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Smoking Cessation
Best Practices in Tobacco Control within the VA
Inpatient Tobacco Treatment Initiation Project
Tobacco Clinical Demonstration Project
Funded by Public Health Strategic Health Care Group
Department of Veterans Affairs
Anne Joseph, MD, MPH
Minneapolis VA Center for Chronic Disease Outcomes
Research
University of Minnesota
Larry An, MD, MPH
University of Minnesota
Background
Smokers who are hospitalized should receive
tobacco dependence treatment while they are
inpatients. Hospitals provide a smoke-free
environment and many patients who smoke abstain
spontaneously during hospitalization. Inpatient
intervention for smoking has shown to be effective,
if follow-up after discharge from the hospital is
provided. A JCAHO accreditation standard includes
inpatient intervention for patients with CHF,
pneumonia and ischemic heart disease. It can be
challenging, however, to deliver tobacco treatment
to inpatients. Barriers include that patients are
often very ill, they may be busy with diagnostic
and/or therapeutic procedures and counseling
resources may be scarce. In addition, different
providers may be responsible for inpatient and
outpatient care, so coordination of tobacco
treatment after discharge from the hospital is
important.
We conducted a demonstration project to
investigate the feasibility and efficacy of
systematic intervention for tobacco use for
inpatients, including one face-to-face encounter
with telephone follow-up for counseling and
provision of smoking cessation medications.
Methods
Setting
This project was conducted at the Minneapolis VA
Medical Center. Two full-time interventionists were
hired to form the Tobacco Treatment Team (TTT) to
provide tobacco cessation services (trained by the
California Smoker’s Helpline). We developed
counseling protocols, and created templates for
standardized note entry into CPRS. The dates of
evaluation were July 14, 2004 to October 3, 2005.
Patients
Each day, TTT members accessed Gains & Losses
Report and identified tobacco users based upon the
nursing admission note. The TTT then attempted to
visit in person each tobacco users newly admitted to
the hospital to offer tobacco treatment services.
This screening visit included a brief assessment of
current and past tobacco use, offer of services, and
assessment of patient interest. The TTT worked
Monday through Friday. Tobacco users admitted to the
hospital over the weekend were screened the
following Monday.
Of those tobacco users screened by the TTT, some
were not appropriate for treatment services. A few
individuals were identified as smokers incorrectly
in the electronic medical record and some patients
were too ill to participate in counseling (for
example they were unresponsive or delirious, had
severe pain, or had ongoing vomiting during the
screening visit.), some patients were not able to
communicate or staff was unable to provide treatment
for other reasons (for example if the patient was
suicidal or threatening).
Treatment
The TTT offered two different programs, depending
on the interests of the patient. For patients who
were not interested in tobacco cessation, the
TTT offered a Management Plan that encouraged the
use of pharmacological therapy (primarily nicotine
replacement) to reduce withdrawal symptoms during
the hospitalization. For patients who were
interested in tobacco cessation, the TTT offered
a Quitplan program that consisted of intensive
behavioral and pharmacological assistance in
quitting.
The behavioral intervention employed
evidence-based strategies identified in national
guidelines. These included a review of the benefits
of quitting, assessment of triggers to smoke and
active problem solving to identify coping
strategies, and encouragement to seek social support
in quitting. Features specific to this inpatient
intervention include linkage to the patient’s reason
for hospitalization if possible (i.e. hospitalized
for pneumonia, foot ulcer, etc.) and encouragement
to discuss creating a smoke-free home environment
upon discharge from the hospital.
The program encouraged use of pharmacological
therapy as appropriate after screening for
contraindications. Tobacco treatment medications
that are available on formulary at the Minneapolis
VAMC include nicotine patch, nicotine gum, nicotine
lozenge, and bupropion SR. Patients who abstained
from smoking since hospitalization were still
encouraged to use pharmacotherapy to prevent the
development of withdrawal symptoms and to encourage
continued abstinence upon hospital discharge.
Combination therapy (two forms of NRT or NRT plus
bupropion SR) was recommended for individuals with
past unsuccessful attempts using a single agent. TTT
recommendations for specific medications were
conveyed to the patient’s hospital medical team who
prescribed the medication. Prescription or change in
tobacco treatment medications after hospital
discharge was preformed by project physicians.
Patients who agreed to receive services were visited
daily during their hospitalization to assess control
of nicotine withdrawal symptoms, monitor for
medication side effects, and provide encouragement
for continued abstinence. Telephone counseling was
providing following discharge with calls scheduled
in a relapse sensitive fashion referenced to the
discharge date (on discharge then 3, 7, 14, 30, 60
days after discharge). As staff workload allowed, a
minimum of three calls was made to reach patients at
teach of the scheduled time points.
Evaluation
For all smokers who requested services, a
follow-up call was placed three months later to
assess tobacco status and encourage relapsed smokers
to make new quit attempts. Data sources for
evaluation of the effectiveness of inpatient tobacco
treatment services come from extraction of templated
TTT screening and follow-up notes and medical center
pharmacy prescription records.
Results
We examined patient flow and workload for 435
days. During this period, 5685 patients were
admitted to the Medical Service wards under
evaluation. There were 984 smokers (17.5%). The TTT
was able to try and see patients on 333 (77%) of
days. The main reasons staff were not available were
administrative duties and personnel changes.
The TTT was able to screen 565 (59%) of tobacco
users who were admitted. The main reasons for not
screening patients were that they were already
discharged (24%), the patient was not available
(10%) or was transferred to another service (7%). Of
those screened, 465 (48% of the total) were eligible
for tobacco treatment. The main reason for
ineligibility was that patients were too ill or
confused to receive care. Twenty percent of the
total number of smokers enrolled for services. The
main reasons for not enrolling were lack of interest
in quitting (20%) and intent to quit on their own
(8%).
We observed that the protocol was quite labor
intensive. Counselors often had to visit the bedside
2-4 times in order to make contact with patients,
and this would occur prior to determination of their
interest in receiving services. The system was
relatively inflexible to staff absences. In
addition, telephone contacts shortly after discharge
were sometimes complicated by ongoing medical issues
at home that took precedence over tobacco counseling
calls.
Conclusions
This demonstration project provided experience
with a systematic approach to all inpatient smokers.
We learned that a high proportion of smokers (20%)
admitted to the hospital are interested in receiving
tobacco treatment. Screening for interest in
treatment using bedside visits, however is
relatively inefficient because a large number of
smokers are missed (41%) in spite of staff
specifically dedicated to this goal. We are
currently investigating alternative methods to refer
patients to treatment that might be more efficient,
since there is substantial unmet demand for
treatment services.
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