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2.  It’s Not That Simple: Tobacco Use Identification and Documentation in Acute Care 
This environmental telephone interview scan was designed to identify: (1) how hospitals in one Canadian province incorporated tobacco use identification/documentation systems into practice; and, (2) challenges/issues with tobacco identification/documentation. Participants included 36/139 hospitals previously identified to offer cessation services. Results showed hospitals aided by researchers monitored and tracked tobacco use; those not aligned with researchers did not. The wording of tobacco items most commonly included use within the last 6-months (42%), 30-days (39%), or 7-days (33%), or use without reference to time (e.g., “Do you smoke?”; 39%); wording sometimes depended on admitting form space limitations. The admission process determined where the tobacco item appeared, which differed by hospital—75% included it on an admitting form (75%) and/or nursing assessment (56%); the item sometimes varied by unit. There were also different processes by which the item triggered delivery of cessation interventions; most frequently (69%), staff nurses were triggered to provide an intervention. The findings suggest that adding a tobacco use question to a hospital’s admitting process is potentially not that simple. Deciding on the purpose of the question, when it will be asked and by whom, space allotted on the form, and how it will trigger an intervention are important considerations that can affect the question wording, form/location, systems required, data extraction, and resources.
doi:10.3390/ijerph10052069
PMCID: PMC3709365  PMID: 23698699
tobacco use and dependence guideline; tobacco use identification; tobacco use documentation
3.  Tobacco cessation Clinical Practice Guideline use by rural and urban hospital nurses: a pre-implementation needs assessment 
BMC Nursing  2012;11:6.
Background
This study was a pre-program evaluation of hospital-based nurses' tobacco intervention beliefs, confidence, training, practice, and perceived intervention barriers and facilitators. It was designed to identify relevant information prior to implementing tobacco cessation guidelines across a large northern rural region, home to 1 urban and 12 rural hospitals.
Methods
This cross-sectional survey was distributed by nurse managers to nurses in the 13 hospitals and returned by nurses (N = 269) via mail to the researchers.
Results
Nurses were somewhat confident providing cessation interventions, agreed they should educate patients about tobacco, and 94% perceived tobacco counselling as part of their role. Although only 11% had received cessation training, the majority reported intervening, even if seldom--91% asked about tobacco-use, 96% advised quitting, 89% assessed readiness to quit, 88% assisted with quitting, and 61% arranged post-discharge follow-up. Few performed any of these steps frequently, and among those who intervened, the majority spent < 10 minutes. The most frequently performed activities tended to take the least amount of time, while the more complex activities (e.g., teaching coping skills and pharmacotherapy education) were seldom performed. Patient-related factors (quitting benefits and motivation) encouraged nurses to intervene and work-related factors discouraged them (time and workloads). There were significant rural-urban differences--more rural nurses perceived intervening as part of their role, reported having more systems in place to support cessation, reported higher confidence for intervening, and more frequently assisted patients with quitting and arranged follow-up.
Conclusions
The findings showed nurses' willingness to engage in tobacco interventions. What the majority were doing maps onto the recommended minimum of 1-3 minutes but intervention frequency and follow-up were suboptimal. The rural-urban differences suggest a need for more research to explore the strengths of rural practice which could potentially inform approaches to smoking cessation in urban hospitals.
doi:10.1186/1472-6955-11-6
PMCID: PMC3384473  PMID: 22545579
4.  Implementation of the Tobacco Tactics Program in the Department of Veterans Affairs 
Journal of General Internal Medicine  2010;25(Suppl 1):3-10.
BACKGROUND
Smoking cessation services in the Department of Veterans Affairs (VA) are currently provided via outpatient groups, while inpatient cessation programs have not been widely implemented.
OBJECTIVE
The objective of this paper is to describe the implementation of the Tobacco Tactics program for inpatients in the VA.
METHODS
This is a pre-/post-non-randomized control study initially designed to teach inpatient staff nurses on general medical units in the Ann Arbor and Detroit VAs to deliver the Tobacco Tactics intervention using Indianapolis as a control group. Coupled with cessation medication sign-off, physicians are reminded to give patients brief advice to quit.
RESULTS
Approximately 96% (210/219) of inpatient nurses in the Ann Arbor, MI site and 57% (159/279) in the Detroit, MI site have been trained, with an additional 282 non-targeted personnel spontaneously attending. Nurses’ self-reported administration of cessation services increased from 57% pre-training to 86% post-training (p = 0.0002). Physician advice to quit smoking ranged between 73–85% in both the pre-intervention and post-intervention period in both the experimental and control group. Volunteers made follow-up telephone calls to 85% (n = 230) of participants in the Ann Arbor site. Hospitalized smokers (N = 294) in the intervention group are reporting an increase in receiving and satisfaction with the selected cessation services following implementation of the program, particularly in regards to medications (p < 0.05).
CONCLUSION
A large proportion of inpatient nursing staff can rapidly be trained to deliver tobacco cessation interventions to inpatients resulting in increased provision of services.
doi:10.1007/s11606-009-1075-9
PMCID: PMC2806966  PMID: 20077145
implementation research; smoking cessation; veterans
5.  Tobacco Use among Emergency Department Patients 
This is the first study to systematically track the tobacco use prevalence in an entire emergency department (ED) population and compare age-stratified rates to the general population using national, provincial, and regional comparisons. A tobacco use question was integrated into the ED electronic registration process from 2007 to 2010 in 11 northern hospitals (10 rural, 1 urban). Results showed that tobacco use documentation (85–89%) and tobacco use (26–27%) were consistent across years with the only discrepancy being higher tobacco prevalence in 2007 (32%) due to higher rates at the urban hospital. Age-stratified outcomes showed that tobacco use remained high up to 50 years old (36%); rates began to decrease for patients in their 50’s (26%) and 60’s (16%), and decreased substantially after age 70 (5%). The age-stratified ED tobacco rates were almost double those of the general population nationally and provincially for all but the oldest age groups but were virtually identical to regional rates. The tobacco use tracking and age-stratified general population comparisons in this study improves on previous attempts to document prevalence in the ED population, and at a more local level, provides a “big picture” overview that highlights the magnitude of the tobacco-use problem in these communities.
doi:10.3390/ijerph8010253
PMCID: PMC3037073  PMID: 21318027
tobacco prevalence; epidemiology; population surveillance; ED tobacco prevalence; hospital tobacco prevalence; tobacco use identification and documentation
6.  Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial 
Background
Programs for smoking cessation for cardiac patients are underused in Canada. We examined the efficacy of an intervention for smoking cessation for patients admitted to hospital for coronary artery bypass graft (CABG) or because of acute myocardial infarction (MI).
Methods
Nurses randomly assigned 276 sequential patients admitted because of acute MI or for CABG who met the inclusion criteria. Participants received an intensive or minimal smoking-cessation intervention. The minimal intervention included advice from physicians and nurses and 2 pamphlets. The intensive intervention included the minimal intervention plus 60 minutes of bedside counselling, take-home materials and 7 nurse-initiated counselling calls for 2 months after discharge. The outcomes were point prevalence of abstinence at 3, 6 and 12 months after discharge.
Results
The 12-month self-reported rate of abstinence was 62% among patients in the intensive group and 46% among those in the minimal group (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.2–3.1). Abstinence was confirmed for 54% of patients in the intensive group and 35% in the minimal group (OR 2.0, 95% CI 1.3–3.6). Abstinence was significantly lower among those who used pharmacotherapy than among those who did not (p < 0.001). Continuous 12-month abstinence was 57% in the intensive group and 39% in the minimal group (p < 0.01). It was significantly higher among patients admitted for CABG than among those admitted because of acute MI (p < 0.05).
Interpretation
Providing intensive programs for smoking cessation for patients admitted for CABG or because of acute MI could have a major impact on health and health care costs.
doi:10.1503/cmaj.080862
PMCID: PMC2696525  PMID: 19546455

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