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Secondhand tobacco smoke (SHS) exposure increases nonsmokers' risk of coronary heart disease and worsens outcomes after hospitalization for acute coronary syndrome, but it is rarely addressed in inpatient cardiac care. We developed and assessed a hospital-based intervention to increase nonsmokers' awareness of SHS as a cardiovascular risk factor. Nonsmokers admitted to 2 cardiac units of a large Boston, Massachusetts, hospital were surveyed before (May 2010 to January 2011) and after (November 2011 to March 2012) a system-level nurse-delivered intervention was implemented in October 2011. It consisted of a revised admission form that prompted nurses to document SHS exposure at admission, provide a pamphlet about SHS risks, and advise nonsmokers to make their home and car smoke free. The primary outcome was patients' short-term recall of advice to keep their home and car smoke free. The secondary outcome was patients' awareness of the cardiovascular risk of SHS exposure. We enrolled 190 nonsmokers before and 142 nonsmokers after implementation. Adjusting for group differences, patients admitted after the system change were more likely to recall being asked if a household member smokes (24% vs 10%, adjusted odds ratio [AOR] 3.6, 95% confidence interval [CI] 1.8 to 7.1, p = 0.0002) and being advised to keep their home and car smoke free (28% vs 2%, AOR 27.3, 95% CI 7.8 to 95.7, p <0.0001). After the intervention, more patients believed that SHS exposure increased cardiovascular risk for nonsmokers (42% vs 21%, AOR 2.6, 95% CI 1.6 to 4.4) and for themselves (39% vs 22%, AOR 2.2, 95% CI 1.3 to 3.8). In conclusion, a system-level intervention in cardiac units successfully increased hospitalized nonsmokers' awareness of the cardiovascular risk of SHS exposure. •A revised admission template prompted nurses to address secondhand smoke (SHS).•We tested it in a pre-post study in 2 cardiac units of a large hospital.•After the change, more patients recalled advice to keep their home smoke free.•After the change, more patients knew that SHS was a cardiovascular risk factor.•A simple tool increased inpatients' awareness of SHS as a cardiovascular risk factor.

Background A hospital admission offers smokers an opportunity to quit. Smoking cessation counseling provided in the hospital is effective, but only if it continues for more than one month after discharge. Providing smoking cessation medication at discharge may add benefit to counseling. A major barrier to translating this research into clinical practice is sustaining treatment during the transition to outpatient care. An evidence-based, practical, cost-effective model that facilitates the continuation of tobacco treatment after discharge is needed. This paper describes the design of a comparative effectiveness trial testing a hospital-initiated intervention against standard care. Methods/design A two-arm randomized controlled trial compares the effectiveness of standard post-discharge care with a multi-component smoking cessation intervention provided for three months after discharge. Current smokers admitted to Massachusetts General Hospital who receive bedside smoking cessation counseling, intend to quit after discharge and are willing to consider smoking cessation medication are eligible. Study participants are recruited following the hospital counseling visit and randomly assigned to receive Standard Care or Extended Care after hospital discharge. Standard Care includes a recommendation for a smoking cessation medication and information about community resources. Extended Care includes up to three months of free FDA-approved smoking cessation medication and five proactive computerized telephone calls that use interactive voice response technology to provide tailored motivational messages, offer additional live telephone counseling calls from a smoking cessation counselor, and facilitate medication refills. Outcomes are assessed at one, three, and six months after hospital discharge. The primary outcomes are self-reported and validated seven-day point prevalence tobacco abstinence at six months. Other outcomes include short-term and sustained smoking cessation, post-discharge utilization of smoking cessation treatment, hospital readmissions and emergency room visits, and program cost per quit. Discussion This study tests a disseminable smoking intervention model for hospitalized smokers. If effective and widely adopted, it could help to reduce population smoking rates and thereby reduce tobacco-related mortality, morbidity, and health care costs. Trial registration United States Clinical Trials Registry NCT01177176.

Background Smoking cessation interventions for hospitalized smokers are effective in promoting smoking cessation, but only if the tobacco dependence treatment continues after the patient leaves the hospital. Sustaining tobacco dependence treatment after hospital discharge is a challenge for health care systems. Our previous single-site randomized controlled trial demonstrated the effectiveness of an intervention that facilitated the delivery of comprehensive tobacco cessation treatment, including both medication and counseling, after hospital discharge. We subsequently streamlined the intervention model to increase its potential for dissemination. This new model is being tested in a larger multi-site trial with broader eligibility criteria in order to enroll a more representative sample of hospitalized smokers. This paper describes the trial design and contrasts it with the earlier study. Methods/Design A 2-arm, 3-site randomized controlled trial is testing the hypothesis that a multi-component Sustained Care intervention is more effective than Standard Care in helping hospitalized cigarette smokers stop smoking after hospital discharge. The trial enrolls adult daily cigarette smokers who are admitted to 1 of 3 participating hospitals in Massachusetts or Pennsylvania. Participants receive the same smoking cessation intervention in the hospital. They are randomly assigned to receive either Standard Care or Sustained Care after hospital discharge. Participants in the Sustained Care arm receive a free 3-month supply of FDA-approved smoking cessation medication and 5 interactive voice response calls that provide tailored motivational messages, medication refills, and access to a live tobacco treatment counselor. Participants in the Standard Care arm receive a smoking cessation medication recommendation and information about community resources. Outcomes are assessed at 1, 3, and 6 months after discharge. The primary outcome is biochemically-validated tobacco abstinence for the past 7 days at 6-month follow-up. Other outcome measures include self-reported tobacco abstinence measures, use of medication and counseling after discharge, hospital readmissions, and program cost-effectiveness. Discussion We adapted a proven intervention for hospitalized smokers to enhance its potential for dissemination and are testing it in a multi-site trial. Study enrollment data suggests that the trial achieved the goal of recruiting a broader sample of hospitalized smokers. Trial registration Comparative Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (Helping HAND2) NCT01714323 . Registered October 22, 2012.

Hospitalized smokers benefit from tobacco counseling received in hospital only if it continues after discharge. Interactive voice response (IVR) technology may be useful in delivering this care. We conducted a randomized controlled trial testing two intensities of follow-up contact using an IVR system; 738 cigarette smokers who received inpatient counseling at an academic medical center were enrolled. Participants were randomized to receive four IVR calls during the first month postdischarge that included the offer of a call back (CB) from a smoking counselor (IVR + CB, N = 368) or 1 IVR call at 2 weeks postdischarge that assessed smoking outcomes without offering any counseling support (IVR, N = 370). All were assessed by human telephone call at 12 weeks. Postdischarge counseling and medication utilization rates and self-reported smoking cessation were assessed at 2 and 12 weeks postdischarge. Of those randomized to IVR + CB, 59% received a CB offer and 34% of those receiving offers accepted. Cessation rates did not differ between IVR + CB and IVR at 2 weeks (39% vs. 39%, rate ratio: 1.02, 95% CI: 0.85-1.22) or 12 weeks (29% vs. 26%, rate ratio: 1.11, 95% CI: 0.90-1.41). Medication use did not differ by group but was higher among those accepting versus declining CB offers (69% vs. 52%, p < .05). An IVR system is feasible for postdischarge follow-up and support for hospitalized smokers. Participants, especially pharmacotherapy users, took advantage of postdischarge counseling offers, although offers were not associated with increased smoking cessation.

Biochemical confirmation (BC) of self-report is the gold standard of evidence for abstinence in smoking cessation research, but difficulty in obtaining samples may bias estimates of quit rates. Proxy confirmation (PC) has not been validated in cessation trials. We assessed the feasibility and validity of PC in a cessation trial for hospitalized smokers. We enrolled 402 daily cigarette smokers during a hospital admission. At enrollment, participants provided demographics, smoking history, and named proxies to confirm their smoking status at follow-up. Participants provided self-reported (SR) 7-day tobacco abstinence by telephone at 6 months post-discharge. SR quitters were asked to mail a saliva sample for BC. Incentives were offered for survey completion ($20) and returned samples ($50). We called proxies for all those with SR to obtain PC. Quit rates were calculated with missing data indicating smoking. We assessed associations of nonresponse with baseline characteristics using chi-squared tests and logistic regression. We calculated the sensitivity and specificity of PC in detecting smokers as determined by BC. All patients named at least one proxy. Response rates were 82% for SR, 84% for PC, and 69% for BC. Observed participant characteristics were unrelated to provision of sample for BC. Estimated quit rates were 35% for SR, 27% for SR + PC, 21% for SR + BC and 27% for SR + BC or PC. Sensitivity of PC was not higher than SR (73% vs. 77%); specificity was lower (84% vs. 100%). PC was feasible but not superior to self-report in a cessation trial.

We assessed whether providing inpatient smokers with nicotine replacement therapy (NRT) to relieve withdrawal symptoms while hospitalized was associated with self-initiated NRT use soon after hospital discharge. We conducted an observational study of 1,895 cigarette smokers admitted to a large hospital over 24 months (July 2007 through June 2009) and seen by a tobacco counselor during hospitalization. Participants were surveyed at 2 weeks after discharge to assess postdischarge NRT use. We calculated adjusted rate ratios (ARRs) for the effect of NRT use in the hospital on the rate of NRT use after discharge, adjusting for gender, age, hospital service, intention to quit, baseline smoking level, length of stay, and counseling duration. 62 percent (1,166/1,895) of enrolled participants received NRT during hospitalization. The survey response rate was 72%. 42 percent (544/1,293) of survey respondents reported initiating postdischarge NRT use within 2 weeks of discharge. NRT use after discharge was more likely to be reported by those who used it in hospital whether they had ever used it prior to hospitalization (ARR: 5.64, 95% CI: 3.95-8.05) or had never used it before (ARR: 4.68, 95% CI: 3.25-6.73). Smokers who received NRT during a hospitalization were more likely to use it after discharge compared with those who did not use NRT in hospital. By encouraging use of this effective cessation aid, supplementing counseling with NRT for hospitalized smokers may promote smoking cessation efforts after discharge.