CIGARETTE SMOKING,
CARDIOVASCULAR DISEASE RISK, AND
IMPLEMENTATION STRATEGIES FOR
SMOKING CESSATION
Adapted and Modified from:
Luepker RV, Lando HA. Tobacco Use and Passive Smoking,
in:
Wong ND, Black HR, Gardin JM, eds. Preventive Cardiology,
Mc Graw Hill, 2000 and
NANCY HOUSTON MILLER, R.N., B.SN., Stanford University
Roger Blumenthal, MD et al ACC Prevention Guidelines 2007
____________________________________________________________
Smoking Statement Issued in 1956 by American Heart
Association
___________________________________________________________
“It is the belief of the committee that much greater
knowledge is needed before any conclusions can be
drawn concerning relationships between smoking and
death rates from coronary heart disease. The
acquisition of such knowledge may well require the use
of techniques and research methods that have not
hitherto been applied to this problem.”
Circulation 1960; vol. 23
___________________________________________________________
Smoking: Mortality
33.5% of smoking-related deaths among Americans
are cardiovascular-related
Male smokers die an average of 13.2 years earlier
than male nonsmokers
Female smokers die an average of 14.5 years
earlier than female nonsmokers
Current cigarette smoking is a powerful
independent predictor of sudden cardiac death in
patients with CHD
Cigarette smoking results in a two- to threefold risk
of dying from CHD
Arch Intern Med. 2003;163:2301–2305.
Surgeon General’s Health Consequences of Smoking, 2004. CDC/NCHS.
Tobacco-Related Mortality, Fact Sheet. CDC.gov/tobacco. February 2004.
Heart Disease and Stroke Statistics—2005 Update, AHA. • MMWR, Vol. 51, No. 14, 2002, CDC/NCHS.
CHD Risk by Cigarette Smoking. Filter Vs. Non-filter.
Framingham Study. Men <55 Yrs.
14-yr. Rate/1000
250
Non-Smoker
Reg. Cig. Smoker
Filter Cig. Smoker
200
206
150
210
100
210
119
112
50
59
0
Total CHD
Myocardial
Infarction
Percent of Population
40
35
30
25
20
15
10
5
0
37.3
33.4
24.1 23.9
20.4 20.2
18.9 17.8
15
11.3
Men
NH White
NH Black
Hispanic
Women
Asian
American Indian or Alaska Native
Prevalence of current smoking for Adults age 18 and older by
race/ethnicity and sex (NHIS:2004).
Source: MMWR. 2004;54:1121-24. NH – non-Hispanic.
Percent of Population
45
40
35
30
25
20
15
10
5
0
24.9
27
24.8
19.2
14
NH Whites
11.9
NH Blacks
Males
Hispanics
Females
Prevalence of high school students in grades 9-12 reporting current
cigarette smoking by race/ethnicity and sex. (YRBS:2005).Source: MMWR.
2006;55:SS-5. June 9, 2006. . NH – non-Hispanic.
• TOBACCO USE AS A CARDIOVASCULAR RISK
FACTOR
• OVERVIEW OF SMOKING CESSATION AND THE
IMPORTANCE OF INTERVENING IN CLINICAL
PRACTICE
• LESSONS LEARNED FROM THE
IMPLEMENTATION AND DISSEMINATION OF A
SUCCESSFUL RESEARCH PROGRAM IN
HOSPITALIZED PATIENTS
• INTRODUCING SYSTEM - WIDE CHANGES FOR
SUCCESS WITH CARDIAC AND OTHER
HOSPITALIZED PATIENTS
SMOKING: THE FACTS
•
FIFTY MILLION AMERICANS SMOKE (1 IN 4 ADULTS)
•
FIFTY PERCENT ATTEMPT TO QUIT ANNUALLY
•
ONLY 42% OF M.I. SMOKERS RECEIVED SMOKING
CESSATION INTERVENTIONS AT HOSPITAL
DISCHARGE (NRMI II)
•
ONLY 21% OF SMOKERS RECEIVED COUNSELING @
CLINIC VISITS (1995)
•
TREATMENT IS MOST OFTEN OFFERED TO THOSE
WITH TOBACCO-RELATED DISEASES
•
DIRECT/INDIRECT MEDICAL COSTS APPROACH
$130 BILLION ANNUALLY
U.S. Deaths Attributable to Cigarette
Smoking, 1994, Centers for Disease
Control and Prevention
Chronic Lung Disease
Lung Cancer
81000, 19%
72000, 17%
24000, 6%
32000, 7%
98000, 23%
123000, 28%
Coronary Heart
Disease
Other Cancers
Stroke
Other
CIGARETTE SMOKING MORTALITY
• ONE IN EVERY FIVE DEATHS FROM CARDIOVASCULAR
DISEASE IN THE UNITED STATES IS SMOKING-RELATED
• ON AVERAGE, SMOKERS DIE SEVEN YEARS EARLIER
THAN NONSMOKERS.
• 430,700 DEATHS OCCUR ANNUALLY FROM CIGARETTE
SMOKING WITH 75% BEING DUE TO CANCERS AND
HEART DISEASE.
• DEATHS FROM LUNG CANCER AMONG WOMEN HAVE
INCREASED 400%. IN 1994, 64,300 WOMEN DIED FROM
LUNG CANCER AND 44,300 DIED FROM BREAST CANCER.
MORBIDITY AND MORTALITY WEEKLY REPORT, 1997
AMERICAN CANCER SOCIETY, ATLANTA GEORGIA, 1996.
Cigarette Smoking as a CHD Risk
Factor
• In PDAY study of autopsies performed on 1443 men and women
aged 15-34 years, smoking was associated with excess of fatty
streaks and raised lesions in the abdominal aorta.
• Mechanism of injury from cigarette smoking may come from injury
to endothelium, and acute effects ma include alterations in clotting,
platelet adhesion, and coronary vasoconstriction due to nicotine.
• Relative risk of CHD death from MRFIT study 2.1 for 1-25
cigarettes/day rising to 2.9 for >25 cigarettes/day
• Acute MI and sudden death strongly associated with cigarette
smoking.
• Cigarette smoking has additive effect to CHD risk above lipids,
obesity, diabetes, and hypertension
Cohort Studies of Environmental
Tobacco Smoke and CHD
Source
Hirayama
Garland
Svendsen
Helsing
Location,Date
Japan 1984
US 1985
US 1987
US 1988
Population
91,540
695
1245
19035
Hole
Layard
UK 1989
US 1995
7987
2916
Tunstall-Pedoe
UK 1995
2278
Steenland
US 1996
309599
Kawachi
US 1997
32046
RR (95% CI)
1.2 (0.9-1.4)
2.7 (0.7-10.5)
2.2 (0.7-6.9)
M 1.3 (1.1-1.6)
F 1.2 (1.1-1.4)
2.0 (1.2-3.4)
M 0.97 (0.7-1.3)
F 0.99 (0.8-1.2)
2.7 (1.3-5.6)
M 1.2 (1.1-1.4)
F 1.1 (-.96-1.3)
F 1.9 (1.1-3.3)
Environmental Tobacco Smoke and
CHD
• 35,000-40,000 deaths annually from acute MI are
associated with environmental tobacco exposure,
significantly more than due to lung cancer.
• Recent meta analysis of passive smoking
incorporating home-based and workplace studies
(1699 cases) showed relative risk of 1.49 (1.29-1.72)
• Sidestream smoke released into the environment
may be more toxic and nonsmokers who are
exposed regularly develop various physiologic
changes and are more sensitive than regular
smokers.
• Lower HDL-C and platelet abnormalities, higher CO
levels and lower exercise tolerance are noted.
Trends in Cigarette Smoking: High School
Youth (Everett et al)
40
35
30
25
20
1991
1995
15
10
5
0
9th Grade
10th
Grade
11th
Grade
12th
Grade
Percent of High School Students Who
Reported Cigarette Smoking, 1995, CDC
WV
MO
WY
OH
ME
NE
RI
NJ
IL
TN
MT
CO
SC
NC
GA
CA
UT
0
10
20
30
40
50
Percent of Adults Who Reported Cigarette
Smoking, 1996, CDC
KY
OH
MO
WV
AK
NC
IL
VA
DE
VT
MA
NY
CO
NE
NM
CT
MN
MD
CA
UT
0
5
10
15
20
25
30
35
Prevention and Intervention Strategies in
Youth
• School-based prevention programs
– Social environment / influences
• Community-based prevention programs
– May enhance effects of school-based programs
• State and federal prevention initiatives
– Anti-tobacco media campaigns
– Restrictions on tobacco advertising
– Restrictions on tobacco availability to minors
– Restrictions on smoking in public places including schools
– Increased taxation
Adult Cessation Strategies
• Contingency contracting (wards for abstinence)
• Social support (from clinician, group, family, friends)
• Relaxation techniques (progressive relaxation, deep
breathing)
• Stimulus control and cue extinction (restricting where
smoking takes place)
• Coping skills
• Reduced smoking and nicotine fading (gradual reduction)
• Multicomponent treatment programs
• Hypnosis
• Acupuncture
• Self-help (written materials, videos, tapes, hotlines, helplines)
• Computer-tailored messages
Time-to-Benefit of Smoking Cessation After
Last Cigarette
Within 20 minutes:
BP decreases; body temperature, pulse rate returns to
normal
Within 24 hours:
Risk of MI decreases
Within 1 year:
Excess risk for CHD is half that of a person who smokes
At 5 years:
Stroke risk is reduced to that of someone who has never
smoked
Within 15 years:
CHD risk is the same as a person who has never smoked
American Lung Association. www.lungusa.org/tobacco/quit_ben.html
Counseling: 5 A’s
Ask: Systematically identify all tobacco-users at
every visit
Advise: Strongly urge all smokers to quit
Attempt: Identify smokers willing to try and quit
Assist: Aid the patient in quitting
Arrange: Schedule follow-up contact
Estimated cessation rate (%)
Efficacy of various behavioural support approaches
20
16.8
15
12.3
13.9
13.1
10.8
10
5
0
No
intervention
(reference
group)
Self-help
Proactive
telephone
counselling
Individual
counselling
Group
counselling
USDHHS. Treating Tobacco use and dependence. A clinical practice guideline. Rockville, MD AHQR 2000.
EFFICACY OF SMOKING CESSATION
INTERVENTIONS (1 YEAR QUIT RATES)
ACUPUNCTURE
----
HYPNOSIS
----
PHYSICIAN ADVICE
6%
SELF-HELP METHODS
14%
NICOTINE PATCH
11-15%
PHYSICIAN ADVICE/SELF-HELP PAMPHLETS
22%
AVERSIVE SMOKING (RAPID PUFFING)
25%
PHARMACOTHERAPY/BEHAVIORAL THERAPY25%
BEHAVIORAL STRATEGIES (GROUP PROG.)
40%
Tailored vs. generic behavioural support material
% Abstinent at 4 months
Self-help materials tailored for the needs of individual
smokers are more effective than standard materials
35
30.7
Generic materials
Tailored materials
30
25
20
15
10
7.7
7.1
9
5
0
Light / moderate (<20 cig/day)
Heavy (>20 cig/day)
Cigarettes smoked per day
Strecher VJ. Patient Educ Couns. 1999; 36: 107-117.
Strecher VJ, et al. Journal of Family Practice. 1994; 39(3): 262–270.
Pharmacologic Treatment Options
TREATMENT
POTENTIAL RISKS
Nicotine patch
Skin rashes and irritation
Nicotine polacrilex (nicotine
gum)
Mouth soreness, hiccups,
dyspepsia, jaw ache
Nicotine nasal spray
Nose and eye irritation, usually
disappears within 1 week
Nicotine inhaler
May cause mouth or throat
irritation
Zyban (bupropion
hydrochloride)
Slight risk of seizure,
contraindicated in those with
eating or seizure disorders
Nicotine Replacement Therapy
Potent psychoactive drug that
induces euphoria
Effects are related to blood
concentration and the rate of
increase in concentration
Safe in patients with cardiovascular disease
Should be used as part of smoking cessation therapy; however, many
individuals may quit without it
Smoking and Nicotine
Other toxins in tobacco smoke, not nicotine, are responsible for
majority of adverse health effects
>4000 different chemicals
Tar, carbon monoxide, irritants, and oxidant
gases
>40 carcinogens
The main adverse effect of nicotine from tobacco is addiction, which
sustains tobacco use
Nicotine dependence leads to continued exposure to toxins in tobacco
smoke
Smith et al. Food Chem Toxicol. 1997;35:1107–30.
Hoffman and Hoffman. J Toxicol Environ Health. 1997;50:307–64.
Benowitz NL. Nicotine Safety and Toxicity. New York: Oxford University Press, 1998.
Nicotine Replacement Therapy (NRT)
Goal: Attenuate symptoms related to nicotine
withdrawal
Dysphoric or depressed mood
Insomnia
Irritability, frustration, or anger
Anxiety
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
NRT: Treatment Options
Forms of NRT: Gum, Patch, Inhaler, Lozenge, Nasal spray, Sublingual
tablet
All forms of NRT appear to be similarly effective
NRT choice may be based on susceptibility to side effects, patient
preference, and availability
Little research on combinations of different types of NRT
Limited evidence that adding another form of NRT to the nicotine patch
increases the success rate
Plasma nicotine concentrations for smoking and NRT
14
Increase in nicotine
concentration ( ng/ml )
12
10
8
Cigarette
Gum 4 mg
6
Gum 2 mg
4
Inhaler
Nasal spray
Patch
2
0
5
10
15
20
25
30
Minutes
Balfour DJ and Fagerström KO. Pharmacol Ther. 1996;72:51-81.
NRT: Benefit of Behavioral Support
Limited Support
Intervention
Nicotine gum
Nicotine transdermal patch
Effect
size
5%
5%
95% CI
4%-6%
4%-7%
Intensive Support
Intervention
Nicotine gum
Nicotine transdermal patch
Nicotine nasal spray
Nicotine inhalator
Nicotine sublingual tablet
Effect size
8%
6%
12%
8%
8%
95% CI
6%-10%
5%-8%
7%-17%
4%-12%
1%-14%
West R, McNeill A and Raw M. Thorax. 2000;55:987-999.
Silagy C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2002; 1.
Safety of NRT
NRT is safe in most individuals with cardiovascular disease, even with
concomitant smoking
There is a negligible risk of cancer compared to the risk from continued
smoking
Although it is a potential fetal teratogen, the benefits outweigh the
risks of smoking during pregnancy
There is a low risk of abuse
Buproprion (Zyban)
Sustained release form of the
antidepressant
Acts by enhancing CNS noradrenergic
and dopaminergic function
Start 1 week before smoking cessation
date
150 mg QD x 3d, then 150 mg BID x 60d
Higher doses and longer duration with greater side effects and no clear
benefit
Buproprion (Zyban) vs. NRT
Jorenby DE et al. N Engl J Med. 1999 Mar 4;340(9):685-91
Other Therapies: Limited Success
Clonidine
Nortryptiline (tricyclic antidepressant)
Maclobemide (MAO-inhibitor)
Buspirone (anxiolytic)
Naloxone (opiate antagonist)
Naltrexone (opiate antagonist)
Amphetamines
‘Reduced risk’ cigarettes
Includes low tar and ‘light’ cigarettes, and novel
products that deliver nicotine with minimal
tobacco combustion
Low tar cigarettes have not be shown to
substantially reduce health hazards of smoking
but do provide sufficient nicotine to sustain
addiction
Some novel products may deliver fewer or lower
levels of toxins but some deliver more carbon
monoxide.
Smoking cessation medications are most likely
safer than any ‘reduced risk’ cigarette
Smokeless tobacco
Snuff or chewing tobacco has been suggested as a
potential aid to harm reduction or smoking
cessation
Such products known to cause oral cancer
Smokeless tobacco is addictive and not
recommended for smoking cessation
CLINICAL PRACTICE GUIDELINE
“TREATING TOBACCO USE AND DEPENDENCE”
• 6,000 ARTICLES (1975-99) INCORPORATING 50
META-ANALYSES
• REF: JAMA 2000; 283: 3244-3254
• AVAILABLE ON HTTP://WWW.AHQR.GOV
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
THE CLINICAL PRACTICE GUIDELINE ON SMOKING
WHAT’S NEW?
•
TREATMENT OF TOBACCO MUST BE CONSIDERED A
CHRONIC DISEASE
•
ALL CLINICIANS SHOULD OFFER AT LEAST A 3 MIN
COUNSELING INTERACTION AT EVERY VISIT
•
ALL SMOKERS WILLING TO QUIT SHOULD BE OFFERED
PHARMACOTHERAPY (EXCEPTIONS: PREGNANT/
BREAST - FEEDING WOMEN, ADOLESCENTS, THOSE
WITH MEDICAL CONTRAINDICATIONS, OR < 10
CIGS/DAY)
THE CLINICAL PRACTICE GUIDELINE ON SMOKING
WHAT’S NEW?
•
CLINICIANS AND HEALTH CARE DELIVERY
SYSTEMS MUST IDENTIFY, DOCUMENT, AND
TREAT EVERY TOBACCO USER
•
INSURERS AND PURCHASERS SHOULD
REIMBURSE:
a. COUNSELING/PHARMACOTHERAPY FOR
PATIENTS
b. CLINICIANS WHO PROVIDE TOBACCO
DEPENDENCE TREATMENT
PERFORMANCE MEASURES FOR SMOKING
CESSATION: HOW DO THEY DIFFER?
AMA - (1) ALL CHRONIC STABLE CORONARY
ARTERY DISEASE PTS IDENTIFIED AS
SMOKERS DURING THE REPORTING YEAR
(2) ALL CHRONIC STABLE CORONARY
ARTERY DISEASE PTS WHO RECEIVE
TOBACCO CESSATION INTERVENTION IN
THE REPORTING YEAR
HCFA - ALL AMI PTS. SMOKING WITHIN ONE YEAR
PRIOR TO ADMISSION WHO RECEIVE SMOKING
CESSATION ADVICE OR COUNSELING DURING
HOSPITALIZATION
PERFORMANCE MEASURES FOR SMOKING
CESSATION: HOW DO THEY DIFFER?
NCQA - BY SURVEY ALL CURRENT/RECENT
QUITTERS THAT HAD ONE OR MORE VISITS
INDICATING THEY RECEIVED ADVICE TO QUIT
FROM AN MCO PRACTITIONER
JCAHO - ALL AMI PATIENTS SMOKING WITHIN THE
YEAR PRIOR TO ADMISSION WHO RECEIVE
SMOKING CESSATION ADVICE OR COUNSELING
DURING HOSPITALIZATION
POINT OF ACCESS: THE USE OF
HOSPITALS FOR SMOKING CESSATION
• 30-40 MILLION PEOPLE HOSPITALIZED ANNUALLY
• 20-30% OF HOSPITALIZED PATIENTS SMOKE
• MOST SMOKERS HAVE HAD TO QUIT
• GREATER MOTIVATION TO QUIT
• OPPORTUNITY FOR COUNSELING
GENERAL INTERVENTION
METHODS
INHOSPITAL
• RN/MD COUNSELING
• AUDIOVISUAL MATERIALS
• SELF-HELP PAMPHLETS
POSTHOSPITAL
• RN INITIATED PHONE CALLS:
WEEKLY X 2-3 WEEKS
MONTHLY X 4-6 MONTHS
• NICOTINE REPLACEMENT THERAPY
• 1-2 FACE-TO-FACE VISITS AS NEEDED
DISSEMINATION OF “STAYING FREE”
SMOKING CESSATION PROGRAM
PRIMARY AIM
• TO DETERMINE EFFECTIVENESS OF INITIAL
IMPLEMENTATION INTO SEVERAL HOSPITALS IN
SAN FRANCISCO BAY AREA
SECONDARY AIM
• TO IMVESTIGATE FACTORS THAT PREDICT
SUSTAINABILITY OF STAYING FREE
STAYING FREE INTERVENTION
WHAT PATIENTS RECEIVE:
– A STRONG PHYSICIAN MESSAGE ABOUT THE
HAZARDS OF SMOKING
– A 17 PAGE WORKBOOK ON QUITTING SMOKING
– A 16 MINUTE VIDEOTAPE SHOWN AT THE
BEDSIDE ABOUT HOW TO REMAIN AN
EX-SMOKER
– A RELAXATION AUDIOTAPE
STAYING FREE INTERVENTION
WHAT PATIENTS RECEIVE:
– A COUNSELING SESSION AT THE BEDSIDE BY A
HEALTH CARE PROFESSIONAL
– PHARMACOLOGICAL THERAPY AS NEEDED
– FOLLOW-UP PHONE CALLS FROM HOSPITAL
STAFF AND/OR PUBLIC HEALTH (1 TO 4)
– OUTPATIENT REFERRALS TO PUBLIC HEALTH
PROGRAMS AND OTHER LOCAL RESOURCES
STANDARD PROGRAM IMPLEMENTATION

STAYING FREE HOSPITAL ADVISORY BOARD
– MULTIDISCIPLINARY TEAM COMPRISED OF
PHYSICIANS, PSYCHOLOGISTS, NURSING STAFF,
SOCIAL WORKERS, RESPIRATORY THERAPISTS
AND OTHERS
• PHYSICIAN ORIENTATION
– HOT PINK STAYING FREE STICKERS PLACED ON
PATIENT CHARTS TO CUE PHYSICIANS TO DELIVER
STRONG MESSAGE
– PHYSICIAN INFORMATION POCKET CARDS
– GRAND ROUNDS OR MONTHLY STAFF MEETING
PRESENTATIONS REGARDING PHYSICIANS’ KEY
ROLE IN SMOKING CESSATION
STANDARD PROGRAM IMPLEMENTATION

PATIENT IDENTIFICATION
– COMPUTERIZED ADMISSIONS FORMS OR PAPER ADMISSIONS SLIPS
– NURSING HISTORIES
– SELF REFERRAL TRIGGERED BY PUBLICITY MATERIALS (E.G.,
POSTERS)
– IDENTIFICATION QUESTIONS
 “HAVE YOU SMOKED ANY TOBACCO PRODUCTS IN THE PAST 30
DAYS?”
 “ARE YOU WILLING TO MAKE AN ATTEMPT TO QUIT SMOKING DURING
THIS HOSPITALIZATION?”
• REFERRAL
– PHYSICIANS, CASE MANAGERS, NURSING AND UNIT STAFF
– DEDICATED STAYING FREE TELEPHONE LINE
– REFERRAL SLIPS
STANDARD PROGRAM IMPLEMENTATION

PATIENT EDUCATION
– NURSING AND/OR INTERVENTION STAFF
PROVIDE PATIENT WORKBOOK, VIDEOTAPE
AND RELAXATION AUDIOTAPE
• FOLLOW-UP TELEPHONE CONTACT
– 1 TO 4 TIMES POST DISCHARGE
MODEL I: A VA HOSPITAL
PALO ALTO HEALTH CARE SYSTEM
• SPECIAL FEATURES:
– INTERVENTION PROVIDED BY PSYCHOLOGISTS,
PSYCHOLOGY INTERNS AND QUALITY ASSURANCE
NURSE
– USE OF CLOSED CIRCUIT TV TO SHOW VIDEO
– USE OF COMPUTERIZED STAYING FREE TEMPLATES
TO DOCUMENT INTERVENTION IN PATIENTS’
ELECTRONIC MEDICAL RECORDS
– STAYING FREE GROUP E-MAIL CREATED TO
DISSEMINATE INFORMATION/UPDATES TO TEAM
– “ASK ME ABOUT STAYING FREE” ID TAGS FOR STAFF
MODEL II: A COUNTY HOSPITAL
SANTA CLARA VALLEY MEDICAL CENTER
• SPECIAL FEATURES:
– INTERVENTION PROVIDED BY PHYSICIANS
– FOLLOW-UP PHONE CALLS PROVIDED BY SANTA
CLARA COUNTY PUBLIC HEALTH TOBACCO
PREVENTION AND EDUCATION PROGRAM
– SPANISH AND VIETNAMESE LANGUAGE
VERSIONS OF STAYING FREE
– CERTIFICATES OF ACHIEVEMENT FOR PATIENTS
MODEL III: COMMUNITY HOSPITALS
• SPECIAL FEATURES:
– MILLS-PENINSULA HEALTH SERVICES
 INTERVENTION PROVIDED BY CARDIAC REHABILITATION
AND A DIVERSE TEAM OF VOLUNTEERS (NURSING
STUDENT, FORMER CARDIAC REHABILITATION PATIENTS,
MENDED HEARTS VOLUNTEERS, RETIRED COUNSELORS)
 DEDICATED STAYING FREE PHONE LINE
– COMMUNITY HOSPITAL OF LOS GATOS
 INTERVENTION PROVIDED BY STAFF CHAPLAIN
 COMPUTERIZED IDENTIFICATION OF ALL SMOKERS AT
ADMISSION
MODEL IV: A UNIVERSITY TEACHING HOSPITAL
STANFORD UNIVERSITY HOSPITAL
• SPECIAL FEATURES:
– PARTNERSHIP WITH COMMUNITY AND PATIENT
RELATIONS PROGRAM
– INTERVENTION PROVIDED BY “SMOKING
CESSATION ADVISORS,” (HEALTH
PROFESSIONAL VOLUNTEERS AND MEDICAL
SCHOOL TRACK UNDERGRADUATES)
MAKING HOSPITAL-WIDE SYSTEM LEVEL
CHANGES THAT SUCCEED
STEP 1:
DETERMINE PERCENTAGE OF ALL SMOKERS
ENTERING A HOSPITAL WHO SMOKED IN
PAST 30 DAYS
• ADMISSION SHEETS
• FACE TO FACE CONTACT (2-4 WEEKS)
MAKING HOSPITAL-WIDE SYSTEM LEVEL
CHANGES THAT SUCCEED
STEP 2:
ACTIVELY SCREEN ALL SMOKERS
• UTILIZE COMPUTERIZED ADMISSION FORM
• INCORPORATE INTO NURSING HISTORIES
• INTEGRATE AS PART OF STANDING CCU/CSU
ADMISSION ORDERS
• INCORPORATE AS A VITAL SIGN
• USE PATIENT STICKERS
MAKING HOSPITAL-WIDE SYSTEM LEVEL
CHANGES THAT SUCCEED
STEP 3:
EXPECT ALL HEALTH CARE PROFESSIONALS
TO INTERVENE
• ASK ABOUT SMOKING STATUS APPROPRIATELY
• OFFER MOTIVATIONAL INTERVIEW
• DOCUMENT, DOCUMENT, DOCUMENT
(TRACKING FORM, PROGRESS NOTES)
MAKING HOSPITAL-WIDE SYSTEM LEVEL
CHANGES THAT SUCCEED
STEP 4:
TRAIN ALL MD’s TO RESPOND
• ASK ABOUT SMOKING STATUS APPROPRIATELY
• OFFER STRONG, CREDIBLE MESSAGE ABOUT
QUITTING
• DETERMINE NEED FOR PHARMACOLOGICAL
THERAPY
• DOCUMENT, DOCUMENT, DOCUMENT
(MEDICAL RECORD, TRACKING FORM)
MAKING HOSPITAL-WIDE SYSTEM LEVEL
CHANGES THAT SUCCEED
STEP 5:
CONSIDER A SYSTEM TO OFFER SELF-HELP
MATERIALS AND BEHAVIORAL COUNSELING
• STANDARDIZE PATIENT EDUCATION MATERIALS
• UTILIZE CLOSED-CIRCUIT TELEVISION FOR
VIDEOTAPES
• DETERMINE WHO CAN BE TRAINED TO PROVIDE
BEHAVIORAL COUNSELING (ie. VOLUNTEERS,
CANDIDATE MEDICAL STUDENTS, CHAPLAINS,
NURSES, PSYCHOLOGISTS)
• PROVIDE A LIST OF COMMUNITY RESOURCES
MAKING HOSPITAL-WIDE SYSTEM LEVEL
CHANGES THAT SUCCEED
STEP 6:
DETERMINE A MECHANISM FOR FOLLOW-UP
• USE SMOKING INTERVENTIONISTS TO UNDERTAKE
PATIENT FOLLOW-UP
• OFFER TELEPHONE CONTACT BY HEALTH CARE
PROFESSIONALS ALREADY MAKING CALLS
• INTEGRATE CALLS WITHIN PUBLIC HEALTH DEPT.
• USE CENTRALIZED TELEPHONE SYSTEM FOR ALL
SMOKERS WITHIN COMMUNITY
• DOCUMENT, DOCUMENT, DOCUMENT
Clinician’s Guide, Agency for Health Care
Policy and Research
Quit Smoking Action Plan, American Lung
Association