The TEAM project: the effectiveness of smoking cessation intervention with hospital patients
Introduction
Hospitalization is an opportunity to reach a large number of smokers at a time when they might be particularly receptive to advice to quit [1], [2], [3], [4]. Smokers are more likely to use hospital services than are nonsmokers [5], so hospitalization represents a good access point for smoking cessation intervention, and the experience of impaired health might make smokers more receptive to health-related messages [2]. In addition, hospital smoking bans and the break in routine that occurs with hospitalization are conditions that should aid cessation efforts. In fact, quit rates after hospitalization are often significantly higher than the rates that would be expected in the general population, even in the absence of smoking cessation intervention [6], [7].
There is a growing literature about the effectiveness of smoking cessation interventions in hospitals [8], [9]. France et al. [9] reviewed studies performed before 1999 and found a total of 20 studies examining the effectiveness of hospital-based smoking cessation interventions that included a control or comparison condition. Results regarding efficacy of interventions were mixed; only eight found statistically significant differences between the control and intervention groups. As noted by the authors of this review, the studies differed in several important dimensions, including reach, intensity of in-hospital counseling, duration of relapse prevention counseling after discharge, and level of training of the intervention staff, which might explain differences in findings. A clear conclusion was that a relapse prevention program that is sustained during the 3- to 5-month period after discharge is an important determinant of success in hospital-based smoking cessation interventions. Less clear was the importance of a high intensity in-hospital intervention performed by staff who are highly trained in smoking cessation counseling and whose effort is dedicated to providing this service. However, Stevens et al. [4] and Hajek et al. [10] found that smoking-cessation interventions performed by hospital staff were inconsistently carried out and did not result in cessation rates that were significantly different from those of controls.
Many of the reviewed studies limited their reach to groups that might be more receptive to smoking cessation messages, such as patients with specific illnesses related to smoking [11], [12], [13] or those who were thinking seriously about quitting [14], [15], [16]. As would be expected, quit rates were typically lower in studies that had fewer exclusions. Three controlled trials did not exclude patients based on readiness to quit or type of illness. Stevens et al. [17] found a significant difference between intervention and control groups in long-term abstinence rates, but abstinence was not biochemically validated. The finding of no effect of counseling interventions on long-term abstinence in the other two studies could have been due to features of the interventions [4], [18]. The relapse prevention components in both studies were briefer than the 3- to 5-month period identified as effective in the France and Glasgow review. Rigotti et al. [18] provided three counseling phone calls in the month after discharge from hospital to patients trying to quit. Stevens et al. [4] provided only one post-discharge counseling phone call and noted that the respiratory therapist interventionists failed to reach many of the patients assigned to the intervention condition.
The present study, the TEAM (Teachable Moment) Project, assessed systems-based interventions implemented in four hospitals in the Twin Cities area. A low-intensity intervention provided by doctors and nurses during regular patient care and a high-intensity intervention in which trained staff using a motivational interviewing approach provided one in-hospital counseling session and up to six counseling phone calls in the 6 months after discharge were compared with a modified usual care (UC) condition in which patients were provided with smoking cessation manuals, but no advice or counseling. The high-intensity condition included features identified as effective in previous studies, such as a strong relapse prevention component and well-trained counselors dedicated to the study. Unlike most previous studies of smoking cessation in hospital in-patients, recruitment was not limited to those with specific medical conditions or to those who were ready to quit. A question of particular interest was whether a treatment condition that included many of the components related to successful outcomes in other studies would be effective in a largely unrestricted patient population.
Section snippets
Hospitals
Four hospitals participated in this study. Two were county facilities in downtown settings and two were private and were in suburbs. During the course of the study, one of the county hospitals was purchased by a managed care organization. The study was approved by Institutional Review Boards at the University of Minnesota and at each participating hospital.
Participants
Participants were drawn from general admissions to the four study hospitals. Patients were potentially eligible if they had smoked a
Participant recruitment and follow-up rates
Fig. 1 is a CONSORT flowchart that describes recruitment, intervention, and follow-up rates [33]. Research assistants screened 55,120 patients during the period from January, 1997, to June, 1999. Thirteen thousand seven hundred thirty-one (24.9%) were smokers and, of those, 5,166 patients were eligible for study participation and 3,988 were approached for consent. We enrolled 2,095 patients (52.5% of patients approached for consent). Major reasons for ineligibility of identified smokers were
Discussion
Advantages of this study were a large sample of patients from a diverse set of hospitals, biochemical validation of self-reported cessation, and the inclusion of a comparison group that received only smoking cessation manuals. The most intensive condition included many elements identified as effective in previous studies, such as a long-term relapse prevention component and well-trained counselors dedicated to the study. It was therefore a relatively strong test of the effectiveness of smoking
Acknowledgements
This research was supported by grant HL54132 from the National Institutes of Health.
References (34)
- et al.
Smokers who are hospitalized: a window of opportunity for cessation interventions
Prev. Med
(1992) - et al.
Smoking cessation interventions among hospitalized patients: what have we learned?
Prev. Med
(2001) - et al.
Transdermal nicotine replacement for hospitalized patients: a randomized clinical trial
Prev. Med
(1998) - et al.
Helping hospitalized smokers quit: new directions for treatment and research
J. Consult. Clin. Psychol
(1993) Missed opportunities to assist hospitalized smokers
Am. J. Prev. Med
(1999)- et al.
Implementation and effectiveness of a brief smoking-cessation intervention for hospital patients
Med. Care
(2000) - et al.
The impact of smoking, alcohol consumption, and physical activity on use of hospital services
Am. J. Public Health
(1999) - et al.
Changes in smoking associated with hospitalization: quit rates, predictive variables, and intervention implications
Am. J. Health Promot
(1991) - et al.
Smoking cessation following admission to a coronary care unit
J. Gen. Intern. Med
(1991) - et al.
Interventions for smoking cessation in hospitalised patients
Cochrane Database Syst. Rev
(2001)