SMOKING CESSATION INTERVENTIONS FOR HOSPITALIZED SMOKERS: A SYSTEMATIC REVIEW

Abstract

Background

A hospital admission provides an opportunity to help people stop smoking. Providing smoking cessation advice, counselling, or medication is now a quality-of-care measure for U.S. hospitals. We assessed the effectiveness of smoking cessation interventions initiated during a hospital stay.

Methods

We searched the Cochrane Tobacco Addiction Review Group's register for randomized and quasi-randomized controlled trials of smoking cessation interventions (behavioral counselling and/or pharmacotherapy) that began during hospitalization and had a minimum of 6 months follow-up. Two authors independently extracted data from each paper, with disagreements resolved by consensus.

Results

33 trials met inclusion criteria. Smoking counselling that began during hospitalization and included supportive contacts for >1 month after discharge increased smoking cessation rates at 6-12 months (pooled OR 1.65, 95% CI 1.44-1.90). No benefit was found for interventions with less post-discharge contact. Counselling was effective when offered to all hospitalized smokers and to the subset admitted for cardiovascular disease. Adding nicotine replacement therapy to counselling produced a trend toward efficacy over counseling alone (OR 1.47, 95% CI 0.92-2.35). One study added bupropion to counselling. It had a nonsignificant result (OR 1.56, 95% CI 0.79-3.06).

Conclusions

Offering smoking cessation counselling to all hospitalized smokers is effective as long as supportive contacts continue for >1 month after discharge. Adding NRT to counselling may further increase smoking cessation rates and should be offered when clinically indicated, especially to hospitalized smokers with nicotine withdrawal symptoms.

Introduction

Tobacco smoking remains the leading preventable cause of death in the United States.¹ Smoking-attributable morbidity and mortality are reduced by smoking cessation, even when it occurs after the onset of a smoking-related disease.² Smokers who are hospitalized have an opportunity to initiate cessation because U.S. hospitals are smoke-free.³ Smokers must abstain temporarily from tobacco use while hospitalized, allowing them to experience tobacco abstinence away from environmental cues to smoke. Hospitalisation may also increase a smoker's motivation to quit because illness, especially if tobacco-related, increases a smokers’ perceived vulnerability to the harms of tobacco use, providing a ‘teachable moment’ for change. Finally, illness brings smokers to the healthcare setting, where smoking cessation interventions can be provided. For these reasons, providing or initiating tobacco dependence treatments in hospitals may be an effective preventive health strategy.

Hospital quality-of-care standards set by the Joint Commission (JCAHO) and Medicare (CMS) now include a tobacco measure.⁴ It assesses the proportion of current or past-year smokers who received smoking advice, counseling, or medication during a hospitalization for acute myocardial infarction, congestive heart failure, or pneumonia. This measure is reported quarterly on a public website and is included in pay-for-performance reimbursement programs.⁵ This development stimulated interest in providing hospital-based smoking intervention. It is critical that programs designed to meet the new quality standard effectively promote smoking cessation after hospital discharge.

Smoking cessation interventions that have been provided in the hospital setting include behavioral counselling of varying intensity, pharmacotherapy with nicotine replacement (NRT) or bupropion, and combinations of the two. This systematic review aims to summarize the evidence about the efficacy of smoking cessation interventions for hospitalized patients. An extended version is published and regularly updated in the Cochrane Database of Systematic Reviews.

Methods

Search strategy

We searched the Cochrane Tobacco Addiction Review Group register of trials, which includes the results of systematic searches, updated quarterly, of MEDLINE, PsycINFO, EMBASE and conference abstracts. Searches for the register cover smoking cessation, nicotine dependence, nicotine addiction and tobacco use. We identified studies mentioning hospital or inpatient or admission in the title, abstract, or keywords. The most recent search was in January 2007. We identified one additional paper from current contents alerting.⁶

Inclusion criteria

We included randomized or quasi-randomized controlled trials that enrolled patients who were hospitalized and were current smokers (defined as having smoked in the month before admission) or recent quitters (defined as having quit from one month to one year before admission) and had at least 6 months of follow-up after randomization. We excluded secondary prevention or cardiac rehabilitation trials that did not recruit on the basis of smoking history, and trials in patients hospitalized for psychiatric disorders or substance abuse (including inpatient tobacco addiction programs). We included trials that recruited hospitalized smokers regardless of their intention to quit smoking and trials that recruited only smokers who planned to quit after discharge.

We included any intervention that was initiated during hospitalization and aimed to increase motivation to quit, assist a quit attempt, or avoid relapse. The intervention could include advice to quit, behavioral counseling, or pharmacotherapy, with or without continued contact after hospital discharge. We developed a priori four categories of counselling intensity based on the duration of contact in the hospital and the duration of follow-up contact after discharge:

1. 1 contact in hospital lasting ≤ 15 minutes and no post-discharge support.

2. ≥1 contact in hospital lasting >15 minutes total and no post-discharge support.

3. Any hospital contact plus post-discharge support lasting ≤1 month.

4. Any hospital contact plus post-discharge support lasting > 1 month.

The intervention could be delivered by physicians, nursing staff, psychologists, smoking cessation counsellors or other hospital staff. The control intervention could be any less intensive intervention or usual care. The principal outcome measure was abstinence from smoking at least 6 months after randomization

Data extraction

Studies identified by search strategies were checked for relevance. Two authors extracted data independently from selected studies, resolving disagreements by consensus. Authors agreed about study inclusion or exclusion for approximately 95% of studies reviewed. We extracted data on study setting, recruitment criteria (including types of admission diagnoses, smoking status at admission, and willingness to make a quit attempt), participant characteristics, method of randomization and allocation concealment, intervention and control conditions (including therapist types, duration of contact and/or medication in hospital and after discharge), and outcome measures (length of follow-up, definition of abstinence, validation of self-reported smoking status).

Data synthesis

To assess outcome, we used the most conservative measure of quitting at the longest follow up. When multiple outcomes were reported, we preferred a biochemically validated quit rate to self-reported abstinence, continuous or sustained abstinence to point prevalence abstinence, and 12-month follow-up to 6-month follow-up. We calculated quit rates based on the numbers of randomized patients, excluding deaths and counting as smokers all patients who dropped out, were lost to follow-up or failed to provide biochemical validation of nonsmoking status. We pooled study outcomes using Mantel-Haenszel fixed-effect model⁷ and expressed results as an odds ratio (OR) for smoking abstinence with a 95% confidence interval. We assessed statistical heterogeneity among studies with the I² statistic⁸; where it exceeded 50%, we explored possible reasons using subgroup analyses or considered the impact of outliers. Where studies were judged by quality criteria to be more prone to bias, we planned sensitivity analyses to assess whether their inclusion altered our findings.

Data were analyzed using the pre-determined four-level classification of intervention intensity. We did a subgroup analysis based on patients’ admitting diagnosis: cardiovascular, respiratory, and cancer. Another subgroup analysis assessed the effects of interventions designed to be delivered to all smokers who were admitted, regardless of the admitting diagnosis.

Description of studies

Thirty-three trials conducted in 9 countries between 1990 and 2007 met inclusion criteria and contributed to the review. (Tables 1, 2) We excluded 51 studies which appeared relevant but did not meet all inclusion criteria.

Table 1.

Trials of Smoking Cessation Counseling

Source	Setting -country/ -# of hospitals	Subjects n, diagnoses -smoking status -willingness to quit	Study design # of arms	Counseling Intervention Inpatient Post-discharge	Control condition	Pharmacotherapy?	Outcome -Abstinence type, -longest f/u, -validation method
Bolman 200240	Netherlands 11 hospitals	789 current smokers (smoked in past week) Admitted to cardiac ward. Willingness to quit not reported	Quasi-experimental, by hospital. 2 arms	MD advice, counseling by staff nurse (15-30 min), self-help material Post-discharge: none [Intensity 2]	Usual care	No	Sustained abstinence. at 12 months No validation
CASIS 199210	USA 3 hospitals	267 current smokers or recent quitters (smoke in past 2 mo). Inpatients with CAD enrolled post-catheterization. Not selected by willingness to quit.	RCT 2 arms	Counseling (40 min) by health educator, self-help material. Post-discharge: telephone calls (at 1, 3 wks and 3m) [Intensity 4]	Advice only	No	Sustained abstinence at 6 mo, 12 mo Validation: CO.
Chouinard 200525	Canada (# hospitals not reported)	168 current smokers (in past month) Inpatients with CVD (MI, angina, CHF) or PVD Not selected by motivation to quit	RCT 3 arms	Group 1: Stage-based counseling by research nurse (10-60 mins, average, 40 min). [Intensity 2] Group 2. Same as group 1 + 6 telephone calls over 2 mo post-discharge [Intensity 4]	Advice only	NRT in 23%, not allocated by study arm	Sustained abstinence at 2 & 6 months Validation: Urine cotinine or CO
Croghan 200536	USA 1 hospital	30 smokers Inpatients having surgery for newly diagnosed lung or esophageal cancer. Willingness to quit not reported.	RCT 2 arms	MD advice + stage-based counseling by trained counselor (45 min) + NRT Post-discharge: none [Intensity 2]	Physician advice only	NRT	7-day point-prevalence abstinence at 6m Validation: CO or saliva tobacco alkaloid
De Busk 199412	USA 5 hospitals	252 current smokers or recent quitters (smoked in past 6m) Inpatients with acute MI. Willing to make a quit attempt	RCT 2 arms	Physician advice + behavioral counseling by research nurse; + self-help material, relaxation tapes). Post-discharge: 8 telephone calls (at 48 hr, 1 wk, and monthly for 6m) [Intensity 4]	Advice only	NRT: Yes (partial) ('reserved for highly-addicted patients');	Sustained abstinence at 6m, 12m. Validation: CO and plasma cotinine.
Dornelas 200018	USA 1 hospital	100 current smokers (smoked in past month). Inpatients with acute MI. Not selected by willingness to quit.	RCT 2 arms	Behavioral counseling (total 20 min); 7 telephone calls post-discharge (at <1, 4, 8, 12, 16, 20, 26 wk) [Intensity 4]	Advice only	No	7-day point-prevalence abstinence at 12m. Validation by significant other (only in 70%).
Feeney 200137	Australia 1 hospital	198 current smokers (smoked in past week). Inpatients with acute MI admitted to CCU. Willingness to quit not reported.	RCT 2 arms	Physician advice to quit + behavioral counseling by nurse (time not specified)); 8 telephone calls post-discharge (at 1,2,3,4 wks and 2,3,6,12m) [Intensity 4] nurse.	Same as intervention in hospital but no follow up after discharge [Intensity 2]	No	Sustained abstinence at 1m,3m, 12m. Validation: Urinary cotinine
Froelicher 200423	USA 10 hospitals	277 female current smokers or recent quitters (smoked in past month), Inpatients with CVD or PVD. Willing to make quit attempt at discharge.	RCT 2 arms	Physician advice, cognitive/behavioural and relapse prevention counseling (30-45 min) by nurse; 5 telephone calls after discharge (at 2,7,21,28,90 days, 5-10 min/call) [Intensity 4]	Modified usual care (physician advice + booklet)	NRT offered after discharge to relapsers who wanted to quit (used by 20% of intervention, 23% of controls).	7-day point-prevalence abstinence at 12m. Validation: Saliva cotinine or family/friend verification
Hajek 200238	UK 17 hospitals	540 current smokers. Inpatients with acute MI who were. willing to stop smoking entirely.	RCT 2 arms	Nurse counseling (20-30 min) + self-help materials. [Intensity 2]	Brief advice + booklet	No	7-day point-prevalence abstinence at 12m. Validation: CO and salivary cotinine.
Hasuo 200424	Japan 1 hospital	120 current smokers or recent quitters (smoked in past month) Inpatients (all diagnoses) Intend to quit at discharge	RCT 2 arms	Nurse counseling (3 × 20 min sessions) + 3 telephone calls after discharge (at 7, 21, 42 days, 5 min/call) [intensity 4]	Same as intervention in hospital but no post-discharge contact [Intensity 2]	No	Abstinence (type not stated) at 12m Validation: urinary cotinine at 12m
Hennrikus 200526	USA 4 hospitals	2095 current smokers (smoked in past week) Inpatients with all diagnoses, not selected by willingness to quit.	RCT 3 arms	Group 1. Physician advice + nurse counseling (motivational interviewing and relapse prevention) for 20 min. (43% of counseling done after discharge, not at bedside). Follow up: 3-6 phone calls over 6m (10 min/call median). [Intensity 4] Group 2: Physician advice + smoking cessation booklet + additional mailed booklet after discharge. [Intensity 1]	Modified usual care (smoking cessation booklet)	No	7-day point-prevalence abstinence at 12m. Validation: Saliva cotinine
Miller 199714	USA 4 hospitals	1942 current smokers. All inpatients (32% cardiovascular, 12% pulmonary diagnoses) Prepared to make quit attempt and willing to get help	RCT 3 arms	Group 1. Physician advice + behavioural counseling (30 min) + self-help material, relaxation tapes, video. Post-discharge: 4 telephone calls (at 48hr, 1, 3 wks, 3m [Intensity 4] Group 2. Physician advice + behavioural counseling (30 min) + self-help material, relaxation tapes, video. Post-discharge: 1 telephone call (at 48 hr) [Intensity 3]	Advice only	No	Sustained abstinence at 3, 6 & 12 months. Validation: Plasma cotinine or family member corroboration.
Mohiuddin 20076	USA 1 hospital	209 current smokers CCU inpatients with MI or acute coronary syndrome or decompensated CHF. Not selected by willingness to quit.	RCT 2 arms	Intervention: Counseling (30 mins) + self-help booklet + free NRT and/or bupropion. Follow up: weekly group meetings (60 min each for up to 3m) with trained tobacco counselor [Intensity 4]	Inpatient: same as intervention group, but no post-discharge contact [Intensity 2]	NRT or bupropion offered on individual basis to both groups	Sustained abstinence at 3m, 6m, 12m. (note: sustained abstinence to 24m reported but not used in pooling) Validation: CO
Nagle 200534	Australia 1 hospital	1422 current smokers or quitters (smoked in past 12m). Inpatients (all diagnoses) excluding intensive care units. Not selected by willingness to quit	RCT 2 arms	Nurse counseling (20 min, withdrawal symptom management, coping skills) + booklet + offer of NRT Follow up: none. [Intensity 2]	Modified usual care (Physician advice + booklet)	NRT in hospital (3% received) and for 5 days after discharge	7-day point-prevalence abstinence at 12m. Validation: Saliva cotinine
Ortigosa 200019	Spain 2 hospitals	90 current smokers. Inpatients with acute MI. Not selected by willingness to quit	RCT 2 arms	Physician advice. Follow up: 3 telephone calls (at 2,3,4 wks). [Intensity 3]	Usual care	No	7-day point-prevalence abstinence at 12m.. Validation: CO
Pedersen 200530	Denmark 1 hospital	105 current smokers Inpatients with cardiac disease, not selected by willingness to quit.	RCT 2 arms	Usual hospital care (advice to quit + information about NRT + NRT available) Follow up: 5 visits after discharge (30 min/meeting); [Intensity 4]	Usual care (advice to quit + NRT available)	NRT (partial)	Abstinence (probably point-prevalence) at 12m. Validation: no.
Pederson 199135	USA 1 hospital	74 current smokers. Inpatients with COPD, not selected by willingness to quit.	RCT 2 arms	Counseling (total 45-160 mins), self-help materials. Post-discharge: none [Intensity 2]	Advice only	No	7-day point-prevalence abstinence at 6m. Validation: Serum COHb (in a sample).
Pelletier 199839	Canada 3 hospitals	504 current smokers. Inpatients with acute MI who were willing to quit	Quasi-experimental, allocation by hospital	Physician advice. Self-help materials. [Intensity 2]	Usual care	No	Abstinence: self-reported PP at 12m Validation: None.
Quist-Paulsen 200321	Norway 1 hospital	240 current smokers Cardiac ward inpatients with MI, unstable angina, post-CABG care. Not selected by willingness to quit.	RCT 2 arms	Nurse counseling (1-2 times, time not specified), advice on using NRT). Post-discharge: 5 telephone calls (2,7,21, days, 3m, 5m) , clinic visit to cardiac nurse at 6 wk); NRT encouraged for subjects with strong urges to smoke in hospital. [Intensity 4]	Usual care (advice + booklet)	NRT	7-day point-prevalence abstinence at 12m. Validation: Urine cotinine.
Reid 200332	Canada 1 hospital	254 current smokers (smoked in past month) Inpatients with MI, CABG, PTCA, coronary angiography Motivated to quit	RCT 2 arms	Nurse counseling (5-10 mins) + booklet . Follow up: nurse call at 4 wks; if smoking, offered 3 × 20 min in-person counseling sessions (wks 4,8,12) and NRT patch recommended for 8 wks. [Intensity 4]	Same as intervention group but no contact after discharge	NRT if relapse after discharge	Abstinence: 7-day PP at 12m. Validation: CO requested in random 25 self-reported non-smokers
Rigotti 199413	USA 1 hospital	87 current smokers or recent quitters (past 6 mo) Inpatients scheduled for CABG surgery. Not selected by willingness to quit.	RCT 2 arms	Behavioral counseling (60 min) by nurse, self-help materials, video. Post-discharge: 1 telephone call (at 1 wk) [Intensity 3]	Advice only	No	Sustained abstinence at 4m, 8m, 12m. Validation: Salivary cotinine.
Rigotti 199715	USA 1 hospital	650 current smokers or recent quitters (smoked in past month) Inpatients with all diagnoses. Not selected by willingness to quit.	RCT 2 arms	MD advice, behavioral counseling (total 15 min) by trained counselor; booklet. Post-discharge: 3 telephone calls (1,2,3 wks) [Intensity 3]	Usual care	NRT in 4%	Abstinence: PP at 6m. Validation: Salivary cotinine.
Simon 199716	USA 1 hospital	299 current smokers. Inpatients undergoing non-cardiac surgery. Prepared to make quit attempt.	RCT 2 arms	Behavioral counseling (30-60 min) by health educator; self-help materials, video. NRT gum for 3 m. if no contraindications. Post-discharge: 5 telephone calls (1-3 wks, 2m, 3m). [Intensity 4]	Advice only	NRT in 65% of intervention, 17% of control	Abstinence: PP at 12m Validation: Serum or saliva cotinine or corroboration by significant other.
Simon 200322	USA 1 hospital	223 current smokers (smoked in past week), in contemplation or action stage, able to use NRT. Inpatients (all diagnoses)	RCT 2 arms (NRT in both arms)	Cognitive/behavioural counseling (30-60 min) by nurse or health educator + booklet Post-discharge: 5 telephone calls at 1,3 wks and 1m, 2m, 3m (<30 min/call); [Intensity 4]	Brief counseling (10 min)	NRT patches × 8 wks to all patients in both groups	Abstinence: 7-day PP at 12m. Validation: Saliva cotinine <15 ng/ml OR spousal corroboration.
Stevens 199311	USA 2 hospitals	1119 current smokers or recent quitters (smoked in past 3 months) Inpatients with all diagnoses. Not selected by willingness to quit.	Not random (allocation alternated between hospitals monthly).	Behavioral counseling (20 min) by masters level counsellor, self-help materials, video. Postdischarge: 1-2 telephone calls (at 1-3 wks) [Intensity 3]	Usual care	No	Sustained abstinence at 3m, 12m. Validation: None
Stevens 200020	USA 2 hospitals	1173 current smokers or recent quitters (smoked in past 3 months) Inpatients with all diagnoses. Not selected by willingness to quit.	Not random (alternated between hospitals monthly).	Behavioral counseling (20 min) by respiratory therapist, self-help materials, video. Post-discharge: 1 telephone call at 1 wk [Intensity 3]	Usual care	No	Sustained abstinence at 6m, 12m Validation: None.
Taylor 19909	USA 4 hospitals	173 current smokers or recent quitters (smoked in past 6 mo) Inpatients with acute MI. Prepared to make a quit attempt.	RCT 2 arms	Behavioral counseling (time not stated) by nurse, self-help materials, relaxation tapes. Post-discharge: 6-7 telephone calls at 1-3 wks + very month for 4m) [Intensity 4]	Usual care	NRT gum given to 5 patients.	Sustained abstinence at 3m, 12m. Validation: Serum thiocyanate, expired air CO.

Table 2.

Trials of Pharmacotherapy

Source	Setting Country # of hospitals	Subjects N, Diagnoses Smoking status Willingness to quit	Study design # of arms	Pharmacotherapy: Intervention, Control	Counseling provided	Outcome Longest f/u, Type of abstinence, Validation method
Nicotine replacement therapy
Campbell 199128	UK 1 hospital	212 current smokers. Inpatients with smoking-related diseases (heart disease, lung disease, other). Willingness to quit not stated.	RCT 2 arms	Intervention: Nicotine gum 2-4 mg, × 3mo Control: Placebo gum × 3 mo	MD advice, counseling (time not stated).by trained counnselor Post-discharge: 5 clinic visits (2, 3, 5 wks, 3m, 6m) with counselor [Intensity 4]	Sustained abstinence at 6m, 12m. Validation: CO.
Campbell 199629	UK 1 hospital	62 current smokers. Inpatients with respiratory or cardiovascular disease who were prepared to make a quit attempt	RCT 2 arms	Intervention: Nicotine patch, 17.5-35 mg, × 12 wk) Control: Placebo patch × 12 mo.	MD advice., counselling (30-60 min) by trained counsellor Post-discharge: 4 clinic visits at 2,4,8,12 wk with counselor [Intensity 4]	Sustained abstinence at 3, 6, 12m. Validation: CO.
Molyneux 200333	UK 1 hospital	274 current smokers (smoked in past month). Medical and surgical inpatients. Not selected by willingness to quit.	RCT 3 arms	Group 1: offer of open label NRT × 6 wks (choice of gum, patch, inhalator, lozenge, nasal spray); 96% used some NRT. Group 2: no NRT, counseling only Group 3: no NRT, usual care.	Groups 1 & 2: Brief counseling (20 min) + booklet. Post-discharge: no contact [Intensity 2] Group 3: usual care	Sustained abstinence at 3m, 12m. Validation: CO
Lewis 199817	USA 1 hospital.	185 current smokers. Inpatients excluding cardiac conditions. Prepared to make quit attempt.	RCT 3 arms	Group 1: Nicotine patch (22 mg for 3 wk + 11 mg for 3 wk) Group 2: Placebo patch Group 3: No NRT	Groups 1 & 2: MD advice, counseling (2-3 mins), self-help materials. Post-discharge: 4 telephone calls at 1,3,6 wks, 6m). [Intensity 4] Group 3: Advice only	7-day point-prevalence abstinence at 6m. Validation: CO.
Vial 200231	Australia 1 hospital	102 current smokers Inpatients (medical and surgical wards) Willing to stop smoking	RCT 3 arms	Groups 1 & 2: Nicotine patches for up to 16 wks Group 3 No NRT	Group 1: Pharmacist consultation about NRT use (30-45 mins) + booklet Post-discharge: up to 16 weekly visits to get patches from hospital pharmacist. [Intensity 4] Group 2: Same as above, but post-discharge visits made to a community pharmacist Group 3: usual care (advice to quit + booklet)	Sustained abstinence at 3m, 6m, 12m. Validation: CO test ‘whenever possible’ - frequency not stated
Bupropion
Rigotti 200627	USA 5 hospitals	254 current smokers (smoked in past month) Inpatients with cardiovascular disease (MI, unstable angina, CHF) or PVD Willing to consider smoking cessation.	RCT 2 arms	Intervention: Bupropion SR 300 mg/day × 12 wk, started in hospital. Control: Placebo × 12 wk	Both groups: Cgnitive/behavioural counseling (30-45 min) by nurse + booklet + videotape. Post-discharge: 5 telephone calls (10 min/call) at 2,7,21 days, 2 mo, 3 mo) Total counseling: 85-90 min	Continuous abstinence at 2,4,12, 52 wks. Validation: Saliva cotinine at 12 and 52 wks, CO at 2 and 4 wks.

All 33 included studies provided stop-smoking advice and/or behavioral counselling in the hospital. The duration of counselling ranged from less than 5 minutes to one hour. A nurse or trained counsellor provided the intervention in 32 studies. Eleven studies included physician advice to quit. Most studies also included self-help materials such as booklets, audiotapes, or videotapes. Follow-up support after hospital discharge was provided in 25 studies; 19 studies provided it by telephone^9-27, while 6 studies had in-person visits.^{6, 28-32} The duration of extended support ranged from one week to 6 months after discharge.

Pharmacotherapy with nicotine replacement therapy (NRT) or bupropion was an optional addition to counselling in many studies, but only 6 studies tested the efficacy of pharmacotherapy independent of counselling. Five of these studies tested the efficacy of adding NRT to counselling,^{17, 28, 29, 31, 33} while one study tested the efficacy of adding bupropion to counselling.²⁷ One other trial tested the efficacy of adding counselling to NRT. ²² No study tested the efficacy of pharmacotherapy versus placebo in the absence of counselling. Pharmacotherapy was allowed as part of the intervention in a number of other studies but the pharmacotherapy was not systematically assigned by group. Ten studies reported providing NRT to a subgroup of patients or did not specify the extent of its use,^{9, 12, 15, 16, 21-23, 25, 30, 32} , while two studies included bupropion in a similar fashion.^{6, 25}

All studies included adults who smoked cigarettes currently or within the past month, but 6 studies also included recent quitters as well as current smokers. ^{10-13, 20, 34} Twenty-eight of 33 studies assessed cigarette abstinence 12 months after hospital discharge. Five studies had only a 6-month follow-up.^{15, 17, 30, 35, 36}

Methodological quality of included studies

Study design and randomization

Twenty-nine of the 33 studies randomized individual patients to experimental condition; 15 of these reported a procedure for random assignment and allocation concealment that we judged likely to avoid recruitment bias.^{9, 14, 16-18, 21, 23, 24, 27, 30-32, 34, 37, 38} Fourteen studies did not report the method of randomization and concealment in sufficient detail to judge the quality. Four studies allocated treatment by hospital rather than by patient; none of these randomly assigned hospitals to condition ^{11, 20, 39, 40} Two allocated treatment by alternating between hospitals over time,^{11, 20} one study used a quasi-experimental design³⁹ and one study⁴⁰ randomly assigned 7 of 11 hospitals to condition but allowed 4 hospitals to choose their condition. Because these 4 studies have the potential problem of recruitment bias and underestimation of confidence limits due to intra-cluster correlation, we conducted a sensitivity analysis on the effect of excluding them.

Definition and validation of tobacco abstinence

Sixteen of 33 studies used the preferred measure, sustained abstinence, to assess outcome. ^{6, 9-14, 20, 25, 27-29, 31, 33, 37, 40} The other 17 studies used point-prevalence abstinence. To avoid over-estimation of treatment effects in smoking cessation studies, self-reported tobacco abstinence should be biochemically validated and patients lost to follow-up counted as smokers.⁴¹ Twenty-seven of 33 studies validated subjects’ self-reports of quitting at the follow-up assessment. Biochemical validation of smoking status was done in 26 studies, by expired air carbon monoxide in 13,^{6, 9, 10, 12, 17, 19, 28, 29, 31-33, 36, 38} and by plasma, salivary, or urinary cotinine in 15 studies.^{12-16, 21-27, 34, 37, 38} One study used corroboration by significant other as the only validation method.¹⁸ Four other studies used “corroboration by significant other” in cases where a plasma or salivary cotinine measure was not available.^{14, 17, 22, 23} Five studies did not validate self-reported quitting at the follow-up assessment.^{11, 20, 30, 39, 40} Most studies recorded those lost to follow-up as continuing smokers.

Results

Effect of counselling interventions

Counseling interventions were analyzed using the pre-determined four-level classification of intervention intensity. Only one study assessed a brief inpatient intervention with no subsequent support (intensity 1).²⁶ This was not more effective than usual care (OR 1.16, 95% CI 0.80 to 1.67). Eight studies tested a longer inpatient intervention with no contact after discharge (intensity 2).^{25, 33-36, 38-40} There was no benefit in the pooled analysis of these studies (OR 1.08, 95% CI 0.89 to 1.29). Similarly, no statistically significant benefit was found in a pooled analysis of 6 studies that tested an inpatient intervention with contacts continuing for up to 1 month after discharge (intensity 3)^{11, 13-15, 19, 20} (OR 1.09, 95% CI 0.91 to 1.31). There was substantial heterogeneity (I² = 53%) in the results of 18 studies that tested the highest intensity intervention (intensity 4), consisting of inpatient counselling that continued for more than 1 month after discharge. ^{6, 9, 10, 12, 14, 16-18, 21-26, 30-32} However, one study was an extreme outlier. ³⁷ It reported a very large effect (OR 49) due to an unusually low cessation rate in the control condition. It also had a very high dropout rate across conditions. Excluding this trial from the meta-analysis reduced the heterogeneity (I² = 35%). The level 4 intervention increased quit rates in the pooled estimate (OR 1.65, 95% CI 1.44 to 1.90).

Sensitivity analyses

Thirteen of the studies testing intensive counselling (intensity 4) included the option of pharmacotherapy, principally NRT.^{6, 9, 12, 14, 16, 17, 21-23, 25, 30-32} The odds ratio for the effect of counselling remained statistically significant when these studies were excluded (OR 1.36, 95% CI 1.04-1.77), suggesting that the efficacy of the intensive counselling interventions was not due to the use of NRT.

Nine of the 17 studies that delivered the highest intervention intensity (intensity 4) only included smokers who were willing to attempt cessation after discharge.^{9, 12, 14, 16, 17, 23, 24, 31, 32} An intervention effect persisted in a pooled analysis of the remaining 8 studies that recruited subjects regardless of their interest in quitting after discharge (OR 1.70, 95% CI 1.38-2.09). Another sensitivity analysis excluded studies that had included subjects who had not smoked for more than one month before admission. ^{9-13, 20, 34} Limiting the analysis to studies that recruited only current smokers (e.g., smoked in the past month) did not change the results (intensity 3: OR 1.01, 95% CI 0.77-1.32; intensity 4, OR 1.57, 95% CI 1.35-1.82).

Pre-planned sensitivity analyses excluded studies with methodological limitations. Excluding the four studies that did not randomly assign treatment by patient did not change the results.^{11,20,39, 40} Excluding the five studies that did not validate self-reported smoking cessation outcomes^{11, 20, 30, 39, 40} did not alter the results (intensity 2: OR 0.94, 95% CI 0.74-1.20; intensity 3, OR 1.01, 95% CI 0.78-1.31; intensity 4: OR 1.65, 95% CI 1.44-1.90).

Effect of pharmacotherapy

No study compared pharmacotherapy to placebo as a single intervention without counselling. Trials of pharmacotherapy either tested the effect of adding pharmacotherapy to counselling or, conversely, the effect of adding counselling to pharmacotherapy. Five trials^{17, 28, 29, 31, 33} tested the effect of adding NRT to counselling. In these trials, NRT was compared with placebo NRT or no NRT. Pooled analysis of these studies produced an OR of 1.47,(95% CI 0.92 to 2.35). One trial offered NRT to all subjects and tested the additional benefit of intensive vs. minimal counselling.²² The OR was 1.71 for sustained abstinence (95% CI 0.90 to 3.23). The result was consistent with the impact of intensive counselling observed in the absence of pharmacotherapy.

One study²⁷ systematically compared the use of bupropion with placebo. It did not detect a statistically significant effect of the drug over intensive counselling alone (OR 1.56, 95% CI 0.79 to 3.06) but the confidence limits were broad.

Effect of intervention by diagnosis

Eleven studies enrolled hospitalized smokers regardless of their admitting diagnosis.^{11, 14, 15, 17, 20, 22, 24, 26, 31, 33, 34} The results in this subgroup were similar to the results for the main analysis. Interventions with the highest category of intensity (counselling in hospital and >1 month of support after discharge) were effective in a pooled analysis of 6 studies (OR 1.43, 95% CI 1.17 to 1.75). ^{14, 17, 22, 24, 26, 31} Less intensive interventions demonstrated no effect (Table 2A).

Eighteen studies limited enrollment to smokers with a cardiovascular admitting diagnosis. 6, 9, 10, 12-14, 18, 19, 21, 23, 25, 27, 28, 30, 32, 38-40 The result of this subgroup analysis resembled the main analysis. There was a significant effect on quitting in the pooled analysis of 11 studies testing the most intensive intervention (intensity 4, OR 1.81, 95% CI 1.53-2.15) ^{6, 9, 10, 12, 14, 18, 21, 23, 25, 30, 32}, but not for studies testing less intensive interventions (Table 2B).

Four studies enrolled only patients with respiratory admitting diagnoses.^{14, 28, 29, 35} None of the studies found a significant effect of the interventions tested. We did not estimate a pooled effect because the interventions were heterogeneous. One very small pilot study tested a hospital intervention for patients with cancer ³⁶ and found no evidence of efficacy.

Comment

This systematic review finds that smoking cessation counselling that begins during hospitalization and provides supportive contacts for over 1 month after discharge increases the odds of smoking cessation by 65% at 6-12 months over what is achieved by hospitalization alone. There is no evidence that less intensive counselling interventions, particularly those that do not continue after hospital discharge, are effective in promoting smoking cessation. The intensive counselling intervention is effective when provided to all hospitalized smokers, regardless of admitting diagnosis.

These finding were robust, remaining statistically significant in a series of sensitivity analyses that excluded studies of lower methodological quality and studies that that allowed the use of NRT as part of the intervention, only enrolled smokers who planned to quit, or included recent quitters along with current smokers. While only 5 of the 17 studies with the sustained intervention continuing for over 1 month after discharge found a significant intervention effect, once they are pooled, the actual impact of this level of intervention is substantial, increasing the odds of quitting by 65%. The effect sizes observed in all these studies may be artificially modest because in many cases the “control” condition was more intensive than usual care or simply brief advice. However, even relatively modest effects can have substantial public health impact when applied at the population level.

While the analysis supports providing the counselling intervention to all hospitalized smokers, it also demonstrates strong benefit for smokers who are admitted for cardiovascular disease. This subgroup of smokers generally achieved higher absolute cessation rates than did smokers in studies that included a broad range of diagnoses. In the pooled analysis, the relative effect of the intensive counselling intervention for patients admitted with cardiovascular diagnoses (OR 1.81, 95% CI 1.53-2.15) was slightly higher than it was when provided to all patients (OR 1.43, 95% CI 1.17-1.75), but the confidence limits overlapped, precluding a conclusion that the relative effect is larger for patients with cardiovascular disease. There is insufficient evidence to conclude that counselling interventions are effective for smokers admitted to hospital with a respiratory diagnosis. However, there is no reason to exclude this group of smokers in interventions that target all hospitalized smokers, which have a strong evidence base.

The effect of pharmacotherapy in hospitalized patients was more difficult to assess because NRT and bupropion have only been tested along with counselling. Adding NRT to counselling in hospitalized smokers produced a 47% increase in the odds of quitting compared to placebo or no drug in the pooled analysis. Although this was not statistically significant (OR 1.47, 95% CI 0.92 to 2.35), there was a clear trend, and the odds ratio and confidence limits were compatible with the effect of NRT in other settings.⁴² Furthermore, NRT is used in hospitalized smokers to treat acute nicotine withdrawal symptoms as well as to promote smoking cessation. Overall, these data support including NRT in interventions for hospitalized smokers.

The evidence regarding the benefit of adding bupropion to counselling in hospitalized patients is limited to one study, in which bupropion was not more effective than placebo.²⁷ However, the confidence limits were broad and the effect size was consistent with evidence from other populations that bupropion is effective for smoking cessation.⁴³ No trial has assessed varenicline, a newer smoking cessation drug, in the hospital setting.

The existing evidence provides stronger support for the benefit of counselling than for pharmacotherapy. In part, this reflects a smaller evidence base of trials testing pharmacotherapy in the hospital setting. Furthermore, counseling and pharmacotherapy may be synergistic. In addition to providing psychological support to quitting, counselling after discharge may also help increase quit rates by improving adherence to cessation medications that were started in the hospital. This conclusion is supported by the single study that compared pharmacotherapy alone with pharmacotherapy plus counselling.²² In that study, the addition of counselling to nicotine replacement increased quit rates.

The counselling intervention in these studies was generally delivered by a research nurse or trained smoking cessation counsellor, not by staff responsible for the patients’ clinical care. The effectiveness of these interventions in routine clinical practice, where interventions will be delivered by clinical staff, needs to be demonstrated. The challenge is illustrated by two studies included in this review that provided a similar intervention in a similar setting.^{11, 20} Counselling was effective when delivered by research staff (masters-level psychologists) in one study but not when delivered by clinical staff (trained respiratory therapists) in the second study.

Determining how to translate these findings effectively and consistently into routine clinical practice is the next task. Studies need to demonstrate the feasibility and effectiveness of hospital-initiated smoking cessation interventions in clinical practice. For example, one of the studies in this review¹⁴ was followed by a report that the program's effectiveness was maintained for the 3 years after the end of a clinical trial.⁴⁴ During that time, approximately half of the admitted smokers accepted the offer of intervention, and those smokers had a cessation rate comparable to that achieved in the randomized trial.

Additional research should assess the cost-effectiveness of the intensive counselling intervention and to explore the impact of counselling on health and healthcare utilization outcomes. One study in this review assessed health care utilization and mortality outcomes in smokers hospitalized with cardiovascular disease.⁶ The intervention produced a large increase in smoking cessation and at two-year follow-up, a substantial decline in hospital readmissions and all-cause mortality. The result was potentially confounded by better blood pressure and cholesterol control and better medication compliance in the intervention group, but it is an example of the type of evidence that could help to promote the broader adoption of hospital-based smoking intervention.

Finally, the results of this review support the JCAHO/CMS decision to include a tobacco measure in the national hospital quality-of-care standards.⁴ The review provides a rationale for expanding the current measure to apply to all hospitalized smokers, rather than just to smokers with MI, CHF, and pneumonia. It also suggests that the current tobacco measure should be strengthened to include an assessment of whether a smoking intervention begun during a hospital stay is linked to support after discharge. This is essential to ensure that the quality standard achieves the goal of promoting smoking cessation after hospital discharge.

Figure 1.

Efficacy of smoking cessation counselling, by intensity of counselling intervention.

Outcome is number quit at longest follow-up (≥6 months) Intensity 1= contact in hospital of ≤ 15 minutes and no post-discharge support. Intensity 2= contact in hospital of >15 minutes and no post-discharge support; Intensity 3= any hospital contact plus post-discharge support lasting ≤1 month. Intensity 4=any hospital contact plus post-discharge support lasting >1 month. I² measures statistical heterogeneity among studies.⁸

Figure 2A.

Efficacy of smoking cessation counselling, by intensity of counselling, in studies that enrolled hospitalized smokers with all admission diagnoses

Outcome: number quit at longest follow-up (≥6 months). See Figure 1 legend for definition of levels of counselling intensity. I² measures statistical heterogeneity among studies.⁸

Figure 2B.

Efficacy of smoking cessation counselling, by intensity of counselling, in studies that enrolled patients who were admitted for cardiovascular disease.

Outcome: number quit at longest follow-up (≥6 months). See Figure 1 legend for definition of levels of counselling intensity. I² measures statistical heterogeneity among studies.⁸

Figure 3.

Efficacy of adding smoking cessation pharmacotherapy to counselling.

Outcome: number quit at longest follow-up (≥6 months). NRT=nicotine replacement therapy. I² measures statistical heterogeneity among studies.⁸