Hospital admissions for treatment of acute myocardial infarction, heart failure or pneumonia present a unique opportunity for healthcare professionals to not only treat the underlying disease but also address the contributing but modifiable risk factors for the current illness. Nicotine dependence has been well established as one of those modifiable risk factors. Research has demonstrated that during any acute hospitalization patients are more receptive to receiving and acting on information that will impact their current illness & mortality. It is a critical “teachable moment” opportunity.(1,2,3) Clinical treatment guidelines established by the U.S. Department of Health and Human Services consortium (4) and position papers published by multiple non-governmental organizations such as the American Medical Association, American Heart Association, American College of Cardiology and the American Thoracic Society, support smoking cessation advice and counseling activities as a 'best practice' intervention for nicotine dependence. This intervention, when initiated in the inpatient setting and followed up in the outpatient or office setting, achieves favorable quit rate results.(5) No other preventative health intervention yields more significant health results than quitting. (4,6) This document reviews and outlines evidence-based, low resource and minimally intrusive actions that can be incorporated into a health care delivery system to improve the rates at which adult smoking cessation advice and counseling is provided to nicotine dependent patients.

Recommendations

The following strategies are based on best practice guidelines and speak to the professional responsibility for all clinical staff with direct patient contact to, at a minimum, ask the questions “do you smoke” and “do you want to quit”. These strategies were compiled from the literature and from an expert panel and are common components of successful programs.

• Designate a physician and Nurse Champion
• Consistently Identify Patients Who Smoke
• Assign Responsibility and Provide Counseling

Designate a Physician and Nurse Champion

By coordinating program activities and educating other health care team members on the guidelines, clinician advocates are key elements of successful program implementation and follow through.(3,7) These clinician champions serve as role models and resources by helping other clinical staff increase their knowledge base and by dispelling myths about the roadblocks to a successful smoking cessation counseling program. Success is enhanced when a clinician champion assembles and works with a multi-disciplinary team. This approach provides greater opportunities for patient contact.(4,8,9,10) Program effectiveness is further enhanced when the clinician champions are themselves non-smokers or former smokers.(11,12) It is well documented that a physician's advice to quit smoking can double the chances that a patient will successfully quit smoking.(4) In collaboration with hospital administration, physicians can also reinforce no smoking policies and ensure that the needed FDA approved pharmaceutical aides are available on formulary. As a leader and role model, the physician champion influences other physicians, nurse colleagues and allied health staff to follow the clinical practice guidelines for nicotine dependence treatment. The nurse champion assumes the pivotal role for oversight and coordination of the program for all patients. The nurse champion should establish the processes used to identify patients that smoke and ensure that the interventions and services provided are documented in a standard format in the medical record. By designing and directing educational opportunities and communicating program goals and objectives, the nurse champion also helps strengthen the skill sets of the clinical staff as they implement the guidelines. In partnership with hospital leadership and the physician champion, the nurse champion can facilitate a multidisciplinary approach to nicotine dependence treatment.

Consistently Identify Patients Who Smoke

Hospitals with high smoking cessation counseling measure rates have frequently revised their documentation practices to ensure that every patient is asked about their smoking status and that this information is documented in a consistent location in the medical record. The physician and nurse champion should work to redefine system processes that identify patients that smoke and communicate this information to the hospital staff. Patient identification and documentation can be as simple as asking the question “have you smoked within the last year?” during the inpatient registration process.(13) Additional clinical documentation about smoking status (e.g., last time the patient smoked, how much the patient smokes, interest in quitting, previous quit attempts) should be centralized and included on a readily accessible form, such as the nursing care plan, to enhance communication with staff who are responsible for providing cessation counseling.

Assign Responsibility and Provide Counseling

The physician and nurse champion should evaluate current treatment processes and identify an efficient and effective strategy for providing smoking cessation counseling. Successful organizations consistently identify smokers, efficiently communicate this information to clinicians and assign the responsibility for providing counseling to a specific individual (or individuals) who consistently document counseling, once it has been provided. Multi-dimensional, multidisciplinary intervention programs tailored to the patient’s readiness level can achieve optimal results when the following components are built into the program: (4,13)

1. The delivery of strong, clear and personalized advice to quit by the physician. This has proven to be significantly effective in motivating patients to quit and doubles the chances that a smoker will quit.(4) It may require no more than 3 - 5 minutes of time.(3,4)
2. An additional 20 minutes of bedside counseling by the lead clinician or designated staff. Repetitive counseling sessions stressing the risks and rewards of quitting are associated with higher quit-success rates.(3) Family involvement is also beneficial.
3. Pharmaceutical aides or nicotine replacement therapy (NRT). Unless contraindicated, providing these tools to all patients has been found to be efficacious, safe and associated with attaining higher sustained quit rates.(4,14)
4. Provide patients with the National Quitline number (1-800-QUIT NOW) and a list of other resources for follow up after hospital discharge. (15)
5. Implement hospital policies that discourage the use of written orders bypassing the hospital’s ‘no smoking’ policy. Such policies reinforce and strengthen the hospital’s role in promoting a patient’s return to health.

Additional Interventions: Going Beyond the Minimum

Research has demonstrated that follow-up calls after discharge and the provision of information about external resources significantly improves patient quit rates. Reports in the literature suggest that 4-5 phone calls are associated with higher quit rates, and as the intensity of follow up treatment increases, so do the quit rates.(6) Patient and clinician focused materials are available from multiple government and non-profit healthcare agencies, and references are included in this packet.

Making a few system changes and allocating resources to support a nicotine dependence treatment program that follows the guidelines will improve patient outcomes and will be reflected in your performance measure rates. Executive involvement and oversight conveys commitment to the program and ensures that policy changes supporting the program are implemented.(16)

References

1. Green J. Forced abstinence & the teachable moment. AHA Hosp Health. June 2003:30-31.

2. Emmons KM, Goldstein MG. Smokers who are hospitalized: A window of opportunity for cessation interventions. Prev Med. 1992;21:262-269.

3. The Smoking Cessation Clinical Practice Guideline Panel and Staff. The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA. 1996;275:1270-1280.

4. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000. Full text

5. Solberg LI, Kottke TE, Conn SA, Brekke ML, Calomeni CA, Conboy, KS. Delivering clinical preventive services is a systems problem. Ann Behav Med. 1997;19:271-278.

6. Cummings SR, Rubin SM, Oster G. The Cost effectiveness of counseling smokers to quit. JAMA. 1989;261:75-79.

7. Orleans CT, Kristeller JL, Gritz ER. Helping hospitalized smokers quit: New directions for treatment research. J Consult Clin Psychol. 1993;61:778-789.

8. West R, Mc Neill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax. 2000;55:987-999.

9. Hill M, Houston Miller N. Compliance enhancement, a call for multidisciplinary team approaches. Circulation. 1996;93:4-6.

10. Zillich AJ, Mc Donough RP, Carter BL, Doucette WR. Influential characteristics of physician/pharmacist collaborative relationships. Ann Pharmacother. 2004;38:764-770.

11. Sarna L, Wewers ME, Brown JK, Lillington L, Brecht M. Barriers to tobacco cessation in clinical practice: Report from a national survey of oncology nurses. Nurs Outlook. 2001;49:166-172.

12. U.S. Public Health Service. Treating Tobacco Use and Dependence—A Systems Approach. A Guide for Health Care Administrators, Insurers, Managed Care Organizations, and Purchasers, November 2000. Available at: http://www.surgeongeneral.gov/tobacco/systems.htm. Accessed 6/22/05.

13. Smith PM, Reilly KR, Houston Miller N, De Busk RF, Taylor CB. Application of a nurse-managed inpatient smoking cessation program. Nicotine & Tobacco Research. 2002;4:211-222.

14. Joseph AM, Fu SS. Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease. Prog Cardiovasc Dis. 2003;45:429-441.

15. Schroeder SA. What to do with a patient who smokes. JAMA. 2005;294:482-487.

16. Emmons KM, Thompson B, Mc Lerran D, Sorenson G, Linnan L, Basen-Engquist, et al. The relationship between organizational characteristics and the adoption of workplace smoking policies. Health Educ Behav. 2000;27:483-501.