Earlier this year the US Surgeon General recommend that tobacco cessation counselling and pharmacotherapy should be offered to smokers in every healthcare setting (US Department of Health and Human Services, 2014).

Hospitalisation presents an excellent opportunity for smoking cessation. However, research suggests that hospital-delivered interventions are only successful if treatment is extended beyond hospital discharge (Rigotti et al, 2012).

Establishing how to sustain tobacco cessation after discharge is a major challenge facing hospitals. The present study (Rigotti et al, 2014) aimed to address this limitation by determining the effectiveness of an evidence-based sustained care intervention of both tobacco cessation counselling and medication on smoking cessation after hospital discharge. The authors hypothesised that sustained care would increase the number of individuals who used the cessation intervention and the number of individuals who were tobacco abstinent at 6 months post-discharge.

Methods

Participants and recruitment

Participants were:

• Smokers (smoked ≥1 cigarette/day during the month before admission)
• Aged 18 years and above
• Individuals who received smoking cessation counselling whilst in hospital
• Smokers who intended to quit following discharge and agreed to take smoking cessation medication

Exclusion criteria included:

• Individuals who had a hospital stay of less than 24 hours
• Substance use in last 12 months other than alcohol, tobacco and marijuana
• Admission for a drug overdose
• Individuals who could not give informed consent
• Individuals admitted to the obstetric or psychiatric units
• Individuals who had life expectancy of less than 12 months or were medically unstable

Recruitment of hospitalised smokers was achieved via electronic registration of patient smoking status at admission. The tobacco treatment service accessed records daily and screened smokers for study inclusion. Participants were randomised to treatment group, which was stratified by cigarette use per day (<10 or ≥10).

Sustained Care Intervention

The sustained care intervention included two components:

1. A free 30-day supply of a tobacco cessation medication of choice (refillable for up to 90 days)
2. 5 automated interactive voice response telephone calls (at 2, 14, 30, 60 and 90 days post-discharge)

The telephone calls offered cessation support and encouraged medication use and adherence. Participants could request to receive a call-back from a counsellor if they were feeling unconfident about abstinence, had questions about medication or had relapsed to smoking. The standard care intervention provided smokers with a recommendation for a cessation medication and a telephone number for a free-call quit line.

Measures

Baseline measures included:

• Demographics (e.g. age, sex)
• Health insurance status
• Smoking history
• Nicotine dependence
• Prior use of cessation treatment
• Presence of a smoker at home
• Importance of and confidence in quitting
• Alcohol use
• Depression

Hospital record gave information regarding:

• Length of hospital stay
• Diagnosis at discharge
• Recommended cessation medication

Participants were contacted at 1, 3 and 6 months post-discharge to collect data on tobacco use and tobacco cessation treatment use (counselling or pharmacotherapy).

Study Outcomes

The primary outcome of abstinence at 6 months was verified by a salivary cotinine sample ≤10 ng/ml (a metabolite of nicotine). Participants using NRT had an in-person verification of exhaled carbon monoxide <9 ppm. Secondary outcomes of self-reported 7-day point prevalence and continuous abstinence were measured at 1, 3 and 6 months post-discharge.

Results

Recruitment and Retention

1,757 inpatients met initial study inclusion criteria. Of these 904 (50%) completed screening for eligibility, 432 (48%) were eligible and 397 patients were consented and randomised to either sustained care (n = 198) or standard care (n =199).

Participant Characteristics

Participants:

• Had an average age of 53
• 48% were male
• 81% were non-Hispanic whites
• 51% had a high school education
• Smoked an average of 16.7 cigarettes per day
• Had an average hospital stay of 5 days
• 45% had a primary discharge diagnosis that was smoking-related

Tobacco cessation treatment in hospital did not differ between intervention groups.

Use of Tobacco Cessation after Discharge

• Participants in the sustained care group were more likely to use cessation treatment during the month after discharge compared to those in the standard care group (83% vs 63%, respectively; relative risk [RR], 1.32 [95% CI, 1.16 to 1.49]; P < .001)
• This was the case for:
  • Pharmacotherapy (79% vs 59%; RR, 1.34 [95% CI, 1.17 to 1.54]; P < .001) and
  • Counselling (37% vs 23%; RR, 1.63 [95% CI, 1.19 to 2.23]; P = .002)

Tobacco Cessation

• A greater number of participants in the sustained care group achieved the primary outcome of biochemically verified past 7-day abstinence at 6 month follow-up compared to those in the standard care group (26% vs 15%, respectively, RR, 1.71 [95% CI, 1.14-2.56]; risk difference, 11% [95% CI, 3%-19%]; P = .009).
• Self-reported abstinence rates were higher for the sustained care group, compared with the standard care group for both point-prevalence abstinence (past 7-days) and continuous abstinence:
  • 7-day self-reported abstinence rates were 52% for sustained care and 39% for standard care at 1 month (RR, 1.33 [95% CI, 1.07 to 1.65]; P = .01)
  • At 6 months, rates were 41% vs 28% respectively (RR, 1.45 [95% CI, 1.10 to 1.92]; P = .008).
  • Self-reported continuous tobacco abstinence was greater in the sustained care group, compared to standard care at every follow-up assessment:
    • 1 month (46% vs 33%, respectively; RR, 1.39 [95% CI, 1.08 to 1.78]; P = .01)
    • 3 months (34% vs 24%; RR, 1.43 [95% CI, 1.04 to 1.97]; P = .03)
    • 6 months (27% vs 16%; RR, 1.70 [95% CI, 1.15 to 2.51]; P = .007).

Conclusions

The proposed sustained care intervention indicates the potential of an effective, low-cost intervention for tobacco cessation following initial abstinence in a hospital setting.

The intervention addresses the challenge of individuals who may get “lost in the system” by offering a novel method for bridging the gap between inpatient and outpatient care. Additionally, the cost per quit analysis suggests that the sustained care intervention also has the potential to be cost effective across a range of smokers.

The following points should be considered in the interpretation of these findings.

• The sustained care intervention reflects combination pharmacotherapy and counselling. It is not possible to determine the individual contribution of the free medication and the voice response support call components of treatment on post-discharge cessation.
• The study only includes participants who intended to quit smoking post-discharge. It is not known how a sustained care intervention may work for smokers who are not motivated to quit.

Links

Rigotti et al. (2014) Sustained care intervention and postdischarge smoking cessation among hospitalized adults: a randomized clinical trial. JAMA. 2014 Aug 20;312(7):719-28. doi: 10.1001/jama.2014.9237. [PubMed abstract]

US Department of Health and Human Services (2014) The health consequences of smoking-50 years of progress: a report of the surgeon general. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdfx

Rigotti NA, Clair C, Munafò MR, Stead LF. (2012) Interventions for smoking cessation in hospitalised patients. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD001837. DOI: 10.1002/14651858.CD001837.pub3.