Journal Article

Medical management of inpatients with tobacco dependency

Evison, Matthew, Ananth, Sachin, McDill, Helen, Restrick, Louise, Spencer, Elspeth, Agrawal, Sanjay, Fullerton, Duncan, Pollington, Jacqueline, Perry, Melanie, Vaghela, Ameet

2024

Overview

Correspondence to Prof Sanjay Agrawal, Department of Respiratory Medicine, Glenfield Hospital, Institute for Lung Health, Leicester, UK; [e-mail] Summary of key clinical practice points Building block 1: screen for tobacco dependence Ask every patient if they smoke Record ‘tobacco dependency’ as an active disease in the medical history Ensure any electronic systems for recording smoking status and supporting referral to the specialist tobacco dependency team are completed Building block 2: advise on the role of nicotine Nicotine drives the dependency to tobacco but is NOT the cause of the harms of smoking The harms of smoking come from thousands of toxic chemicals produced when tobacco is burnt to create smoke Keeping these toxic chemicals out of the body during the hospital admission will help acutely unwell patients recover more quickly Nicotine withdrawal can be very unpleasant, and it is important to provide nicotine in safe, alternative ways to help alleviate this Being smoke-free does not have to mean being nicotine-free during a hospital admission or after discharge from hospital Building block 3: initiate combination nicotine replacement therapy (NRT) as soon as possible Use a Rapid Inpatient NRT Prescribing Protocol and prescribe a 25 mg/16hour nicotine patch plus a fast-acting nicotine product (inhalator, lozenge, mouth spray) The most serious risk of relapsing back to smoking is prescribing an insufficient dose of NRT and not adequately addressing the patient’s withdrawal symptoms and urges to smoke Building block 4: complete a referral to an on-site tobacco dependency advisor (TDA) Refer all patients with tobacco dependence to the TDA team unless they opt-out or ensure automated referral processes to the TDA team when the patient is recorded as tobacco dependent, allowing them to opt-out at first approach by the TDA Advise on the benefits of working with specialist tobacco dependency advisors If no on-site team is available, complete an automated onward referral to local community services to provide ongoing treatment & support after discharge Building block 5: provide accurate and consistent information on Vaping Nicotine vapes deliver high dose fast-acting nicotine which can help to alleviate withdrawal and urges to smoke Vaping is an effective tool in the treatment for tobacco dependency and can be used to support patients during a hospital admission and to help achieve long term abstinence When using nicotine vapes as part of their tobacco dependency treatment plan, inpatients should be advised to switch entirely from smoking to vaping (and NRT) to maximise the harm reduction, both during the admission and after discharge If provided in the inpatient setting, nicotine vapes should be used alongside combination NRT as patients may not be able to use the vape at certain times or in certain environments (eg, the internal hospital building) Vaping is more likely to be effective when provided alongside behaviour change support from a TDA during the hospital admission and after discharge Vaping is not risk free. Additional information on reputable sources can be sought from local government stop smoking services From an environmental perspective, avoid single-use products Vapes should not be used when using home oxygen therapy Building block 6: discuss, offer and prescribe nicotine analogue medications Nicotine analogue medications (varenicline, cytisine) are effective treatments for tobacco dependency and can be discussed and commenced at the point of admission or during the admission Combination therapies (eg, NRT and nicotine analogues) are as effective if not more effective than single therapies and support abstinence in the unique environment of the inpatient setting (NRT provides additional nicotine needed during the escalation phase of varenicline during a smoke-free admission) Scope This Clinical Statement provides evidenced-based, practical advice for hospital clinicians to identify, initiate treatment and ensure specialist care for adult inpatients with a dependency to tobacco. By following the framework set out below, hospital clinicians can ensure optimal patient outcomes by: helping to alleviate withdrawal and urges to smoke for inpatients facilitating smoke-free hospital admissions referring for specialist support to help change deeply engrained smoking behaviours and start many patients on the journey to achieving long term abstinence from tobacco While the interventions and pharmacotherapy used in hospital are similar to those in community settings or other outpatient settings, the focus of this clinical statement is inpatients in the hospital setting. Building Blocks Framework – quick reference version Specialist behaviour change training and motivational interviewing for tobacco dependency advisors was considered outside the scope of this document and outside that of most hospital clinicians’ day to day work.

• Publisher: BMJ Publishing Group Ltd and British Thoracic Society,BMJ Publishing Group LTD
• Subject: Abstinence / Advisors / Automation / BTS Clinical Statement / Cigarettes / Clinical medicine / Community / Comorbidity / Disease prevention / Drug dosages / Health behavior / Health promotion / Hospitals / Humans / Inpatient care / Inpatients / Intervention / Lung Cancer / Morbidity / Mortality / Nicotine / Patients / Public health / Smoking / Smoking Cessation / Substance abuse treatment / Tobacco / Tobacco and the lung / Tobacco control / Tobacco Use Disorder / Vaping