Web-Based Intervention for Transitioning Smokers From Inpatient to Outpatient Care: An RCT

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Introduction

Smoking-cessation follow-up care after hospitalization is known to be effective. Cost-effective and disseminable interventions adoptable by hospitals are needed.

Design

RCT.

Setting/participants

Fourteen hundred eighty-eight current smokers recruited during a tertiary care hospital stay were randomly assigned to Usual Care (UC) or Usual Care plus Web-Based Intervention (WI). Data were collected in 2011–2013 and analyzed in 2014–2015.

Intervention

UC provided brief bedside advice to quit, a quit plan template, and quitline contact information. WI included access to a website with asynchronous e-message communication with a tobacco counselor, use of interactive self-assessments, helpful cessation information, and access to additional web resources, as well as automated e-mail messages tailored for health concern and readiness to quit.

Main outcome measures

Self-reported 30-day abstinence at 6 months was the primary outcome; a subset was verified by saliva cotinine.

Results

Six-month follow-up was completed by 83% of participants. No difference was found between study arms for self-reported abstinence rates in intent-to-treat (25.4% WI vs 26.8% UC) and complete case (31.3% WI vs 31.4% UC) analyses. Reduced smoking was reported by 45.5% (WI, n=276) and 47% (UC, n=296) of non-abstinent responders (p=0.59). Using a 10-ng/mL cotinine cut off, abstinence was verified in 52.1% of WI and 62.5% of UC (p=0.11). Significant covariates associated with abstinence at 6 months were being male, not smoking during hospitalization, being very confident in quitting, planning to quit/stay quit, smoking fewer days in the past 30 days, fewer years of smoking, and having cerebrovascular or connective tissue rheumatic disease as primary hospital diagnosis.

Conclusions

Lack of difference between treatment arms suggests a strong effect for UC, WI was not effective, or both. Low intervention engagement may be partially responsible. Self-reported abstinence rates were relatively high in both arms, although the biochemically verified rates indicate over-reporting of abstinence. These findings suggest brief bedside counseling for all hospitalized smokers is beneficial.

Trial Registration

This study is registered at www.clinicaltrials.gov NCT01277250.

Introduction

Despite impressive declines during the past 50 years, tobacco use continues as a major public health issue in the U.S.1 Approximately 18% of U.S. adults smoke cigarettes, with the highest prevalence in the South (19.7%).2 Almost 0.5 million U.S. adults die prematurely each year because of smoking, with smoking-attributable annual health costs estimated at nearly $170 billion.3

Comprehensive tobacco control policies and programs have effectively reduced tobacco-related morbidity, mortality, and healthcare expenditures.1, 4 In 1992, the Joint Commission required hospitals to be smoke free and in 2012 adopted optional tobacco care quality measures.5 This smoking ban, together with smoking-cessation interventions during hospitalization, has yielded smoking reduction and cessation among hospitalized patients.4, 6 The requisite indoor smoking ban may force abstinence initiating a smoking-cessation attempt. In addition, feelings of increased health vulnerability during hospitalization may raise smokers’ perceptions of personal health risk, thereby increasing their motivation to quit.7, 8, 9 During hospitalization, patients have easier access to smoking-cessation services, including pharmacotherapy for withdrawal symptoms, to assist a quit attempt. However, brief in-hospital interventions do not necessarily convert temporary smoking abstinence into long-term abstinence.10 The meta-analysis of Rigotti and colleagues11 indicates that interventions initiated during hospitalization and continued at least 1 month post-discharge increase the odds of cessation at 6 months by 37%–71%, depending on the population. Interventions continuing beyond discharge are suggested as essential to achieving long-term effects.

Web-assisted tobacco interventions (WATIs), an innovative e-health approach, have potential for low-cost reach to millions of smokers.12 Reviews of WATIs among the general population indicate they can be effective in aiding cessation, especially when interactive and tailored, compared with self-help booklets or no intervention; however, results are mixed when compared with controls receiving in-person or telephone counseling.13, 14, 15 WATIs have been found more effective when tailored among smokers seeking to quit and when used in addition to nicotine-replacement therapy.16, 17 This suggests the utility of tailored WATIs among smokers in general; however, the only report for hospitalized smokers was for German rehabilitation hospital patients who had double the quit rates than a control group.18

The purpose of this study was to examine the effectiveness and cost effectiveness of an interactive and semi-tailored web-based smoking-cessation intervention that transitioned patients from inpatient to outpatient care against usual care. This study is part of the Consortium of Hospitals Advancing Research on Tobacco collaborative,19 NIH-funded projects testing the effectiveness and cost effectiveness of interventions initiated at hospitalization. This manuscript describes both intent-to-treat (ITT) and complete case (CC) analyses of 6-month follow-up smoking cessation and reduction by study condition, as well as predictors of smoking cessation, biochemical verification of abstinence, and cost results. In addition, findings regarding the use of cessation aides (pharmacotherapy, services) and e-cigarettes post-hospitalization and intervention engagement are presented.

Section snippets

Methods

This study was a 1:1-ratio two-arm RCT initiated with smokers during a hospitalization and continued post-discharge for 6 months. The study was approved by the University of Alabama at Birmingham IRB. Study methods have previously been published.20

Results

Between July 12, 2011, and May 22, 2013, a total of 1,488 eligible patients consented to the study and were randomized, representing 71.4% of those eligible, 28.9% of those screened, and 15.6% of those identified as smokers at admission (Figure 1). Seven-hundred forty-eight patients were assigned to the intervention arm. At 6 months, follow-up surveys were completed by 81.1% of WI and 85.1% of UC participants (p=0.040). Compared with respondents, participants not providing data at 6 months were

Discussion

This two-arm RCT examining the effectiveness of a WATI that transitioned inpatients to outpatient care resulted in no difference between study groups in 30-day point prevalence smoking abstinence or reduction rates at 6 months post-hospitalization. Although WI did not appear to be more effective for smoking cessation or reduction than UC, the self-reported smoking-cessation rates at 6-month follow-up in both study arms were higher than those in many other WATIs (range, 9.7%–25.8%),38, 39 and

Conclusions

This randomized controlled effectiveness study found no additional effect of a web-based intervention for post-hospital smoking-cessation care over brief existing in-patient hospital smoking-cessation services at 6 months after hospitalization. Although both study arms have self-reported abstinence rates around 31%, saliva cotinine verification indicates about 40% inflation, suggesting true quit rates were more likely 16%–20%. These findings support requiring at least minimal cessation

Acknowledgments

This study is part of the Consortium of Hospitals Advancing Research on Tobacco (CHART) initiative, jointly sponsored by the National Heart, Lung, and Blood Institute, National Cancer Institute, National Institute on Drug Abuse, and NIH Office of Behavioral and Social Science Research.

The research presented in this paper is that of the authors and does not reflect the official policy of NIH. The funding source was the National Institute of Drug Abuse (U01DA031515). The funding organization had

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