Hospitalization as a Teachable Moment for Cigarette Smoking Cessation

As is well known, cigarette smoking is one of the greatest catastrophes of public health worldwide. In 2004, it was estimated that one third of all cancer mortality in Korean men was attributed to cigarette smoking; smoking is also among main risk factors of varying serious diseases, including cardiovascular and respiratory diseases. These diseases have caused 20 million premature deaths in the United States within the last 50 years.1,2) Lowering the smoking rate has, therefore, been an important public health goal for primary prevention of diseases.

The effectiveness of counseling for cigarette smoking cessation by a healthcare professional has been well established. According to a United States public health report, counseling for smoking cessation can be effective in as brief as a 3-minute counseling session by a physician.3) Many physicians, however, hold negative beliefs that counseling is too time-consuming, or is ineffective, even if it could be equally as effective as pharmacological treatment.4)

In the study conducted by Kim et al.5) in this issue, patients who were hospitalized participated in 30-minute counseling sessions, facilitated by third-year family medicine residents. After being discharged, patients participated in telephone consultation three times for three months. The study showed success in regard to smoking cessation; the cessation rate was 42.4% at a three month follow-up, as compared to the 43.9% cessation rate of varenicline at weeks 9 to 12. Similarly, a German study observed a cessation rate of 41.7%, where admitted patients received counseling, with eight follow-up as noted by authors.6,7)

The population involved in this study is the key factor in explaining the relatively high cessation rate. Counseling sessions were offered to patients who were being hospitalized for diseases related to cigarette smoking. Hospital admission for the diagnosis and treatment of these diseases could have enhanced patients' motivation toward preventive health behavior due to increased concern with their own health status, as well as the realization that behavioral change is perhaps the most important step that one can take. In this way, diagnosis of diseases could be a positive cue to action regarding health behavior change, and hospital admission for these diseases could serve as a teachable moment. These patients were ready to change, at least during admission, and physicians should not miss the opportunity to help these patients change.

It should be reiterated that this study included telephone follow-up for a period of 3 months. Follow-up is essential in maintaining the effectiveness of counseling. For instance, unpublished data about brief counseling from the National Screening Program for Transitional Ages revealed that the effectiveness of cigarette smoking cessation counseling was undetectable after two years, even when significant motivation enhancement had been noticed within several months of the counseling.8) Telephone follow-up three times for three months was inexpensive, and was as effective as the eight-time telephone follow-up for the same amount of time in a German study.7)

Considering the effectiveness of counseling, primary care physicians should make an attempt to integrate cigarette cessation counseling for patients at their teachable moment such as admitted patients, in their daily practice. Serious consideration should be given to a policy that would encourage physicians to talk with their patients about cigarette smoking, and the reimbursement scheme for counseling including telephone follow-up will be key to this discussion.