Intensive Smoking Cessation Intervention Reduces Mortality in High-Risk Smokers With Cardiovascular Disease

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.

Cardiac Rehabilitation Programs: Content, Effectiveness, Limitations, and Gaps in Knowledge

Cardiac rehabilitation (CR) constitutes a valuable therapeutic approach for patients with a broad spectrum of cardiovascular diseases facilitating the development and maintenance of a desirable level of physical, social, and psychological functioning following the onset of cardiovascular disease. Nowadays, cardiac rehabilitation programs emphasize the use of a multidisciplinary approach. The current review aims at presenting the state-of-the-art knowledge on the indications of patients entering cardiac rehabilitation programs, including their core components, duration, and effectiveness. Following a careful review of the international literature, we conclude that there are significant differences between the most commonly cited international CR guidelines as well as additional limitations and gaps in knowledge. Despite the benefits associated with CR and despite their widespread acceptance, CR referrals and program attendance remains low, while many questions have not been so far addressed through scientific research. Overall, the findings of our study suggest a critical need for the development of robust and evidence-based standardized CR interventions to increase their use and effectiveness throughout the world.

[Anti-smoking intervention in the acute phase of acute coronary syndrome: Is there additional benefit in patients included in a cardiac rehabilitation program?]

BACKGROUND

Smoking is a challenge in secondary prevention after acute coronary syndrome (ACS). The objective was to assess whether the early anti-smoking intervention (ASI), in the acute hospitalization phase, improves the abstinence rate obtained during a cardiac rehabilitation program (CRP).

METHODS

Multicenter clinical trial in which smoker patients admitted for ACS were randomized 1:1 to receive or not ASI from the first day of admission. Upon discharge, both groups were referred to the CRP, performing abstinence controls using co-oximetry. Patients lost were considered smokers.

RESULTS

72 patients were included, 58 men (80.5%), mean age 53 ± 8.1 years. They were admitted for ST elevation myocardial infarction 42 (58%), non-ST elevation myocardial infarction 29 (40%) and unstable angina 1 (1.3%). They smoked an average of 22 ± 11.3 cigarettes/day (pack-year index 37 ± 20). They completed the Richmond test (8.8 ± 1.3) and Fagestrom (5.69 ± 2.1). 36 patients (50%) were randomized to ASI, with no differences in the baseline characteristics of both groups. The dropout rate at the time of inclusion in CRP was higher in the ASI group (69 vs. 44%; p 0.034; OR 2.84), without statistical significance at discharge from the CRP (58 vs. 50%; p 0.478; OR 1.4) or at 12 months (58 vs. 44%; p 0.24; OR 1.75).

CONCLUSIONS

The ASI during admission significantly improves the smoking cessation rate at the time of inclusion in the CRP. Part of these beneficial effects are reduced in the follow-up losing statistical significance with respect to the control group.

Primary care-based smoking cessation treatment and subsequent healthcare service utilisation: a matched cohort study of smokers using linked administrative healthcare data

BACKGROUND

No research has assessed the individual-level impact of smoking cessation treatment delivered within a general primary care patient population on multiple forms of subsequent healthcare service use.

OBJECTIVE

We aimed to compare the rate of outpatient visits, emergency department (ED) visits and hospitalisations during a 5-year follow-up period among smokers who had and had not accessed a smoking cessation treatment programme.

METHODS

The study was a retrospective matched cohort study using linked demographic and administrative healthcare databases in Ontario, Canada. 9951 patients who accessed smoking cessation services between July 2011 and December 2012 were matched to a smoker who did not access services, obtained from the Canadian Community Health Survey, using a combination of hard matching and propensity score matching. Outcomes were rates of healthcare service use from index date (programme enrolment or survey response) to March 2017.

RESULTS

After controlling for potential confounders, patients in the overall treatment cohort had modestly greater rates of the outcomes: outpatient visits (rate ratio (RR) 1.10, 95% CI: 1.06 to 1.14), ED visits (RR 1.08, 95% CI: 1.03 to 1.13) and hospitalisations (RR 1.09, 95% CI: 1.02 to 1.18). Effect modification of the association between smoking cessation treatment and healthcare service use by prevalent comorbidity was found for outpatient visits (p=0.006), and hospitalisations (p=0.050), but not ED visits.

CONCLUSIONS

Patients who enrolled in smoking cessation treatment offered through primary care clinics in Ontario displayed a modest but significantly greater rate of outpatient visits, ED visits and hospitalisations over a 5-year follow-up period.

Intensive versus short face-to-face smoking cessation interventions: a meta-analysis

OBJECTIVES

To evaluate the efficacy of intensive smoking cessation interventions (ISCIs) directly compared with shorter interventions (SIs), measured as successful quitting.

METHOD

Medline, Embase, the Cochrane Library and CINAHL were searched on 15 October 2021. Peer-reviewed randomised controlled trials (RCTs) of adult, daily smokers undergoing an ISCI were included. No setting, time or language restrictions were imposed. Risk of bias and quality of evidence was assessed using the Cochrane tool and Grading of Recommendations, Assessment, Development and Evaluation, respectively. Meta-analyses were conducted using a random-effects model.

RESULTS

17 550 unique articles were identified and 17 RCTs evaluating 9812 smokers were included. 14 studies were conducted in Europe or the USA. The quality of the evidence was assessed as low or moderate. Continuous abstinence was significantly higher in ISCIs in the long term (risk ratio 2.60, 95% CI 1.71-3.97). Direction and magnitude were similar in the short term; however, they were not statistically significant (risk ratio 2.49, 95% CI: 0.94-6.56). When measured as point prevalence, successful quitting was still statistically significant in favour of ISCIs, but lower (long term: 1.64, 1.08-2.47; short term: 1.68, 1.10-2.56). Sensitivity analysis confirmed the robustness of the results.

CONCLUSION

ISCIs are highly effective compared to SIs. This important knowledge should be used to avoid additional morbidity and mortality caused by smoking.

Impact of smoking cessation counseling among acute myocardial infarction patients on post-hospitalization mortality rates: a systematic review

Objective

The current systematic review aimed to assess the impact of smoking cessation counseling (SCC) on patients’ short- and long-term mortality after acute myocardial infarction (AMI).

Methods

The Cochrane guidelines were used to conduct a systematic review of Medline (PubMed), ScienceDirect, CINAHL Cochrane database, and Google Scholar for studies on the impact of SCC on AMI patients’ mortality.

Results

Five studies were found to meet the predefined inclusion criteria. Smoker patients were not routinely counseled to quit smoking during their post-AMI hospital stay. Studies showed a reduction in mortality among AMI patients’ who received SCC compared with patients who did not receive it.

Conclusions

SCC during hospitalization and after discharge is a simple and cost-effective intervention that improves AMI patients’ survival.

Smoking cessation: health system challenges and opportunities

The systematic integration of evidence-based tobacco treatment has yet to be broadly viewed as a standard-of-care. The Framework Convention on Tobacco Control recommends the provision of support for tobacco cessation. We argue that the provision of smoking cessation services in clinical settings is a fundamental clinical responsibility and permits the opportunity to more effectively assist with cessation. The role of clinicians in prioritising smoking cessation is essential in all settings. Clinical benefits of implementing cessation services in hospital settings have been recognised for three decades-but have not been consistently provided. The Ottawa Model for Smoking Cessation has used an 'organisational change' approach to its introduction and has served as the basis for the introduction of cessation programmes in hospital and primary care settings in Canada and elsewhere. The significance of smoking cessation dwarfs that of many preventive interventions in primary care. Compelling evidence attests to the importance of providing cessation services as part of cancer treatment, but implementation of such programmes has been slow. We recognise that the provision of such services must reflect the realities and resources of a particular health system. In low-income and middle-income countries, access to treatment facilities pose unique challenges. The integration of cessation programmes with tuberculosis control services may offer opportunities; and standardisation of peri-operative care to include smoking cessation may not require additional resources. Mobile phones afford unique opportunities for interactive cessation programming. Health system change is fundamental to improving the provision of cessation services; clinicians can be powerful advocates for such change.

Implementation of a systematic tobacco treatment protocol in a surgical outpatient setting: a feasibility study

Background

Smoking cessation programs started as late as 4 weeks before surgery reduce perioperative morbidity and death, yet outpatient clinic interventions are rarely provided. Our aim was to evaluate the feasibility of implementing a tobacco treatment protocol designed for an outpatient surgical setting.

Methods

We completed a pre-post feasibility study of the implementation of a systematic, evidence-based tobacco treatment protocol in an outpatient colorectal surgery clinic. Outcomes included smoking prevalence, pre- and postimplementation smoker identification and intervention rates, recruitment, retention, smoking cessation and provider satisfaction.

Results

Preimplementation, 15.5% of 116 surveyed patients were smokers. Fewer than 10% of surveyed patients reported being asked about smoking, and none were offered any cessation intervention. Over a 16-month postimplementation period, 1198 patients were seen on 2103 visits. Of these, 950 (79.3%) patients were asked smoking status on first visit and 1030 (86.0%) were asked on at least 1 visit. Of 169 identified smokers, 99 (58.6%) were referred to follow-up support using an opt-out approach. At 1-, 3- and 6-month follow-up, intention-to-quit rates among 78 enrolled patients were 24.4%, 22.9% and 19.2%, respectively. Postimplementation staff surveys reported that the protocol was easy to use, that staff would use it again and that it had positive patient responses.

Conclusion

Implementation of our smoking cessation protocol in an outpatient surgical clinic was found to be feasible and used minimal clinic resources. This protocol could lead to increases in identification and documentation of smoking status, delivery of smoking cessation interventions and rates of smoking reduction and cessation.

Pain intensity, e-cigarette dependence, and cessation-related outcomes: The moderating role of pain-related anxiety

Pain and nicotine dependence are prevalent, co-occurring conditions posited to interact in the manner of a positive feedback loop; however, most research to date has been conducted among tobacco cigarette smokers. Initial evidence suggests that pain is a risk factor for greater e-cigarette dependence, and additional research is needed to examine covariation between pain and e-cigarette use. There is reason to suspect that pain-related anxiety (i.e., the tendency to respond to pain with anxiety or fear) may be associated with greater e-cigarette dependence and difficulty quitting, and that pain intensity and pain-related anxiety may interact to confer greater risk for e-cigarette use. The current study represents the first examination of cross-sectional associations between pain intensity, pain-related anxiety, and e-cigarette dependence, motivation to quit, history of lifetime e-cigarette quit attempts, perceived barriers to cessation, and negative expectancies during abstinence from e-cigarettes. Participants (N = 520 e-cigarette users, 52.1% female, Mage = 34.85) completed an online survey assessing health behaviors. Results indicated that pain-related anxiety was positively associated with e-cigarette dependence and perceived barriers to cessation (ps < 0.05). Pain-related anxiety was found to moderate relations between pain intensity and primary outcomes, such that pain intensity was positively associated with motivation to quit, likelihood of past failed quit attempt, and negative abstinence expectancies among participants who endorsed high (but not moderate or low) levels of pain-related anxiety. Future research would benefit from examining prospective associations between pain-related anxiety, pain intensity, and e-cigarette use/cessation trajectories among individuals with chronic pain.

The efficacy and safety of varenicline alone versus in combination with nicotine lozenges for smoking cessation among hospitalised smokers (VANISH): study protocol for a randomised, placebo-controlled trial

INTRODUCTION

Smoking is a leading cause of premature deaths globally. The health benefits of smoking cessation are many. However, majority of quit attempts are unsuccessful. One way to potentially improve success rates is to evaluate new combinations of existing smoking cessation therapies that may work synergistically to decrease the intensity of withdrawal symptoms and cravings.

AIMS

To evaluate the feasibility, efficacy and safety of the combination of varenicline and nicotine replacement therapy (NRT) lozenges versus varenicline alone in assisting hospitalised smokers to quit.

METHODS AND ANALYSIS

This is a multicentre, randomised, placebo-controlled trial. Adults with a history of smoking ≥10 cigarettes per day on average in the 4 weeks prior to their hospitalisation will be recruited. Participants will be randomly assigned to either the intervention group and will receive varenicline and NRT lozenges, or the control group and will receive varenicline and placebo lozenges. All participants will be actively referred to behavioural support from telephone Quitline. Participants are followed up at 1 and 3 weeks and 3, 6 and 12 months from the start of treatment. The primary outcome is carbon monoxide validated prolonged abstinence from 2 weeks to 6 months after treatment initiation. Secondary outcomes include self-reported and biochemically validated prolonged and point prevalence abstinence at 3, 6 and 12 months, self-reported adverse events, withdrawal symptoms and cravings, adherence to treatment, Quitline sessions attended and others. According to the Russell Standard, all randomised participants will be accounted for in the primary intention-to-treat analysis.

ETHICS AND DISSEMINATION

The trial will be conducted in compliance with the protocol, the principles of Good Clinical Practice, the National Health and Medical Research Council National Statement on Ethical Conduct in Human Research (updated 2015) and the Australian Code for the Responsible Conduct of Research (2018). Approval will be sought from the Human Ethics Committees of all the participating hospitals and the university. Written informed consent will be obtained from each participant at the time of recruitment.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry (ACTRN12618001792213).

Combined Utility of 25 Disease and Risk Factor Polygenic Risk Scores for Stratifying Risk of All-Cause Mortality

While genome-wide association studies have identified susceptibility variants for numerous traits, their combined utility for predicting broad measures of health, such as mortality, remains poorly understood. We used data from the UK Biobank to combine polygenic risk scores (PRS) for 13 diseases and 12 mortality risk factors into sex-specific composite PRS (cPRS). These cPRS were moderately associated with all-cause mortality in independent data within the UK Biobank: the estimated hazard ratios per standard deviation were 1.10 (95% confidence interval: 1.05, 1.16) and 1.15 (1.10, 1.19) for women and men, respectively. Differences in life expectancy between the top and bottom 5% of the cPRS were estimated to be 4.79 (1.76, 7.81) years and 6.75 (4.16, 9.35) years for women and men, respectively. These associations were substantially attenuated after adjusting for non-genetic mortality risk factors measured at study entry (i.e., middle age for most participants). The cPRS may be useful in counseling younger individuals at higher genetic risk of mortality on modification of non-genetic factors.

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams.Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations.Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes.Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.

Variability in patient sociodemographics, clinical characteristics, and healthcare service utilization among 107,302 treatment seeking smokers in Ontario: A cross-sectional comparison

Background

Since 2005, the Smoking Treatment for Ontario Patients (STOP) program has provided smoking cessation treatment of varying form and intensity to smokers through 11 distinct treatment models, either in-person at partnering healthcare organizations or remotely via web or telephone. We aimed to characterize the patient populations reached by different treatment models.

Methods

We linked self-report data to health administrative databases to describe sociodemographics, physical and mental health comorbidity, healthcare utilization and costs. Our sample consisted of 107,302 patients who enrolled between 18Oct2005 and 31Mar2016, across 11 models operational during different time periods.

Results

Patient populations varied on sociodemographics, comorbidity burden, and healthcare usage. Enrollees in the Web-based model were youngest (median age: 39; IQR: 29–49), and enrollees in primary care-based Family Health Teams were oldest (median: 51; IQR: 40–60). Chronic Obstructive Pulmonary Disease and hypertension were the most common physical health comorbidities, twice as prevalent in Family Health Teams (32.3% and 30.8%) than in the direct-to-smoker (Web and Telephone) and Pharmacy models (13.5%-16.7% and 14.7%-17.7%). Depression, the most prevalent mental health diagnosis, was twice as prevalent in the Addiction Agency (52.1%) versus the Telephone model (25.3%). Median healthcare costs in the two years up to enrollment ranged from $1,787 in the Telephone model to $9,393 in the Addiction Agency model.

Discussion

While practitioner-mediated models in specialized and primary care settings reached smokers with more complex healthcare needs, alternative settings appear better suited to reach younger smokers before such comorbidities develop. Although Web and Telephone models were expected to have fewer barriers to access, they reached a lower proportion of patients in rural areas and of lower socioeconomic status. Findings suggest that in addition to population-based strategies, embedding smoking cessation treatment into existing healthcare settings that reach patient populations with varying disparities may enhance equitable access to treatment.

Secondary prevention and cardiovascular care across Europe: A survey of European Society of Cardiology members’ views

Introduction:

Secondary prevention of cardiovascular disease is a significant clinical challenge and despite European Society of Cardiology (ESC) Guidelines, evidence confirms sub-optimal patient care.

Aim:

The aim of this study was to evaluate ESC members’ opinions on the current provision of cardiovascular prevention and rehabilitation services across Europe and explore barriers to guideline implementation.

Method:

Electronic surveys using a secure web link were sent to members of the ESC in eight purposively selected ESC affiliated countries.

Results:

A total of 479 professionals completed the survey, of whom 67% were cardiologists, 8.6% general physicians, 8.2% nurses and 16.2% other healthcare professionals. Respondents were predominantly (91%) practising clinicians, generally highly motivated regarding cardiovascular disease prevention, but most reported that secondary prevention in their country was sub-optimal. The main barriers to prevention were lack of available cardiac rehabilitation programmes and long-term follow-up, patients’ disease perception and professional attitudes towards prevention. While knowledge of the prevention guidelines was generally good, practices such as motivational counselling and better educational tools were called for to promote exercise, smoking cessation and for nutritional aspects.

Conclusions:

The provision of services focusing on the secondary prevention of cardiovascular disease varies greatly across Europe. Furthermore, despite ESC Guidelines and a strong evidence base supporting the efficacy of secondary prevention, the infrastructure and co-ordination of such care is lacking. In addition patient motivation is considered poor and some professionals remain unconvinced about the merits of prevention. The disappointing results outlined in this survey emphasise that improved tools are urgently required to educate both patients and professionals and confirm the priority of cardiovascular prevention internationally.

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.

Evaluation of smoking cessation treatment initiated during hospitalization in patients with heart disease or respiratory disease

Objective:

To evaluate the effectiveness of a smoking cessation program, delivered by trained health care professionals, in patients hospitalized for acute respiratory disease (RD) or heart disease (HD).

Methods:

Of a total of 393 patients evaluated, we included 227 (146 and 81 active smokers hospitalized for HD and RD, respectively). All participants received smoking cessation treatment during hospitalization and were followed in a cognitive-behavioral smoking cessation program for six months after hospital discharge.

Results:

There were significant differences between the HD group and the RD group regarding participation in the cognitive-behavioral program after hospital discharge (13.0% vs. 35.8%; p = 0.003); smoking cessation at the end of follow-up (29% vs. 31%; p < 0.001); and the use of nicotine replacement therapy (3.4% vs. 33.3%; p < 0.001). No differences were found between the HD group and the RD group regarding the use of bupropion (11.0% vs. 12.3%; p = 0.92). Varenicline was used by only 0.7% of the patients in the HD group.

Conclusions:

In our sample, smoking cessation rates at six months after hospital discharge were higher among the patients with RD than among those with HD, as were treatment adherence rates. The implementation of smoking cessation programs for hospitalized patients with different diseases, delivered by the health care teams that treat these patients, is necessary for greater effectiveness in smoking cessation.

Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis

A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane's tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54⁻0.85) and ET (HR = 0.75, 95% CrI = 0.60⁻0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57⁻0.99), ET (HR = 0.75, 95% CrI = 0.56⁻0.99) and PE (HR = 0.68, 95% CrI = 0.47⁻0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58⁻0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted.

Smoking cessation after engagement in HIV care in rural Uganda

People living with HIV (PLWH) are more likely to smoke compared to HIV-uninfected counterparts, but little is known about smoking behaviors in sub-Saharan Africa. To address this gap in knowledge, we characterized smoking cessation patterns among people living with HIV (PLWH) compared to HIV-uninfected individuals in rural Uganda. PLWH were at least 40 years of age and on antiretroviral therapy for at least three years, and HIV-uninfected individuals were recruited from the clinical catchment area. Our primary outcome of interest was smoking cessation, which was assessed using an adapted WHO STEPS smoking questionnaire. We fit Cox proportional hazards models to compare time to smoking cessation between PLWH pre-care, PLWH in care, and HIV-uninfected individuals. We found that, compared to HIV-uninfected individuals, PLWH in care were less likely to have ever smoked (40% vs. 49%, p = 0.04). The combined sample of 267 ever-smokers had a median age of 56 (IQR 49-68), 56% (n = 150) were male, and 26% (n = 70) were current smokers. In time-to-event analyses, HIV-uninfected individuals and PLWH prior to clinic enrollment ceased smoking at similar rates (HR 0.8, 95% CI 0.5-1.2). However, after enrolling in HIV care, PLWH had a hazard of smoking cessation over twice that of HIV-uninfected individuals and three times that of PLWH prior to enrollment (HR 2.4, 95% CI 1.3-4.6, p = 0.005 and HR 3.0, 95% CI 1.6-5.5, p = 0.001, respectively). In summary, we observed high rates of smoking cessation among PLWH after engagement in HIV care in rural Uganda. While we hypothesize that greater access to primary care services and health counseling might contribute, future studies should better investigate the mechanism of this association.

Advancing Health Policy and Program Research in Diabetes: Findings from the Natural Experiments for Translation in Diabetes (NEXT-D) Network

PURPOSE OF REVIEW

To advance our understanding of the impacts of policies and programs aimed at improving detection, engagement, prevention, and clinical diabetes management in the USA, we synthesized findings from a network of studies that used natural experiments to evaluate diabetes health policies and programs.

FINDINGS

Studies from the Natural EXperiments for Translation in Diabetes (NEXT-D) network used rigorous longitudinal quasi-experimental study designs (e.g., interrupted time series) and analytical methods (e.g., difference-in-differences) to augment causal inference. Investigators partnered with health system stakeholders to evaluate whether glucose testing rates changed from before-to-after clinic interventions (e.g., integrating electronic screening decision prompts in New York City) or employer programs (e.g., targeted messaging and waiving copayments for at-risk employees). Other studies examined participation and behavior change in low- (e.g., wellness coaching) or high-intensity lifestyle modification programs (e.g., diabetes prevention program-like interventions) offered by payers or employers. Lastly, studies assessed how employer health insurance benefits impacted healthcare utilization, adherence, and outcomes among people with diabetes. NEXT-D demonstrated that low-intensity interventions to facilitate glucose testing and enhance engagement in lifestyle modification were associated with small improvements in weight but large improvements in screening and testing when supported by electronic health record-based decision-support. Regarding high-intensity diabetes prevention program-like lifestyle programs offered by payers or employers, enrollment was modest and led to weight loss and marginally lower short-term health expenditures. Health plans that incentivize patient behaviors were associated with increases in medication adherence. Meanwhile, shifting patients to high-deductible health plans was associated with no change in medication use and preventive screenings, but patients with diabetes delayed accessing healthcare for acute complications (e.g., cellulitis). Findings were more pronounced among lower-income patients, who experienced increased rates and acuity of emergency department visits for diabetes complications and other high-severity conditions. Findings from NEXT-D studies provide informative data that can guide programs and policies to facilitate detection, prevention, and treatment of diabetes in practice.

Effect of smoking cessation on the risk of dementia: a longitudinal study

Objective

To determine the risk of developing dementia in relation to duration of smoking cessation by using a nationwide health claims database.

Methods

This cohort study included 46,140 men aged 60 years or older from Korean National Health Insurance System – National Health Screening Cohort, a population‐based national health screening program from 2002 to 2013. The changes in smoking habit from a questionnaire during the first (2002 and 2003) and second (2004 and 2005) health examination periods, participants were divided into continual smokers, short‐term (less than 4 years) quitters, long‐term (4 years or more) quitters, and never smokers. Participants were followed‐up for 8 years from January 1, 2006 for the development of overall dementia, Alzheimer's disease, and vascular dementia.

Results

Compared to continual smokers, long‐term quitters and never smokers had decreased risk of overall dementia (hazard ratio, HR 0.86 95% CI, confidence interval 0.75–0.99 and HR: 0.81; 95% CI: 0.71–0.91, respectively). Never smokers had decreased risk of Alzheimer's disease (HR: 0.82; 95% CI: 0.70–0.96) compared to continual smokers. Finally, both long‐term quitters (HR: 0.68; 95% CI: 0.48–0.96) and never smokers (HR: 0.71; 95% CI: 0.54–0.95) had decreased risk of vascular dementia compared to continual smokers.

Interpretation

Smoking was associated with increased risk of dementia. Smokers who quit for a prolonged period of time may benefit from reduced risk of dementia. Therefore, smokers should be encouraged to quit in order to reduce the risk of developing dementia, especially in the elderly population who are already at risk.

A Collaborative Model for Facilitating the Delivery of Smoking Cessation Treatments to Cancer Patients: Results From Three Oncology Practices in South Carolina

Introduction: Continued smoking by cancer patients causes adverse cancer treatment outcomes, but few patients receive evidence-based smoking cessation as a standard of care.

Aim: To evaluate practical strategies to promote wide-scale dissemination and implementation of evidence-based tobacco cessation services within state cancer centers.

Methods: A Collaborative Learning Model (CLM) for Quality Improvement was evaluated with three community oncology practices to identify barriers and facilitate practice change to deliver evidence-based smoking cessation treatments to cancer patients using standardized assessments and referrals to statewide smoking cessation resources. Patients were enrolled and tracked through an automated data system and received follow-up cessation support post-enrollment. Monthly quantitative reports and qualitative data gathered through interviews and collaborative learning sessions were used to evaluate meaningful quality improvement changes in each cancer center.

Results: Baseline practice evaluation for the CLM identified the lack of tobacco use documentation, awareness of cessation guidelines, and awareness of services for patients as common barriers. Implementation of a structured assessment and referral process demonstrated that of 1,632 newly registered cancer patients,1,581 (97%) were screened for tobacco use. Among those screened, 283 (18%) were found to be tobacco users. Of identified tobacco users, 207 (73%) were advised to quit. Referral of new patients who reported using tobacco to an evidence-based cessation program increased from 0% at baseline across all three cancer centers to 64% (range = 30%–89%) during the project period.

Conclusions: Implementation of quality improvement learning collaborative models can dramatically improve delivery of guideline-based tobacco cessation treatments to cancer patients.

Automated Telephone Follow-up for Smoking Cessation in Smokers With Coronary Heart Disease: A Randomized Controlled Trial

Introduction

Smokers with coronary heart disease (CHD) benefit from in-hospital cessation treatment, but relapse is common without ongoing support postdischarge. The purpose of this study was to determine if smoking abstinence would be higher after hospital discharge in smokers who received automated telephone follow-up (ATF) and nurse-counseling, compared with a standard care (SC) control group.

Methods

A total of 440 smokers hospitalized with CHD were randomly assigned to the ATF group (n = 216) or to the SC group (n = 224). Participants in the ATF group received automated phone calls 3, 14, 30, 60, 90, 120, 150, and 180 days after hospital discharge. The ATF system posed questions concerning smoking status, confidence in staying smoke-free, and need for assistance. If flagged by the ATF system, a nurse-counselor provided additional counseling by phone. Self-reported continuous smoking abstinence was assessed 26 and 52 weeks postdischarge using intention-to-treat analysis. The main outcome measure was continuous abstinence for weeks 1–26 postdischarge.

Results

Participants in the ATF group achieved higher abstinence rates for weeks 1–26 than those in the SC group (odds ratio [OR] = 1.53, 95% confidence interval [CI] = 1.01 to 2.33). There was no significant difference between groups in abstinence rates for weeks 27–52 (OR = 1.37; 95% CI = 0.89 to 2.09).

Conclusions

ATF-mediated follow-up helped smokers with CHD achieve abstinence during the intervention period. There was a trend toward clinically important improvements for weeks 27–52; but between-group differences for this time point did not achieve statistical significance.

Clinical Trial Number

NCT00449852.

Implications

Automated telephone follow-up exerts its effect by reinforcing participants’ efforts to be smoke-free and by proactively linking people requiring assistance to individualized support (eg, telephone counseling). This study shows that automated telephone follow-up can assist smokers with CHD in remaining smoke-free; however, the success of automated telephone follow-up is limited to the treatment period and abstinence rates after the treatment period were not statistically different from among those receiving standard care. Extended treatment via automated telephone follow-up may provide a solution to extend cessation assistance beyond hospital discharge.

Impact of the Tobacco Treatment Guidelines for High Risk Groups (TOB.g): A pilot study among physicians specializing in CVD, Diabetes and COPD

INTRODUCTION

The 2017 Tobacco Cessation Guidelines for High-risk Groups (TOB-G) is a comprehensive document on best practices for smoking cessation in clinical practice. The purpose of this pilot study was to assess physician satisfaction and changes in tobacco-related knowledge, self-efficacy and attitudes following exposure to training in the TOB-G guidelines for patients with cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), or diabetes.

METHODS

A pre-post pilot study was conducted. All participating physicians received an electronic or printed copy of the TOB-G guidelines for patients with CVD, COPD or diabetes. Physicians were also exposed to a one-day training focused on the key clinical practice recommendations from the TOB.g guidelines. Outcome measurement occurred via survey before, immediately following and 6 months after exposure to the training.

RESULTS

Fifty physicians participated in the TOB.g training session. High rates of participant satisfaction were documented (exceeded expectations 47.7%; met expectations to a great extent 52.3%). Significant increases in physician knowledge and self-efficacy were documented immediately following and 6 months after exposure to the guideline training session. Exposure to the training was associated with positive changes in some but not all tobacco-related treatment attitudes, however these were no longer significant at the 6-month follow-up. Lower knowledge, confidence and unfavourable attitudes were documented for aspects of treatment related to pharmacotherapy.

CONCLUSIONS

Positive changes in previously reported barriers to the delivery of tobacco treatment among physicians were documented following exposure to the TOB.g guidelines and training for patients with CVD, COPD or diabetes.

Effect of an Evidence-based Inpatient Tobacco Dependence Treatment Service on 30-, 90-, and 180-Day Hospital Readmission Rates

INTRODUCTION

Smoking is a risk factor for hospitalization and interferes with patient care due to its effects on pulmonary function, wound healing, and interference with treatments and medications. Although benefits of stopping smoking are well-established, few hospitals provide tobacco dependence treatment services (TDTS) due to cost, lack of mandatory tobacco cessation standards and lack of evidence demonstrating clinical and financial benefits to hospitals and insurers for providing services.

METHODS

This study explored the effect of an inpatient TDTS on 30-, 90-, and 180-day hospital readmissions. To carry out this work, 3 secondary datasets were linked, which included clinical electronic health record data, tobacco cessation program data, and statewide health care utilization data. Odds ratios (ORs) were calculated using inverse propensity score-weighted logistic regression models, with program exposure as the primary independent variable and 30 (90 and 180)-day readmission rates as the dependent variable, and adjustment for putative covariates.

RESULTS

Odds of readmission were compared for patients who did and did not receive TDTS. At 30 days postdischarge, smokers exposed to the TDTS had a lower odds of readmission (OR=0.77, P=0.031). At 90 and 180 days, odds of readmission remained lower in the TDTS group (ORs=0.87 and 0.86, respectively), but were not statistically significant.

DISCUSSION

Findings from the current study, which are supported by prior studies, provide evidence that delivery of TDTS is a strategy that may help to reduce hospital readmissions.

The Evolving Epidemiology of Atherosclerotic Cardiovascular Disease in People with Diabetes

Atherosclerotic cardiovascular disease (ASCVD) is a leading global cause of death and accounts for most deaths among individuals with diabetes. This article reviews the latest observational and trial data on changes in the relationship between diabetes and ASCVD risk, remaining gaps in how the role of each risk factor is understood, and current knowledge about specific interventions. Differences between high-income countries and low-income and middle-income countries are examined, barriers and facilitators are discussed, and a discussion around the concept of ideal cardiovascular health factors (Life's Simple 7) is focused on.

Systematic Review of Clinician-Reported Barriers to Provision of Smoking Cessation Interventions in Hospital Inpatient Settings

Background: Although the hospital inpatient setting arguably provides an ideal opportunity to engage patients in smoking cessation interventions, this is done infrequently. We therefore aimed to systematically review the perceived barriers to the implementation of smoking cessation interventions in the hospital inpatient setting.

Methods: A systematic literature search was conducted specific to hospital-based healthcare workers’ perceived barriers to implementing smoking cessation interventions. Reported barriers were categorised using the capability, opportunity and motivation (COM-B) framework.

Results: Eighteen studies were selected for inclusion, which consisted of cross-sectional surveys and interviews. The most commonly identified barrier in capability was lack of knowledge (56% of studies); in Opportunity, it was a lack of time (78%); while in Motivation, a lack of perceived patient motivation to quit smoking (44%). Seventeen other barriers were also endorsed, but less frequently.

Conclusion: Healthcare workers report a plethora of barriers to providing smoking cessation interventions in hospital settings, which cover all aspects of the COM-B framework. These impediments need to be addressed in a multidisciplinary approach, at clinical, educational, and administrative levels, to improve intervention provision.

The Effect of an Inpatient Smoking Cessation Treatment Program on Hospital Readmissions and Length of Stay

OBJECTIVE

The objective of this study is to estimate the impact of an inpatient tobacco cessation treatment program on 30-day readmission rates and length of stay (LOS).

METHODS

Participants were 28,994 patients admitted to the hospital between July 2012 and July 2014. Smokers were identified through the electronic medical records system and were offered cessation treatment. Program effects were estimated by using a difference-in-differences approach, comparing all smokers to all nonsmokers before versus after introduction of the program. Readmission rates were modeled by using probit regression; LOS was modeled by using truncated negative binomial regression. Models controlled for age, sex, race, payer, hospital department, severity of illness, and intensive care unit days.

RESULTS

The hospital-initiated smoking cessation intervention had no significant effect on 30-day readmission rates or LOS. Other control variables had the expected signs and were statistically significant.

CONCLUSIONS

The evaluation of an inpatient tobacco dependence treatment did not find significant short-term changes in healthcare utilization in the first 30 days after initial hospitalization.

Interventions for smoking cessation in patients admitted with Acute Coronary Syndrome: a review

Tobacco smoking contributes to about six million deaths per year and is predicted to increase in the future. Several pharmacological interventions are used for smoking cessation. Trials using nicotine replacement therapy (NRT) in acute coronary syndrome (ACS) showed inconclusive results. Furthermore, three trials using bupropion in patients admitted with ACS failed to show improvement in smoking cessation compared with placebo. Interestingly, only one trial using varenicline was successful in achieving smoking abstinence in the acute setting. With regard to behavioural interventions, a meta-analysis found that telephone counselling was successful in both the acute and stable settings, with greater effect in the acute setting. The best results for smoking cessation were found in trials that used a combination of pharmacological and behavioural interventions. The objective of this report is to review the results of studies on interventions used for smoking cessation after an ACS.

Academic and Government Partnerships to Address Diabetes in the USA: a Narrative Review

PURPOSE OF REVIEW

Multi-sector partnerships are broadly considered to be of value for diabetes prevention and management. The purpose of this article is to summarize academic and government collaborations focused on diabetes prevention and management.

RECENT FINDINGS

Using a narrative review approach, we identified 17 articles describing 10 academic and government partnerships for diabetes management and surveillance. Challenges and gaps in the literature include complexity of diabetes management vis a vis current healthcare infrastructure; a paucity of racial/ethnic diversity in translational efforts; and the time/effort needed to maintain strong relationships across partner institutions. Academic and government partnerships are of value for diabetes prevention and management activities. Acknowledgment that the key priorities of government programming are often costs and feasibility is critical for collaborations to be successful. Future translational efforts of diabetes prevention and management programs should focus on the following: (1) expansion of partnerships between academia and local health departments; (2) increased utilization of implementation science for enhanced and efficient implementation and dissemination; and (3) harnessing of technological advances for data analysis, patient communication, and report generation.

Feasibility and acceptability of a telephone- and face-to-face-delivered counseling intervention for smoking cessation in Dutch patients with coronary heart disease

Intensive behavioral counseling interventions combined with nicotine replacement therapy have increased smoking abstinence rates in cardiac patients, but little is known about their feasibility when initiated upon hospital admission and continued post-discharge. The current study was an evaluation of the use, appreciation, and fidelity of two post-discharge counseling interventions designed for cardiac patients to quit smoking that differed in their delivery mode. In a controlled trial with cross-over randomization at the cardiac unit level, hospitalized smokers in eight cardiac units of eight Dutch hospitals were assigned either telephone counseling (n = 223) or nurse-administered face-to-face counseling (n = 157) using the Ask-Advise-Refer strategy. Eligible patients also received nicotine replacement therapy. Data based on counselors' registration forms and patients' telephone surveys at 6-month follow-up were analyzed. Most patients (>90%) participated in at least one counseling session, and the majority participated in at least five out of a maximum of seven sessions. Higher levels of adherence to either the telephone or face-to-face counseling sessions were associated with higher smoking abstinence rates at the 6-month follow-up, whereas higher nicotine patch use was not associated with abstinence. Patients positively evaluated the content, duration, and number of sessions, and rated the face-to-face counseling significantly better than the telephone counseling for quitting smoking. The counselors largely complied with the intervention protocols. The current intervention offers evidence of feasibility and may improve outpatient continuity of smoking care. Monitoring the use and delivery of such complex interventions is recommended to promote effective dissemination in cardiac practice.

An Epidemiological Study of Population Health Reveals Social Smoking as a Major Cardiovascular Risk Factor

PURPOSE

To present nationally representative data on the prevalence of "social" smoking and its relationship to cardiovascular health.

DESIGN

A population-based, cross-sectional survey on cardiovascular health and its risk factors across the United States.

SETTING

Million Hearts^® cardiovascular screenings that took place in community settings.

PARTICIPANTS

De-identified data were collected on a convenient sample of 39, 555 participants.

MEASURES

Reported smoking status, blood pressure, and total cholesterol.

ANALYSIS

The prevalence of current smoking, social smoking, and non-smoking were cross-tabulated and stratified by sample characteristics. The adjusted estimates were derived from multiple logistic regression models, adjusting for demographics and other biometric measures.

RESULTS

Ten percent identified as social smokers. Social smokers were more likely to be aged between 21 and 40, male, and Hispanic. Social smokers had significantly higher risks of having hypertension (odds ratio [OR]: 2.08, 95% confidence interval [CI]: 1.80-2.41) and elevated cholesterol (OR: 1.53, 95% CI: 1.33-1.75) than non-smokers. There was no significant difference between social smokers and current smokers (OR = 0.94, 95% CI = 0.80-1.14 for hypertension and OR = 0.95, 95% CI = 0.81-1.11 for elevated cholesterol).

CONCLUSION

This is the first population health study to compare the blood pressure and cholesterol levels of people who self-identify as current verses social smokers. Although previous smoking behavior was not controlled for in the analysis, this study demonstrates there is no significant difference in the prevalence of elevated blood pressure or cholesterol among the 2 smoking groups.

Psychological interventions for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

SEARCH METHODS

We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

MAIN RESULTS

This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

AUTHORS' CONCLUSIONS

This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

A Mixed Method Review of Tobacco Cessation for the Cardiopulmonary Rehabilitation Clinician

PURPOSE

To systematically survey the literature, describe the current tobacco science, and perform a mixed method review of randomized control trials of tobacco research in the cardiopulmonary population.

METHODS

Mixed method review was conducted on major resource databases. Inclusion criteria were English language with a minimum follow-up of 6 months, published between January 1, 2007, and June 30, 2016; adult smokers ≥18 years of age with cardiovascular and/or pulmonary disease; initiation of subject recruitment from hospital or community; tobacco cessation (TC) as the main aim of the study; biometric validation of smoking status; first-line TC medications; and nonpharmacological treatments.

RESULTS

The pooling of the 10 studies through forest plot analysis revealed the effect of tobacco continuous abstinence rates significant at 3, 6, and 12 months (total OR = 3.73; 95% CI, 2.58-5.38). Also, tobacco point prevalence rates of TC treatments demonstrated overall effects that were significant at the different end points (total OR = 2.63; 95% CI, 1.90-3.64). In both cases, the higher ORs were found in the 3 months end point. Most successful interventions consisted of a combination of pharmacological and nonpharmacological therapy (predominantly counseling).

CONCLUSIONS

The evidence continues to support the recommended first-line TC pharmacotherapy and nonpharmacological practices published in the 2008 national guidelines. Implications for cardiopulmonary rehabilitation clinicians are discussed.

Behavioral activation for smoking cessation and mood management following a cardiac event: results of a pilot randomized controlled trial

Background

Smoking cessation following hospitalization for Acute Coronary Syndrome (ACS) significantly reduces subsequent mortality. Depressed mood is a major barrier to cessation post-ACS. Although existing counseling treatments address smoking and depression independently in ACS patients, no integrated treatment addresses both. We developed an integrated treatment combining gold standard cessation counseling with behavioral activation-based mood management; Behavioral Activation Treatment for Cardiac Smokers (BAT-CS). The purpose of this pilot randomized controlled trial was to test feasibility, acceptability, and preliminary efficacy of BAT-CS vs. Standard of Care (SC).

Methods

Participants were recruited during hospitalization for ACS and were randomly assigned to BAT-CS or SC. The nicotine patch was offered in both conditions. Smoking, mood, and stress outcomes were collected at end-of-treatment and 24-week follow-up.

Results

Fifty-nine participants (28 BAT-CS, 31 SC) were recruited over 42 weeks, and assessment completion was above 80% in both conditions. Treatment acceptability and fidelity were high. At 24 week follow-up adjusted odds ratios favoring BAT-CS were 1.27 (95% CI: 0.41–3.93) for 7-day point prevalence abstinence and 1.27 (95% CI: 0.42–3.82) for continuous abstinence. Time to first smoking lapse was significantly longer in BAT-CS (62.4 vs. 31.8 days, p = 0.03). At 24-weeks, effect sizes for mood and stress outcomes ranged from η²_partial of.07–.11, with significant between treatment effects for positive affect, negative affect, and stress.

Conclusions

The design of this study proved feasible and acceptable. Results provide preliminary evidence that combining behavioral activation with standard smoking cessation counseling could be efficacious for this high risk population. A larger trial with longer follow-up is warranted.

Trial registration

NCT01964898. First received by clinicaltrials.gov October 15, 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4250-7) contains supplementary material, which is available to authorized users.

A systematic review of possible serious adverse health effects of nicotine replacement therapy

We conducted a systematic literature review to identify and critically evaluate studies of serious adverse health effects (SAHEs) in humans using nicotine replacement therapy (NRT) products. Serious adverse health effects refer to adverse events, leading to substantial disruption of the ability to conduct normal life functions. Strength of evidence evaluations and conclusions were also determined for the identified SAHEs. We evaluated 34 epidemiological studies and clinical trials, relating NRT use to cancer, reproduction/development, CVD, stroke and/or other SAHEs in patients, and four meta-analyses on effects in healthy populations. The overall evidence suffers from many limitations, the most significant being the short-term exposure (≤12 weeks) and follow-up to NRT product use in most of the studies, the common failure to account for changes in smoking behaviour following NRT use, and the sparse information on SAHEs by type of NRT product used. The only SAHE from NRT exposure we identified was an increase in respiratory congenital abnormalities reported in one study. Limited evidence indicated a lack of effect between NRT exposure and SAHEs for CVD and various reproduction/developmental endpoints. For cancer, stroke and other SAHEs, the evidence was inadequate to demonstrate any association with NRT use. Our conclusions agree with recent statements from authoritative bodies.

Smoking and common mental disorders in patients with chronic conditions: An analysis of data collected via a web-based screening system

OBJECTIVE

Smoking is the largest preventable cause of death and disability in the UK and remains pervasive in people with mental disorders and in general hospital patients. We aimed to quantify the prevalence of mental disorders and smoking, examining associations between mental disorders and smoking in patients with chronic physical conditions.

METHOD

Data were collected via routine screening systems implemented across two London NHS Foundation Trusts. The prevalence of mental disorder, current smoking, nicotine dependence and wanting help with quitting smoking were quantified, and the relationships between mental disorder and smoking were examined, adjusting for age, gender and physical illness, with multiple regression models.

RESULTS

A total of 7878 patients were screened; 23.2% screened positive for probable major depressive disorder, and 18.5% for probable generalised anxiety disorder. Overall, 31.4% and 29.2% of patients with probable major depressive disorder or generalised anxiety disorder respectively were current smokers. Probable major depression and generalised anxiety disorder were associated with 93% and 44% increased odds of being a current smoker respectively. Patients with depressive disorder also reported higher levels of nicotine dependence, and the presence of common mental disorder was not associated with odds of wanting help with quitting smoking.

CONCLUSION

Common mental disorder in patients with chronic physical health conditions is a risk factor for markedly increased smoking prevalence and nicotine dependence. A general hospital encounter represents an opportunity to help patients who may benefit from such interventions.

Lifestyle Modification in Secondary Prevention: Beyond Pharmacotherapy

Despite significant advances in medical technology and pharmacology, cardiovascular disease (CVD) remains a major contributor to health care expenses and the leading cause of death in the United States. Patients with established CVD and their health care providers are challenged with achieving cardiovascular risk reduction to decrease the likelihood of recurrent cardiovascular events. This "secondary prevention" can be achieved, in part, through adherence to prescribed pharmacotherapies that favorably modify major coronary risk factors (ie, hypertension, hypercholesterolemia, diabetes, and obesity). However, lifestyle modification can also be helpful in this regard, providing independent and additive benefits to the associated reductions in cardiovascular morbidity and mortality. Accordingly, physicians and other health care providers should routinely counsel their coronary patients to engage in structured exercise and increased lifestyle physical activity, consume a heart-healthy diet, quit smoking and avoid secondhand smoke, and purposefully address psychosocial stressors that may elevate cardiovascular risk. These lifestyle interventions, either as an adjunct to medication therapy or independently in those patients where medications may be poorly tolerated, cost prohibitive, or ineffective, can significantly decrease cardiovascular mortality and the risk of recurrent cardiac events.

Life Years Gained From Smoking-Cessation Counseling After Myocardial Infarction

INTRODUCTION

Hospitalization for acute myocardial infarction (AMI) is an opportune time to counsel smokers to quit. Studies have demonstrated lower short-term mortality for counseled versus non-counseled smokers; yet, little is known about the long-term survival benefits of post-AMI smoking-cessation counseling (SCC).

METHODS

Data from the Cooperative Cardiovascular Project, a prospective cohort study of elderly patients with AMI between 1994 and 1996 with >17 years of follow-up, were used to evaluate the association of SCC with short- and long-term mortality in smokers with AMI. Life expectancy and years of potential life gained were used to quantify the long-term survival benefits of SCC. Cox proportional hazards models with exponential extrapolation were used to estimate life expectancy.

RESULTS

The analysis included 13,815 smokers, of whom 5,695 (41.2%) received SCC. Non-counseled smokers had higher crude mortality than counseled smokers over all 17 years of follow-up. After adjustment for patient and hospital characteristics, SCC was associated with a 22.6% lower 30-day mortality and a 7.5% lower mortality over 17 years. These survival differences produced higher life expectancy estimates for counseled smokers than non-counseled smokers at all ages, which resulted in average gains in life years of 0.13 (95% CI=-0.31, 0.56) to 0.58 (95% CI=0.25, 0.91) years, with the largest gains observed in older smokers.

CONCLUSIONS

SCC is associated with longer life expectancy and gains in life years in elderly smokers with AMI, supporting the importance of post-AMI counseling efforts.

Efficacy and Safety of Smoking Cessation Interventions in Patients With Cardiovascular Disease

Background—

Although the efficacy and safety of smoking cessation interventions are well established, their efficacy and safety in patients with cardiovascular disease (CVD) remain unclear. The objective of this study was to evaluate the efficacy and safety of pharmacological and behavioral smoking cessation interventions in CVD patients via a meta-analysis of randomized controlled trials.

Methods and Results—

EMBASE, PsycINFO, MEDLINE, PubMed, and the Cochrane Tobacco Addiction Specialized Register were searched for randomized controlled trials evaluating the efficacy of smoking cessation pharmacotherapies and behavioral therapies in CVD patients. Outcomes of interest were smoking abstinence at 6 and 12 months, defined using the most rigorous criteria reported. Data were pooled across studies for direct comparisons using random-effects models. Network meta-analysis using a graph-theoretical approach was used to generate the indirect comparisons. Seven pharmacotherapy randomized controlled trials (n=2809) and 17 behavioral intervention randomized controlled trials (n=4666) met our inclusion criteria. Our network meta-analysis revealed that varenicline (relative risk [RR]: 2.64; 95% confidence interval [CI], 1.34–5.21) and bupropion (RR: 1.42; 95% CI, 1.01–2.01) were associated with greater abstinence than placebo. The evidence about nicotine replacement therapies was inconclusive (RR: 1.22; 95% CI, 0.72–2.06). Telephone therapy (RR: 1.47; 95% CI: 1.15–1.88) and individual counseling (RR: 1.64, 95% CI: 1.17–2.28) were both more efficacious than usual care, whereas in-hospital behavioral interventions were not (RR: 1.05; 95% CI, 0.78–1.43).

Conclusions—

Our meta-analysis suggests varenicline and bupropion, as well as individual and telephone counseling, are efficacious for smoking cessation in CVD patients.

Risk factor control, adherence to medication and follow up visit, five years after coronary artery bypass graft surgery

Introduction: Inadequate adherence to medication and follow up visits were proposed correlated with cardiovascular mortality and complications. This study was planned to evaluate medication and follow up adherence and risk factor control in patients with coronary artery disease 5 years after coronary artery bypass grafting (CABG). Methods: In this retrospective cohort study, adult patients who underwent CABG in 2010 were enrolled. Conventional and probable risk factor control and adherence to medication and follow up visits were assessed. Results: 196 patients were recruited to the study. Uncontrolled blood pressure, blood glucose and low-density lipoprotein (LDL)were reported in 48%, 61% and 32% of patients, respectively. More than 63% of former smokers restarted smoking during 6-12 months after bypass. Poor medication adherence was present in 10.7% in the study population. The last follow up visit time for 30% of patients was later than 12 months after CABG. Conclusion: Poor risk factors control and adherence to follow up visits was common among patients undergoing CABG.

Guidelines for the Treatment of Smoking in Hospitalized Patients

Between 15 and 27% of patients admitted to Spanish hospitals are smokers. Hospitalization is an ideal time for a smoker to decide to quit. We performed a MEDLINE search of controlled, randomized or observational studies associated with helping hospitalized patients quit smoking, published between January 1, 2002 and September 30, 2015. On the basis of the results of those studies, we have issued some recommendations for the treatment of smoking in hospitalized patients. The recommendations were drawn up according to the GRADE system. Offering the smoker psychological counselling and prolonging follow-up for at least 4 weeks after discharge is the most effective recommendation for helping hospitalized patients to quit.

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.

Factors associated with study attrition in a pilot randomised controlled trial to explore the role of exercise-assisted reduction to stop (EARS) smoking in disadvantaged groups

Background

Study attrition has the potential to compromise a trial’s internal and external validity. The aim of the present study was to identify factors associated with participant attrition in a pilot trial of the effectiveness of a novel behavioural support intervention focused on increasing physical activity to reduce smoking, to inform the methods to reduce attrition in a definitive trial.

Methods

Disadvantaged smokers who wanted to reduce but not quit were randomised (N = 99), of whom 61 (62 %) completed follow-up assessments at 16 weeks. Univariable logistic regression was conducted to determine the effects of intervention arm, method of recruitment, and participant characteristics (sociodemographic factors, and lifestyle, behavioural and attitudinal characteristics) on attrition, followed by multivariable logistic regression on those factors found to be related to attrition.

Results

Participants with low confidence to quit, and who were undertaking less than 150 mins of moderate and vigorous physical activity per week at baseline were less likely to complete the 16-week follow-up assessment. Exploratory analysis revealed that those who were lost to follow-up early in the trial (i.e., by 4 weeks), compared with those completing the study, were younger, had smoked for fewer years and had lower confidence to quit in the next 6 months. Participants who recorded a higher expired air carbon monoxide reading at baseline were more likely to drop out late in the study, as were those recruited via follow-up telephone calls. Multivariable analyses showed that only completing less than 150 mins of physical activity retained any confidence in predicting attrition in the presence of other variables.

Conclusions

The findings indicate that those who take more effort to be recruited, are younger, are heavier smokers, have less confidence to quit, and are less physically active are more likely to withdraw or be lost to follow-up.

Sex and age differences in the achievement of control targets in patients with type 2 diabetes: results from a population-based study in a South European region

Background

We aimed to determine the degree to which control targets of glycaemia and cardiovascular risk factors were achieved among patients with type 2 diabetes and to investigate sex- and age-related differences in this population.

Methods

This cross-sectional, population-based study was conducted in Spain. Glycated hemoglobin (HbA1c), blood pressure, LDL-c, HDL-c, triglycerides, BMI, and smoking history were obtained from electronic clinical primary care records (n = 32,638 cases). The proportions of patients who met control targets were determined according to sex and age groups. Comparisons between groups were conducted with t-tests for continuous variables, tests for trends in proportions for categorical and ordinal variables, and Pearson’s chi-square tests and binary logistic regression models for categorical variables.

Results

The overall proportions of patients with type 2 diabetes who met the target objectives for HbA1c (<7 %, 53 mmol/mol), blood pressure (130/80 mmHg), and LDL-cholesterol (100 mg/dl) were 60, 40 and 41 %, respectively. Women were less likely than men to meet the control targets of HbA1c (59 vs 61 %), LDL (35 vs 45 %), and HDL (58 vs 78 %). Patients under 65 years of age presented poorer control than older age groups. Only a minority of patients with type 2 diabetes met the composite target objectives for glycemic control, blood pressure, and LDL.

Conclusions

There are differential gaps in the control results of female patients and younger patients, which should prompt improvements in case management and care. There is room for further improvement in the cardiometabolic control of patients with type 2 diabetes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0533-9) contains supplementary material, which is available to authorized users.

Effectiveness of the Tobacco Tactics Program in the Trinity Health System

INTRODUCTION

This study determined the effectiveness of the Tobacco Tactics intervention.

DESIGN/SETTING/PARTICIPANTS

This was a pragmatic, quasi-experimental study conducted from 2010 to 2013 and analyzed from 2014 to 2015 in five Michigan community hospitals; three received the Tobacco Tactics intervention, and two received usual care. Smokers (N=1,528) were identified during hospitalization, and sent surveys and cotinine tests after 6 months. Changes in pre- to post-intervention quit rates in the intervention sites were compared with usual care control sites.

INTERVENTION

The toolkit for nurses included: (1) 1 continuing education unit contact hour for training; (2) a PowerPoint presentation on behavioral and pharmaceutical interventions; (3) a pocket card entitled "Helping Smokers Quit: A Guide for Clinicians"; (4) behavioral and pharmaceutical protocols; and (5) a computerized template for documentation. The toolkit for patients included: (1) a brochure; (2) a cessation DVD; (3) the Tobacco Tactics manual; (4) a 1-800-QUIT-NOW card; (5) nurse behavioral counseling and pharmaceuticals; (6) physician reminders to offer brief advice to quit coupled with medication sign-off; and (7) follow-up phone calls by trained hospital volunteers.

MAIN OUTCOME MEASURES

The effectiveness of the intervention was measured by 6-month 30-day point prevalence; self-reported quit rates with NicAlert(®) urinary biochemical verification (48-hour detection period); and the use of electronic medical record data among non-responders.

RESULTS

There were significant improvements in pre- to post-intervention self-reported quit rates (5.7% vs 16.5%, p<0.001) and cotinine-verified quit rates (4.3% vs 8.0%, p<0.05) in the intervention sites compared with no change in the control sites. Propensity-adjusted multivariable analyses showed a significant improvement in self-reported 6-month quit rates from the pre- to post-intervention time periods in the intervention sites compared to the control sites (p=0.044) and a non-statistically significant improvement in the cotinine-verified 6-month quit rate.

CONCLUSIONS

The Tobacco Tactics intervention, which meets the Joint Commission standards for inpatient smoking, has the potential to significantly decrease smoking among inpatient smokers.

TRIAL REGISTRATION

This study is registered at www.clinicaltrial.gov NCT01309217.