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1 Running head: SMOKING CESSATION 1 Inpatient to Outpatient Smoking Cessation Program Phillip D. Taylor University of Utah College of Nursing Scholarly Project Spring 2013

2 SMOKING CESSATION 2 Table of Contents Executive Summary 3 Problem Statement 4 Significance of Proposed Project 5 Objectives 5 Search Strategy 6 Literature Review 6 Theoretical Framework 11 Implementation 12 Implementation of Objectives 14 Evaluation 17 Conclusion 18 Appendix I (IRB Approval) 20 Appendix II (Poster) 21 References 22

3 SMOKING CESSATION 3 Executive Summary Smoking continues to be a major cause of morbidity and accounts for 443,000 deaths annually in the United States. Over the past 15 years public awareness and increased research has helped to decrease the overall smoking rate. Despite these efforts 20% of Americans continue to smoke. Smokers are treated in hospitals more often than nonsmokers (Wilkins, Shields, & Rotermann, 2009). Hospitals provide an opportunity to help smokers become more aware of the potentially devastating health effects of their habit. Most hospital based smoking cessation programs do not follow current evidence based recommendations for depth of smoking cessation education and post hospital follow up. Research on the topic of smoking cessation is extensive and demonstrates that inpatient smoking cessation programs are successful. These programs should focus on individualized education and post discharge follow up. Pharmacologic interventions such as nicotine replacement therapy, bupropion and varenicline are beneficial. Highest quit rates are obtained when personalized education, pharmacologic interventions, and post discharge follow up are combined. The Inpatient to Outpatient Smoking Cessation program aimed to help patients at the University of Utah Hospital quit smoking during their inpatient stay and to remain smoke free after discharge. The objectives of the Inpatient to Outpatient Smoking Cessation Program are as follows: to help hospitalized patients become aware of how smoking contributes to their health, create a discharge cessation plan, provide telephone follow up for one month after discharge, review the inpatient smoking cessation literature, and report to the findings of this program to the Evidence Based Nursing Practice Counsel at the University of Utah. Results: Participants (n=20) were inpatients that were at least 19 years of age and had been smoking at least one cigarette per day prior to hospital admission. Patients received individualized smoking cessation education an average of 1.2 times for minutes each episode while in the hospital. Nicotine replacement therapy was offered. These patients were then followed through telephone contact for 4 weeks after discharge. At the conclusion of this program 50% of patients were able to remain smoke free throughout the follow up period. An additional 20% were able to reduce their smoking. These results are impressive when compared to other studies of this type. Significant bias and other factors may have influenced these results. Considering these factors future studies with larger cohort size and length of follow up are needed to verify the outcomes described here. The Inpatient to Outpatient Smoking Cessation program was a success and further demonstrates the need for implementation of more aggressive anti-smoking programs in the inpatient setting. These programs should include post discharge follow up. Follow up is an essential part of helping patients to overcome their addiction to nicotine. This program was completed under the supervision of University of Utah College of Nursing Supervisory Committee members: Tamara Melville DNP, PMHNP Chair, Katie Ward DNP, WHNP, ANP, and Dianne Fuller DNP, APRN, FNP-C. Content experts included Brandon Jennings Pharm.D. from the University of Utah College of Pharmacy, and Linda Egbert BSN, RN, Quality Specialist of University of Utah Health Care.

4 SMOKING CESSATION 4 Problem Statement The evidence that smoking contributes to poor health and disease is well established (Forey, Thornton, & Lee, 2011). Many societal measures are being put into action: commercials on television now broadcast this message to millions of people; legislative measures to ban smoking from public and private areas such as restaurants and parks continue to be passed across the country; taxation of tobacco products such as cigarettes continues to increase almost yearly. Despite these measures to influence smokers to quit, twenty percent Americans continue to smoke (CDC, 2012b). It is estimated that smoking leads to 443,000 premature deaths in the United States (CDC, 2012b; Larzelere & Williams, 2012). These deaths are preventable. Mass media and public opinion may influence a few to stop smoking, but the fight to save lives must also be fought on an individual basis. Every healthcare provider should ask his or her patients two questions do you smoke? and do you want to quit? (Larzelere & Williams, 2012). Asking these questions at a time when the patient is vulnerable to change may influence their decision to stop smoking. Hospitalized patients are in this vulnerable state having been forced to examine their health due to extreme circumstances (Campbell, Pieters, Mullen, Reece, & Reid, 2011). The implementation of a smoking cessation program to address these issues is needed at the University of Utah. Such a program would involve finding individuals who are ready to quit smoking and formulating an individualized plan that will make them successful after returning home. Continued support for patients post discharge is a vital step to helping these individuals to be successful (Rigotti, Munafo, & Stead, 2008). Maintaining contact for a period of time will help encourage the patients to continue to be smoke free. Smoking continues to be an individual and societal battle. As healthcare professionals we have an obligation to assist others in making healthy choices. A smoking cessation program

5 SMOKING CESSATION 5 at the University of Utah hospital would help those who struggle with this addiction and their communities to maintain health and wellness. Significance of Proposed Project The negative contribution of smoking to individuals and society is well known. Smoking will be the cause of death in one in five Americans. The United States experiences 443,000 deaths related to smoking annually. Many of these deaths are attributable to cancers related to smoking (CDC, 2012b). These statistics demonstrate the need for change in American society. While some changes have occurred through taxation and public service announcements there is still work to be done. Individuals who smoke when hospitalized are at a vulnerable crossroads for changing their lives. A current smoking cessation program at the University of Utah only mildly addresses the need for these individuals to change. Furthermore, it does nothing to help these individuals once they are discharged from the hospital. The proposed Inpatient to Outpatient Smoking Cessation Program would fill in these gaps in care by providing education and encouragement to the patient during their hospital stay. It also provides a working plan to individuals once they return home. The impact of this project on the individual who is attempting to stop smoking may be lifelong. Some benefits may include; shorter subsequent hospital stays, increased quality of life, and increased income. The benefits of this project for the University of Utah include; decreased respiratory complications during and after surgical procedures, shorter length of stay for the patient, decreased healthcare acquired pneumonia, and improved quality in patient care. Objectives 1. Help hospitalized patients who are smokers evaluate how smoking has affected them and their disease process.

6 SMOKING CESSATION 6 2. Initiate a post hospital discharge smoking cessation plan for program participants prior to them discharging from the hospital. 3. Maintain telephone contact with program participants for one month post discharge to assess continued smoking cessation and provide encouragement for continued smoking cessation. 4. Review the literature regarding smoking cessation and previously attempted inpatient to outpatient smoking cessation programs. 5. Give oral presentation of results to Evidence Based Nursing Practice Counsel at the University of Utah for consideration for hospital wide implementation in spring Search Strategy Research articles for this program were found using electronic databases. These include Pubmed and Cinahl. Years for retrieval included 1993 to present. Key words were, smoking cessation, methods, inpatient, and outpatient programs. The internet was also used to retrieve the most recent smoking population statistics from the CDC, and the State of Utah. Literature Review The purpose of this review is to understand the components of creating and implementing an inpatient to outpatient smoking cessation program in the University of Utah Hospital. This review will address the following areas; the hospital as a teachable moment for smoking cessation, current hospital based smoking cessation programs, effectiveness of pharmacological smoking cessation interventions and a discussion of the effectiveness of these programs. Background Smoking is the cause of death in one in five Americans and accounts for 443,000 deaths annually (CDC, 2012b). Public anti-smoking campaigns are pervasive. A national media

7 SMOKING CESSATION 7 campaign launched by the CDC advertises quit lines and the negative effects of smoking (CDC, 2012a). These national media ads are run locally. Despite these public efforts 20% of Americans continue to smoke (CDC, 2009). Hospitals can play a major role in the fight against smoking. Generally, smokers spend more time in the hospital than non-smokers (Wilkins, et al., 2009). Most hospitals offer smoking cessations programs to their smoking patients (Rigotti, Clair, Munafo, & Stead, 2012). The majority of these programs require minimal effort from staff to meet compliance to qualify for public funding (Fiore, Goplerud, & Schroeder, 2012). Currently patients at the University of Utah receive brief bedside smoking education that requires minimal effort from the nurse and has minimal effect on the patient. This translates to patients who are receiving minimal smoking cessation education in the hospital setting. The Joint Commission has recognized that hospitals can do more. In January of 2012 the Joint Commission released an additional performance measure, regarding smoking cessation education inside of a hospital setting (Joint Commission, 2012). It is common knowledge that measures put forth by the Joint Commission set the standard for hospital accreditation nationally (Fiore, et al., 2012). Although the measure is optional now it behooves hospitals to implement this measure now in anticipation of it becoming an accreditation requirement. Hospital Environment Hospitalization is a traumatic and emotional time in a patient s life. During their stay they are receptive to change. Research shows that intensive care patients benefit from brief motivational interviewing sessions.(clark & Moss, 2011) It is easy for hospital staff to link current patient health to past health choices (Azevedo (2010), Barreto (2012)). Inpatient

8 SMOKING CESSATION 8 motivational interviewing sessions help the patient to gain the necessary mindset to stop their addiction. Overview of hospital based programs Smokers who enter any hospital setting receive smoking cessation education. The level and amount of education varies from facility to facility with few hospitals providing comprehensive cessation care (Faseru et al., 2011). The lack of complete care leaves the patient vulnerable to relapse back into addiction. Patient follow up is the most important component of hospital smoking cessation programs (Rigotti, et al., 2012). A recent review of hospital based programs for smoking cessation revealed that only 11 of 33 hospitals reported providing patients with post discharge follow up (Faseru, et al., 2011). Rigotti et al. (2012) in a systematic review demonstrated that follow-up length was variable, ranging from one month to one year. Rigotti et al. (2012) concluded that follow-up should be for at least one month. The recommended four weeks of follow up is need as the patient is vulnerable to relapse back into smoking after severe illness and the initiation of a smoking cessation intervention. Returning home further increases this vulnerability as their addiction is often associated with daily routine (Chang, 2003). The Tobacco Cessation Performance Measure by Joint Commission also mandates a minimum of four weeks of post discharge follow up (Joint Commission, 2012). There are two major reasons why outpatient follow up is neglected. First, effective follow-up is expensive (Rigotti, et al., 2012). Researchers are currently trying to determine if the use of less expensive measures such as quit lines are as effective as telephone follow up (Grossman et al., 2012). The results of this trial are not yet available but may provide a simple alternative to institutions where cost is a limiting factor for implementation of a smoking

9 SMOKING CESSATION 9 cessation program (Grossman, et al., 2012). Second, follow up is not a requirement by the Joint Commission and other accrediting bodies (Fiore, et al., 2012). Hospitals do not have a financial incentive at this time to provide comprehensive outpatient follow up. Components of smoking cessation programs The two components of smoking cessation programs are counseling and pharmacologic treatment. With respect to counseling, a Cochran review (2012) of 50 in-hospital smoking cessation programs showed counseling sessions being using in all studies. Variations existed in the type of counseling and duration. Counseling sessions lasted 5 minutes to several hours (Rigotti, et al., 2012). With no clear consensus on duration of counseling sessions it should be left up to the individual healthcare provider to gauge patient interest and clinical condition to acceptance of such counseling. Counseling sessions should be focused on assessing the willingness of the patient to stop smoking. The 5 A s methodology (Ask, Advise, Assess, Assist, and Arrange) has been used widely in both inpatient and outpatient settings. This methodology has been found to be effective in the outpatient programs ("Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary," 2008). Its efficacy is hard to gauge in the inpatient setting because (two reasons why, time and qualified personnel) (Quinn et al., 2009). One study resolved these problems by implementing a modified version of the 5 A s, Ask, Advise and Refer (AAR) (Berndt et al., 2011). Using the AAR method allows for referral to specialized individuals to help overcome these barriers. Pharmacologic interventions are a mainstay in smoking cessation. Rigotti et al. (2012) found no studies that compared the effectiveness of a pharmacologic intervention to placebo.

10 SMOKING CESSATION 10 The three most common pharmacologic treatments for smoking cessation are nicotine replacement therapy (NRT), bupropion, and varenicline (Rigotti, et al., 2012). NRT is available in many forms. Gum, patches, and inhalers are some of the more common types. NRT is easy to use and can be bought with or without a prescription. It allows the patient to increase or decrease the amount of nicotine based on their physical withdrawal symptoms. NRT can increase the chances of cessation by 50-70% (L. Stead, Perera, Bullen, Mant, & Lancaster, 2008). NRT is an important adjunct to counseling and has shown to increase the chance of long term smoking cessation (Ortega et al., 2011). NRT is the most widely form of smoking cessation adjunct (Rigotti, et al., 2012; Rigotti, et al., 2008). Bupropion a norepinephrine dopamine reuptake inhibitor is used to treat mood disorders and as an adjunct in smoking cessation (Gardner & Kosten, 2007). Bupropion may be used in conjunction with NRT. A randomized controlled trial of smoking cessation with use of Bupropion demonstrated little or no effect of the medication on cessation rates (Planer et al., 2011; Rigotti, et al., 2012). However, researchers did not use NRT during the time it took for Bupropion to be effective (Planer, et al., 2011). Varenicline a nicotine agonist is designed to help decrease the physical symptoms associated with smoking cessation. Varenicline when used in hospitalized patients has demonstrated no effect on the rate of smoking cessation (Rigotti, et al., 2012; Steinberg et al., 2011). It also carries the unpleasant side effect of vivid dreams. This makes it a less desirable choice for in-patient programs. Future Directions At present there is little incentive for hospitals to initiate intensive smoking cessation programs that involve counseling and post discharge follow-up. The new Joint Commission

11 SMOKING CESSATION 11 performance measure may improve this. The cost of follow-up remains the largest barrier for hospitals to overcome. This is especially true when the key component of follow up is addressed. The evidence based recommendation is a minimum of 4 weeks of follow up (Rigotti, et al., 2012). The type of follow up is less important. It can vary from in-person to telephone contact. Future research may yield new evidence that referral to a quit line is also effective (Grossman, et al., 2012). For inpatient programs a modified version of the 5 A s teaching model may be more effective as it emphasizes referral to knowledgeable members of a smoking cessation team. Counseling sessions are an essential part of the inpatient program. These sessions should assess the willingness to quit, the relationship of smoking to their disease process, and the obstacles that the patient will need to overcome once they return home. NRT is the most effective pharmacologic measure when paired with counseling all patients should be offered NRT during their hospital stay and upon discharge (Rigotti, et al., 2012). Theoretical Framework The Social Cognitive theory (SCT) has been used extensively as a framework for explanation of human behavior. This theory was first introduced by Albert Bandura a Canadian psychologist in 1985 (Polit & Beck, 2008). This theory focuses on the principles of selfefficacy, outcome expectations and behavioral goals (Longo, Lent, & Brown, 1992). Selfefficacy focuses on how much a person is able to believe in their personal behavioral change. Smoking cessation behaviors can be explained through this framework by examining the components that influence self-efficacy to promote behavioral change. These components are: past experience, verbal persuasion, vicarious experience, and physiologic cues (Polit & Beck, 2008). Smoking cessation programs focus on changing behavior. For smokers the behavior of smoking is so engrained that great effort must be made in order to stop smoking. The SCT helps

12 SMOKING CESSATION 12 to explain how a smoking cessation program can affect such change. SCT explains that selfefficacy is the driving force for change. One area that a smoking cessation program can affect self-efficacy is through persuasion. Counseling sessions that are motivational can help to animate and be a driving force in increasing the amount of self-efficacy in a person. Counseling sessions can also help to create realistic expectations. These expectations are necessary to avoid disappointment from missed goals. Missing an expectation may cause a smoker to discontinue cessation efforts. Behavioral goals can also motivate the smoker to quit. These are the incentives that the smoker will strive to obtain. The rewards from not smoking are improved physical health and economic gain from not buying cigarettes. These incentives can be strong motivators towards increasing self-efficacy. Implementation 1. Help hospitalized patients who are smokers evaluate how smoking has affected them and their disease process. a. Education in the form of brief motivational interviewing sessions will be delivered to patients who are open to smoking cessation. This education will include information regarding how smoking has contributed to their disease process. This information will take place during the inpatient stay with each session lasting minutes. b. IRB approval will be obtained to protect all health information that will be gathered. The project will strictly follow all IRB recommendations. 2. Initiate a post hospital discharge smoking cessation plan for program participants prior to them discharging from the hospital.

13 SMOKING CESSATION 13 a. The patient will have clear post discharge instructions for smoking cessation. These instructions will have written materials with quit line referral, how to avoid triggers, plan for follow-up with primary care and NRT medication teaching. b. The discharging physician will be contacted and asked to provide NRT as a medication on the discharge medication list. 3. Maintain telephone contact with program participants for one month post discharge to assess continued smoking cessation and provide encouragement for continued smoking cessation. a. Contact will be maintained on weekly basis for a period of one month. These conversations will address six areas: motivation for continued abstinence or reduction with positive encouragement being given, the level of cessation (total abstinence versus decrease use of cigarettes), the willingness of the patient to continue with cessation, use of NRT, if NRT was prescribed on discharge, if primary care follow-up addressed smoking cessation. 4. Review the literature regarding smoking cessation and previously attempted inpatient to outpatient smoking cessation programs. a. A review of the literature will be performed using Pubmed. Relevant articles found through systematic reviews will also be used. Internet based searches using the search engine Google will also be used to find relevant materials to include for teaching sessions. Key terms used in the searches are: smoking cessation, admission, follow up, inpatient, nicotine replacement, bupropion, and varenicline. b. A first draft of the literature review was submitted in October 2012 for approval from scholarly project chair.

14 SMOKING CESSATION 14 c. The literature will continue to be edited throughout the course of scholarly project 1 and Give oral presentation of results to Evidence Based Nursing Practice Counsel at the University of Utah for consideration for hospital wide implementation in spring a. An oral presentation will be given to the Evidence Based Nursing Practice Counsel at the University of Utah in the spring of Implementation of Objectives Objective 1- The Bedside Visit My objective to help patients understand how smoking has affected their disease process is being fulfilled through the participant education sessions that were given in the hospital. These sessions occurred at the bedside and are discussed below. The National Cancer Institute publication Clearing the Air was used to help educate participants in the smoking cessation process. The education sessions are minutes depending on the participant s ability to focus and participate. The main focus is the avoidance of environmental triggers the participant will encounter once returning home. These triggers are important to understand and have varied with each participant. Per verbal report the participants acknowledge that mental awareness of triggers and challenges associated with returning home, better prepares them to avoid a relapse. If the participant will remain in the hospital for an extended period of time multiple visits are made to reinforce education given during the initial education session. Inpatient follow-up has been rare due to short hospital stays. Participants are offered nicotine replacement therapy (NRT) during the visit and are also asked if they would like to be sent home with nicotine patches. If the participants refuse NRT in the hospital they are educated on the use of the quit line in their area where they can receive NRT patches for free if

15 SMOKING CESSATION 15 they should feel they need them once returning home. Participants were consented and contact information was requested for their primary care provider and their personal telephone. Objective 2-The Discharge Plan The objective of creating a discharge smoking cessation plan was successful in the participant gathering phase. The smoking cessation booklet Clearing the Air by the National Cancer Institute provides many useful tips to help create a smoking cessation discharge plan ("Clearing the Air," 2008). These interventions include identifying and replacing triggers with healthy habits such as exercise. This also includes making the first quit day the first day of discharge from the hospital. NRT is also discussed as a way to make quitting more effective. Objective 3- Participant Follow-up After discharge from the hospital participants are followed with weekly telephone contact for a period of 4 weeks. Due to variability in the time and day of discharge participants are contacted the week after leaving the hospital. At this time in the data gathering process participants are scattered throughout the 4 week follow-up process with the initial enrollees terminating their 4th week this week. During these contacts participants are asked about cigarette usage, continued willingness to quit or decrease their smoking habit and if they have been to their primary care provider since discharge. Lastly they are asked if their primary care provider discussed continued smoking cessation at the visit if it has occurred. Objective 4 Literature review The literature review has been completed and no new information regarding better outcomes from inpatient smoking cessation programs has been found during subsequent searches. Objective 5-Discemination

16 SMOKING CESSATION 16 On May 15 th 2013 this program and its outcome will be discussed with the Evidence Based Nursing Practice Counsel and the University of Utah.

17 SMOKING CESSATION 17 Evaluation Project Objective Evaluation of Objective Educate hospitalized smokers Completion of one smoking cessation education session with enrollment into the study. IRB approval. Initiate post discharge plan Completion of plan with discussion of triggers, NRT, and post hospital follow-up. Successful contact with physician staff to request prescription for discharge NRT Follow-up for one month Completion of four successful telephone contacts. Assessment of level of abstinence or decrease in cigarette usage. Review the literature Acceptance of literature review by scholarly project chair Report to Evidence Based Nursing Practice Counsel Give power point presentation to council members with inpatient smoking cessation program recommendations on May 15 th 2013.

18 SMOKING CESSATION 18 Conclusion The program was able to gather 20 participants during the 5 weeks of the implementation phase. Of these 20 participants 6 were lost to follow-up. This loss of follow up resulted for a variety of reasons. Some of these reasons are failure of the participant to answer follow up phone calls, wrong number given to principal investigator (PI) during in hospital education session, lack of minutes available when participant used a prepaid cell phone, and death. The death of the participant was unrelated to the program. The remaining 14 participants were able to reduce or quit smoking per verbal report at the end of the 4 weeks of follow up. The total number who quit smoking was 10. This represents 50% of the program participants being able to quit smoking. This result is significantly better than other studies of this nature. A recent Cochrane review of 38 inpatient smoking cessation programs revealed a mean quit rate of 21% (L. F. Stead & Lancaster, 2012). Multiple factors may have contributed to this program s results. Some of these factors may include: participant empathy for the PI, lack of confirmatory biologic testing, small cohort size, and not controlling for factors such as severity of illness, length of hospital stay, and previous quit attempts. Overall these results demonstrate that inpatient smoking cessation education programs that follow patients after discharge may help inpatients to take advantage of their hospital stay and remain smoke free after discharge. Furthermore, these results also demonstrate that implementation of such a program is possible at the University of Utah with minimal resources and that a program such as this may help further the health and wellness of patients served by this institution. Recommendations to the Evidence Based Nursing Practice Counsel will include: hiring a full time Registered Nurse to complete individualized smoking education, and post hospital discharge telephone follow up. Contacting outpatient primary care providers will also be

19 SMOKING CESSATION 19 recommended as this contact is crucial for continuity of care. A change in education materials that will focus on triggers when the patient arrives home is also recommended.

20 SMOKING CESSATION 20 Appendix I Clearing the Air by the National Cancer Institute can be obtained from

21 SMOKING CESSATION 21 Appendix II

22 SMOKING CESSATION 22 References Barreto, R. B., Pincelli, M. P., Steinwandter, R., Silva, A. P., Manes, J., & Steidle, L. J. (2012). Smoking among patients hospitalized at a university hospital in the south of Brazil: prevalence, degree of nicotine dependence, and motivational stage of change. Jornal Brasileiro de Pneumologia, 38(1), Berndt, N. C., Bolman, C., de Vries, H., Segaar, D., van Boven, I., & Lechner, L. (2011). Smoking Cessation Treatment Practices: Recommendations for Improved Adoption on Cardiology Wards. Journal of Cardiovascular Nursing. doi: /JCN.0b013e318231f424 Campbell, S., Pieters, K., Mullen, K. A., Reece, R., & Reid, R. D. (2011). Examining sustainability in a hospital setting: Case of smoking cessation. Implement Sci, 6, 108. doi: / CDC. (2009). Cigarette smoking among adults and trends in smoking cessation - United States, Morbidity and Mortality Weekly Report, 58(44), CDC. (2012a, 3/29/2012). CDC Launches Tobacco Education Campaign Retrieved 2012, 12/1, from CDC. (2012b). Tobacco-Related Mortality, 2012, from ortality/index.htm Chang, S. O. (2003). Types of smoking temptation. Taehan Kanho Hakhoe Chi, 33(4), Clark, B. J., & Moss, M. (2011). Secondary prevention in the intensive care unit: does intensive care unit admission represent a "teachable moment?". Critical Care Medicine, 39(6), doi: /CCM.0b013e bb

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