What is the best intervention to help hospitalized patients quit smoking?

The Hospitalist. 2008 June;2008(06):

June 1, 2008|The Hospitalist

Allan V. Prochazka, MD, MSc;Alma Palisoc, MD

Case

A 56-year-old male with a 60-pack-a-year history of cigarette smoking is admitted to the telemetry unit with an initial assessment of acute coronary syndrome. Because there is a no-smoking policy in the hospital, he is willing to comply but is concerned about tobacco withdrawal symptoms.

Overview

As of 2006, approximately 20.8% of U.S. adults smoke cigarettes.1 Responsible for approximately 438,000 deaths annually, cigarette smoking is the most important preventable cause of death and disease in the U.S.2

Smoking cessation reduces the risk of tobacco-related diseases; the potential health benefits are numerous. This is most evident in the reduction of cardiovascular disease events upon tobacco abstinence.3 Yet, it remains a constant struggle for smokers to quit and stay abstinent.

The main barrier to quitting is nicotine addiction, which causes tolerance and physical dependence. Upon cessation of tobacco use, withdrawal symptoms, such as irritability, restlessness, impatience, and depression may occur within a few hours, peak within the first several days, and then wane during the next few months.

The crucial time frame to prevent relapse is the first week of cessation. For smokers to stay off cigarettes, they must break from routines, behaviors, or cues that trigger the urge to smoke.4

Among patients with acute myocardial infarction (AMI) in a study done by Van Spall, et al., 39% of them still smoked.5 Indeed, smoking is associated with 1.5 to three times increased relative risk of AMI, and hospitalists increasingly must manage cardiovascular disease patients’ tobacco dependence during their hospital stay.

With policies prohibiting smoking in almost all U.S. hospitals, hospitalization may be the opportune time to help patients try to quit and avoid relapse.

Intervention strategies: Methods for smoking cessation need to target two aspects that support tobacco use—physical and psychological factors. High-intensity counseling and systematic behavioral intervention followed by sustained contact—in person or by phone up to one month after discharge—are effective behavioral interventions for sustained tobacco cessation.6 Pharmacotherapy also helps when added to high-intensity counseling of a hospitalized patient. It especially is beneficial for controlling withdrawal symptoms.

In addition, with policies prohibiting smoking in almost all U.S. hospitals, temporary tobacco abstinence promotes smoking cessation for hospitalized patients. Unfortunately, most hospitalized patients go back to smoking soon after discharge. Hospitalization may be the opportune time to help patients try to quit and avoid relapse.

Some hospitals feature inpatient smoking cessation programs in which nurse practitioners and counselors educate and counsel patients. It is highly recommended that a multidisciplinary team be involved in a tobacco cessation program catered to an individual patient’s needs. However, most hospitals have no such program. Nevertheless, the hospitalist can help a patient with brief or low-intensity tobacco cessation counseling, pharmacotherapy for nicotine withdrawal symptom control if clinically indicated, and follow-up upon discharge for relapse prevention.

Key Points

Determine if the hospitalized patient is ready to quit smoking. Counsel the patient based on his/her willingness to quit.
If patient is ready to quit, counsel using the 5 A’s: Ask, Advise, Assess, Assist, and Arrange.
If patient isn’t ready to quit, counsel using the 5 R’s: Relevance, Risks, Rewards, Roadblocks, and Repetition.
Refer patients to inpatient smoking-cessation program if available.
Pharmacotherapy should be used selectively based on potential adverse effects and the patient’s concomitant medical conditions.
Arrange follow-up for tobacco-cessation therapy to ensure abstinence.

The Bottom Line

Bedside counseling on quitting smoking, post-discharge follow-up, and selective use of pharmacotherapy facilitate tobacco cessation in the hospitalized patient.

Additional Reading

Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service 2000.
Ludvig J, Miner B, and Eisenberg, MJ. Smoking cessation in patients with coronary artery disease. Am Heart J. 2005;149(4):565-572;
Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs. placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA 2006;296(1):56-63.
Havranek EP. Smoking cessation counseling and the quality of care for acute myocardial infarction. Am Heart J. 2007;154:211-212.