Editorial

Abstract

Over the last decade, a large body of evidence has accumulated demonstrating the efficacy and effectiveness of nicotine-replacement therapy (NRT) for smoking cessation.1–3 Randomized, placebo-controlled trials have demonstrated that NRT will double cessation rates across a variety of health care settings, even when provided with minimal adjunctive behavioral counseling.1,3 In 1996, after a comprehensive and systematic scientific review of the literature, the Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Guideline Panel recommended that clinicians provide a smoking-cessation intervention that includes the offer of NRT to all smokers, at every clinical encounter. However, surveys of smokers that have assessed the frequency of clinician-delivered smoking-cessation interventions suggest that clinicians are missing many opportunities to assist their patients who smoke. For example, a population-based survey of 3037 cigarette smokers who saw a physician in the previous 12 months found that only 46% reported that they were advised to quit, only 15% were offered help, and only 9% were given prescriptions for NRT (NRT was not available over the counter at the time of the study).4 A study comparing smoking intervention rates during the years 1991–1995, utilizing a random sample of more than 3200 office-based physicians, found that only 16% to 29% smokers’ office visits included counseling and only 0.4% to 2.2% of visits included an NRT prescription.5 Clearly, clinicians are not coming close to meeting the standard for smoking-cessation interventions outlined by AHCPR, at least not in the outpatient setting. One might argue that the demands of outpatient office practice limit the time and resources available for delivering smoking-cessation interventions, especially in the era of managed care. In contrast to outpatient care, hospitalization provides multiple and unique opportunities to deliver smoking-cessation interventions. The mere presence of the patient in the hospital for several hours or days should increase access to smoking-cessation resources and treatments. Moreover, recent research has demonstrated that hospital-based smoking-cessation interventions can enhance smoking cessation, especially when access to NRT is included in the intervention. For example, a multicomponent, case-management smoking-cessation intervention has been developed and tested at Stanford University. This intervention includes an in-hospital message delivered by a physician, an in-hospital behavioral-counseling session conducted by a nurse, access to NRT, and follow-up telephone counseling.6–9 Initial trials of the Stanford case-management system, conducted with patients hospitalized with a myocardial infarction, produced smoking-cessation rates of up to 70% at 1 year, compared with 45% to 53 % among usual care groups.6,8 Two subsequent studies, conducted among patients with and without cardiovascular disease, also demonstrated the efficacy of the case-management approach.7,9 These impressive findings from multiple trials suggest that high cessation rates can be achieved by a case-management approach that takes advantage of the teachable moment of hospitalization, utilizes both a physician and nurse-manager to deliver components of the intervention, combines behavioral strategies with pharmacotherapy, and provides multiple follow-up contacts. However, as reported by Rigotti and colleagues10 in this issue of the journal, clinicians are not taking full advantage of the teachable moments associated with hospitalization. Among 650 smokers admitted to a teaching hospital, only 5% received NRT during their stay, despite an average length of stay of 6 days, and exclusion of patients who were admitted to an intensive care unit for terminal care or for less than 48 hours. Although rates of NRT use were higher among subjects who were experiencing nicotine withdrawal, less than 10% of those who were experiencing significant withdrawal received NRT. Clearly, nicotine withdrawal among these patients was grossly undertreated. Moreover, more than 40% of the subjects in the sample studied by Rigotti and colleagues expressed an intention to quit in the next 30 days, suggesting that clinicians were also missing an important opportunity to build commitment toward quitting during hospitalization. Since patients must abstain from smoking during hospitalization anyway, beginning NRT during hospitalization may help motivate those patients who are already considering quitting to stay quit after they leave the hospital. Factors that might explain underutilization of NRT in the hospital setting include safety concerns, organiAddress correspondence and reprint requests to: Michael G. Goldstein, MD, Bayer Institute for Health Care Communication and Brown University School of Medicine, West Haven, CT 06516. The full text of this article is available via AJPM Online at http://www.elsevier.com/locate/ajpmonline.