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BMJ. 2002 January 12; 324(7329): 64.
PMCID: PMC1122028

Helping patients in hospital to quit smoking

Dedicated counselling services are effective—others are not
Robert West, professor of psychology

This issue reports a study that nicely encapsulates the problems facing hospitals who want to encourage and help their patients to stop smoking (p 87).1 The study focuses on inpatients with cardiac disorders who want to stop smoking and examines whether a brief intervention (averaging 34 minutes) delivered on the ward by nurses would help them stop. It finds no effect at six weeks and at follow up after one year. This mirrors results with other patient groups. Most notably two large randomised controlled trials, one in the United Kingdom and one in Denmark, have found that a brief intervention by midwives failed to improve pregnant smokers' chances of stopping.2,3 All three studies also found that busy staff had considerable difficulty finding time to undertake the counselling. How can one square this with claims that brief advice from healthcare professionals leads patients to stop smoking and that behavioural support increases the chances of success of attempts to quit?4

Although it seems confusing, in fact there is a pattern. As regards brief advice from healthcare professionals, the key point is that this advice is delivered opportunistically to all smokers, takes just a few minutes and is aimed not at helping smokers to stop but at triggering an attempt to quit.4 What happens in the attempt will then depend on the smokers and the treatment they subsequently get. It is apparent from studies such as that of Hajek et al1 that the treatment package needs to be commensurate with the severity of the dependence it seeks to overcome.

As regards that treatment package, a Cochrane review clearly shows that behavioural support and counselling increases a smoker's chances of achieving lasting abstinence.5 However, close analysis of the evidence indicates that the behavioural support must be reasonably extensive and delivered by someone employed and trained for the task rather than someone trying to fit it into other duties. For example, there are four trials in the Cochrane review involving hospital patients receiving counselling totalling 60 minutes or more with follow up for at least six months and biochemical confirmation of abstinence. These studies yield an odds ratio of 1.97 (95% confidence interval 1.33 to 2.90, n=944) in favour of the intervention. There are two studies in this population with similarly rigorous methods involving counselling of around 30 minutes or less. For these the intervention was not effective (odds ratio 1.23, 0.76 to 2.13, n=931). Analysis of studies contained in two more recent reviews yield similar conclusions.6,7

Similarly, a close inspection of the Cochrane systematic review of controlled trials on counselling pregnant smokers shows that where counselling was delivered by staff employed for the purpose, preterm abstinence rates were considerably higher in the intervention groups (odds ratio 2.04, 1.69 to 2.47, n=3775).8 In contrast, studies in the Cochrane review plus the two more recent randomised trials show no effect of counselling delivered by midwives fitting it into their other duties (odds ratio 1.22, 0.89 to 1.66, n=2118).

Hajek et al's treatment package did not incorporate any pharmacotherapy (nicotine replacement or bupropion), presumably because of concerns over safety in this group.1 However, McRobbie and others have recently reported the results of a randomised trial which finds that bupropion improved abstinence rates over six months in people with cardiovascular disease (H McRobbie et al, 3rd European society for research in nicotine and tobacco conference, Paris, 2001). Nicotine replacement has been evaluated in such patients as well and appears to be well tolerated, although efficacy has not yet been clearly established.9

Optimal treatment for the life threatening disorder known as tobacco dependence is now accepted to consist of structured behavioural support involving multiple sessions combined with nicotine replacement or bupropion.4 Therefore it would no longer seem acceptable for hospitals to attempt to meet the smokers' needs with brief interventions undertaken by staff who have only scant training and expertise and many other calls on their time.

Fortunately, at present the NHS has a specialist smoking service organised at the health authority level, and in theory all that hospital staff need do is to refer their patients to that service. In practice, hospitals will need to work closely with the established smoking cessation services in their locality to set up comprehensive referral systems. Unfortunately, the future of this fledgling service is uncertain because the UK government has so far failed to make a decision on funding the service for the forthcoming year.10,11

Notes

Papers p 87

Footnotes

 Robert West has received travel funds from and undertaken research and consultancy for manufacturers of nicotine replacement products and bupropion.

References

1. Hajek P, Taylor TZ, Mills P. Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and bypass surgery: randomised controlled trial. BMJ. 2002;324:87–89. [PMC free article] [PubMed]
2. Hajek P, West R, Lee A, Foulds J, Owen L, Eiser JR, et al. Randomised controlled trial of a midwife-delivered brief smoking cessation intervention in pregnancy. Addiction. 2001;96:485–494. [PubMed]
3. Wisborg K, Henriksen TB, Secher NJ. A prospective intervention study of stopping smoking in pregnancy in a routine antenatal care setting. Br J Obstet Gynaecol. 1998;105:1171–1176. [PubMed]
4. West R, McNeill A, Raw M. National smoking cessation guidelines for health professionals: an update. Thorax. 2000;55:987–999. [PMC free article] [PubMed]
5. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2001;3:CD003086. [PubMed]
6. France E, Glasgow R, Marcus A. Smoking cessation among hospitalized patients: what have we learned? Prev Med. 2001;32:376–388. [PubMed]
7. Munafi M, Rigotti N, Lancaster T, Stead L, Murphy M. Interventions for smoking cessation in hospitalised patients: a systematic review. Thorax. 2001;56:656–663. [PMC free article] [PubMed]
8. Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev. 2000;2:CD001055. [PubMed]
9. Joseph AM, An LC. Tobacco smoking in patients with cardiovascular disease. Am J Hypertens. 2001;3:313–322. [PubMed]
10. Coleman T, West R. Newly available treatments for nicotine addiction. Smokers wanting help with stopping now have effective treatment options. BMJ. 2001;322:1076–1077. [PMC free article] [PubMed]
11. Raw M, McNeill A, Watt J, Raw D. National smoking cessation services at risk. BMJ. 2001;323:1140–1141. [PMC free article] [PubMed]

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