Sustained care intervention and postdischarge smoking cessation among hospitalized adults: a randomized clinical trial

Abstract

Importance: Health care systems need effective models to manage chronic diseases like tobacco dependence across transitions in care. Hospitalizations provide opportunities for smokers to quit, but research suggests that hospital-delivered interventions are effective only if treatment continues after discharge.

Objective: To determine whether an intervention to sustain tobacco treatment after hospital discharge increases smoking cessation rates compared with standard care.

Design, setting, and participants: A randomized clinical trial compared sustained care (a postdischarge tobacco cessation intervention) with standard care among 397 hospitalized daily smokers (mean age, 53 years; 48% were males; 81% were non-Hispanic whites) who wanted to quit smoking after discharge and received a tobacco dependence intervention in the hospital; 92% of eligible patients and 44% of screened patients enrolled. The study was conducted from August 2010 through November 2012 at Massachusetts General Hospital.

Interventions: Sustained care participants received automated interactive voice response telephone calls and their choice of free smoking cessation medication (any type approved by the US Food and Drug Administration) for up to 90 days. The automated telephone calls promoted cessation, provided medication management, and triaged smokers for additional counseling. Standard care participants received recommendations for postdischarge pharmacotherapy and counseling.

Main outcomes and measures: The primary outcome was biochemically confirmed past 7-day tobacco abstinence at 6-month follow-up after discharge from the hospital; secondary outcomes included self-reported tobacco abstinence.

Results: Smokers randomly assigned to sustained care (n = 198) used more counseling and more pharmacotherapy at each follow-up assessment than those assigned to standard care (n = 199). Biochemically validated 7-day tobacco abstinence at 6 months was higher with sustained care (26%) than with standard care (15%) (relative risk [RR], 1.71 [95% CI, 1.14-2.56], P = .009; number needed to treat, 9.4 [95% CI, 5.4-35.5]). Using multiple imputation for missing outcomes, the RR for 7-day tobacco abstinence was 1.55 (95% CI, 1.03-2.21; P = .04). Sustained care also resulted in higher self-reported continuous abstinence rates for 6 months after discharge (27% vs 16% for standard care; RR, 1.70 [95% CI, 1.15-2.51]; P = .007).

Conclusions and relevance: Among hospitalized adult smokers who wanted to quit smoking, a postdischarge intervention providing automated telephone calls and free medication resulted in higher rates of smoking cessation at 6 months compared with a standard recommendation to use counseling and medication after discharge. These findings, if replicated, suggest an approach to help achieve sustained smoking cessation after a hospital stay.

Trial registration: clinicaltrials.gov Identifier: NCT01177176.

Figure 1

Study Flow (CONSORT) diagram Footnotes: *Study inclusion criteria: ≥18 yo, daily smoker, plans to quit and will accept cessation medication after discharge. † Patients may have had more than one reason for study ineligibility. ‡ Substance abuse refers to past-year illicit drug use (except marijuana) or alcohol or drug overdose as reason for current admission. ∫ Numbers of patients who withdrew and died are cumulative.

Figure 2

Effect of the intervention in subgroups Footnotes: RR=Relative Risk, with 95% confidence limits shown. C n = the number of patients with 7d abstinence in Standard Care (control group); C N = the total number of patients in Standard Care (control group); I n = the number of patients with 7d abstinence from Sustained Care (intervention group); I N is the total number of patients in Sustained Care (intervention group). LOS = length of hospital stay. Inpt NRT = inpatient nicotine replacement therapy. CESD8= Center for Epidemiological Studies Depression Scale (8-item version) Circulatory includes cardiovascular, peripheral vascular, and cerebrovascular diseases.