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It used to be that patients were able to smoke in the hospital. I have vivid memories of clusters of men sharing cigarettes in the shabby bathroom at Boston City Hospital during the 1960s. It was not only the patients who smoked. Smoke breaks were common among the hospital staff, especially nurses; cigarettes were sold in hospital canteens, and many hospital directors in the 1970s and 1980s were chain smokers (I worked with 2 of them). Step by step it became more difficult for hospitalized smokers to smoke. Hospitals stopped selling cigarettes in their canteens (in the case of Veterans Affairs, this sparked an ongoing fight with the US Congress1). The Joint Commission mandated in 1992 that hospitals be smoke free; smoking rates among health care workers—even nurses—plummeted2; and medications for smoking cessation became widely available.3 An important loophole in the 1992 Joint Commission regulations was the exemption of psychiatric hospitals. However, recently they have begun to restrict smoking as well, even without a regulatory mandate to do so; between 2005 and 2011, the proportion of state mental hospitals that outlawed smoking inside the hospital increased from 20% to 79%.4 Yet, as Regan et al5 remind us, many smokers still find a way to smoke during their hospitalization. Regan et al revisited a 1995 study (published in 2000)6 at Massachusetts General Hospital (MGH) in which 25% of hospitalized smokers continued to smoke during their hospital stay. In the current study, which included 5399 smokers hospitalized at the MGH between 2007 and 2010, the rate of smokers who smoked during hospitalization had decreased slightly, to 18.4%. Factors associated with lower rates of smoking among hospitalized smokers were winter months (it is cold in those outdoor Boston smoking shelters), age of 50 years or older, admission to a cardiac unit, and the intention to quit smoking. Factors associated with higher smoking rates while hospitalized were longer hospital stays and documented craving for cigarettes (but not amount of daily cigarettes previously smoked). A striking difference between the 2 periods was the increased use of nicotine replacement therapy, which increased from 5% in 1995 to 62% for the 2007-2010 period. Yet, using nicotine replacement therapy only deferred in-hospital smoking; it did not prevent it. Unstated was the extent to which patients were referred to the Massachusetts telephone quit line. It is also unclear how much the prevalence of smoking among hospitalized patients decreased between the 2 periods, although it is likely that it followed the national trend of a slow but steady decline.7 Like other aspects of tobacco control, this study shows us how far we have come and how much more needs to be done. There is increasing pressure to remove the outdoor smoking areas that serve as a refuge for hospitalized patients and employees to sneak out for a smoke, representing a transition from smoke-free hospitals to smoke-free campuses. Of course, smoking while hospitalized—as Regan et al remind us—can impair healing, and the opportunity to stop smoking can be the first step toward the important goal of long-term smoking cessation. When hospital employees join these patients in the smoking shelters, it sends the wrong message about hospitals tolerating smoking among its workers. Indeed, some medical institutions, notably the Cleveland Clinic, are refusing to hire smokers. Another option is for hospitals to evolve to smoke-free campuses. This sends a strong message about the harms of tobacco use and serves as a deterrent to both patients and employees, who then must travel off the hospital grounds to smoke, something that is not possible for many smokers (eg, on smoke-free campuses there is no smoking within outdoor patios—a frequent site for smokers unable to travel from the hospital). Unfortunately, some patients and employees will simply take their smoking off campus, aggravating hospital neighbors with their smoke and cigarette butts. How can hospitals help smokers to at least refrain from smoking while hospitalized and even better help them to quit? Regan et al give us some answers. They recommend that a system should be in place that identifies all smokers on admission, flags the smoking status in the medical record, and alerts the medical team that a smoker needs help with cravings and that smoking cessation treatment should therefore be started. Of course, not all hospitals have a Tobacco Treatment Service akin to the one at MGH, but at the very least there should be a health professional group (eg, physicians, nurses, respiratory therapists, pharmacists, behavioral psychologists, or some combination of these) that can work with smokers to prevent nicotine withdrawal symptoms and help them quit. Referral to a toll-free telephone quit line, available in every state, can be accomplished by fax or telephone (1-800-QUITNOW). In addition to nicotine replacement therapy, tailored use of oral medications, such as bupropion hydrochloride or varenicline, may be appropriate in selected cases. Of interest in the study by Regan et al is that cravings were a better predictor of smoking during hospitalization than the absolute number of cigarettes previously smoked. Given the recent trend among smokers to smoke fewer cigarettes, we will likely be seeing more and more hospitalized smokers who do not experience nicotine withdrawal but who should still be counseled about quitting. It is likely that there will be increasing regulatory pressures on hospitals to do the right thing and help smokers quit. The new recommendations of The Joint Commission leave smoking cessation as one optional performance measure that can be chosen from among 14 potential ones, from which hospitals must choose 4.8 It is likely that many hospitals will elect to stick with previous performance measures, such as care pathways for congestive heart failure, acute myocardial infarction, or community-acquired pneumonia, and defer the smoking measure because it requires hospitals to call smokers and document tobacco use status approximately 30 days after hospital discharge. However, it is likely that the National Quality Forum and the Centers for Medicare and Medicaid Services will add tobacco dependence treatment as a regulatory standard in the near future, possibly as early as 2013. The lessons from the study by Regan et al can help hospitals get a head start on smoking cessation. Back to top Article Information Correspondence: Dr Schroeder, Department of Medicine, UCSF School of Medicine, 3333 California St, Ste 430, San Francisco, CA 94143-1211(firstname.lastname@example.org). Published Online: November 5, 2012. doi:10.1001/2013.jamainternmed.308 Conflict of Interest Disclosures: None reported. References 1. Hamlett-Berry K. Smoking cessation policy in the VA health care system: where have we been and where are we going? In: Isaacs SL, Schroeder SA, Simon JA, eds. VA in the Vanguard: Building on Success in Smoking Cessation. Washington, DC: Dept of Veterans Affairs; 2005:7-29 2. Tong E, Strouse R, Hall J, Kovac M, Schroeder SA. National survey of U.S. health professionals' smoking prevalence, cessation practices, and beliefs. Nicotine Tob Res. 2010;12:734-74120507899PubMedGoogle ScholarCrossref 3. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: Public Health Service; 2008 4. Schacht L, Ortiz G, Lane M. Smoking Policies and Practices in State Psychiatric Hospitals 2011. Alexandria, VA: National Association of State Mental Health Program Directors Research Institute; 2012 5. Regan S, Viana JC, Reyen M, Rigotti NA. Prevalence and predictors of smoking by inpatients during a hospital stay [published online November 5, 2012]. Arch Intern Med. 2012;21(172):1670-1674Google Scholar 6. Rigotti NA, Arnsten JH, McKool KM, Wood-Reid KM, Pasternak RC, Singer DE. Smoking by patients in a smoke-free hospital: prevalence, predictors, and implications. Prev Med. 2000;31(2, pt 1):159-16610938217PubMedGoogle ScholarCrossref 7. Schroeder SA, Warner KE. Don't forget tobacco. N Engl J Med. 2010;363(3):201-20420647196PubMedGoogle ScholarCrossref 8. Fiore MC, Goplerud E, Schroeder SA. The Joint Commission's new tobacco-cessation measures: will hospitals do the right thing? N Engl J Med. 2012;366(13):1172-117422417200PubMedGoogle ScholarCrossref
Archives of Internal Medicine – American Medical Association
Published: Nov 26, 2012
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