smoking cessation program in the hospital setting · intervention to help them quit smoking....
TRANSCRIPT
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
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
TelASK Smoking Cessation Program Manager
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
All admissions (smokers/recent ex-smokers)
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
3 different database
Start date
Jan 27th, 2014
Last data entry
July 26th, 2015
All admissions (smokers/recent ex-smokers)
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
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%
3 different database
Start date
Jan 27th, 2014
Last data entry
July 26th, 2015
All admissions (smokers/recent ex-smokers)
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
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
Model”. Nicotine & Tobacco Research, Volume 12, Number 1 (January 2010) 11–18. Robert D.
Reid, & all, . Can J Cardiol 2006;22(9):775-780.
3 different database
Start date
Jan 27th, 2014
Last data entry
July 26th, 2015
All admissions (smokers/recent ex-smokers)
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
Jan 26th, 2015
Quit rate at 6 months (phone call)
6 months later
TelASK Smoking Cessation Program Manager
TelASK Smoking Cessation Program Manager
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
1) Promoting smoking cessation during hospitalization for coronary artery disease. Robert D.
Reid and all, Can J Cardiol 2006;22(9):775-780
• 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
1) Promoting smoking cessation during hospitalization for coronary artery disease. Robert D.
Reid and all, Can J Cardiol 2006;22(9):775-780
• 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
Model”. Nicotine & Tobacco Research, Volume 12, Number 1 (January 2010) 11–18. Robert D.
Reid, & all, . Can J Cardiol 2006;22(9):775-780.
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