Helping patients kick the habit

In the face of recent reports that U.S. smoking rates are no longer declining, hospitalists may be ideally situated to help patients quit.

In the face of recent reports that U.S. smoking rates are no longer declining, hospitalists may be ideally situated to help patients quit using tobacco, experts say.

For starters, patients aren't allowed to smoke in the hospital, and may be too sick to even think about lighting up. In addition, those whose heart attacks, strokes or lung disease may be linked to smoking could be especially open to change.


“You have this wonderful window of opportunity,” said Nancy Rigotti, FACP, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital in Boston. “Being in the hospital gives patients a chance to experience life without tobacco and free of the environmental cues that may act as triggers.”

Even so, it's not enough for hospitalists to simply advise patients on the benefits of quitting, according to research by Dr. Rigotti and others who have studied the effectiveness of inpatient tobacco cessation programs. For programs to be successful, patients need to be offered nicotine-replacement products or other medication to help them cope with withdrawal symptoms. And just as important, patients must be hooked up with outpatient services so they get support after discharge.

“It's one of those things that a little bit of effort in the hospital can have a lot of payback as long as you carry it over to the outpatient setting,” said Dr. Rigotti.

Going beyond advice

According to a recent survey by the Centers for Disease Control and Prevention, much work remains to be done if smoking is to lose its place as the leading cause of preventable death in the U.S. The survey found that 20.6% of people aged 18 and older smoked in 2008, compared to 19.8% in 2007. Federal health officials were hoping to cut the smoking rate to 12% or less by 2010.

The Centers for Medicare and Medicaid Services and The Joint Commission have named smoking cessation advice/counseling as a core performance measure for cases of acute myocardial infarction (MI), congestive heart failure and pneumonia, and there is talk of expanding that goal to include all patients. But experts say such advice often doesn't amount to much.

“Advice can range from, ‘Hey, you should quit smoking,’ to 25 minutes of counseling,” said Lisa Shah, ACP Member, a University of Chicago hospitalist who does clinical research on tobacco cessation. “If a nurse or physician just checks a box, what does that translate into?”

A study of 834 MI patients at 19 U.S. centers backs up that view. The study, published in October 2008 in Archives of Internal Medicine, concluded that “smoking cessation counseling, as documented in the patients' medical record, was not associated with smoking cessation, while the presence of a formal inpatient smoking cessation program was associated with successful quitting.”

Hospitals need a systematic approach, from admission through discharge, Dr. Rigotti said. At Massachusetts General, the electronic admission form includes a question on smoking. A “yes” allows the doctor to immediately click on an order for a nicotine patch, and sends off an automatic referral to a smoking counselor.

“Doctors tend to undertreat nicotine withdrawal in the hospital setting,” said Dr. Rigotti, whose research has found that giving patients nicotine-replacement products increases their chances of quitting after they go home.

Once in the ward, patients at Massachusetts General find a booklet on smoking that is placed on all beds by the housekeeping staff, and they get some initial advice from the nurse. The counselor then takes the conversation to the next level.

“The counselor does not come in to the patient with an attitude (of), ‘You got to quit,’” said Dr. Rigotti. “She comes in and sees if people are interested and (if) she can help motivate patients to use the opportunity of being in the hospital.”

Helping after discharge

Follow-up is key, Dr. Rigotti said. Her program recently received a grant from the National Heart, Lung and Blood Institute to test whether smoking cessation rates after hospital discharge can be increased by providing medication at discharge, as well as a series of computerized phone calls over three months that offer patients help with managing medication and other cessation efforts. In previous research at Massachusetts General, 23% of admitted patients who smoked and underwent a standard in-hospital program reported they were still abstaining at 12 weeks after discharge, and that using nicotine-replacement products was associated with a better chance of quitting. This program didn't have a post-discharge component, however.

Smoking cessation efforts need to be easy to carry out because doctors and nurses already have so many things that require their attention, said Stephen Liu, ACP Member, a hospitalist who worked with the nursing staff to create an inpatient tobacco cessation program at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

His hospital uses a standard “tobacco use admission form” to identify tobacco users. This ensures they get any needed medication for smoking cessation, and a visit by a nurse certified in tobacco counseling. In addition, all discharge summaries include a checklist to assess smoking status, as well as information on where patients can get help, like Web sites and a toll-free state “quitline.” Dr. Liu also sometimes calls primary care physicians to let them know a patient is motivated to quit and needs to be followed as an outpatient, he said.

“After patients are admitted, patients often say, ‘I'm never going to smoke again,’ or ‘I'm never going to drink again. This is my wake-up call and I'm going to turn my life around,’” Dr. Liu said. “But I tell people that the easy part is stopping in the hospital. The hard part is going home, where all the triggers are to start again. This is why making sure that patients have adequate support after discharge is important.”

Smoking cessation programs aren't just happening at major academic centers. Bucyrus Community Hospital, a 25-bed facility in rural Ohio, was recently recognized by The Joint Commission for having one of the best programs in the country. Suzanne Binau, fund development, grants and volunteers manager for the hospital, said the smoking cessation program is an integral part of the hospital's “smoke-free culture.”

The program includes inpatient counseling within 24 hours of admission and, if the patient is willing, a series of five to eight post-discharge counseling sessions. About 75% of hospitalized tobacco users go on to the outpatient program, and of that group, about 60% complete the program and are tobacco-free at the end, Ms. Binau said.

Theresa Hensley, the hospital's tobacco treatment coordinator, said it helps to make hospitalized smokers comfortable from the start through the use of nicotine-replacement products. “If you can make them comfortable, it makes them much more receptive and moves them further along the process of thinking, ‘Maybe I can quit and maybe I ought to give it a try’,” Ms. Hensley said.

Dr. Shah, of the University of Chicago, said patients often have a lot of misinformation about how best to quit. She said many of them think “going cold turkey” is the best approach, though “we know the cold turkey quit rate is only 7% to 10%.”

Her research focuses in particular on the barriers that make it hard for low-income African-Americans to quit. These barriers range from financial issues, such as not being able to afford medications to assist with cessation, to environmental barriers such as living with multiple smokers or not having easy access to a formal smoking cessation program.

Dr. Shah's research has found that among African-American smokers admitted to the hospital, 85% are abstinent at discharge, as measured by a breath test, but only 10% remain abstinent and test negative at one month after discharge. Despite hospitals being smoke-free, 15% of smokers are able to sneak a cigarette in during hospitalization.

“These poor cessation rates may be due to patients not receiving the post-discharge support they need, and advice to quit simply not being enough,” she said.