Add a second question to the smoking conversation

Secondhand smoke exposure common among cardiac inpatients.

It's hard to imagine a cardiac inpatient who has never talked about smoking status with a health care professional. But secondhand smoke exposure is much less discussed, according to a recent study.

Researchers at Massachusetts General Hospital in Boston surveyed nonsmokers who were admitted to the cardiac unit in 2010 and hospitalized for at least 48 hours. Almost a quarter of the patients (22%) had been exposed to secondhand smoke in their car, home, or workplace in the 30 days before admission.

But only 17.3% remembered a physician or nurse asking about secondhand smoke exposure during their hospitalizations, and only 3 patients (or 1.4%) had been advised to keep their environments smoke-free. The results, published as a research letter in JAMA Internal Medicine on Nov. 10, 2014, also showed a lack of recognition of the dangers of secondhand smoke, with only slightly more than half the patients agreeing that it increased their risk of heart attack significantly.

That's not enough, according to Nancy A. Rigotti, MD, FACP, the study's senior author and professor of medicine at Massachusetts General Hospital, who recently spoke with ACP Hospitalist about how hospitalists can work on this issue.

Q: What led you to study secondhand smoke exposure?

A: We know that secondhand smoke is a risk factor for cardiovascular disease for everyone—especially for people with established coronary heart disease. For them, reducing their exposure to secondhand smoke reduces their risk of future cardiac events. Even small reductions in secondhand smoke exposure appear to be valuable. For example, a substantial body of research shows that rates of hospital admission for myocardial infarction decrease following the passage of a state or local law banning smoking in work sites, bars, and restaurants.

As physicians, we ask our patients about smoking status all the time. Fewer and fewer of our patients are actively smoking, especially patients with cardiovascular disease, because many of them quit when they were first diagnosed. What we don't think about is how much secondhand tobacco smoke our patients might be exposed to. We're not paying any attention to it, and we should be.

Q: Should clinicians be asking all cardiac patients about secondhand smoke exposure?

A: In my opinion, they should. We know that it's a risk factor and we should be assessing it and then delivering the message that it's important to avoid it. That means not permitting anyone to smoke in your home and your car. These are the places where people are most likely to be exposed to secondhand smoke these days, because for most of the country, you can't smoke at work, in restaurants, or in public places.

Q: How exactly should clinicians deliver that message?

A: The first thing is to tell patients, especially those with cardiovascular disease, that even small amounts of secondhand smoke are harmful to their heart health. This may be news to them. It is a risk that they should take seriously.

Having a smoke-free home and car is important to reducing cardiac risk. The challenge is how to get there if they live with a smoker. Physicians or nurses can also help them negotiate those kinds of efforts. We just reported on a project that we did in our cardiac floors. We gave every patients a table tent that people could take home that said, “For the sake of my heart, this home is smoke-free.” And we gave them information and advice about the importance of having a smoke-free home and car. We showed that this simple intervention resulted in more patients being aware that secondhand smoke was harmful to heart health.

Many people are aware that secondhand smoke is harmful to lungs but they don't really understand that it is also is a risk factor for the heart … so just telling people that by itself can be helpful and encourage them. If a physician advises a patient to have a smoke-free home, it's easier for them to go home to the smokers that they're living with and say, “My doctor said that being around any smoke is risky for my heart and I need to avoid it. I need to ask you to only smoke outside.”

Q: Should doctors have this conversation themselves rather than delegate to another team member?

A: Doctors are busy. Someone else on the team can ask about secondhand smoke exposure, but if there is secondhand smoke exposure, I think it's a good idea for the doctor to say, “Here's my advice. It's important to keep your home and car smoke-free.” Advice doesn't take a lot of time. Then it can be, “If you have questions about this, there's someone else I can have talk to you about this in more detail.”

Q: Should this conversation be focused specifically on patients with cardiovascular disease?

A: We should be assessing secondhand smoke exposure in all patients, inpatients and outpatients. It's especially important for patients with cardiovascular disease and that's why we started there. However, we should be asking all our patients, just as we ask them if they smoke. If the patient doesn't smoke, we should follow that up with “Does anyone in your household smoke?,” which is a reasonable, quick assessment of risk. You could also ask, “Do you allow smoking in your home and car?” At Mass General, we've now added that to the nursing assessment form for newly admitted hospital patients. So we've now got the infrastructure where we could develop an intervention and train people to give the right advice.