Sustained Care Intervention and Postdischarge Smoking Cessation Among Hospitalized Adults

Abstract

IMPORTANCE Health care systems need effective models to manage chronic diseases like tobacco dependence across transitions in care. Hospitalizations provide opportunities for smokers to quit, but research suggests that hospital-delivered interventions are effective only if treatment continues after discharge. OBJECTIVE To determine whether an intervention to sustain tobacco treatment after hospital discharge increases smoking cessation rates over standard care. DESIGN A randomized controlled trial conducted from August 2010-November 2012 compared Sustained Care, a post-discharge tobacco cessation intervention, vs. Standard Care among hospitalized adult smokers who received a tobacco dependence intervention in the hospital and wanted to quit smoking after discharge. SETTING Massachusetts General Hospital, Boston, MA. PARTICIPANTS 397 hospitalized daily smokers (mean age 53 years, 48% male, 81% nonhispanic white). 92% of eligible patients and 44% of screened patients enrolled. INTERVENTION Sustained Care participants received automated interactive voice response telephone calls and their choice of free FDA-approved cessation medication for 90 days. The automated calls promoted cessation, provided medication management, and triaged smokers for additional counseling. Standard Care patients received recommendations for post-discharge pharmacotherapy and counseling. MAIN OUTCOMES Biochemically-validated past 7-day tobacco abstinence 6 months after discharge (primary outcome); self-reported tobacco abstinence and smoking cessation treatment use at 1, 3, and 6 months. RESULTS Smokers assigned to Sustained Care (n=198) used more counseling and more pharmacotherapy at each follow-up than those assigned to Standard Care (n=199). Biochemically-validated 7-day tobacco abstinence at 6 months was higher with Sustained Care than Standard Care (26% vs. 15%; RR 1.71, 95% CI 1.14–2.56, p=0.009; NNT=9.4, 95% CI 6.4–35.5). Using multiple imputation for missing outcomes, the RR was 1.55 (95%CI 1.03–2.21, p=0.038). Sustained Care also produced higher self-reported continuous abstinence rates for 6 months after discharge (27% vs. 16%; RR 1.70, 95% CI 1.15–2.51, p=0.007). CONCLUSION Among hospitalized adult smokers who planned to quit smoking, a post-discharge intervention providing automated telephone calls and free medication resulted in higher rates of smoking cessation at 6 months compared with a standard recommendation to use counseling and medication after discharge. These findings, if replicated, suggest an approach to help achieve sustained smoking cessation after a hospital stay.

Smoking cessation interventions for adults aged 50 or older: A systematic review and meta-analysis

“…We also found that studies using biochemical verification showed higher cessation rates than those without, which was seemingly contradictory to evidence that self-reported cessation rates were overestimated (Noonan et al, 2013; Rigotti et al, 2014). For instance, one study investigating the validity of self-reported cessation by a biochemical test found that 15 out of 72 self-reported quitters did not pass the urine cotinine test, resulting in an over-reporting rate of 21% (Noonan et al, 2013).…”

“…Biochemical verification was dichotomized, indicating whether self-reported smoking cessation status was verified by biochemical methods, such as examining the carbon monoxide (CO) level in exhaled air and cotinine level in saliva or urine. It has been reported that self-reported cessation rates were higher than biochemically verified rates in a given study (Noonan et al, 2013; Rigotti et al, 2014). Follow-up times reported in different units were converted to values in months, and they were further classified into three categories: up to 3 months (reference), 3 to 12 months (binary variable), and over 12 months (binary variable).…”

Increased Evidence-Based Tobacco Treatment Through Oklahoma Hospital System Changes

“…4,5 Furthermore, recent data have highlighted the potential of delivering tobacco-cessation interventions during the hospital stay, particularly when supplemented with post-discharge counseling and medication, as a particularly effective strategy to promote cessation. 6 Based on 2011 hospitalization, population, and tobacco use prevalence data, an estimated 120,000 tobacco users are admitted to Oklahoma hospitals annually. [7][8][9][10] In an effort to seize this opportunity to intervene, the Oklahoma Hospital Association (OHA), Oklahoma Tobacco Settlement Endowment Trust Fund, and select hospitals partnered to implement healthcare system changes to integrate a sustainable tobacco-cessation protocol for all tobacco-using patients.…”

Postdischarge Smoking Cessation in Subgroups of Hospitalized Smokers: A Latent Class Analysis

“…16 This current analysis found proportionally more racial minorities in subgroups with both the highest and the lowest probabilities of cessation. This suggests that differences in cessation after discharge may be more complex than demographics and based in part on patterns of cessation predictors.…”