Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial.

PURPOSE: To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers. DESIGN: Pre-post quasi-experimental trial. SETTING: General medical units of four US Department of Veterans Affairs hospitals. SUBJECTS: 898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively). INTERVENTION: The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback. MEASURES: The primary outcome was self-reported 7-day point prevalence abstinence at six months. ANALYSIS: Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression. RESULTS: Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI95)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI95=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001). CONCLUSIONS: Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.

Implementing Best Evidence in Smoking Cessation Treatment for Hospitalized Veterans: Results from the VA-BEST Trial.

BACKGROUND: Although the US Department of Veterans Affairs (VA) has promoted adherence to smoking cessation guidelines since 1997, hospitalized smokers do not consistently receive assistance in quitting. METHODS: In a pre-post guideline implementation trial on the inpatient medicine units of four VA hospitals, the effectiveness of a multimodal intervention (enhanced academic detailing, modification of the nursing admission template, patient education materials and quitline referral, practice facilitation and staff feedback) changing practice behavior was evaluated. Peridischarge interviews were conducted with 824 patients to assess receipt of nurses' and physicians' delivery of the 5A's (Ask, Advise, Assess, Assist, Arrange) in hospitalized smokers. RESULTS: Subjects were significantly more likely to have received each of the 5A's from a nurse during the postimplementation period (except for "advise to quit"). More patients were assisted in quitting (75% versus 56%, adjusted odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.6, 3.1) and had follow-up arranged (23% versus 18%, adjusted OR = 1.5, 95% CI = 1.0, 2.2) by a nurse during the postimplementation period. However, unadjusted results showed no improvement in seven-day point prevalence abstinence at six-month follow-up (13.5% versus 13.9%). Nurses' self-efficacy in cessation counseling, as measured in a survey of 166 unit nurses, improved following guideline implementation. DISCUSSION: A multifaceted intervention including enhanced academic detailing is an effective strategy for improving the delivery of smoking cessation services in medical inpatients. To promote long-term cessation, more intensive interventions are needed to ensure that motivated smokers receive guideline-recommended treatment (including pharmacotherapy and referral to outpatient cessation counseling).

A PDA intervention to sustain smoking cessation in clients with socioeconomic vulnerability.

This article describes a pilot study to explore use of a personal digital assistant (PDA) to sustain smoking cessation after discharge in clients with socioeconomic vulnerability. The major aim is to describe technology acceptance (perceived ease of use, usefulness, and attitude), portability, technical difficulty, satisfaction, and use time. The sample includes 31 medical surgical clients with average age of 47.35 (+/-13.3), average household income of $13,629 (+/-8,204), average number in the household of 2.67 (+/-2.22), and average education of 11th grade. The results demonstrate mean use time of 9.28 (+/-3.23) hr, or about 1 hr over 8 weeks. Technology acceptance responses indicate the PDA is viewed as useful to the task of smoking cessation but is not perceived as easy to use. The most beneficial aspect is the portability. There are benefits to a PDA smoking cessation intervention but more study is needed before it can be used in practice.

An exploratory study of multicomponent treatment intervention for tobacco dependency.

PURPOSE: To conduct an exploratory study of two interventions to help smokers abstain over a period of 3 months. The specific aims were to describe the outcomes, test feasibility of the study design, and evaluate effect size. DESIGN AND METHODS: A randomized experimental design was used in a sample of 42 patients who received multicomponent treatment intervention (MTI) or standard care (SC) in a midwestern city in the United States. Variables were behavioral (quit rate, self-efficacy, motivation), psychosocial (depression, partner interaction), and symptom management (use of nicotine replacement therapy [NRT]). Data analysis included descriptive statistics and repeated measures ANOVA. RESULTS: The typical participant was Caucasian, middle aged, nicotine dependent, married or partnered, and employed, and had a high school education. Participants in the MTI group were more likely to use NRT and to have higher self-reported quit rates at follow-up. Statistically significant differences were found between groups over time for self-efficacy and positive to negative behavior ratio. Barriers to quitting were relapse, stress, weight gain, lack of support, and depression that were more frequent in the SC group. For effect size (0.25), probability level (.05), and power (.80), a sample size of 140 patients was calculated. CONCLUSIONS: The MTI group had higher quit rates, more NRT, higher self-efficacy, and more positive behavioral interactions. Limitations of the study included self-report of tobacco use, small sample, and attrition. The investigators suggest a future study with a larger sample to test whether multicomponent interventions with telephone calls after discharge are more effective than is standard care in helping patients to quit and continue to abstain from smoking.