smoking cessation program in the hospital setting · intervention to help them quit smoking....

Smoking Cessation Program

in the hospital setting

Add units S8 (RVH) → Surgical heart unit (D7C), start on Nov 17th, 2014

C7N (GLEN) → Vascular surgery unit (April 27th, 2015)

DS1 (GLEN) → Pre-op clinic (August 26th, 2015)

Originals sites

M5 (RVH) → Medical heart unit (C7C & C7S)

Th5 (MCI) → Pneumology unit (D8)

11e (MGH) → Coronary Care unit

Michel Lebel, RN, BSc

Relationships with commercial interests

• In the past year have received honorarium for a

smoking cessation website development

funded by J&J

• This program has received support from Pfizer

Canada Inc. for developing the Impact program

brochure provided to patients

Disclosure

1) What is the relevant of implementing a smoking

cessation program in the hospital setting?

2) What are the key elements to maximize the

smoking cessation rate in hospitalized patients?

Questions

All smokers and ex-smokers (< 6 months) will be seen,

consulted, offered treatment and follow-up (regardless of

their willingness to quit).

IMPACT program: main objective

Not ready to quit

Offer Rx for managing cravings and nicotine withdrawal

and explore pros and cons of smoking;

Ready to quit

Set a quit date, select Rx, provide advice on

strategies, devise a quit plan and provide follow-up

support;

Recent ex-smoker (< 6 months)

Offer personalized advice to prevent relapse & follow-up.

Smoking Cessation Program

in the hospital setting, why?

65% of smokers hospitalized with myocardial

infarction (MI) intend to quit smoking in the

next 30 days1 (compared with only 20% of non-

hospitalized smokers)

Almost 2/3 of smokers resumed smoking < 1 year1

1) Interactive voice response telephony to promote smoking cessation in patients with heart disease: A pilot study Robert

D. Reid *, Andrew L. Pipe & all, Prevention and Rehabilitation Centre, University of Ottawa Heart Institute, Ottawa,

Canada.

Half of those resumed smoking within 1 month1

Hospitalization

A good opportunity Hospitals provide a smoke-free environment

• Smoke-free environment ↓ the triggers to smoke

1) Interactive voice response telephony to promote smoking cessation in patients with heart disease: A pilot study Robert

D. Reid & all, Prevention and Rehabilitation Centre, University of Ottawa Heart Institute, Ottawa, Canada.

• Patients have access to health care professionals

Smokers can get optimal treatment (Rx),

adjustment (withdrawal) with proper use1

• People who are in hospital because of a

smoking-related illness are likely to be more

receptive to help in giving up smoking1

• It‟s a good opportunity to offer Rx to ↓ craving and

nicotine withdrawal1

Steps of the IMPACT program

• Smoking status is identified through the patient‟s

medical and/or nursing history (eventually also done

from admission and ER)

• Smoking status is determined using a standard

question: “Have you used any form of tobacco in the

past six months?”

• The counsellor provides minimal or intensive

counselling based on the patient‟s readiness to quit

smoking.

Steps of the IMPACT program

• All smoking patients are encouraged to use nicotine

replacement therapy (NRT), varenicline or bupropion during the hospitalization to ↓ symptoms of nicotine

withdrawal and ↑ quit rate success (according to the guidelines)

• Pharmacotherapy and behavioural strategies are

discussed and specific assistance is offered

• They are provided with a self-help booklet, the

interactive voice response (IVR) follow-up or a list of

contacts for smoking cessation assistance

Pharmacotherapy should be considered:

a) to assist patients to manage nicotine withdrawal in hospital;

GRADE*: 1C (Strong Recommendation Low Quality Evidence)

b) for use in-hospital and post hospitalization to promote long

term cessation.

GRADE*: 1B (Strong Recommendation Moderate Quality Evidence)

Pharmacotherapy guidelines

CANADIAN SMOKING CESSATION CLINICAL PRACTICE GUIDELINE, CAN-ADAPTT. (2011).

• NRT or bupropion helped about 80% more people to

quit than placebo 10 who quit with placebo / 18 will quit with NRT or bupropion

• Varenicline more than doubled the chances of

quitting compared with placebo 10 who quit with placebo / 28 will quit with varenicline

• Combination of NRT is as effective as varenicline,

and more effective than single types of NRT.

Importance of the pharmacotherapy

NB. Pharmacotherapy is covered every year for 12 weeks for each type

of Rx (NRT, Varenicline and Bupropion). And up to 24 weeks for

Varenicline

Safety of the nicotine replacement therapy

1) Promoting smoking cessation during hospitalization for coronary artery disease. Robert D.

Reid and all, Can J Cardiol 2006;22(9):775-780

• Considerable evidence supports NRT safety for patients with

stable CAD.

• Nicotine delivered via the patch enters the venous system at

levels markedly lower than those produced in the arterial system by

the inhalation of tobacco smoke.

• Smokers using NRT receive much lower levels of nicotine than

they would if they smoke.

• They do not receive any of the many other compounds present in

tobacco smoke (including carbon monoxide).

At the MUHC

14-42 mg 2 mg 2 mg 1 mg

1 cigarette per hour (15 cpd)

Patch 21 mg Comfort zone

Gum 4 mg

Pre-printed orders

Importance of the follow-up

• Bedside counselling followed by telephone

support for at least 1 month after D/C increases

smoking cessation rate by almost 40% (risk ratio (RR)

1.37, 95% confidence interval (CI) 1.27 to 1.48; 25 trials) 1

• Effective programs to stop smoking are those

that begin during a hospital stay and include

counselling with follow-up support for at least

one month after discharge 1

• Effective regardless the reason of the admission 1

1) Hospitalized smokers, a Meta-Analysis of interventions trials. Rigotti and all, Cochrane Library 2012

IMPACT Program is based on the Ottawa Model for Smoking Cessation

Between April 2003 and March 2004,

almost 1300 smokers were identified

at admission and 91% received

intervention to help them quit

smoking.

Original Investigation Smoking cessation for hospitalized smokers: An evaluation of the “Ottawa

Model”. Nicotine & Tobacco Research, Volume 12, Number 1 (January 2010) 11–18. Robert D.

Reid, & all, . Can J Cardiol 2006;22(9):775-780.

TelASK Smoking Cessation Program Manager

• Patients on interactive voice response will be

contacted 3,14,30,60,90,120,150 and 180

days following hospital

• A series of questions concerning the

patient‟s current smoking status, confidence in

staying smoke-free and the use of Rx

• If patients have resumed smoking or that their

confidence is low, then they are contacted by

the Quit Line or by the MUHC counsellor

Follow-up with

Quit line and MUCH

MUHC

3 different databases

1)Base information from all admissions since the

beginning of the program on January 27th 2014

up to July 26th 2015 (18 months)

2)Pre and post evaluation

3)Cessation rate for those who accept the phone

call follow-up (TelASK database) Jan 27th 2014 up

to Jan 26th 2015 (12 months)

RESULTS

CANADIAN SMOKING CESSATION CLINICAL PRACTICE GUIDELINE, CAN-ADAPTT. (2011).

3 different databases

Start date

Jan 27th, 2014

Last data entry

July 26th, 2015

All admissions (smokers/recent ex-smokers)

3 different database

Start date

Jan 27th, 2014

Last data entry

July 26th, 2015


Pre-evaluation

May 6th to

Aug 16 th 2013

Post-evaluation

July 2ndto

Dec 4th 2014

6 months later 6 months later

Pre implementation Implementation Post implementation

Last data entry

June 12th, 2015

Last data entry

Feb 28th, 2014


Start date

Jan 27th, 2014

Last data entry

July 26th, 2015


Pre-evaluation

May 6th to

Aug 16 th 2013

Post-evaluation

July 2ndto

Dec 4th 2014



Last data entry

June 12th, 2015

Last data entry

Feb 28th, 2014

Start date

Jan 27th, 2014 Last data entry

Jan 26th, 2015

Quit rate at 6 months (phone call)

6 months later

All admissions (smokers/recent ex-smoker)

Start date

Jan 27th, 2014

Last data entry

July 26th, 2015

Units covered since Jan 27th, 2014: CCU (MGH), M5 (RVH) and Th5 (MCI)

Add units: Nov 17th, 2014 on S8 (RVH) and April 27th, 2015 on C7N (Glen)

All admissions (smoker/recent ex-smoker)

Stage of change

Pharmacotherapy during the hospitalisation

Comparaison du taux (%) de l‟utilisation de

la pharmacothérapie avant et après

l‟implantation du programme IMPACT

↑11%

Pharmacotherapy at discharge

Comparaison du taux (%) de l‟ordonnance au congé

faite durant les 3 premiers mois de l‟implantation et la

même période une année plus tard

↑17%


Start date

Jan 27th, 2014

Last data entry

July 26th, 2015


Pre-evaluation

May 6th to

Aug 16 th 2013

Post-evaluation

July 2ndto

Dec 4th 2014



Last data entry

June 12th, 2015

Last data entry

Feb 28th, 2014

Pre and post implementation

Goal: estimation on the natural quit rate before

implementation of the program and measure the IMPACT

after on the quit rate;

Steps: Daily screening completed for all admitted

patients (both smokers and non-smokers) until

25 smokers have agreed to a six-months follow-up call

for each unit;

Screening: Pre-implementation have to be completed

before the beginning of the program and the post-

implementation have to start at least 6 months after.

NB. Workplan developed by the University of Ottawa Heart Institute

Recruitment phase Pre and post implementation

Pre-implementation done between May 6th to August 16th 2013

Post-implementation done between July 2th to December 4th 2014

NB. 22/460 = 4.8%, 28/540 = 5.2%

Smoking prevalence (data from the pre/post evaluation)

20%

50%

Recruitment phase Pre and post implementation

9/202 (total smokers screen)= 4%

Pre-implementation

Post-implementation

Quit rate RESULTat 6 months Pre and post implementation

(7 days prevalence point)

Consider as smokers

Consider as smokers

Post-implementation group

Pre-implementation group

IMPACT result

on smoking cessation

↑20 %

IMPACT Program is based on the Ottawa Model Smoking Cessation

Original Investigation Smoking cessation for hospitalized smokers: An evaluation of the “Ottawa




Start date

Jan 27th, 2014

Last data entry

July 26th, 2015


Pre-evaluation

May 6th to

Aug 16 th 2013

Post-evaluation

July 2ndto

Dec 4th 2014



Last data entry

June 12th, 2015

Last data entry

Feb 28th, 2014

Start date

Jan 27th, 2014 Last data entry

Jan 26th, 2015

Quit rate at 6 months (phone call)

6 months later


RDY: Ready to quit

RQH: Recent Quitter,

High confident

RQL: Recent Quitter,

Low confident

Follow-up with

Quit line and MUHC

Phone follow-up system (TelASK)

On phone follow-up and

request a call back

287 call back requests during the 6 months

follow-up for 133 patients

(average of 2.2 requests per patient)

Result on quit rate (TelASK follow-up)

N= Jan 27th, 2014 to Jan 26th 2015

79/158 (50%) are smoke free at 6 months after D/C

(7 days point-prevalence abstinence)

Smoke free after 6 months after D/C

(7 days prevalence point)

Average of 50% smoke free on TelASK follow-up system

Keys messages

MUHC • Have to be in the standard care

• Hospitalisation = good timing for counselling and

follow-up to help them to quit otherwise even with

high motivation to quit, they relapse 2/3 after 1 year

• Counselling, Rx and follow-up ↑ quit rate

• It‟s a team work success

• It‟s working (20% increase)

1) What is the relevant of implementing a smoking

cessation program in the hospital setting?

Hospitalisation = good timing

• Often is a smoking-related illness (more likely to be

receptive to quit)

• Smokers can get optimal treatment (Rx),

adjustment with proper use

Questions

2) What are the key elements to maximize the smoking

cessation rate in hospitalized patients?

Counselling, Rx and follow-up (> 1 month) →

↑ quit rate

THANKS

Extra slides

• Cigarette smoking is a prominent causative factor

in the development of coronary artery disease 1

(CAD)

Tobacco impact in heart disease



• It ↑ blood coagulability and platelet aggregation,

reduces oxygen delivery, causes coronary

vasoconstriction and increases myocardial work1

• Smokers with CAD who quit smoking ↓ the relative

risk of death and nonfatal reinfarction by 36% and

32%, respectively 1

• Quitting smoking appears to be the most effective

intervention or treatment to reduce mortality in

patients with CAD who smoke1

Tobacco impact in heart disease



• Quitting smoking is as important as other

secondary treatments, such as1:

statins for lowering cholesterol

acetylsalicylic acid

beta-blockers

angiotensin-converting enzyme inhibitors

An evaluation of the Ottawa Model for

smoking cessation

• April 2003-March 2004, 1276 smokers were

identified, 1164 (91%) received intervention

• Nurse counsellor provided minimal (70%) or intensive

(30%) counselling to those 1164 smokers

• NRT was prescribed in-hospital to 33% of patients (47% for the IMPACT program)

• The IVR system was able to establish contact post

hospitalization with 74% of patients

• 53% of pts received additional intervention after D/C

Result: 6 months after D/C, 44% smoke free (7 days

point-prevalence abstinence) Original Investigation Smoking cessation for hospitalized smokers: An evaluation of the “Ottawa



Interactive Voice Response telephony

(IVR): A pilot study • Between Nov 2004 and May 2005, 186 patients

charts were reviewed for eligibility.

75 were excluded because they did not meet the eligibility criteria

(same day hospitalisation, <5 cpd, living too far away)

• 100/111 agrees to participate (90%)

• Randomly: 50 to usual care and 50 to the IVR group IVR: will be contacted via telephone on days 3, 14 and 30

• The mean number of calls completed per participant

was 2 (70% for Day3, 72% for day14 and 68% for day30)

• 23/50 (46%) participants in the IVR request help

Result: 12 months after D/C, 46% smoke free versus

group control at 34.7% (7 days point-prevalence abstinence)

Interactive voice response telephony to promote smoking cessation in patients with heart disease: A pilot study

Robert D. Reid *, Andrew L. Pipe & all, Prevention and Rehabilitation Centre, University of Ottawa Heart Institute,

Ottawa, Canada.

Ottawa Model

for smoking cessation study

Original intervention Smoking cessation for hospitalized smokers: An „„evaluation of the Ottawa Model‟‟ Robert D.

Reid and all, Nicotine & tobacco research; vol 12; numbert 1 (january 2010) 11-18

• 6 months after D/C, 29.4% (↑ 11%) smoke free

versus 18.3% (6-month continuous abstinence rate)

Team work (units)

1) Refer

(smoking cessation

consult)

2) Offer the PRN

medication when

prescribed

3) Make sure the

D/C order included

the Rx for smoking

cessation

Team work (units) Brief smoking cessation intervention;

Inform the patient about the smoking consult request

Need the doctor‟s agreement for the Rx order

including the D/C order

Number of call with no contact

smoking cessation program in the hospital setting · intervention to help them quit smoking....

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