Brief Smoking Cessation Intervention in Hospitalized Patients With Cardiovascular Disease

INTRODUCTION

Since 2000 the Hospital Universitari de Bellvitge (HUB; the Bellvitge University Hospital) has been part of the Xarxa Catalana d'Hospitals Lliures de Fum (XHLF; the Catalan Network of Smoke-Free Hospitals). Admission to an XHLF hospital brings together 3 circumstances that help initiate a period of abstinence from tobacco: disease, hospitalization, and a smoke-free environment. Disease, especially if related to smoking, can increase a patient's motivation to quit.¹ Further, hospitalization increases a patient's self-perception of vulnerability, stimulating the autoassessment of health and lifestyle, and affords health professionals the opportunity to begin therapeutic interventions.² Beginning a smoking cessation treatment during a patient's hospitalization might therefore be effective.³

Recent data indicate that only 30.8% of patients who are hospitalized may actually be asked about their smoking habits.⁴ The aim of the present work was to determine the rates of continued abstinence from smoking in patients admitted to the HUB for cardiovascular disease, all of whom were subject to a brief smoking cessation intervention during their hospitalization, at 1, 3, 9, and 12 months following discharge. Attempts were also made to identify the predictors of continued abstinence in these patients.

METHODS

This prospective cohort study involved 252 patients admitted for cardiovascular disease to the cardiology or the angiology and vascular surgery units of the HUB (located in L'Hospitalet de Llobregat, Barcelona) between October 2003 and October 2005.

During hospitalization, patient demographic and tobacco consumption data were recorded in structured interviews. All data were collected by a trained nurse within the context of a medical assistance protocol. All patients were subjected to a 30 min-long behavior assessment, received written self-help information, and information from the HUB's Smoking Dehabituation Unit.

Nicotine dependence was measured using the Fagerström test; a score of ≥7 was taken to indicate high dependence, 5-6 to indicate medium dependence, and ≤4 as low dependence. Patient baseline characteristics were stratified by the admitting unit. All were offered nicotine substitution therapy according to standard protocol.

Data regarding the continued abstinence from smoking following discharge were collected retrospectively via a telephone interview performed by a group of trained psychologists; these interviews took place between March and August 2006. The patients were asked about their tobacco consumption following discharge. Patients who declared themselves not to have smoked since leaving hospital were deemed to be abstinent; those who had taken up smoking once again were recorded as relapsed. The duration of abstinence was taken as the time between discharge from hospital and the date of relapse.

Qualitative variables were recorded as percentages and compared using the Pearson c² test. Quantitative variables were recorded as means (standard deviation) if they met the criteria of normal distribution, or as medians (percentiles 25; 75) if they did not. Comparisons were made using the Student t test for paired samples or the Mann Whitney U test as appropriate.

Smoking abstinence rates at 1, 3, 9, and 12 months after hospital discharge were estimated using the Kaplan-Meier method, and the log-rank test used to analyze the differences between survival curves. Those variables that showed a significant association with abstinence were entered into a Cox regression model to obtain hazard rations (HR) and 95% confidence limits (95% CI). Significance was set at P≤.05. All calculations were performed using SPSS v.12 software (SPSS Inc., Chicago, Illinois, USA).

RESULTS

During the study period, 252 patients were subjected to the brief smoking cessation intervention described. After discharge from hospital, 38 (15.1%) of these patients could not be contacted via telephone after 4 attempts, and 22 (8.7%) had died. A total of 192 patients therefore made up the final study population, which included 176 men (91.7%) and 16 women (8.3%); the median age was 56 (47; 64.5) years.

Some 79.2% (152 patients) were hospitalized in the cardiology unit, and 20.8% (40) in the angiology and vascular surgery unit. Some 58.6% (112) were eventually discharged with a diagnosis of ischemic cardiomyopathy (acute myocardial infarction, angina, or acute coronary syndrome without elevation of the ST segment), 19.4% (37) with a diagnosis of peripheral vascular disease (acute/ chronic ischemic syndrome of the extremities, venous thrombosis, or blue finger syndrome), and 22% (42) with a diagnosis of some other cardiovascular disease (precordial pain, heart failure, syncope, high blood pressure, arrhythmia, valve disease, or pericardial or aortic disease). At baseline 36.3% (49) smoked more than 30 cigarettes/day, 53.3% (72) waited no longer than 5 min to light their first cigarette of the day, and 53.3% (72) showed high nicotine dependence according to the Fagerström test. Table 1 shows the baseline characteristics of the patients.

Differences were seen in the age of hospitalization (P=.008) and the length of time spent in hospital (P<.001) depending on the admitting unit; patients admitted by the cardiology unit were younger and spent a shorter period in hospital. Tobacco consumption and nicotine dependency were similar in both admission groups (P=.56 and .79 respectively)

At 24 h post-discharge, 76.6% (147) of the patients remained abstinent from smoking. No significant differences were seen between the characteristics (Table 2) of the abstinent and non-abstinent patients at 24 h. Median follow-up time was 12 (0.43; 12) months. The abstinence rate decreased over the following year, from 71.35% at 1 month to 67.19%, 64.05%, and 62.17% at 3, 9, and 12 months respectively (Table 2). Differences in abstinence rates were seen between patients with different diagnoses on discharge (P=.019); patients with ischemic cardiomyopathy showed the highest abstinence rates over the follow-up period (Figure).

Figure 1. Rate of continued abstinence from smoking according to diagnosis on discharge.

The variables sex, age at hospitalization, and diagnosis at discharge were introduced into the Cox regression model to estimate the HR for abstinence from smoking. The patients diagnosed with ischemic cardiomyopathy were found to be 1.79 times less likely to take up smoking again compared to those with other diagnoses (HR=0.56; 95% CI, 0.36-0.87).

DISCUSSION

The present work assesses the impact of a smoking cessation intervention provided to patients with cardiovascular disease—all smokers—during their time in hospital. None of these patients was subject to systematic follow-up after discharge.

The number of patients who remained abstinent following the intervention fell progressively over the experimental period. This agrees with the findings of Bolamn et al⁵ and Hajek et al⁶ who assessed the effect of a minimal smoking cessation intervention on patients with cardiovascular disease during their hospitalization period; these authors reported that the intervention had been unable to maintain abstinence from smoking at 12 months after discharge from hospital.

A Cochrane³ review concludes that patients admitted for cardiovascular disease are more receptive to smoking cessation interventions, probably due to their perception of the seriousness of their condition. In the present study, the patients who maintained the highest abstinence rates were those with a diagnosis of ischemic cardiomyopathy. In fact, the only independent factor found to predict abstinence from smoking was this diagnosis.

The main limitation of this study is the use of patient-declared information, which could suffer some degree of systematic error or bias. Another weakness is the loss of participants during follow-up. Some of the other variables analyzed, eg, baseline tobacco consumption and nicotine dependence may have shown significant associations with abstinence had no such losses occurred. Finally, the study had no control group; the results cannot, therefore, be used to assess the effectiveness of the intervention on smoking cessation.

The absence of clearly effective smoking cessation treatments during hospitalization has led to research being promoted in this area, and a number of articles have now been published on the impact of different interventions and the factors that predict continued abstinence from smoking.

The experience gained at our center suggests that, for patients with cardiovascular disease, a minimum intervention during hospitalization is probably insufficient to maintain the abstinence rate recorded at discharge from hospital. Based on the results of Quist-Paulsen et al,⁷ the impact of such a minimum intervention at our center might be best if resources were focused on patients in the cardiology unit with further input from the Smoking Dehabituation Unit after discharge.⁸

ACKNOWLEDGMENTS

The authors thank Gilma López Salguero, Taida Costa Català, Rocío López González, Rebeca Monterde Roldán, Silvia Salvador, and Antonio García Baena for their help in this work.

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Correspondence: Dr S. Morchón Ramos.
Unidad de Deshabituación Tabáquica. Servicio de Medicina Preventiva. Hospital Universitario de Bellvitge.
Feixa Llarga, s/n. 08907 L'Hospitalet de Llobregat. Barcelona. España.
E-mail: [e-mail]

Received February 29, 2008.
Accepted for publication June 4, 2008.