Smoke Screens


Nobody thought it was possible. Could all indoor workplaces in Ireland—including pubs—be made smoke-free? Now, a law enacted in 2004 is seen as a triumph for public health policy worldwide.1

Smoking kills 438,000 people a year in the United States, and 8.6 million have a serious smoking-related illness.2 Research shows many outpatient physicians do not judge it worthwhile to talk with their patients about quitting smoking because they assume they will have no effect. The assumption is that even if patients quit, they will relapse.

Yet ample evidence suggests hospitalists can have a positive effect by intervening during a patient’s hospital visit.

Data also show that an individual will relapse an average of seven times before being able to take the step for the long term. Relapse is a part of the process, each time teaching an individual something about his or her motivation and behavior.

“Doctors who address smoking with patients can double or even triple the chances of their quitting,” says Shawn Ralston, MD, pediatric hospitalist at Presbyterian Hospital in Albuquerque, N.M. A few pointed questions and a show of compassion to the patient in the hospital could make a world of difference.

Golden Opportunity

Stephen Liu, MD, MPH, a hospitalist and an assistant program director at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H., has been interested in smoking-cessation interventions since his residency in DHMC’s Leadership Preventive Medicine Residency Program in 2003, where he worked on improving care for pneumonia patients. His efforts took off as a result of the Centers for Medicare and Medicaid Services (CMS) pay-for-performance measures, which made smoking-cessation counseling a key component of admission and discharge documentation for a number of disease states.

The approach used with adult patients at DHMC is the brainchild of Colleen Warren, a registered nurse on the medicine unit on which Dr. Liu worked.

“The more times that smokers hear the message [about quitting], the more likely they are to try to quit,” says Dr. Liu. “We capitalized on that [point when] we developed a tobacco treatment team in our hospital. The team, which includes two to five motivated nurses, social workers, or care managers in most units of the hospital, pursued training including an online tobacco treatment course through U Mass Medical Center.”

In January 2006, DHMC was awarded a grant from the New Hampshire Department of Health and Human Services to standardize the treatment of hospitalized smokers. This includes conducting tobacco screening, assessing a patient’s readiness to quit, providing brief counseling, documenting the status and stage of change into the electronic medical record, and referring the patient to community resources upon discharge. The funding allowed the institution to support Warren and Dr. Liu as they coordinated the team and its work. These efforts, including counseling, nicotine replacement therapy, and cessation medications, are also available free to DHMC employees.

DHMC is participating in the CMS demonstration project, in which the hospital publicly reports performance measures for several conditions on the CMS Web site. In addition, many more performance measures are publicly reported on the DHMC quality-measures Web site. Although the team initially targeted the intervention to performance measures related to pneumonia and heart failure hospitalizations, they decided to offer interventions to all patients admitted to the hospital. Of these patients, about 20% are smokers, Dr. Liu says.

Hospitalists can use their time with patients to help them kick the habit

Hospitalists can use their time with patients to help them kick the habit

Because financial support wasn’t available at first and staff time was voluntary, the work was more difficult. Data from a six-month pilot intervention on two inpatient floors at DHMC showed patient assessments increased from 2% to 85%. In addition, the percentage of eligible heart failure and pneumonia patients receiving smoking cessation advice or counseling prior to discharge has risen from 30% before 2005 to 80% to 90%.

“We have found that hospitalization is a golden opportunity to address smoking cessation in patients in that they become acutely aware of how the smoking has affected their health,” says Dr. Liu. Because patients frequently go without smoking for several days while hospitalized, they learn they can live without smoking and feel much better.

“The key for our kind of intervention is not only assessing it and addressing it while they are hospitalized, but making sure that we link them to resources after they leave,” Dr. Liu says. Those resources include telephone quit lines or local support groups and/or local cessation clinics.

Counseling patients can be personally and professionally fulfilling, says Dr. Liu. He recalls a 50-year-old man—a lifelong smoker—admitted for pancreatitis. The day he was discharged, he showed Dr. Liu a hospital-produced packet of information. The patient said he had been reading it during his stay, decided he was motivated to quit, and had called the quit line.

Dr. Liu and his team use what they call the five A’s:

  • Ask (does the patient smoke and has he/she tried to quit?);
  • Advise the patient to quit;
  • Assess (if the patient is ready to try to quit);
  • Assist (the patient in planning treatment and referrals); and
  • Arrange for a follow-up visit.

As part of their counseling, DHMC team members ask patients whether they have used assistive medication, such as nicotine-replacement therapy, bupropion (Wellbutrin) or varenicline (Chantix), in their attempts. They find out what patients have and have not tried. Then they ask, “How can we as a hospital help so that you will not restart smoking when you get home?”

A slightly longer counseling session with a motivated patient means a provider can explore whether they know their triggers for smoking, such as stress, alcohol use, or being around other smokers, and help the patient develop a proactive plan for when they are re-exposed to triggers upon discharge.

Counseling Parents of Hospitalized Children

In Dr. Ralston’s case, her research and the research of others inspired her to begin counseling the parents of hospitalized children.3-4 She was conducting research on respiratory illness, specifically bronchiolitis—the most common reason children are hospitalized.

She noticed the vast majority of children had had secondary smoke exposure. The work of C. Andrew Aligne, MD, formerly in the department of general pediatrics at the University of Rochester (N.Y.) Medical Center, inspired her.5-6 His analyses of attributable risk data revealed that the major and preventable cause of death in children is secondary smoke from parents.

But the issue really crystallized for Dr. Ralston when she encountered the work of Jonathan Winickoff, MD, MPH, an assistant professor of pediatrics at Harvard Medical School and a researcher with the Massachusetts General Hospital Center for Child and Adolescent Health Policy in Boston.

“The AHRQ guidelines show a huge amount of literature that say hospitalization is a great time to address smoking in adults,” says Dr. Ralston. “The [quit rate in office patients] will move from 5% to 12% or 15%, depending on the message. But in hospitalized adults, the quit rate can rise to 25% or 27%. Dr. Winickoff said, ‘Why can’t hospitalization for children be a teachable moment for parents?’ ”7

Another researcher who inspired Dr. Ralston was William R. Miller, PhD, who created the motivational interviewing model. Motivational interviewing is used with individuals to elicit and examine the ambivalence surrounding their unhealthy behaviors. Dr. Miller, retiring this year from the University of New Mexico (Albuquerque), began his work in the area of alcohol abuse. He and his colleagues have increasingly used motivational interviewing in other areas of addiction.

Dr. Ralston says what she has learned from motivational interviewing—and how she counsels parents of hospitalized children differently because of it—primarily pertains to her willingness to talk to people about a difficult subject. Instead of bombarding parents with facts about how smoking is bad for their children—which they already believe but don’t want to talk about—she learned to focus on the parents’ needs instead of the effects on the child.

“And there is the issue of bringing it up when this is not technically your patient,” she says. But after fine-tuning and developing her technique, she now assumes a value-neutral, nonjudgmental, open-ended approach using motivational interviewing. “Eventually it becomes easy to do.”

When approaching a parent to offer help, says Dr. Ralston, “I will lead by acknowledging that the experience the parent is having is extremely stressful. Then, after addressing the primary illness of the child and what the plan is for that, I say, ‘I see [from our records] that you are smoking. Have you tried to quit? Are you interested in quitting now? What might I be able to do to help you?’ If there is an opening, then I’ll go into more extensive counseling.

“You don’t need all the data behind you. I use my expertise more to motivate pediatricians, not the parents.” Another tack she takes to motivate pediatricians to empathically address smoking is to ask them to think of something they do that they know is bad for them but that they continue to do.


“There have been some studies that have shown [disappointing] outcomes when we intervene with hospitalized patients, but I’m more optimistic,” says Dr. Liu. “I feel that as long as we can make a difference in some people’s lives and get them to quit after they leave the hospital, then it’s worth the effort.”

Look at what you are willing to do, advises Dr. Ralston. “If that is a brief message and then a referral to a quit line, that’s fabulous,” she says. “You still might double the quit rate.” Given the temporal nature of the hospitalist-patient relationship, there may be a good number of ways hospitalists could effect change by offering a few encouraging words. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.


  1. Koh HK, Joossens LX, Connolly GN. Making smoking history worldwide. N Engl J Med. 2007 Apr 12;356(15):1496-1498.
  2. Centers for Disease Control and Prevention. Targeting Tobacco Use: The Nation’s Leading Cause of Preventable Death, 2007. Available at Last accessed June 18, 2007.
  3. Ralston S, Kellett N, Williams RL, et al. Practice-based assessment of tobacco usage in southwestern primary care patients: a Research Involving Outpatient Settings Network (RIOS Net) study. J Am Board Fam Med. 2007;20(2):174-180.
  4. Ralston S, Mahshid R. The pediatric hospitalist and the smoking parent. Pediatric Research Day 2006. Available at Albuquerque: Office of Research and Creative Endeavors, Department of Pediatrics, University of New Mexico Health Sciences Center; 2006. Last accessed June 18, 2007.
  5. Aligne CA, Stoddard JJ. Tobacco and children. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997 Jul;151(7):648-653. Erratum in: Arch Pediatr Adolesc Med 1997 Oct;151(10):988. Comment in: Arch Pediatr Adolesc Med. 1997 Dec;151(12):1269. Arch Pediatr Adolesc Med. 2000 Aug;154(8):850.
  6. Leonard K, Mosquera M, Aligne CA. Pediatrics in the community: Taking a collective breath to help children who have asthma. Pediatr Rev. 2007;28:152-153.
  7. Winickoff JP, Hillis VJ, Palfrey JS, et al. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics. 2003 Jan;111(1):140-145.

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