A hospital stay is a window of opportunity to help patients quit smoking, and hospitalists are well positioned to take advantage of it.
There's good reason to go the extra mile in providing smoking cessation therapies—recent studies suggest that nicotine addiction is undertreated, even among high-risk inpatients. In a national registry study, 97% of smokers hospitalized with myocardial infarction (MI) were counseled to quit smoking, but only 7% filled a prescription for varenicline or bupropion within 90 days after discharge.
“Although these medications are certainly not the right answer for every patient, they are likely to be useful in more than just 7% of patients with a recent MI,” said study author Neha Pagidipati, MD, a cardiologist and assistant professor of medicine at Duke University School of Medicine in Durham, N.C.
Inpatients were significantly more likely to fill prescriptions if they were younger, were female, lived in areas with above-average high school graduation rates, had chronic obstructive pulmonary disease (COPD) or peripheral arterial disease, or underwent revascularization in the hospital, Dr. Pagidipati and her colleagues reported in the September 2017 JAMA Cardiology.
Such findings suggest a need to target therapies, experts said. “I believe that clinicians can best match smoking cessation methods to individual patients by having a conversation with them, and seeing what patients are interested in and able to participate in,” said Dr. Pagidipati. “For example, some patients may not have the time to participate in counseling, while others may be completely uninterested in taking medication.”
Who's most—and least—likely to quit
Demographic and clinical factors can tip the scales toward or against a successful quit attempt. Gender is a major modifier, experts said. “We know that women have more difficulty quitting smoking than men, and they also have different concerns and barriers to quitting,” said Natacha De Genna, PhD, an assistant professor of psychiatry and epidemiology at the University of Pittsburgh School of Medicine.
Studies show that women are more likely than men to report using e-cigarettes to regulate mood and manage stress and body weight, she noted. “It's important for clinicians to be aware of those concerns and address them in smoking cessation counseling.”
Female inpatients also are more likely than men to use e-cigarettes, and often do so to try to reduce or quit traditional cigarette use. The prevalence of e-cigarette use was 22% in a cross-sectional study of tobacco users Dr. De Genna and her colleagues published in the November/December 2017 Journal of Addiction Medicine, but the majority of the female patients had used them.
In the study, users of e-cigarettes tended to be younger and female and started smoking earlier in life, but smoked as much and as often as other study participants, said Dr. De Genna. “These patients may benefit most from directed discussions about the use of evidence-based, FDA-approved therapies for smoking cessation.”
Gender also seems to modify the efficacy of specific treatments. A population-based study found the nicotine patch to be significantly more effective than no smoking cessation treatment for male smokers, but not for women. Conversely, varenicline significantly outperformed no treatment for women who smoked, but not men. These findings match trial data and highlight the need to consider gender when offering treatment for smoking cessation, the study authors wrote in the September 2017 Drug and Alcohol Dependence.
Studies have also shown that hospitalization for a smoking-related condition such as MI increases the chances that patients will quit smoking after discharge. “Given the clear link between cardiac events and current smoking, it makes sense to target these patients aggressively, and this is a cost-effective approach,” said Anne Melzer, MD, an assistant professor in the division of pulmonary, allergy, sleep and critical care medicine at the University of Minnesota in Minneapolis.
Pneumonia is another common reason for hospitalization and often is smoking-related, but patients typically don't know this, Dr. Melzer said. Discussing this link as part of smoking cessation counseling can help patients move toward quitting, she added.
But the health benefits of cessation aren't the factor that motivates many inpatients to successfully quit, cautioned Frank Leone, MD, director of the Comprehensive Smoking Treatment Program at the University of Pennsylvania in Philadelphia.
Instead, he tells them, “Let's stop talking about quitting, and start talking about treating the voice in your head that keeps you from doing what you want to do.” This approach respects a smoker as someone “who both wants to quit and doesn't want to,” and frames a prescription like varenicline as a way to “control the instinct that keeps you from quitting,” Dr. Leone said.
Mental health issues can pose formidable barriers to tobacco cessation. A study of 397 inpatient smokers found that patients with comorbid depressive symptoms, alcohol misuse, and heavy nicotine dependence were significantly less likely to quit smoking after discharge than lighter smokers and individuals with smoking-related diseases but no depressive symptoms or alcohol misuse.
Patients with mental and behavioral issues may express readiness to quit but need more intensive interventions to do so, said study author Nancy Rigotti, MD, FACP, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital and Harvard Medical School in Boston. She and her associates reported the findings in the October-December 2017 Substance Abuse.
Physicians should consider all these factors but should look more broadly than “the low-hanging fruit—the patients who have already decided to quit,” Dr. Leone counseled. “It's impossible to identify who's not going to quit,” he said. “Even if patients go back to smoking, starting treatment in the hospital means they will have started medications that catch up with them. This will put the primary care doctor in a much better position to start outpatient treatment.”
Experts suggest that hospitalists start treating nicotine addiction at admission, not discharge, and that they customize prescriptions by patient preferences and degree of nicotine dependence.
All inpatients who use tobacco should be offered nicotine replacement therapy, which can “ease them into a quit attempt,” said Dr. Melzer. Among more than 1,500 smokers admitted for exacerbation of COPD, inpatient replacement therapy significantly increased the likelihood of receiving tobacco cessation medications at discharge and using them afterward, she and her colleagues reported in the June 2016 Journal of General Internal Medicine.
Avoid a “one size fits all” approach to therapy, she said. For pack-a-day smokers, she titrates dosing of the patch plus short-acting nicotine gum, lozenge, or inhaler.
Dr. Rigotti takes a similar approach. “In our experience, heavier smokers—those who smoke more than 15 cigarettes a day—often require more than just a 21-mg nicotine patch,” she said. “We often use a combination of a patch plus nicotine inhaler, lozenge, or gum as needed to provide adequate suppression of cravings in hospital.” Lighter smokers typically receive a 14-mg patch, and nondaily smokers are offered nicotine gum, lozenge, or inhaler, which they can use when they start to feel cravings.
Desire to quit can evolve during a hospital stay, so it's best to ask about intentions closer to discharge, Dr. Melzer said. Data on prescribing smoking cessation medications at discharge are mixed. In a study of more than 1,300 inpatient smokers with COPD exacerbations, no single medication or combination significantly increased the chances of quitting at 90 days compared with no treatment.
However, patients who received varenicline had more than twice the odds of quitting as those prescribed the nicotine patch. Short-acting nicotine replacement therapy was least effective, Dr. Melzer and her colleagues reported in the April 2016 Journal of Hospital Medicine.
“It's hard to know what to make of the lack of association between medications and successful quitting from our observational study,” said Dr. Melzer. Patients who received pharmacotherapy for tobacco use might have been more nicotine-dependent in the first place or might have needed counseling or better titration of their medications to control symptoms, she said.
Regardless, patient preferences should weigh heavily in discharge prescription decisions, she said. “Patients who are strongly motivated to quit, but who want to be able to smoke for a short period of time while they work on quitting, may do well with [varenicline],” she said. Patients with concurrent depression might do well with bupropion and nicotine replacement therapy, while those with dental problems might wish to avoid nicotine gum, she added.
Fitting so many considerations into a packed hospital schedule requires creative solutions. Massachusetts General Hospital has an opt-out tobacco cessation service, “which is more efficient than trying to get staff to remember to order a smoking consult,” Dr. Rigotti said. During the admission process, nurses fill out a 30-day tobacco history that goes automatically to the tobacco treatment service.
Trained counselors then visit smokers at bedside to ensure adequate nicotine replacement, offer help to quit, and provide discharge referrals to the state telephone quitline, which provides free counseling and a sample of free replacement therapy.
This approach assists busy hospitalists who may not have time to do extensive counseling, Dr. Rigotti said. For hospitals that lack dedicated smoking coaches, “nurses are a great resource to provide counseling and remind physicians to treat nicotine withdrawal,” she added. “Some smaller hospitals use respiratory therapists. If the hospital has a pharmacist on the inpatient side, this is an ideal person to teach patients about proper use of nicotine replacement and answer questions.”
Many other hospitals have support teams with specially trained pharmacists or tobacco counselors who assess patients and recommend medications, Dr. Melzer said. Hospital teams should develop clear processes for referring patients to smoking cessation resources after discharge and starting them on medication in-house and at discharge, she added. “Order sets that encompass decision support can be very helpful.”