Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial

Abstract

Objectives To investigate the effectiveness of the systematic default provision of smoking cessation support to all adult smokers admitted to hospital, relative to usual care.Design Open, cluster randomised controlled trial.Setting Acute medical wards in one large teaching hospital in the United Kingdom.Participants 264 patients randomised to intervention and 229 to usual care; primary outcome data were available at four weeks for 260 and 224 patients, respectively. All adult smokers and recent ex-smokers able to give informed consent were eligible for entry into the study. InterventionsThe intervention comprised systematic smoking ascertainment and default provision of behavioural support and cessation pharmacotherapy for the duration of the hospital stay for all smokers and recent ex-smokers, with follow-up and referral to community services after discharge. Usual care comprised cessation support delivered at the initiative and discretion of clinical staff. All staff and patients were aware of group assignment. Main outcome measuresSmoking cessation at four weeks, validated by measuring exhaled carbon monoxide. Secondary outcomes were uptake of inpatient behavioural support, use of cessation pharmacotherapy, referral to and uptake of community support after discharge, and validated smoking cessation at six months. Participants lost to follow-up were assumed to have reverted to smoking.Results All patients in the intervention group received at least brief advice to quit smoking, compared to 106 (46%) patients in the usual care group. Cessation at four weeks was achieved by 38% (n=98) of intervention patients and 17% (n=37) of usual care patients (adjusted odds ratio 2.10 (95% confidence interval 0.96 to 4.61), P=0.06, number of patients needed to treat 8). Uptake of inpatient behavioural support, use of pharmacotherapy, and referral to and uptake of community support after discharge were all substantially and statistically significantly higher in the intervention group than in the usual care group. Cessation at six months was achieved by 19% (n=47) of intervention and 9% (n=19) of usual care patients, although this difference was not significant (adjusted odds ratio 1.53 (95% confidence interval 0.60 to 3.91); P=0.37).Conclusions Substantial improvements in smoking cessation among smokers admitted to hospital can be achieved by systematic ascertainment and delivery of cessation support in secondary care. Trial registration International Standard Randomised Controlled Trial Number ISRCTN25441641. IntroductionTobacco smoking is the largest avoidable cause of premature death and disability in both developed and developing countries. Half of all lifelong smokers die as a consequence of their smoking, typically from lung cancer, chronic obstructive pulmonary disease, or cardiovascular disease.1 Average life expectancy among smokers is 10 years less than among never smokers, and quitting smoking generates considerable benefits in both quantity and quality of life, almost irrespective of age at quitting.1 Inte...

Prevalence of smoking among patients treated in NHS hospitals in England in 2010/2011: a national audit: Table 1

“…Separate funding streams for community and hospital services mitigate against service integration since both services can argue that the other is responsible for inpatient smoking cessation provision. Our own recent trial data demonstrate that treating smoking as a default at the point of admission substantially increases the proportion of smokers accepting support,6 and this approach is now recommended in NICE guidance3 and the British Thoracic Society's Recommendations for Hospital Smoking Cessation Services 7. The findings of the present study indicate that default provision of behavioural support and pharmacotherapy to smokers treated as inpatients in English hospitals has the potential to reach 1.1 million smokers each year.…”

Treatment of tobacco dependence in UK hospitals: an observational study

“…[13][14][15] Evidence is also growing that smoking cessation in hospitalised patients is effective. 9,12 The 'Ottawa Model' for smoking cessation, a systematic approach to tobacco dependence treatment used in Canadian hospitals, was recently shown to yield significantly lower rates of readmissions and emergency department attendances, as well as significant reduction in 1-and 2-year mortality. 12 The reasons for patients not being asked about quitting are likely multifactorial, but include beliefs that addressing smoking is too challenging or not a priority, and that patients might not want to quit, with smoking seen as a lifestyle choice rather than a medical problem that requires treatment.…”

“…11 There is evidence from both the UK and abroad that inpatient treatment of tobacco dependence increases quit rates and reduces readmissions. 9,12 The National Institute for…”

“…There is evidence from the UK that hospital-based smoking cessation interventions work. 9 Furthermore, simply referring a smoker to community services might be less effective. 10 Smoking cessation is important not only for the prevention of ill health, but also as a core treatment for many pre-existing conditions.…”

Organizational Development: Driving Forces and Barriers Encountered when Implementing Smoking Cessation Programs

“…One way to improve the commitment of administrators is to use the reduction in smoking among hospitalized patients and their smoking status after discharge as measures of success (Reid, Pipe, & Quinlan, 2006). These goals are accomplished through a variety of interventions (OMSC) aimed at dealing with specific issues (smoking cessation), as well as through ongoing processes (policies and systems) (Katz et al, 2014;Murray et al, 2013). Making this connection to healthcare's mission to provide quality care and outreach, clarifies the importance of developing objectives to attain these goals among the people who control resource allocations.…”