Helping hospital patients quit: what the evidence supports and what guidelines recommend

Electronic Cigarettes and Smoking Cessation in the Perioperative Period of Cardiothoracic Surgery: Views of Australian Clinicians

For patients who smoke, electronic cigarettes may offer a pathway to achieve tobacco abstinence and reduce the risk of postoperative complications. Clinicians have a pivotal role in supporting smoking cessation by patients with lung cancer and coronary artery disease throughout the perioperative period of cardiothoracic surgery. However, the views of Australian cardiothoracic clinicians on electronic cigarettes and smoking cessation are unknown. Semi-structured interviews were conducted with 52 cardiothoracic surgeons, anaesthetists, nurses and physiotherapists in six hospitals in Sydney and thematically analysed. Clinicians’ knowledge about electronic cigarettes and the regulatory environment surrounding them was limited. Clinicians believed that: electronic cigarettes, though unlikely to be safe, were safer than tobacco cigarettes; electronic cigarettes may have a harm reduction role in public health; and electronic cigarettes were a potential smoking cessation tool for the extraordinary circumstances of surgery. The professional role of a clinician and their views about electronic cigarettes as a perioperative smoking cessation aid had an influence on future clinician-patient interactions. Electronic cigarette use is increasing in Australia and clinicians are likely to receive more frequent questions about electronic cigarettes as a cessation aid. Stronger guidance for clinicians is needed on the topic of electronic cigarettes and cardiothoracic surgery.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial

PURPOSE

To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers.

DESIGN

Pre-post quasi-experimental trial.

SETTING

General medical units of four US Department of Veterans Affairs hospitals.

SUBJECTS

898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively).

INTERVENTION

The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback.

MEASURES

The primary outcome was self-reported 7-day point prevalence abstinence at six months.

ANALYSIS

Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression.

RESULTS

Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI₉₅)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI₉₅=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001).

CONCLUSIONS

Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.

Implementation of the Tobacco Tactics intervention versus usual care in Trinity Health community hospitals

Background

Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework.

Methods

This pragmatic study used a mixed methods, quasi-experimental design in five Michigan community hospitals of which three received the nurse-administered Tobacco Tactics intervention and two received usual care. Nurses and patients were surveyed pre- and post-intervention.

Measures included reach (patient participation rates, characteristics, and receipt of services), adoption (nurse participation rates and characteristics), implementation (pre-to post-training changes in nurses' attitudes, delivery of services, barriers to implementation, opinions about training, documentation of services, and numbers of volunteer follow-up phone calls), and maintenance (continuation of the intervention once the study ended).

Results

Reach: Patient participation rates were 71.5 %. Compared to no change in the control sites, there were significant pre- to post-intervention increases in self-reported receipt of print materials in the intervention hospitals (n = 1370, p < 0.001). Adoption: In the intervention hospitals, all targeted units and several non-targeted units participated; 76.0 % (n = 1028) of targeted nurses and 317 additional staff participated in the training, and 92.4 % were extremely or somewhat satisfied with the training. Implementation: Nurses in the intervention hospitals reported increases in providing advice to quit, counseling, medications, handouts, and DVD (all p < 0.05) and reported decreased barriers to implementing smoking cessation services (p < 0.001). Qualitative comments were very positive (“user friendly,” “streamlined,” or “saves time”), although problems with showing patients the DVD and charting in the electronic medical record were noted. Maintenance: Nurses continued to provide the intervention after the study ended.

Conclusions

Given that nurses represent the largest group of front-line providers, this intervention, which meets Joint Commission guidelines for treating inpatient smokers, has the potential to have a wide reach and to decrease smoking, morbidity, and mortality among inpatient smokers. As we move toward more population-based interventions, the RE-AIM framework is a valuable guide for implementation.

Trial registration

ClinicalTrials.gov, NCT01309217

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0511-6) contains supplementary material, which is available to authorized users.

Smoking cessation care among patients with head and neck cancer: a systematic review

OBJECTIVE

To examine the effectiveness of smoking cessation interventions in improving cessation rates and smoking related behaviour in patients with head and neck cancer (HNC).

DESIGN

A systematic review of randomised and non-randomised controlled trials.

METHODS

We searched the following data sources: CENTRAL in the Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL up to February 2016. A search of reference lists of included studies and Google Scholar (first 200 citations published online between 2000 and February 2016) was also undertaken. The methodological quality of included studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). 2 study authors independently screened and extracted data with disagreements resolved via consensus.

RESULTS

Of the 5167 studies identified, 3 were eligible and included in the review. Trial designs of included studies were 2 randomised controlled trials and 1 non-randomised controlled trial. 2 studies received a weak methodological rating and 1 received a moderate methodological rating. The trials examine the impact of the following interventions: (1) nurse delivered cognitive-behaviour therapy (CBT) via telephone and accompanied by a workbook, combined with pharmacotherapy; (2) nurse and physician brief advice to quit and information booklets combined with pharmacotherapy; and (3) surgeon delivered enhanced advice to quit smoking augmented by booster sessions. Only the trial of the nurse delivered CBT and pharmacotherapy reported significant increases in smoking cessation rates. 1 study measured quit attempts and the other assessed consumption of cigarettes per day and readiness to change. There was no significant improvement in quit attempts or cigarettes smoked per day among patients in the intervention groups, relative to control.

CONCLUSIONS

There are very few studies evaluating the effectiveness of smoking cessation interventions that report results specific to the HNC population. The 3 trials identified reported equivocal findings. Extended CBT counselling coupled with pharmacotherapy may be effective.

TRIAL REGISTRATION NUMBER

CRD42016016421.

Use of Nutrition Standards to Improve Nutritional Quality of Hospital Patient Meals: Findings from New York City's Healthy Hospital Food Initiative

BACKGROUND

Most hospital patient meals are considered regular-diet meals; these meals are not required to meet comprehensive nutrition standards for a healthy diet. Although programs exist to improve nutrition in hospital food, the focus is on retail settings such as vending machines and cafeterias vs patient meals. New York City's Healthy Hospital Food Initiative (HHFI) provides nutrition standards for regular-diet meals that hospitals can adopt, in addition to retail standards.

OBJECTIVE

This study was undertaken to describe regular-diet patient menus before and after implementation of the HHFI nutrition standards.

DESIGN

The study involved pre- and post- menu change analyses of hospitals participating in the HHFI between 2010 and 2014.

PARTICIPANTS/SETTING

Eight New York City hospitals, selected based on voluntary participation in the HHFI, were included in the analyses.

MAIN OUTCOME MEASURES

Nutritional content of regular-diet menus were compared with the HHFI nutrition standards.

STATISTICAL ANALYSES PERFORMED

Nutrient analysis and exact Wilcoxon signed-rank tests were used for the analysis of the data.

RESULTS

At baseline, no regular-diet menu met all HHFI standards, and most exceeded the daily limits for percentage of calories from fat (n=5), percentage of calories from saturated fat (n=5), and milligrams of sodium (n=6), and they did not meet the minimum grams of fiber (n=7). Hospitals met all key nutrient standards after implementation, increasing fiber (25%, P<0.01) and decreasing sodium (-19%, P<0.05), percentage of calories from fat (-24%, P<0.01), and percentage of calories from saturated fat (-21%, P<0.05). A significant increase was seen in fresh fruit servings (667%, P<0.05) and decreases in full-fat and reduced-fat milk servings (-100%, P<0.05), refined grain servings (-35%, P<0.05), and frequency of desserts (-92%, P<0.05).

CONCLUSIONS

Regular diet menus did not comply with the HHFI nutrition standards at baseline. Using the HHFI framework, hospitals significantly improved the nutritional quality of regular-diet patient menus. The standards were applied across hospitals of varying sizes, locations, menu types, and food service operations, indicating feasibility of this framework in a range of hospital settings.

Health care professionals implementing a smoke-free policy at inpatient psychiatric units

Smoke-free grounds policies (SFGPs) were introduced to inpatient psychiatric hospital settings to improve health among patients, staff, and visitors. We conducted an ethnographic study in Northern British Columbia, Canada, to describe how the implementation of SFGPs is affected by institutional cultures. Data reported here included participant observation, document review, informal discussions (n = 11), and interviews with health care professionals (HCPs; n = 19) and staff (n = 2) at two hospitals. We used iterative and inductive processes to derive thematic findings. Findings related to HCPs illustrate how local contexts and cultural factors affect SFGP implementation. These factors included individual beliefs and attitudes, the influence of group norms, leadership and consensus building, and locale-specific norms. Strong, consultative leadership, in which leaders solicited input from and long-term support of people most directly responsible for policy implementation, was key to success.

Web-based smoking cessation intervention that transitions from inpatient to outpatient: study protocol for a randomized controlled trial

BACKGROUND

E-health tools are a new mechanism to expand patient care, allowing supplemental resources to usual care, including enhanced patient-provider communication. These applications to smoking cessation have yet to be tested in a hospitalized patient sample. This project aims to evaluate the effectiveness and cost-effectiveness of a tailored web-based and e-message smoking cessation program for current smokers that, upon hospital discharge, transitions the patient to continue a quit attempt when home (Decide2Quit).

DESIGN

A randomized two-arm follow-up design will test the effectiveness of an evidence- and theoretically-based smoking cessation program designed for post-hospitalization.

METHODS

A total of 1,488 patients aged 19 or older, who smoked cigarettes in the previous 30 days, are being recruited from 27 patient care areas of a large urban university hospital. Study-eligible hospitalized patients receiving usual tobacco cessation usual care are offered study referral. Trained hospital staff assist the 744 patients who are being randomized to the intervention arm with registration and orientation to the intervention website. This e-mail and web-based program offers tailored messages as well as education, self-assessment and planning aids, and social support to promote tobacco use cessation. Condition-blind study staff assess participants for tobacco use history and behaviors, tobacco use cost-related information, co-morbidities and psychosocial factors at 0, 3, 6, and 12 months. The primary outcome is self-reported 30-day tobacco abstinence at 6 months follow-up. Secondary outcomes include 7-day point prevalence quit rates at 3-, 6-, and 12-month follow-up, 30-day point prevalence quit rates at 3 and 12 months, biologically confirmed tobacco abstinence at 6-month follow-up, and multiple point-prevalence quit rates based on self-reported tobacco abstinence rates at each follow-up time period. Healthcare utilization and quality of life are assessed at baseline, and 6- and 12-month follow-up to measure program cost-effectiveness from the hospital, healthcare payer, patient, and societal perspectives.

DISCUSSION

Given the impact of tobacco use on medical resources, establishing feasible, cost-effective methods for reducing tobacco use is imperative. Given the minimal hospital staff burden and the automated transition to a post-hospitalization tailored intervention, this program could be an easily disseminated approach.

TRIAL REGISTRATION

Current Intervention Trial NCT01277250.

Addressing obesity in the hospitalized patient: a needs assessment

OBJECTIVE

To perform a needs assessment to determine the extent to which hospitalist providers recognize and intervene upon obese patients in the hospital setting.

METHODS

A chart review was performed for patients admitted to the hospitalist service at Johns Hopkins Bayview Medical Center between September 1 and October 1, 2008. Patient charts were reviewed for documentation of obesity and treatment plans were ordered and implemented. Demographic data for patients and hospitalist providers was also collected. Providers were also surveyed about their documentation practices related to obesity and any perceived barriers.

RESULTS

Forty-nine percent (136/276) of admitted patients were obese. Obesity was documented in 19% (26/136) of admission notes and a discrete plan was made to address obesity 7% (10/136) of the time. Hospitalist providers were more likely to document obesity in patients <60 years old (85% versus 55% respectively, P <0.007), and in patients with body mass indices (BMI) >or= 35 (77% versus 44% respectively, P < 0.004). Provider survey results suggest that providers do not document obesity because it is not considered to be an acute issue (67%), and they elect not to address obesity because they lack the time (63%), skill (37%), and they believe that their efforts will be unsuccessful (33%).

CONCLUSION

Documentation of obesity by hospitalist providers is poor. Because an inpatient admission has been characterized as a teachable moment when patients are willing to reflect on behavior change, this may be an ideal time to counsel and educate obese patients.

Promoting tobacco dependence treatment in nursing education

ISSUES

There are 17.3 million nurses worldwide, the largest group of health-care professionals, and they have great potential to address the epidemic of tobacco use and its related morbidity and mortality. However, the evidence indicates that the educational preparation of nurses for tobacco control remains inadequate.

APPROACH

This paper provides an overview of the efficacy of nurses in the delivery of smoking cessation interventions, existing tobacco control content in nursing educational programs, model curricula, teaching resources and strategies for reducing barriers to curricular change.

KEY FINDINGS

Despite the efficacy of nursing intervention for tobacco cessation, lack of appropriate knowledge and/or skill presents a major problem for implementation. An important factor fostering this lack of preparation is limited tobacco control content in current nursing educational programs. Barriers to enhancing and building this curricula include lack of preparation of educators, low priority for this content in an already overloaded curricula, negative attitudes, continued smoking by nursing students and/or faculty and lack of tested curricula. The availability of new tobacco control resources, including those specifically tailored for nurses can assist educators in teaching this content and nurses in implementing interventions.

IMPLICATIONS

Research and changes in policy are needed to ensure that nursing education includes essential content on tobacco control.

CONCLUSION

Nurses can be effective in delivering tobacco cessation interventions. Efforts are needed to promote curriculum that ensures that all nursing students and practicing nurses receive tobacco control content and are competent in the delivery of interventions; and to disseminate resources to nursing educators