hospital inpatients.

METHODS

Medical and surgical inpatients who were current smokers at the time of admission were randomised to receive either usual care (no additional advice at admission), counselling alone (20 minute intervention with written materials), or NRT plus counselling (counselling intervention with a 6 week course of NRT). Continuous and point prevalence abstinence from smoking (validated by exhaled carbon monoxide <10 ppm) was measured at discharge from hospital and at 3 and 12 months, and self-reported reduction in cigarette consumption in smokers was assessed at 3 and 12 months.

RESULTS

274 inpatient smokers were enrolled. Abstinence was higher in the NRT plus counselling group (n=91) than in the counselling alone (n=91) or usual care (n=92) groups. The difference between the groups was significant for validated point prevalence abstinence at discharge (55%, 43%, 37% respectively, p=0.045) and at 12 months (17%, 6%, 8%, p=0.03). The respective differences in continuous validated abstinence at 12 months were 11%, 4%, 8% (p=0.25). There was no significant difference between counselling alone and usual care, or in reduction in cigarette consumption between the treatment groups.

CONCLUSIONS

NRT given with brief counselling to hospital inpatients is an effective routine smoking cessation intervention.

Does smoking status influence the prognosis of bladder cancer? A systematic review

OBJECTIVE

To summarize, in a systematic review, the evidence for the effect of stopping smoking on recurrence, cancer-specific and all cause-mortality among smokers with newly diagnosed bladder cancer.

MATERIALS AND METHODS

Two electronic databases and the reference lists of identified primary studies and reviews were searched. Studies were included if a hazard ratio and its confidence intervals could be extracted. A predefined set of study characteristics was extracted which defined whether studies were giving valid prognostic data on the effects of smoking in reasonably homogenous cohorts. The results of studies were synthesized qualitatively.

RESULTS

Fifteen relevant studies were identified; former and current smokers were combined in many studies. Many studies produced information on prognosis that was confounded by the mixing of incident and prevalent cases. Only three studies examined the influence of smoking on prognosis in only incident cases, most of whom had superficial disease. Of these, only one was of high quality. These three studies and the other 12 showed suggestive evidence that continued smoking or a lifetime of smoking constitutes a moderate risk factor for recurrence and death, and that stopping smoking could favourably change this. However, the evidence base for this is weak because of the methodological shortcomings and because most studies' results were not statistically significant. A life-table model showed that if stopping smoking altered the prognosis, the size of the benefit would be clinically worthwhile.

CONCLUSION

There is suggestive evidence that stopping smoking might favourably alter the course of bladder cancer, but this is insufficient for clinicians to inform patients that doing so will improve their prognosis, and for providing specialized services to assist in stopping smoking to patients with bladder cancer.