Effectiveness of smoking-cessation interventions for urban hospital patients: study protocol for a randomized controlled trial

Interventions for smoking cessation in hospitalised patients

BACKGROUND

In 2020, 32.6% of the world's population used tobacco. Smoking contributes to many illnesses that require hospitalisation. A hospital admission may prompt a quit attempt. Initiating smoking cessation treatment, such as pharmacotherapy and/or counselling, in hospitals may be an effective preventive health strategy. Pharmacotherapies work to reduce withdrawal/craving and counselling provides behavioural skills for quitting smoking. This review updates the evidence on interventions for smoking cessation in hospitalised patients, to understand the most effective smoking cessation treatment methods for hospitalised smokers.

OBJECTIVES

To assess the effects of any type of smoking cessation programme for patients admitted to an acute care hospital.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 7 September 2022.

SELECTION CRITERIA

We included randomised and quasi-randomised studies of behavioural, pharmacological or multicomponent interventions to help patients admitted to hospital quit. Interventions had to start in the hospital (including at discharge), and people had to have smoked within the last month. We excluded studies in psychiatric, substance and rehabilitation centres, as well as studies that did not measure abstinence at six months or longer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was abstinence from smoking assessed at least six months after discharge or the start of the intervention. We used the most rigorous definition of abstinence, preferring biochemically-validated rates where reported. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 82 studies (74 RCTs) that included 42,273 participants in the review (71 studies, 37,237 participants included in the meta-analyses); 36 studies are new to this update. We rated 10 studies as being at low risk of bias overall (low risk in all domains assessed), 48 at high risk of bias overall (high risk in at least one domain), and the remaining 24 at unclear risk. Cessation counselling versus no counselling, grouped by intensity of intervention Hospitalised patients who received smoking cessation counselling that began in the hospital and continued for more than a month after discharge had higher quit rates than patients who received no counselling in the hospital or following hospitalisation (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.24 to 1.49; 28 studies, 8234 participants; high-certainty evidence). In absolute terms, this might account for an additional 76 quitters in every 1000 participants (95% CI 51 to 103). The evidence was uncertain (very low-certainty) about the effects of counselling interventions of less intensity or shorter duration (in-hospital only counselling ≤ 15 minutes: RR 1.52, 95% CI 0.80 to 2.89; 2 studies, 1417 participants; and in-hospital contact plus follow-up counselling support for ≤ 1 month: RR 1.04, 95% CI 0.90 to 1.20; 7 studies, 4627 participants) versus no counselling. There was moderate-certainty evidence, limited by imprecision, that smoking cessation counselling for at least 15 minutes in the hospital without post-discharge support led to higher quit rates than no counselling in the hospital (RR 1.27, 95% CI 1.02 to 1.58; 12 studies, 4432 participants). Pharmacotherapy versus placebo or no pharmacotherapy Nicotine replacement therapy helped more patients to quit than placebo or no pharmacotherapy (RR 1.33, 95% CI 1.05 to 1.67; 8 studies, 3838 participants; high-certainty evidence). In absolute terms, this might equate to an additional 62 quitters per 1000 participants (95% CI 9 to 126). There was moderate-certainty evidence, limited by imprecision (as CI encompassed the possibility of no difference), that varenicline helped more hospitalised patients to quit than placebo or no pharmacotherapy (RR 1.29, 95% CI 0.96 to 1.75; 4 studies, 829 participants). Evidence for bupropion was low-certainty; the point estimate indicated a modest benefit at best, but CIs were wide and incorporated clinically significant harm and clinically significant benefit (RR 1.11, 95% CI 0.86 to 1.43, 4 studies, 872 participants). Hospital-only intervention versus intervention that continues after hospital discharge Patients offered both smoking cessation counselling and pharmacotherapy after discharge had higher quit rates than patients offered counselling in hospital but not offered post-discharge support (RR 1.23, 95% CI 1.09 to 1.38; 7 studies, 5610 participants; high-certainty evidence). In absolute terms, this might equate to an additional 34 quitters per 1000 participants (95% CI 13 to 55). Post-discharge interventions offering real-time counselling without pharmacotherapy (RR 1.23, 95% CI 0.95 to 1.60, 8 studies, 2299 participants; low certainty-evidence) and those offering unscheduled counselling without pharmacotherapy (RR 0.97, 95% CI 0.83 to 1.14; 2 studies, 1598 participants; very low-certainty evidence) may have little to no effect on quit rates compared to control. Telephone quitlines versus control To provide post-discharge support, hospitals may refer patients to community-based telephone quitlines. Both comparisons relating to these interventions had wide CIs encompassing both possible harm and possible benefit, and were judged to be of very low certainty due to imprecision, inconsistency, and risk of bias (post-discharge telephone counselling versus quitline referral: RR 1.23, 95% CI 1.00 to 1.51; 3 studies, 3260 participants; quitline referral versus control: RR 1.17, 95% CI 0.70 to 1.96; 2 studies, 1870 participants).

AUTHORS' CONCLUSIONS

Offering hospitalised patients smoking cessation counselling beginning in hospital and continuing for over one month after discharge increases quit rates, compared to no hospital intervention. Counselling provided only in hospital, without post-discharge support, may have a modest impact on quit rates, but evidence is less certain. When all patients receive counselling in the hospital, high-certainty evidence indicates that providing both counselling and pharmacotherapy after discharge increases quit rates compared to no post-discharge intervention. Starting nicotine replacement or varenicline in hospitalised patients helps more patients to quit smoking than a placebo or no medication, though evidence for varenicline is only moderate-certainty due to imprecision. There is less evidence of benefit for bupropion in this setting. Some of our evidence was limited by imprecision (bupropion versus placebo and varenicline versus placebo), risk of bias, and inconsistency related to heterogeneity. Future research is needed to identify effective strategies to implement, disseminate, and sustain interventions, and to ensure cessation counselling and pharmacotherapy initiated in the hospital is sustained after discharge.

Integrating the "Quit and Stay Quit Monday" Model into Smoking Cessation Services for Smokers with Mental Health Conditions: A Pilot Randomized Controlled Trial

Introduction

People with mental health conditions (MHCs) are less likely to achieve long-term abstinence than people without MHCs. The Quit and Stay Quit Monday (QSQM) model offers a long-term approach to treating tobacco use by encouraging people to quit, requit, or recommit to quit smoking every Monday.

Aim

To evaluate the efficacy, patient satisfaction, and patient engagement with an intervention that integrated the QSQM model into multicomponent smoking cessation services among people with an MHC.

Methods

This was a randomized controlled pilot trial. Eligibility criteria were as follows: (1) ≥18 years old, (2) smoked a cigarette in the past 30 days, (3) diagnosis of an ICD-10 MHC, (4) interest in quitting smoking, (5) able to receive services in English, and (5) had an active email and a cell phone. The intervention group (n = 33) received QSQM-focused telephone coaching, a weekly QSQM email newsletter, a SmokefreeTXT anchored around a Monday quit date, and 4 weeks of nicotine replacement therapy (NRT). The control group (n = 36) received information about contacting their state Quitline for usual services. Primary outcomes were self-reported quit attempts, 7-day abstinence, and intervention satisfaction at 3 months.

Results

Twenty-four participants (73%) in the intervention group began telephone coaching, 26 (79%) enrolled in the QSQM email newsletter, 19 (58%) enrolled in SmokefreeTXT, and 15 (46%) used NRT. Using a penalized intent-to-treat approach, quit attempts in the intervention and control groups were 63.6% and 38.9% (OR 2.75, 95% CI 1.03-7.30), respectively. Seven-day abstinence in the two groups was 12.1% and 5.6% (OR 2.35, 95% CI 0.40-13.74), respectively. Of the 15 intervention group participants who set a quit date during the intervention, 13 (86.7%) selected a Monday quit day. Qualitative interviews revealed positive participant experiences with picking a Monday quit day. On follow-up surveys, 89.5%, 69.3%, and 64.3% of intervention participants reported that the counseling, QSQM email, and text messaging, respectively, were very or somewhat helpful.

Conclusions

The QSQM model was acceptable and potentially efficacious among people with MHCs, but intervention engagement and satisfaction were modest. Future research should adapt or develop new QSQM delivery approaches to improve patient engagement and potential efficacy of the model. This trial is registered with clinicaltrials.gov (NCT04512248).

Impact of Smoking Cessation Interventions Initiated During Hospitalization Among HIV-Infected Smokers

INTRODUCTION

Smoking is a key determinant of mortality among people living with HIV (PLWH).

METHODS

To better understand the effects of smoking cessation interventions in PLWH, we conducted a pooled analysis of four randomized controlled trials of hospital-initiated smoking interventions conducted through the Consortium of Hospitals Advancing Research on Tobacco (CHART). In each study, cigarette smokers were randomly assigned to usual care or a smoking cessation intervention. The primary outcome was self-reported past 30-day tobacco abstinence at 6-month follow-up. Abstinence rates were compared between PLWH and participants without HIV and by treatment arm, using both complete-case and intention-to-treat analyses. Multivariable logistic regression was used to determine the effect of HIV status on 6-month tobacco abstinence and to determine predictors of smoking cessation within PLWH.

RESULTS

Among 5550 hospitalized smokers, there were 202 (3.6%) PLWH. PLWH smoked fewer cigarettes per day and were less likely to be planning to quit than smokers without HIV. At 6 months, cessation rates did not differ between intervention and control groups among PLWH (28.9% vs. 30.5%) or smokers without HIV (36.1% vs. 34.1%). In multivariable regression analysis, HIV status was not significantly associated with smoking cessation at 6 months. Among PLWH, confidence in quitting was the only clinical factor independently associated with smoking cessation (OR 2.0, 95% CI = 1.4 to 2.8, p < .01).

CONCLUSIONS

HIV status did not alter likelihood of quitting smoking after hospital discharge, whether or not the smoker was offered a tobacco cessation intervention, but power was limited to identify potentially important differences.

IMPLICATIONS

PLWH had similar quit rates to participants without HIV following a hospital-initiated smoking cessation intervention. The findings suggest that factors specific to HIV infection may not influence response to smoking cessation interventions and that all PLWH would benefit from efforts to assist in quitting smoking.

TRIAL REGISTRATION

(1) Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial: NCT01305928. (2) Web-based smoking cessation intervention that transitions from inpatient to outpatient: NCT01277250. (3) Effectiveness of smoking-cessation interventions for urban hospital patients: NCT01363245. (4) Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (HelpingHAND2): NCT01714323.

Does Smoking Intensity Predict Cessation Rates? A Study of Light-Intermittent, Light-Daily, and Heavy Smokers Enrolled in Two Telephone-Based Counseling Interventions

INTRODUCTION

Though many interventions have been shown to be effective in helping smokers quit, outcomes may differ between light and heavy smokers. We identified differences in baseline characteristics and post-intervention cessation rates among smoker groups at two safety-net hospitals.

METHODS

We retrospectively analyzed cessation rates in 1604 patients randomized to either a quitline referral (1-2 telephone counseling sessions) or intensive counseling program (seven telephone sessions). Participants were stratified into light-intermittent (smoked on ≤24 of last 30 days), light-daily (smoked on >24/30 days, 1-9 cigarettes per day [CPD]), or heavy smokers (smoked on >24/30 days, ≥10 CPD). We compared baseline characteristics between smoker types using chi-squared tests, then identified predictors of 30-day abstinence using a multivariable model.

RESULTS

Compared with light-daily and light-intermittent smokers, heavy smokers were more likely to be white, male, concomitant e-cigarette users, to have high-risk alcohol use, to have used quitting aids previously, to have current or lifetime substance use (excluding cannabis), and have lower confidence in quitting. However, in multivariable analysis, smoker type was not significantly associated with cessation. The statistically significant predictors of cessation at 6 months were higher confidence in quitting and enrollment in the intensive counseling intervention.

CONCLUSIONS

Smoker type (light-intermittent, light-daily, or heavy) does not independently predict success in a cessation program. However, smoker type is strongly associated with patients' confidence in quitting, which may be one predictor of cessation.

IMPLICATIONS

This study of two safety-net hospitals emphasizes that the number of cigarettes smoked per day does not independently predict smoking cessation. Additionally, heavy smokers are at highest risk for the detrimental health effects of tobacco, yet have lower confidence and motivation to quit. Confidence in quitting may be one factor that affects cessation rates; however, further study is needed to identify which other attributes predict cessation. These findings suggest that smoker type may still be a useful proxy for predicting cessation and that interventions specifically designed for and validated in heavy smokers are needed to better aid these individuals.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to stop smoking.

OBJECTIVES

To evaluate the efficacy of MI for smoking cessation compared with no treatment, in addition to another form of smoking cessation treatment, and compared with other types of smoking cessation treatment. We also investigated whether more intensive MI is more effective than less intensive MI for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. We also searched trial registries to identify unpublished studies. Date of the most recent search: August 2018.

SELECTION CRITERIA

Randomised controlled trials in which MI or its variants were offered to smokers to assist smoking cessation. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional non-MI intervention components not matched between arms. We excluded trials in pregnant women as these are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RR) and 95% confidence intervals (CI) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. We extracted data on mental health outcomes and quality of life and summarised these narratively.

MAIN RESULTS

We identified 37 eligible studies involving over 15,000 participants who smoked tobacco. The majority of studies recruited participants with particular characteristics, often from groups of people who are less likely to seek support to stop smoking than the general population. Although a few studies recruited participants who intended to stop smoking soon or had no intentions to quit, most recruited a population without regard to their intention to quit. MI was conducted in one to 12 sessions, with the total duration of MI ranging from five to 315 minutes across studies. We judged four of the 37 studies to be at low risk of bias, and 11 to be at high risk, but restricting the analysis only to those studies at low or unclear risk did not significantly alter results, apart from in one case - our analysis comparing higher to lower intensity MI.We found low-certainty evidence, limited by risk of bias and imprecision, comparing the effect of MI to no treatment for smoking cessation (RR = 0.84, 95% CI 0.63 to 1.12; I² = 0%; adjusted N = 684). One study was excluded from this analysis as the participants recruited (incarcerated men) were not comparable to the other participants included in the analysis, resulting in substantial statistical heterogeneity when all studies were pooled (I² = 87%). Enhancing existing smoking cessation support with additional MI, compared with existing support alone, gave an RR of 1.07 (95% CI 0.85 to 1.36; adjusted N = 4167; I² = 47%), and MI compared with other forms of smoking cessation support gave an RR of 1.24 (95% CI 0.91 to 1.69; I² = 54%; N = 5192). We judged both of these estimates to be of low certainty due to heterogeneity and imprecision. Low-certainty evidence detected a benefit of higher intensity MI when compared with lower intensity MI (RR 1.23, 95% CI 1.11 to 1.37; adjusted N = 5620; I² = 0%). The evidence was limited because three of the five studies in this comparison were at risk of bias. Excluding them gave an RR of 1.00 (95% CI 0.65 to 1.54; I² = n/a; N = 482), changing the interpretation of the results.Mental health and quality of life outcomes were reported in only one study, providing little evidence on whether MI improves mental well-being.

AUTHORS' CONCLUSIONS

There is insufficient evidence to show whether or not MI helps people to stop smoking compared with no intervention, as an addition to other types of behavioural support for smoking cessation, or compared with other types of behavioural support for smoking cessation. It is also unclear whether more intensive MI is more effective than less intensive MI. All estimates of treatment effect were of low certainty because of concerns about bias in the trials, imprecision and inconsistency. Consequently, future trials are likely to change these conclusions. There is almost no evidence on whether MI for smoking cessation improves mental well-being.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I² = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I² = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I² = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Characteristics of Urban Inpatient Smokers With and Without Chronic Pain: Foundations for Targeted Cessation Programs

BACKGROUND

Cigarette smoking and chronic pain are prevalent, comorbid conditions with significant consequences for individuals and society. Despite overlap between smoking and chronic pain, and pain's role as a potential barrier to quitting, there are no validated interventions targeted for smokers with chronic pains (SWCPs).

OBJECTIVE

To compare characteristics of urban inpatient smokers with and without chronic pain to inform the development of SWCP-targeted cessation interventions.

METHODS

This study reports partial results from a randomized comparative effectiveness trial of two smoking cessation interventions (NCT01363245). Participants were enrolled at two safety net hospitals in New York, NY in 2011-2014. Data were collected from the electronic health record and an interviewer-administered survey. Participants were considered to have chronic pain if they affirmed having "long-lasting, persistent, or chronic pain in the last six months" on survey.

RESULTS

Among smokers assessed for pain (n = 1093), the prevalence of chronic pain was 44%. SWCPs were more likely to report depressive symptoms and to have a history of psychiatric diagnosis (nonsubstance related) than smokers without pain. Severe problems with mobility and with performing usual activities were more common in SWCPs. No significant difference was observed in sex, race, education, nicotine dependence level, confidence in quit ability, or history of substance misuse. Conclusions/Importance: Chronic pain in smokers admitted to safety net hospitals is prevalent and associated with hindered mobility, history of psychiatric diagnosis, and prescription opioid use. Urban safety net hospitals are an appropriate setting in which to pilot SWCP-targeted cessation programs, which should be designed with consideration for patients' psychiatric history and mobility status.

Smoking Cessation Advisory Intervention in Patients with Cardiovascular Disease

Introduction:

Several studies have examined the efficacy of smoking cessation therapies in the general population. However little is known about the efficacy of these advisory methods in cardiovascular patients.

Aim:

The aim of the study is to determine the prevalence and the characteristics of smoking abstinence in cardiovascular patients, after a smoking intervention during hospitalization.

Methods:

The study involved 442 patients, smokers admitted for cardiovascular disease to the Department of Cardiology. During hospitalization patient’s data were collected and all patients were subjected to a 30-minutes long advisory session with drug administration in selected cases (varenicycline, bupropione, nocitine replacement therapy), according to standard protocol. After the discharge patients were asked about smoking abstinence at time intervals of 24 hours, 1 month, 3, 6 and 12 months.

Results:

After hospital discharge 11 patients (2.49%) could not be contacted after several attempts and 19 patients (4.3%) were died during follow up period. A total of 412 patients (218 men and 194 women, mean age 56.49+10.57 years) made up the final study population. Twenty four hours after hospital discharge 364 patients (88.35%) had quitted smoking. At 1, 3, 6 and 12 months the abstinence rates were 70.87%, 64.8%, 55.82% and 47.83% respectively. Patients with ischaemic cardiovascular diseases (angina – infarction) had a significantly higher probability of quitting smoking at 12 months (Hazard ratio: 0.64 – p=0.01).

Conclusion:

A smoking cessation program in cardiovascular patients during hospitalization was unlikely to result in success. These patients might benefit by following programs promoting smoking cessation in experienced specialized centers, involving a group of health professionals, such as psychologists and/or trained nurses.

Disparities in hospital smoking cessation treatment by immigrant status

Despite the efficacy of nicotine replacement therapy (NRT) in promoting smoking cessation, no studies have been done to evaluate NRT prescribing rates among immigrants, a vulnerable minority population in the United States. The aim of this study is to explore for differences in NRT prescribing behavior by immigrant status. Participants were enrolled in a smoking cessation trial for hospitalized patients between July 2011 and April 2014 at two NYC hospitals. For this analysis, we used baseline data from patient surveys and electronic medical-record reviews to examine associations between immigrant status and prescription of NRT in-hospital and on discharge, as well as acceptance of NRT in-hospital. We included age, gender, education, health literacy, race, ethnicity, English language ability, inpatient service, and site insurance in the models as potential confounders. Our study population included 1,608 participants, of whom 21% were not born in the United States. Bivariate analysis found that nonimmigrants were more likely than immigrants to be prescribed NRT in the hospital (46.1% vs. 35.7%, p = .0006) and similarly on discharge (19.4% vs. 15.3%, p = .09). Both groups were equally likely to accept NRT in-hospital when prescribed. On multivariable analysis, being an immigrant (OR 0.65), Black race (OR 0.52), and Hispanic ethnicity (OR 0.63) were associated with lower likelihood of being prescribed NRT in-hospital. Multivariable analysis for provision of NRT prescription at discharge showed no significant difference between immigrants and nonimmigrants. These findings show differences in in-hospital smoking cessation treatment between immigrants and nonimmigrants.

Comparison of the Substance Use Brief Screen (SUBS) to the AUDIT-C and ASSIST for detecting unhealthy alcohol and drug use in a population of hospitalized smokers

Hospitalized patients have high rates of unhealthy substance use, which has important impacts on health both during and after hospitalization, but is infrequently identified in the absence of screening. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify use of tobacco, alcohol, illicit drugs, and non-medical use of prescription drugs, and was previously validated in primary care patients. This study assessed the diagnostic accuracy of the SUBS in comparison to longer screening instruments to identify unhealthy and high-risk alcohol and drug use in hospitalized current smokers. Participants were 439 patients, aged 18 and older, who were admitted to either two urban safety-net hospitals in New York City and enrolled in a smoking cessation trial. We measured the performance of the SUBS for identifying illicit drug and non-medical use of prescription drugs in comparison to a modified Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and its performance for identifying excessive alcohol use in comparison to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). At the standard cutoff (response other than 'never' indicates a positive screen), the SUBS had a sensitivity of 98% (95% CI 95-100%) and specificity of 61% (95% CI 55-67%) for unhealthy alcohol use, a sensitivity of 85% (95% CI 80-90%) and specificity of 75% (95% CI 78-87%) for illicit drug use, and a sensitivity of 73% (95% CI 61-83%) and specificity of 83% (95% CI 78-87%) for prescription drug non-medical use. For identifying high-risk use, a higher cutoff (response of '3 or more days' of use indicates a positive screen), the SUBS retained high sensitivity (77-90%), and specificity was 62-88%. The SUBS can be considered as an alternative to longer screening instruments, which may fit more easily into busy inpatient settings. Further study is needed to evaluate its validity using gold standard measures in hospitalized populations.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial

PURPOSE

To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers.

DESIGN

Pre-post quasi-experimental trial.

SETTING

General medical units of four US Department of Veterans Affairs hospitals.

SUBJECTS

898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively).

INTERVENTION

The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback.

MEASURES

The primary outcome was self-reported 7-day point prevalence abstinence at six months.

ANALYSIS

Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression.

RESULTS

Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI₉₅)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI₉₅=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001).

CONCLUSIONS

Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.

Long-term abstinence and predictors of tobacco treatment uptake among hospitalized smokers with serious mental illness enrolled in a smoking cessation trial

Hospital patients with serious mental illness (SMI) have high rates of smoking. There are few post-discharge treatment models available for this population and limited research on their treatment uptake following discharge. This study is a secondary analysis of an RCT that compared multi-session intensive telephone counseling versus referral to state quitline counseling at two safety net hospitals in New York City. For this analysis, we selected all trial participants with a history of schizophrenia, schizoaffective disorder or bipolar disorder (N = 384) and used multivariable logistic regression to compare groups on self-reported 30-day abstinence at 6 months and to identify patient factors associated with use of tobacco treatment. Analyses found no significant group differences in abstinence 6 months (28% quitline vs. 29% intervention, p > 0.05), use of cessation medications (42% quitline vs. 47% intervention, p > 0.05) or receipt of at least one counseling call (47% quitline vs. 42% intervention, p > 0.05). Patients with hazardous drinking (p = 0.04) or perceived good health (p = 0.03) were less likely to use cessation medications. Homeless patients were less likely to use counseling (p = 0.02). Most patients did not use cessation treatment after discharge, and the intensive intervention did not improve abstinence rates over quitline referral. Interventions are needed to improve use of cessation treatment and long-term abstinence in patients with SMI.

Implementation of the Tobacco Tactics intervention versus usual care in Trinity Health community hospitals

Background

Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework.

Methods

This pragmatic study used a mixed methods, quasi-experimental design in five Michigan community hospitals of which three received the nurse-administered Tobacco Tactics intervention and two received usual care. Nurses and patients were surveyed pre- and post-intervention.

Measures included reach (patient participation rates, characteristics, and receipt of services), adoption (nurse participation rates and characteristics), implementation (pre-to post-training changes in nurses' attitudes, delivery of services, barriers to implementation, opinions about training, documentation of services, and numbers of volunteer follow-up phone calls), and maintenance (continuation of the intervention once the study ended).

Results

Reach: Patient participation rates were 71.5 %. Compared to no change in the control sites, there were significant pre- to post-intervention increases in self-reported receipt of print materials in the intervention hospitals (n = 1370, p < 0.001). Adoption: In the intervention hospitals, all targeted units and several non-targeted units participated; 76.0 % (n = 1028) of targeted nurses and 317 additional staff participated in the training, and 92.4 % were extremely or somewhat satisfied with the training. Implementation: Nurses in the intervention hospitals reported increases in providing advice to quit, counseling, medications, handouts, and DVD (all p < 0.05) and reported decreased barriers to implementing smoking cessation services (p < 0.001). Qualitative comments were very positive (“user friendly,” “streamlined,” or “saves time”), although problems with showing patients the DVD and charting in the electronic medical record were noted. Maintenance: Nurses continued to provide the intervention after the study ended.

Conclusions

Given that nurses represent the largest group of front-line providers, this intervention, which meets Joint Commission guidelines for treating inpatient smokers, has the potential to have a wide reach and to decrease smoking, morbidity, and mortality among inpatient smokers. As we move toward more population-based interventions, the RE-AIM framework is a valuable guide for implementation.

Trial registration

ClinicalTrials.gov, NCT01309217

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0511-6) contains supplementary material, which is available to authorized users.

CHARTing a Path to Pragmatic Tobacco Treatment Research

INTRODUCTION

It is important to consider the degree to which studies are explanatory versus pragmatic to understand the implications of their findings for patients, healthcare professionals, and policymakers. Pragmatic trials test the effectiveness of interventions in real-world conditions; explanatory trials test for efficacy under ideal conditions. The Consortium of Hospitals Advancing Research on Tobacco (CHART) is a network of seven NIH-funded trials designed to identify effective programs that can be widely implemented in routine clinical practice.

METHODS

A cross-sectional analysis of CHART trial study designs was conducted to place each study on the pragmatic-explanatory continuum. After reliability training, six raters independently scored each CHART study according to ten PRagmatic Explanatory Continuum Indicator Summary (PRECIS) dimensions, which covered participant eligibility criteria, intervention flexibility, practitioner expertise, follow-up procedures, participant compliance, practitioner adherence, and outcome analyses. Means and SDs were calculated for each dimension of each study, with lower scores representing more pragmatic elements. Results were plotted on "spoke and wheel" diagrams. The rating process and analyses were performed in October 2014 to September 2015.

RESULTS

All seven CHART trials tended toward the pragmatic end of the spectrum, although there was a range from 0.76 (SD=0.23) to 1.85 (SD=0.58). Most studies included some explanatory design elements.

CONCLUSIONS

CHART findings should be relatively applicable to clinical practice. Funders and reviewers could integrate PRECIS criteria into their guidelines to better facilitate pragmatic research. CHART study protocols, coupled with scores reported here, may help readers improve the design of their own pragmatic trials.

Smoking-Cessation Interventions for Urban Hospital Patients: A Randomized Comparative Effectiveness Trial

INTRODUCTION

Hospitalization is a unique opportunity for smoking cessation, but prior interventions have measured efficacy with narrowly defined populations. The objective of this study was to enroll smokers admitted to two "safety net" hospitals and compare the effectiveness of two post-discharge cessation interventions.

DESIGN

A randomized comparative effectiveness trial was conducted.

SETTING/PARTICIPANTS

At two New York City public hospitals, every hospitalized patient identified as a smoker (based on admission records) was approached. Inclusion criteria were: smoked cigarettes in the past 30 days; spoke English, Spanish, or Mandarin; had a U.S. phone number; not discharged to an institution where follow-up or smoking was limited; and not pregnant/breastfeeding. Of 18,797 patients identified as current smokers between July 2011 and April 2014, a total of 3,047 (16%) were discharged before being approached, 3,273 (17%) were not current smokers, 4,026 (21%) had no U.S. phone number, 2,831 (15%) were ineligible for other reasons, and 3,983 (21%) refused participation. In total, 1,618 (9%) participants enrolled in the study. During follow-up, 69% of participants were reached at 2 months and 68% at 6 months.

INTERVENTION

At discharge, participants were randomized to multisession telephone counseling from study staff (n=804) or referral to the state quitline for proactive outreach and counseling (n=814).

MAIN OUTCOME MEASURES

Self-reported abstinence at 6 months was measured. Analyses were conducted in late 2015.

RESULTS

One quarter of participants were homeless or in unstable housing, 60% had a history of substance abuse, 43% reported current hazardous drinking, and half had a psychiatric diagnosis other than substance abuse. At follow-up, the rate of abstinence (30-day point prevalence) was higher in the intensive counseling arm than the quitline arm at 2 months (29.0% vs 20.7%; relative risk=1.40; 95% CI=1.13, 1.73) and 6 months (37.4% vs 31.5%; relative risk=1.19; 95% CI=1.01, 1.40).

CONCLUSIONS

Intensive counseling was more effective than referral to the state quitline. Long-term abstinence was excellent in both groups. Many patients were not eligible for enrollment despite minimal exclusion criteria.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01363245.

Interventions for tobacco use cessation in people living with HIV and AIDS

BACKGROUND

Tobacco use is highly prevalent amongst people living with HIV/AIDS (PLWHA) and has a substantial impact on morbidity and mortality.

OBJECTIVES

To assess the effectiveness of interventions to motivate and assist tobacco use cessation for people living with HIV/AIDS (PLWHA), and to evaluate the risks of any harms associated with those interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO in June 2015. We also searched EThOS, ProQuest, four clinical trial registries, reference lists of articles, and searched for conference abstracts using Web of Science and handsearched speciality conference databases.

SELECTION CRITERIA

Controlled trials of behavioural or pharmacological interventions for tobacco cessation for PLWHA.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised electronic data collection form. They extracted data on the nature of the intervention, participants, and proportion achieving abstinence and they contacted study authors to obtain missing information. We collected data on long-term (greater than or equal to six months) and short-term (less than six months) outcomes. Where appropriate, we performed meta-analysis and estimated the pooled effects using the Mantel-Haenszel fixed-effect method. Two authors independently assessed and reported the risk of bias according to prespecified criteria.

MAIN RESULTS

We identified 14 studies relevant to this review, of which we included 12 in a meta-analysis (n = 2087). All studies provided an intervention combining behavioural support and pharmacotherapy, and in most studies this was compared to a less intensive control, typically comprising a brief behavioural intervention plus pharmacotherapy.There was moderate quality evidence from six studies for the long-term abstinence outcome, which showed no evidence of effect for more intense cessation interventions: (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.72 to 1.39) with no evidence of heterogeneity (I(2) = 0%). The pooled long-term abstinence was 8% in both intervention and control conditions. There was very low quality evidence from 11 studies that more intense tobacco cessation interventions were effective in achieving short-term abstinence (RR 1.51, 95% CI 1.15 to 2.00); there was moderate heterogeneity (I(2) = 42%). Abstinence in the control group at short-term follow-up was 8% (n = 67/848) and in the intervention group was 13% (n = 118/937). The effect of tailoring the intervention for PLWHA was unclear. We further investigated the effect of intensity of behavioural intervention via number of sessions and total duration of contact. We failed to detect evidence of a difference in effect according to either measure of intensity, although there were few studies in each subgroup. It was not possible to perform the planned analysis of adverse events or HIV outcomes since these were not reported in more than one study.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that combined tobacco cessation interventions provide similar outcomes to controls in PLWHA in the long-term. There is very low quality evidence that combined tobacco cessation interventions were effective in helping PLWHA achieve short-term abstinence. Despite this, tobacco cessation interventions should be offered to PLWHA, since even non-sustained periods of abstinence have proven benefits. Further large, well designed studies of cessation interventions for PLWHA are needed.

Fidelity monitoring across the seven studies in the Consortium of Hospitals Advancing Research on Tobacco (CHART)

BACKGROUND

This paper describes fidelity monitoring (treatment differentiation, training, delivery, receipt and enactment) across the seven National Institutes of Health-supported Consortium of Hospitals Advancing Research on Tobacco (CHART) studies. The objectives of the study were to describe approaches to monitoring fidelity including treatment differentiation (lack of crossover), provider training, provider delivery of treatment, patient receipt of treatment, and patient enactment (behavior) and provide examples of application of these principles.

METHODS

Conducted between 2010 and 2014 and collectively enrolling over 9500 inpatient cigarette smokers, the CHART studies tested different smoking cessation interventions (counseling, medications, and follow-up calls) shown to be efficacious in Cochrane Collaborative Reviews. The CHART studies compared their unique treatment arm(s) to usual care, used common core measures at baseline and 6-month follow-up, but varied in their approaches to monitoring the fidelity with which the interventions were implemented.

RESULTS

Treatment differentiation strategies included the use of a quasi-experimental design and monitoring of both the intervention and control group. Almost all of the studies had extensive training for personnel and used a checklist to monitor the intervention components, but the items on these checklists varied widely and were based on unique aspects of the interventions, US Public Health Service and Joint Commission smoking cessation standards, or counselor rapport. Delivery of medications ranged from 31 to 100 % across the studies, with higher levels from studies that gave away free medications and lower levels from studies that sought to obtain prescriptions for the patient in real world systems. Treatment delivery was highest among those studies that used automated (interactive voice response and website) systems, but this did not automatically translate into treatment receipt and enactment. Some studies measured treatment enactment in two ways (e.g., counselor or automated system report versus patient report) showing concurrence or discordance between the two measures.

CONCLUSION

While fidelity monitoring can be challenging especially in dissemination trials, the seven CHART studies used a variety of methods to enhance fidelity with consideration for feasibility and sustainability.

TRIAL REGISTRATION

Dissemination of Tobacco Tactics for hospitalized smokers. Clinical Trials Registration No. NCT01309217.Smoking cessation in hospitalized smokers. Clinical Trials Registration No. NCT01289275.Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial. Clinical Trials Registration No. NCT01305928.Web-based smoking cessation intervention that transitions from inpatient to outpatient. Clinical Trials Registration No. NCT01277250.Effectiveness of smoking-cessation interventions for urban hospital patients. Clinical Trials Registration No. NCT01363245.Comparative effectiveness of post-discharge interventions for hospitalized smokers. Clinical Trials Registration No. NCT01177176.Health and economic effects from linking bedside and outpatient tobacco cessation services for hospitalized smokers in two large hospitals. Clinical Trials Registration No. NCT01236079.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to quit smoking.

OBJECTIVES

To determine whether or not motivational interviewing (MI) promotes smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. Date of the most recent search: August 2014.

SELECTION CRITERIA

Randomized controlled trials in which motivational interviewing or its variants were offered to tobacco users to assist cessation.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate. The main outcome measure was abstinence from smoking after at least six months follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We counted participants lost to follow-up as continuing smoking or relapsed. We performed meta-analysis using a fixed-effect Mantel-Haenszel model.

MAIN RESULTS

We identified 28 studies published between 1997 and 2014, involving over 16,000 participants. MI was conducted in one to six sessions, with the duration of each session ranging from 10 to 60 minutes. Interventions were delivered by primary care physicians, hospital clinicians, nurses or counsellors. Our meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting (risk ratio (RR) 1.26; 95% confidence interval (CI) 1.16 to 1.36; 28 studies; N = 16,803). Subgroup analyses found that MI delivered by primary care physicians resulted in an RR of 3.49 (95% CI 1.53 to 7.94; 2 trials; N = 736). When delivered by counsellors the RR was smaller (1.25; 95% CI 1.15 to 1.63; 22 trials; N = 13,593) but MI still resulted in higher quit rates than brief advice or usual care. When we compared MI interventions conducted through shorter sessions (less than 20 minutes per session) to controls, this resulted in an RR of 1.69 (95% CI 1.34 to 2.12; 9 trials; N = 3651). Single-session treatments might increase the likelihood of quitting over multiple sessions, but both regimens produced positive outcomes. Evidence is unclear at present on the optimal number of follow-up calls.There was variation across the trials in treatment fidelity. All trials used some variant of motivational interviewing. Critical details in how it was modified for the particular study population, the training of therapists and the content of the counselling were sometimes lacking from trial reports.  

AUTHORS' CONCLUSIONS

Motivational interviewing may assist people to quit smoking. However, the results should be interpreted with caution, due to variations in study quality, treatment fidelity, between-study heterogeneity and the possibility of publication or selective reporting bias.

Increasing prevalence of electronic cigarette use among smokers hospitalized in 5 US cities, 2010-2013

INTRODUCTION

Little is known about the pattern of electronic cigarette (e-cigarette) use over time or among smokers with medical comorbidity.

METHODS

We assessed current cigarette smokers' use of e-cigarettes during the 30 days before admission to 9 hospitals in 5 geographically dispersed US cities: Birmingham, AL; Boston, MA; Kansas City, KS; New York, NY; and Portland, OR. Each hospital was conducting a randomized controlled trial as part of the NIH-sponsored Consortium of Hospitals Advancing Research on Tobacco (CHART). We conducted a pooled analysis using multiple logistic regression to examine changes in e-cigarette use over time and to identify correlates of e-cigarette use.

RESULTS

Among 4,660 smokers hospitalized between July 2010 and December 2013 (mean age 57 years, 57% male, 71% white, 56% some college, average 14 cigarettes/day), 14% reported using an e-cigarette during the 30 days before admission. The prevalence of e-cigarette use increased from 1.1% in 2010 to 10.3% in 2011, 10.2% in 2012, and 18.4% in 2013; the increase was statistically significant (p < .0001) after adjustment for age, sex, education, and CHART study. Younger, better educated, and heavier smokers were more likely to use e-cigarettes. Smokers who were Hispanic, non-Hispanic black, and who had Medicaid or no insurance were less likely to use e-cigarettes. E-cigarette use also varied by CHART project and by geographic region.

CONCLUSIONS

E-cigarette use increased substantially from 2010 to 2013 among a large sample of hospitalized adult cigarette smokers. E-cigarette use was more common among heavier smokers and among those who were younger, white, and who had higher socioeconomic status.