Smoking Cessation: There’s Work to be Done

Although the economic and health impact of tobacco use is staggering, we, as healthcare providers, are doing a poor job of identifying patients at risk and providing treatment options. As nurses focused on prevention, it may be difficult to accept the findings of a recent study that revealed less than 23% of smokers hospitalized for coronary heart disease received smoking cessation counseling or therapy.¹ In a retrospective study of data from 282 hospitals in the United States, JAMA Internal Medicine reports little more than one in five smokers were counseled or received pharmacotherapy during their hospital stay for coronary heart disease.

A similar study cited in JAMA Cardiology also found just 7% of myocardial infarction patients on Medicare filled prescriptions for smoking cessation medications within 90 days of discharge. Smokers hospitalized for a cardiac event may be very motivated to quit the habit; thus, these two studies show that we are missing critical opportunities to encourage and assist patients to quit tobacco use.

Additionally, there is wide variation across hospitals in initiating smoking cessation therapy. The best-performing hospitals are initiating treatment for approximately two-thirds of smokers hospitalized for CHD events. The worst performing are initiating therapy in less than 10% of these patients. After a review of hospitals of all sizes and locations, the hospital was a more important predictor of receiving smoking cessation counseling and treatment than the patient. The authors concluded this reflects the administration and the hospital culture. Some hospitals are emphasizing smoking cessation while others do not address it at all.

The Clinical Practice Guideline Treating Tobacco Use and Dependence reports at least 70% of smokers see a physician annually, and many more come in contact with nurses, respiratory therapists, physician assistants, or other clinicians.² However, fewer than 40% of smokers reported that a healthcare provider ever discussed their smoking or medications to help them quit. In a study reported in the American Journal of Preventive Medicine, smokers state that advice from a healthcare provider is an important motivator to try to stop smoking.³

These guidelines emphasize the importance of coordinated efforts between healthcare institutions and public agencies, healthcare administrators, and insurers in identifying tobacco dependence as a key component of healthcare delivery.⁴ The following are key points:

1. Even brief interventions enhance the motivation to quit.
2. Even if patients are unwilling to attempt to quit at the time of intervention, they are more likely to attempt to quit in the future.
3. Increasing societal pressure exists to quit smoking, and interventions aimed at quitting are cost-effective.

Clinicians and healthcare systems must consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting. Including tobacco use assessment as a vital sign has been shown to increase the likelihood that tobacco use is assessed and documented routinely.

Multiple strategies are available to healthcare providers as they assess and assist patients. These are explored in PCNA’s new Behavior Change Mini Certificate.

References:

1. Pack QR, et al “Smoking cessation pharmacotherapy among smokers hospitalized for coronary heart disease” JAMA Internal Medicine 2017; DOI:10.1001/jamainternmed.2017.3489
2. Fiore MC, Jaen CR, Baker TB, et al. Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services; 2008.
3. Whitlock EP, Orleans CT, Pender N, et al. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267-284. doi: 10.1016/S0749-3797(02)00415-4.
4. HEDIS measures. National Committee for Quality Assurance Web site. http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx.