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Systematic review with meta-analysis
High-intensity interventions promote smoking cessation among hospitalized patients
  1. Jamie S Ostroff
  1. Memorial Sloan Kettering Cancer Center, New York, New York, USA
  1. Correspondence to:Jamie S Ostroff
    Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10022, USA; ostroffj{at}mskcc.org

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Context

Hospitalisation represents a potent ‘teachable moment’ for the delivery of smoking cessation interventions. Many smokers are hospitalised for tobacco-related diseases that personalise the risks of persistent smoking and thereby enhance motivation to quit and receptivity to tobacco cessation assistance. Most hospitals are smoke-free and many have adopted broad, smoke-free campus policies that further restrict smoking on hospital grounds, making smoking during hospitalisation particularly difficult and inconvenient. These external restrictions increase the likelihood of smokers being amenable to the use of tobacco cessation medications to help manage symptoms of acute nicotine withdrawal. Recognising the potential value of promoting smoking cessation during hospitalisation, the US Joint Commission has established a set of tobacco cessation performance indicators in an effort to improve quality of care for hospitalised smokers.1 This confluence of factors highlights the importance of systematically reviewing the published literature of relevant studies and identifying evidence-based practices for treating tobacco dependence in hospital settings.

Methods

In order to determine the effectiveness of smoking cessation interventions initiated during hospitalisation, Rigotti and colleagues have reviewed and summarised the findings from randomised and quasi-randomised clinical trials conducted with hospitalised patients who were current smokers or recent quitters at the time of hospitalisation. Trials that recruited all hospitalised smokers and those who were planning to quit were included. Interventions were delivered by physicians, nurses, tobacco treatment specialists and other clinical staff. Studies conducted in psychiatric or substance abuse inpatient settings were excluded. Studies that only reported short-term abstinence rates (less than 6 months following hospitalisation) were also excluded. Both acute care and rehabilitation hospitals were included and analyses were conducted separately for each type of hospital setting. Sensitivity analyses examined the relative benefit of various components of cessation interventions for various subgroups of patients.

Findings

Fifty trials met the inclusion criteria. Smoking cessation interventions that begin during hospitalisation and include at least 1 month of follow-up counselling should be considered the standard of quality care (‘best practices’) for hospitalised smokers. No benefit was found for less intensive counselling interventions. Similar findings were found for a subgroup of patients hospitalised because of cardiovascular disease. Similar findings were found for acute care and rehabilitation hospital settings. Cessation interventions that also included nicotine replacement therapy (NRT) demonstrate enhanced effectiveness. There is insufficient evidence that adding bupropion or varenicline to intensive counselling increases cessation rates over counselling alone

Commentary

The findings are largely consistent with prior reviews2 citing the effectiveness of hospital-based cessation interventions as well as the importance of delivering an adequate intensity (duration) of tobacco cessation counselling combined with cessation medications for superior outcomes. The selection criteria were well justified. Given that NRT can provide immediate relief for acute nicotine withdrawal, it is not surprising that other cessation medications with proven efficacy (ie, varenicline and bupropion) requiring gradual dosing for therapeutic efficacy may not be as good a fit for the management of acute nicotine withdrawal in an acute care hospital setting though further research is needed. On the basis of these findings, NRT should be readily available in all hospital formularies and recommended for use by hospitalised smokers.

Several design issues warrant further consideration in future studies. To date, most clinical trials have compared cessation interventions to usual care that varies considerably and typically includes control conditions receiving no known treatment, brief physician advice and/or self-help materials. To facilitate the discovery of improvements in tobacco cessation treatment for hospitalised smokers, it is recommended that future cessation trials benchmark their proposed treatment enhancements with best practices3 rather than no treatment (usual care) controls. The findings clearly demonstrate the importance of providing adequate intensity of counselling interventions (defined as follow-up counselling for at least 1 month after discharge); however, more information is needed regarding the optimal frequency and duration (time and number of contacts) of counselling interventions for hospitalised smokers. Assessing the cost effectiveness of cessation interventions is also warranted and will guide the allocation of hospital resources. Further work is needed to examine the efficacy of cessation interventions for non-cigarette (ie, smokeless, pipe and cigar) tobacco users. Identifying optimal dissemination strategies for implementing cessation interventions in the routine care of hospitalised smokers is a high priority for future research. In order to close the research to practice gap, cessation interventions must be evidence-based, acceptable to patients and sustainable within the resource limitations of hospital settings.

References

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Footnotes

  • Competing interests None.