Commentary

The small but well designed clinical trial by Mohiuddin et al found that a smoking cessation programme increased quit rates and reduced hospital admissions and mortality in high risk cardiac patients. Several aspects of their cessation intervention deserve comment. First, although the Joint Commission on Accreditation of Healthcare Organizations quality initiatives encourage US hospitals to identify and intervene in smokers admitted with acute cardiac syndromes, few provide the 30 minute inpatient counselling session described here. Second, the intervention included weekly counselling for 3 months after discharge. Outpatient counselling is unavailable or not covered for most Americans. In 2005, only 14 states covered cessation counselling for all Medicaid recipients and only 1 state (Oregon) covered all forms of counselling and medication.¹ Third, medications, which probably doubled quit rates,² were provided to patients free of charge, and 75% of patients in the intervention group took advantage of them. Fourth, multiple opportunities for re-treatment were allowed. We know that tobacco dependence is a chronic, relapsing condition, and >25% of the intervention group were re-treated during the study period.

This landmark study calls to mind the first study of lipid lowering that showed a significant reduction in mortality and forever changed clinical practice.³ Even if we ignore the effect on mortality, the costs to identify and intervene in smokers are minimal compared with hospital costs. The study should serve as a call to all payers, public and private, to re-evaluate their coverage for intensive tobacco cessation interventions. Physicians need to advocate for increasing coverage and decreasing barriers to effective smoking cessation treatments.