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Inpatient Smoking Cessation Strategy Promising, but Effects Aren't Long Lasting


 

Clinical question

How effective is intensive smoking cessation support for hospitalized patients?

Bottom line

Therapy provided by highly trained smoking cessation practitioners, combined with pharmacotherapy and community support referrals upon discharge, may increase short-term quit rates among hospitalized smokers. However, this effect did not persist at 6 months. Moreover, this study did not address the cost-effectiveness of such an intensive strategy. (LOE = 1b-)

Reference

Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ 2013;347:f4004.

Study design

Randomized controlled trial (nonblinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Investigators at a large teaching hospital in the United Kingdom randomized 18 medical wards, using concealed allocation, to deliver either usual care for smoking cessation or the intervention strategy. Almost 500 patients were enrolled in the study and received smoking cessation treatment based on the allocation of their admission ward. The intervention consisted of identification of smokers upon admission, followed by delivery of smoking advice and offer of cessation support. Patients who accepted the support received daily in-hospital counseling by a trained smoking cessation practitioner. Initial sessions lasted 20 minutes to 30 minutes; subsequent sessions were 10 minutes long. Patients were also prescribed dual nicotine replacement therapy (transdermal patch plus either gum, lozenge, or nasal spray) or varenicline therapy, if preferred. Additionally, intervention patients received referrals to community cessation support services upon discharge. Patients on the usual care ward received cessation advice and support according to the usual practices of the providers involved in their care. The intervention group patients were younger and more likely to be male. Additionally, because of randomization by admission ward, the majority of intervention patients came from cardiac wards, whereas the majority of usual care patients came from respiratory wards. Finally, many eligible oncology patients were not included in the trial because of their doctors’ reluctance to have the study team approach these terminally ill patients. All patients in the intervention group received advice to quit compared with less than half of the patients in the usual care group. The use of pharmacotherapy and cessation support therapy, both in the hospital and upon discharge, was greater in the intervention group. The quit rate at 4 weeks, defined as self-reported smoking cessation validated by exhaled carbon monoxide measurement, favored the intervention group (38% vs 17%; P = .06), but did not quite reach statistical significance. When oncology patients (n = 45) were excluded from the analysis retrospectively, however, the result was significant (42% quit rate in the intervention group vs 17% in the usual care group; P = .006). Six-month cessation rates, though also higher in the intervention group, were not statistically different (19% vs 9%; P = .37).

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

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