Smoking Cessation Interventions In Hospital Settings: Implementing the Evidence Nancy Rigotti, MD Tobacco Research & Treatment Center, General Medicine Division, Massachusetts General Hospital, Harvard Medical School nrigotti@partners.org
HOSPITALIZATION window of opportunity for smoking cessation Smoke-free hospitals require temporary tobacco abstinence Illness motivates smokers to try to quit Hospitalized smokers are accessible for treatment Interventions starting in the hospital help smokers to stay quit after discharge What is the evidence?
Intervention Trials in Hospitalized Smokers with MI Author Interventions Cessation Rate Control Intervention Burt (1971) MD advice 28% * 62% RN home visit Taylor (1991) RN counseling 32% * 61% at bedside+ 3 mo after d/c Burt, Lancet, 1971; Taylor, Ann Intern Med 1991 * p<.05
Treating hospitalized smokers 1991: RCT showed efficacy in MI patients 1993: Cost effectiveness analysis More cost-effective than other secondary cardiac prevention interventions Editorial: An idea whose time has come 1990-2002 more studies 2002, 2008: Cochrane systematic reviews 2004, 2012: Hospital Quality Measures
META-ANALYSIS: INTERVENTIONS FOR HOSPITALIZED SMOKERS (Rigotti NA, Munafo MR, Stead L., Arch Int Med 2008) RCT or quasi-experimental trials Subjects: Current or recent smoker (past month) Intervention: Counseling or pharmacotherapy Starts during hospital stay May or may not continue after discharge Follow-up: at least 6 months Exclude: inpatient substance abuse / psychiatric units
META-ANALYSIS: INTERVENTIONS FOR HOSPITALIZED SMOKERS (Rigotti NA, Munafo MR, Stead L., Arch Int Med 2008) Stop-smoking advice or counseling (33 trials) Contact in hospital: 5-60 minutes Nurse or trained counselor (32), MD (11) Follow-up support after discharge (25) Duration: 1 week - 6 months Telephone (19), in person visit (9) Adding pharmacotherapy (6 trials) Nicotine replacement (5), bupropion (1)
INTENSITY OF COUNSELING INTERVENTIONS Intensity level Duration of counseling in the hospital Duration of support after discharge 1 < 15 min None 2 > 15 min None 3 Any < 1 mo 4 Any > 1 mo
RESULTS All hospital-initiated smoking interventions (Rigotti NA, Munafo MR, Stead L. Cochrane Library 2007) In-hospital counseling Support after d/c # trials Odds Ratio 95% CI 1 < 15 min None 1 1.16 0.80-1.67 2 > 15 min None 8 1.08 0.89-1.29 3 Any < 1 mo 6 1.09 0.91-1.31 4 Any > 1 mo 17 1.65 1.44-1.90
DOES DIAGNOSIS MATTER? (Rigotti NA, Munafo MR, Stead L. Cochrane Library 2007) Admission Diagnosis # Trials Odds Ratio 95% CI Cardiovascular disease 11 1.81 1.54-2.15 All diagnoses 6 1.43 1.17-1.75 Intervention is effective regardless of diagnosis Absolute cessation rates are higher for CVD
SHOULD MEDICATION BE ADDED TO COUNSELING? (Rigotti NA, Munafo MR, Stead L. Cochrane Library 2007) Medication Patients # of Trials Odds Ratio 95% CI NRT Noncardiac 5 1.47 0.92-2.35 Bupropion Cardiac 1 1.56 0.79-3.06 Effect of NRT is not statistically significant, but OR is consistent with trials in other settings Little evidence about bupropion, none for varenicline
CONCLUSIONS (Rigotti NA, Munafo MR, Stead L. Cochrane Library 2007, Arch Int Med 2008) Bedside counseling followed by telephone support for > 1 month after discharge increases the odds of smoking cessation by 65% It is effective regardless of the reason for admission It is not effective with less support after discharge Adding NRT to counseling may increase cessation rates (OR 1.47, CI 0.92-2.35) and relieves withdrawal
CHALLENGES Hospitalized smokers Translating research into practice (usual care) Sustaining treatment after discharge
What Stimulated Hospitals to Address Tobacco NATIONAL HOSPITAL QUALITY MEASURES 2004: Among patients who Smoked in past 12 months AND Discharge diagnosis = MI or CHF or pneumonia Does chart document that smoking cessation advice, counseling or medication offered during hospital stay? Data are publicly reported to compare hospital quality 2012: More comprehensive measures adopted Apply to all hospital patients Require documentation of both medication and counseling both in hospital and after discharge
MGH INPATIENT MODEL Step 1: Routine smoking status ID at admit Step 2: Brief intervention on care unit Step 3: Extended intervention (dedicated counselor) Step 4: Post-discharge care
MGH SYSTEM for Inpatients Step 1: Routine smoking status ID at admit On doctors computerized admission order set On nurses computerized order entry set Generates electronic list of smokers for the Tobacco Treatment Service
MGH SYSTEM for Inpatients Step 1: Routine smoking status ID at admit in an electronic database Step 2: Care team job - quit advice, NRT order Booklet put on every bed by housekeeping
MGH SYSTEM for Inpatients Step 1: Routine smoking status ID at admit in an electronic database Step 2: Care team job - quit advice, NRT order Booklet put on every bed by housekeeping Step 3: Smoking counselor visit Assess nicotine withdrawal relief, desire to quit Assist to make a plan to quit Step 4: Link to post-discharge care Refer to Quitline for counseling Medication on discharge med list
SMOKING CESSATION OUTCOMES January- June 2007 (n=553) Outcome All Patients (ITT) Quit for past week 2 weeks after discharge 24% 3 months after discharge 18%
CHALLENGES Hospitalized smokers Translating research into practice (usual care) Sustaining treatment after discharge
CHALLENGE Sustain Treatment after Discharge Counseling support after discharge Interactive voice response (IVR) system makes automatic calls, offers counseling support Use of medication after discharge
IVR-Smoking Status and Counseling Institute for Health Policy
CHALLENGE Sustain Treatment after Discharge Counseling support after discharge Interactive voice response (IVR) system makes automatic calls, offers counseling support Use of medication after discharge Put on discharge medication list and offer free sample at discharge to remove barrier to starting immediately
Helping HAND Study Improving tobacco treatment delivery after discharge (RC1 HL099668) 330 Smokers Admitted to MGH Randomize Standard Care N=165 Extended Care* N=165 Outcomes assessed at 1 and 6-month follow-up Tobacco abstinence at 6 months Tobacco abstinence at 1 month Use of tobacco treatment (counseling or medication) Cost effectiveness (cost/quit) * Extended Care = 5 IVR calls over 3 months with counselor call-back option + 30 days of free medication of patient s choice in hand at discharge
CHALLENGE Sustain Treatment after Discharge Other ideas are being tested in 6 NHLBI & NCIfunded randomized controlled trials under way Enroll smoker in telephone quitline while in hospital, start counseling before discharge and continue after Offer free NRT through the quitline after discharge Enroll in web-based counseling after discharge Train nursing staff to do the intervention
BIG PICTURE Tobacco use = chronic disease Managing chronic disease requires a continuum of care Hospital = a node in the health care continuum Hospital-based Hospital-initiated intervention Start before admission, continue after discharge (pre-op interventions)