How to support smoking cessation after hospital discharge

Over 3.2 million adults who smoke are hospitalized each year in the US.^[] Although hospital no-smoking policies provide an opportunity for these patients to quit during hospitalization, offering sustained smoking cessation treatment during the outpatient care transition remains a challenge for healthcare systems.^[]

One model to end smoking after hospitalization continues tobacco cessation treatment within the healthcare system, mirroring the treatment of other chronic conditions.^[] In this approach, discharged patients receive cessation medication and a 3-month support period of telephone-based behavioral counseling and medication management from a specialist.

Another post-discharge care model transfers smoking cessation treatment from the hospital to a resource based in the community, typically the national system of telephone quitlines (QLs) featuring coaches that offer free behavioral counseling and medication samples.

Research findings published in JAMA Internal Medicine showed that health system-based intervention for smoking cessation was more effective than a community-based QL model during 3 months of active treatment after hospital discharge.

Hospitalization’s effect on smoking cessation

In an interview with MDLinx, a study researcher (and primary care physician involved in tobacco use and treatment) discussed the JAMA Internal Medicine findings in detail, including its implications for longer-term smoking cessation programs in real-world hospital settings.

Hospital admission is a great opportunity for people who smoke to begin tobacco cessation treatment, lead study author Nancy A. Rigotti, MD, told MDLinx.

“Hospital policies do not permit smoking in the hospital,” she said, “and the circumstances that led to a patient’s hospital admission can make the health risks of tobacco use more salient and increase motivation to quit.”

Dr. Rigotti, the director of the Tobacco Research and Treatment Center at Massachusetts General Hospital and professor at Harvard Medical School in Boston, explained that addressing tobacco use in the hospital will provide long-term benefits only if the treatment continues after discharge. “But we don’t know the best way to provide this continuing quit assistance,” she said.

Healthcare system vs community strategy

The study by Dr. Rigotti and colleagues tested two models for supporting continued smoking cessation following discharge.

Patients in the study were people who smoke, had been admitted to three different US hospitals, and were randomized to receive post-discharge treatment with either a health system-based transitional tobacco care management (TTCM) program (n = 706) or electronic referral to a community-based QL (n = 703).

Both interventions provided smoking cessation counseling along with nicotine replacement therapy (NRT) for up to 3 months. The TTCM program offered an 8-week course of NRT at discharge with seven automated calls that offered a hospital-based counselor call-back option. In contrast, the QL intervention, which directed referrals from the hospital electronic health record to the state QL, provided a total of five counseling calls as well as an NRT sample.

A significantly greater number of participants in the TTCM group used smoking cessation counseling and pharmacotherapy at 1 and 3 months after discharge compared with the participants randomized to the QL group. A greater proportion of patients randomized to TTCM reported sustained cigarette abstinence for 3 months, as well as greater point-prevalence abstinence at 1 and 3 months.

Long-term support

The 6-month biochemically verified point-prevalence abstinence (the study’s primary outcome) was not significantly different between the TTCM and QL interventions. Dr. Rigotti explained that while the hospital model outperformed the QL intervention for the first 3 months, relapse occurred in both groups once the interventions stopped.

“There can be slips and rebounds, and the healthcare system provides ongoing treatment to smokers who are making the journey to tobacco abstinence,” she added.

She said these findings suggested that “continuing contact for a longer period of time—perhaps with support like text messages, phone call reminders, or even a longer period of nicotine replacement—might be helpful.” Although QLs are not set up to provide this ongoing service, Dr. Rigotti stated that healthcare systems could provide it.

“Stopping smoking increases every individual’s life expectancy and improves quality of life, no matter how old they are or whether they already have a smoking-related disease,” Dr. Rigotti said.

Dr. Rigotti noted that employing methods to help people who smoke quit is essentially providing healthcare for chronic addictive disease, saying, “Keeping treatment in the healthcare system allows a person to coordinate all their care and to work with clinicians whom they already know and trust.”

What physicians can do

According to Dr. Rigotti, clinicians should ask any newly admitted patient whether they’ve smoked any tobacco products in the past month. “If so, they should be offered nicotine replacement to minimize any nicotine withdrawal that they may have in the hospital due to the abrupt tobacco abstinence required in the hospital,” she added.

Dr. Rigotti explained that patients who have smoked within the month of admission should also be offered bedside counseling to support cigarette cessation after hospital discharge.

The first is a prescription for a smoking cessation medication, continuing the nicotine replacement provided in the hospital, or adding another medication like varenicline. The second is a direct referral to behavioral smoking cessation support that will start immediately after discharge.

“This could be referral to a state QL, to a website or text messaging program [like smokefree.gov], or referral to an outpatient smoking cessation program provided by their hospital or doctor,” she concluded.