ReviewHelping hospital patients quit: What the evidence supports and what guidelines recommend
Introduction
Tobacco smoking is detrimental to almost every organ in the body and is a known cause of cancer, cardiovascular and respiratory disease and a diminished health status (US Department of Health and Human Services, 2004). World wide, four million people die of tobacco-related disease annually (Jha et al., 1999). If current trends in global tobacco use continue, tobacco smoking can be expected to become the leading cause of premature death in the world within 30 years (MacKay and Eriksen, 2002, Taylor and Bettcher, 2000).
While the prevalence of smoking is declining in high-income countries, statistics indicate that 26% of males and 22% of females in the United States continue to smoke daily (MacKay and Eriksen, 2002). The United States prevalence is similar to prevalence estimates in the United Kingdom and New Zealand but higher than that in Australia (MacKay and Eriksen, 2002, Australian Institute of Health and Welfare, 2002). Given unacceptably high rates of tobacco use in developed countries the need remains for continued development and implementation of effective and sustainable cessation strategies (Commonwealth Department of Health and Age Care, 1999).
Hospitalization represents an attractive opportunity to implement smoking cessation interventions given a capacity of interventions in this setting to reach large numbers of smokers, at a time when they are more receptive to modifying their tobacco use (Orleans et al., 1993, Emmons and Goldstein, 1992, Glasgow et al., 1991), prevented from using tobacco (NSW Health Department, 1999), and have access to health professionals who can provide smoking cessation advice, medications and support (Munafo et al., 2001). Despite these characteristics, international research consistently report low rates of cessation intervention with hospital patients (Emmons and Goldstein, 1992, McCarty et al., 2001a, McCarty et al., 2001b, Bolman et al., 2002, NSW Health Department, 2002, Emmons et al., 2000).
Reviews of health care practices across a number of health care settings have found that two commonly reported barriers to the provision of preventive care were a belief that its provision will have little or no beneficial impact for patients, and a lack of knowledge of what are recommended preventive care practices (Cabana et al., 1999). Such barriers are also reported to impede the provision of smoking cessation care (McCarty et al., 2001a, McCarty et al., 2001b, Tsui et al., 2004, McClure et al., 1997).
Two sources of evidence available to inform and guide hospital staff in their delivery of smoking cessation care are systematic reviews and clinical practice guidelines. In order for systematic reviews and guidelines to be clinically useful to health professionals, there findings or recommendations must be relevant to patient groups within the specific clinical settings of interest (Rothwell, 2005), and must provide information regarding specific care delivery strategies. As a number of strategies can be used by hospital practitioners to encourage patient smoking cessation (Wolfenden et al., 2003), systematic reviews and guidelines should therefore incorporate research conducted in the hospital setting and provide recommendations regarding specific smoking cessation care strategies in hospitals.
Specifically, an important consideration for hospital clinicians interested in providing effective cessation care is the intensity of the intervention such as the required duration and number of intervention contacts (Wolfenden et al., 2003). Similarly, given the range of intervention components available to clinicians to select from, such as counselling, NRT, self-help materials and follow-up support, guidance as to the most appropriate components or combinations of such components is required (Wolfenden et al., 2003). Guidance as to the effectiveness of different types of health professionals or combinations of health professionals in delivering smoking cessation care would also assist the development and delivery of effective smoking cessation care.
Given the need for specific guidance for hospital based health professionals, a review was undertaken with an aim to critically appraise the systematic review evidence for, and clinical practice guideline recommendations regarding:
- (1)
Hospital smoking cessation interventions of varying intensity.
- (2)
Hospital smoking cessation intervention components.
- (3)
The delivery of smoking cessation interventions by various hospital health care providers.
- (4)
The delivery of smoking cessation interventions by multiple hospital providers.
- (5)
Single versus multiple component smoking cessation interventions.
Section snippets
Review scope
The review focused on smoking cessation care strategies that could be delivered by hospital staff to patients during the preoperative and/or inpatient care of patients. The review did not extend to strategies for special patient groups such as pregnant women and patients with a primary psychiatric diagnosis, as such patient groups are likely to require specialised cessation care.
Data source
The review incorporated information from systematic reviews of smoking cessation interventions conducted by the
Cochrane reviews
Thirty Cochrane reviews were identified. Twenty one of these reviews (Møller et al., 2001, Stead and Hughes, 1997, White et al., 2002, Hajek and Stead, 2004, Abbot et al., 1998, Hughes et al., 2004, Hughes et al., 2000, Gourlay et al., 2004, Secker-Walker et al., 2002, Sinclair et al., 2004, Huibers et al., 2003, Park et al., 2004, Ussher et al., 2005, Stead and Lancaster, 2002a, Stead and Lancaster, 2002b, Lancaster and Stead, 1998, David et al., 2001, Lancaster and Stead, 2002a, Lancaster and
Discussion
The review of meta-analyses restricted to hospital studies provided evidence supporting the provision in hospitals of intensive interventions, the use of repeated follow-up telephone support and identified nursing staff as having the capacity to deliver efficacious interventions to cardiac patients who smoke. None of the meta-analyses restricted to hospital studies provided evidence to support the use of other interventions components individually, the provision of multi-component
Conclusions
Relative to smoking cessation research conducted in primary care settings, hospital based smoking cessation research is in its infancy (Fiore et al., 2000). Given the limited number of smoking cessation trials conducted in hospitals, clinical practice guidelines, with consideration of intervention cost and feasibility, appear to have based clinical recommendations regarding smoking cessation practices in hospitals on the strength of evidence from primary care. Based on the small number of
Acknowledgments
The authors acknowledge the support of Hunter New England Population Health, the Hunter Medical Research Institute and the University of Newcastle.
References (69)
- et al.
Smokers who are hospitalized: a window of opportunity for cessation interventions
Prev. Med.
(1992) - et al.
Smoking cessation interventions among hospitalized patients: what have we learned?
Prev. Med.
(2001) - et al.
Nurses' attitudes concerning the delivery of brief cessation advice to hospitalized smokers
Prev. Med.
(2001) External validity of randomised controlled trials: ‘to whom do the results of this trial apply?
Lancet
(2005)- et al.
Hypnotherapy for smoking cessation
Cochrane Database Syst. Rev.
(1998) 2001 National drug strategy household survey
(2002)- et al.
Preventive care in the emergency department: diagnosis and management of smoking and smoking-related illness in the department: a systematic review
Acad. Emerg. Med.
(2002) - et al.
Evaluation of a nurse-managed minimal-contact smoking cessation intervention for cardiac inpatients
Health Educ. Res.
(2002) - et al.
Why don't physicians follow clinical practice guidelines?
J. Am. Med. Assoc.
(1999) National Tobacco Strategy
(1999)