Research Articles
The use of nicotine-replacement therapy by hospitalized smokers1

https://doi.org/10.1016/S0749-3797(99)00095-1Get rights and content

Abstract

Background: No-smoking policies are mandatory in U.S. hospitals. Consequently, smokers who are hospitalized must temporarily stop smoking. Nicotine-replacement therapy (NRT) could help hospitalized smokers relieve nicotine withdrawal symptoms, comply with no-smoking policies, and sustain tobacco abstinence after discharge. The extent of NRT use in the hospital setting is unknown. We describe the prevalence and patterns of NRT use in hospitalized smokers.

Design: Prospective observational study within a randomized smoking-intervention trial.

Setting/ Participants: Six hundred fifty adult smokers admitted to the medical and surgical services of a large urban teaching hospital that prohibits smoking in all indoor areas. Follow-up was at 6 months.

Main Outcome Measure: Inpatient pharmacy records of nicotine patch or gum use.

Results: Only 34 of 650 smokers (5.2%) received NRT during their hospital stay, including only 9.6% of smokers who reported difficulty refraining from smoking while hospitalized and 9.0% of hospitalized smokers with nicotine withdrawal. NRT was more likely to be prescribed to patients with nicotine withdrawal (OR 2.23; 95% CI: 1.01, 4.90), a higher daily cigarette consumption (OR 1.04; 95% CI: 1.01, 1.06), and a longer hospitalization (OR 1.05; 95% CI: 1.00, 1.10). NRT use was independent of a patient’s intention to quit smoking after discharge and was not associated with smoking cessation 1 and 6 months after discharge.

Conclusions: NRT was rarely used in this hospital, even among those who could have benefited from it to treat nicotine-withdrawal symptoms. When NRT was used, relief of nicotine withdrawal, rather than assistance with smoking cessation, appeared to be the primary goal. Greater use of NRT could benefit the estimated 6.5 million smokers who are hospitalized annually by reducing nicotine withdrawal, encouraging smoking cessation, and ensuring compliance with hospital no-smoking policies.

Introduction

United States hospitals are now required to have no-smoking policies in order to be accredited.1, 2 Therefore, a hospital stay requires a smoker to abstain temporarily from tobacco. This offers hospitalized smokers an opportunity to initiate cessation, but it can also precipitate nicotine-withdrawal symptoms in hospitalized smokers, causing discomfort and reducing smokers’ compliance with no-smoking policies.3, 4, 5 Nicotine-replacement therapy (NRT) is an effective smoking-cessation treatment that reduces the symptoms of nicotine withdrawal.6, 7 Nicotine-replacement therapy offers hospitalized smokers a way to reduce the discomfort of nicotine withdrawal in the hospital and increase the chance of remaining abstinent from tobacco after discharge.

Smoking-cessation clinical practice guidelines from the Agency for Health Care Policy and Research (AHCPR) recommend that hospitalized smokers be offered all effective smoking-cessation treatments, including NRT where appropriate.7 Nicotine-replacement therapy is considered appropriate first-line therapy for smoking unless medically contraindicated. Relative contraindications are the presence of severe or unstable angina, serious ventricular arrhythmias, or recent myocardial infarction.7 While patients with these diagnoses are usually hospitalized, many other hospitalized smokers do not have these conditions and would be eligible for NRT. The AHCPR guidelines also endorse the temporary use of NRT during a smoker’s hospitalization with the more limited goal of reducing nicotine-withdrawal symptoms. Despite these recommendations, little is known about the extent or pattern of NRT use in hospitalized smokers. The goal of this study was to describe the prevalence and pattern of NRT use in a large sample of hospitalized smokers.

Section snippets

Methods

We analyzed data from 650 adult smokers who participated in a randomized, controlled trial of an inpatient smoking counseling intervention conducted at Massachusetts General Hospital, an 860-bed Boston teaching hospital that prohibited smoking in all indoor areas at the time of the study. The study methods have been described in detail.8 During 1 year (1994–1995), we recruited adult (≥18 years old) smokers admitted to the medical and surgical services, excluding those who were transferred from

Study population

The study enrolled 650 hospitalized smokers, all of whom survived to discharge. We followed 602 of the 635 survivors (95%) for 1 month and 542 of 615 survivors (88%) for 6 months. The sample was 55% male, 92% white, 42% married, and 42% employed. Mean age was 49.2 ± 16.2 (1 SD) years. Mean educational attainment was 12.4 ± 2.5 years. A prior smoking-related disease diagnosis (ischemic cardiovascular disease, peripheral vascular disease, cerebrovascular disease, chronic obstructive pulmonary

Discussion

Nicotine-replacement therapy was rarely used in this hospital, even among patients who might have particularly benefited from its use, e.g., those who reported having difficulty refraining from smoking in the hospital or who had nicotine-withdrawal symptoms. Even fewer patients used NRT to maintain their tobacco abstinence after hospital discharge despite its established efficacy as a smoking-cessation aid.

The primary indication for NRT is to aid smoking cessation by reducing

Conclusions

In conclusion, this study indicates that NRT is rarely used in the hospital setting, despite the presence of nicotine-withdrawal symptoms among hospitalized smokers. The AHCPR smoking-cessation practice guideline was released in 1996, after this study was conducted (1994–1995), and it is possible that NRT is now more often prescribed to hospitalized smokers. However, the nicotine gum and patch became over-the-counter drugs in 1996. Physicians now prescribe NRT less often to outpatients and may

Acknowledgements

We are indebted to Anne Thorndike, MD, Becky Kemp, Brayden Mathews, and Elizabeth Niewoehner, MD, for help in data collection.

Supported by a grant from the American Cancer Society, Massachusetts Division, and by a National Cancer Institute Preventive Oncology Academic Award (#CA01673) to Dr. Rigotti.

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