Smoking remains the leading preventable cause of death in the US, accounting for approximately one of every five deaths (420,000 people) each year [1
]. The burden of tobacco-related illnesses in the US Veterans Administration (VA) population is particularly high, and the prevalence of smoking is estimated to be 21 to 40% higher in veterans than in the general population [2
]. Hospitalization has been identified as a 'teachable moment' for many smokers [4
]. Nearly all VA hospitals have become smoke-free, and can provide a supportive environment in which smokers are not exposed to their usual external cues to smoke [5
]. Moreover, approximately 50% of hospitalized smokers are ready to quit within 30 days [6
], and 80% are willing to discuss smoking cessation with a counselor during hospitalization [7
]. Data from the External Peer Review Program (a contracted review of the quality of VA care) suggest that over 90% of VA smokers receive advice to stop smoking during hospitalization; however, the quality and scope of such counseling is unclear.
Although adherence to smoking cessation guidelines has been actively promoted since 1997, VA hospitals typically do not facilitate cessation interventions in hospitalized smokers by providing inpatient staff with appropriate education, resources, and performance feedback, as recommended by US Public Health Service (USPHS) guidelines [1
]. Additional institutional barriers in the VA include: a specialty focus on smoking cessation counseling in the majority of VA hospitals, in which most patients are referred to a multi-session smoking cessation program [8
]; lack of continuity of care after discharge, with limited opportunities to promote continued abstinence [5
]; and variable policies and practices in the dispensing of drug therapy for cessation that may contribute to the under use of effective pharmacotherapy [10
]. With regard to referral, few hospitalized smokers attend smoking cessation classes or clinics after discharge [11
]. In the VA, the primary reasons that patients do not follow up are: access problems (36%), lack of commitment to quitting (35%), and unhappiness with the group format (14%), which is the primary counseling format offered in many VA hospitals [12
]. In addition, the delay between referral and an initial smoking cessation appointment can be critical [8
], as a large proportion of smokers relapse within one week of quitting [13
VA hospitals are challenged to find resources to implement the types of programs shown to be effective in research studies. Effective cessation programs typically include a high-intensity inpatient component (≤ 1 hour of face-to-face counseling) combined with sustained relapse prevention measures (≥ 4 weeks of counseling) and pharmacotherapy [11
]. Much less is known about the effectiveness of 'hybrid' interventions that combine low-intensity inpatient counseling (defined as a single session lasting 10 minutes or less)[1
] with sustained relapse prevention delivered by non-research personnel. Such strategies may be more realistic in practice than high-intensity interventions, as they place fewer demands on inpatient staff and are consistent with the 'ask, advise, and refer' model of cessation counseling that has been promoted in primary care [18
The proposed study will test an implementation intervention to increase quit rates in hospitalized smokers in noncritical care settings by facilitating staff nurses' delivery of recommended smoking cessation services and reducing patient barriers to participation in cessation counseling. Of all the members of the inpatient team, VA staff nurses (including registered nurses (RNs) and licensed practical nurses (LPNs)) are best positioned to deliver a brief smoking cessation intervention because of their ready access to patients and education in patient education and counseling. Several controlled trials have demonstrated that nurse-delivered counseling can increase quit rates in hospitalized patients [19
]. Although most of these trials have employed high-intensity interventions [11
], low intensity counseling by staff nurses can also yield favorable results [23
Thus, the primary aim of this practical clinical trial is to:
1. Determine the effect of a nurse-initiated intervention, which couples low intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients.
Hypothesis 1a: Smoking cessation rates at three and six month follow-up, as measured by seven-day point prevalence abstinence (PPA) will be greater for intervention patients than usual care patients.
Hypothesis 1b: Intervention patients will be more likely to receive prescriptions for recommended pharmacotherapy for smoking cessation and referral to telephone counseling, compared to usual care patients.
To gain insight into mechanisms promoting the adoption of recommended practices by nurses and to determine the relative economic value of the intervention, key secondary aims are to:
1. Determine the impact of the intervention on nurses' attitudes toward and self-efficacy for providing smoking cessation counseling.
Hypothesis 2: Nurses attitudes toward cessation counseling and self-efficacy in providing such counseling will increase after being exposed to the intervention.
2. Identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals and learn how to tailor the intervention to specific sites.
3. Determine the short-term cost-effectiveness of this implementation intervention.