General strategy 9. Clinical issues when assisting a pregnant patient in smoking cessation Recommendation: For every hospitalized patient, the following steps should be taken: (a) ask each patient on admission if he/she smokes and document smoking status; (b) for current smokers, list smoking status on the admission problem list and as a discharge diagnosis; (c) assist all smokers with quitting during the hospitalization, using treatments identified as effective in this guideline, including nicotine replacement therapy if appropriate; and (d) provide advice and assistance on how to remain abstinent after discharge. (Strength of Evidence = C) It is vital that hospitalized patients attempt to quit smoking, because smoking may interfere with their recovery. Among cardiac patients, second heart attacks are more common in those who continue to smoke (Multiple Risk Factor Intervention Trial Research Group, 1990). Lung, head, and neck cancer patients who are successfully treated, but who continue to smoke, are at elevated risk for a second cancer (Browman, Wong, Hodson, et al., 1993). Smoking negatively affects bone and wound healing (Jones, 1985). Every hospital in the United States must now be smoke free if it is to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As a result, hospitalized patients may be particularly motivated to make a quit attempt for two reasons. First, the illness resulting in hospitalization may have been caused or exacerbated by smoking, highlighting the patient's personal vulnerability to the health risks of smoking. Second, motivation may be enhanced during hospitalization because the smoker is temporarily housed in a smoke-free environment. For these reasons, clinicians should use hospitalization as an opportunity to promote smoking cessation in their patients who smoke (Hurt, Lauger, Offord, et al., 1991; Stevens, Glasgow, Hollis, et al., 1993). Patients in longterm care facilities should also receive cessation interventions identified as efficacious in this guideline. Specifically, clinicians and hospital administrators should collaborate to ensure that systems are in place that identify the smoking status of all patients admitted to a hospital and that provide at least a brief clinical intervention to every hospitalized patient who smokes. Finally, smokers may experience nicotine withdrawal symptoms during a hospitalization. Clinicians should consider providing temporary nicotine patch therapy during a hospitalization to reduce such symptoms. Efficacy of Inpatient Hospital Smoking Cessation Treatment Five studies met selection criteria for analyses examining the effectiveness of inpatient hospital smoking cessation treatment compared with usual care. Because of the limited number of studies, no attempt was made to separate the level or type of treatment. Results are shown in Table 19. Evidence. Smoking cessation interventions among hospitalized patients increase rates of smoking cessation. (Strength of Evidence = A) Smokers With Psychiatric Comorbidity Recommendation: Smokers with comorbid psychiatric conditions should be offered smoking cessation treatments identified as effective in this guideline. (Strength of Evidence = C) Recommendation: Although it is not necessary to assess for psychiatric comorbidity prior to initiating smoking treatment, such assessment may be helpful in that it allows the clinician to prepare for an increased likeli Table 19. Efficacy of inpatient smoking cessation treatment (n = 5 studies) hood of smoking relapse or for exacerbation of the comorbid condition in response to nicotine withdrawal. (Strength of Evidence = C) The term "psychiatric comorbidity” refers to the co-occurrence of smoking with another psychiatric disorder. Psychiatric comorbidity is important to the assessment and treatment of smokers for several reasons: Psychiatric disorders are more common among smokers than in the general population. For instance, as many as 30-50 percent of patients seeking smoking cessation services may have a history of depression, and 20 percent or more may have a history of alcohol abuse or dependence (Brandon, 1994; Glassman, Stetnes, Walsh, et al., 1988; Hall, Munoz, Reus, et al., 1993; also cf. Breslau, 1995; Breslau, Kilbey, and Andreski, 1994). Smoking cessation or nicotine withdrawal may exacerbate a patient's comorbid condition. For instance, smoking cessation may elicit or exacerbate depression among patients with a prior history of affective disorder (Glassman, 1993; Glassman, Covey, Dalack, et al., 1993). As noted in the Specialized Assessment section in Chapter 3, smokers with psychiatric comorbidities have heightened risk for relapse to smoking after a cessation attempt (Brandon, 1994; Glassman, Covey, Dalack, et al., 1993; Hall, Munoz, Reus, et al., 1993). Although psychiatric comorbidity places smokers at increased risk for relapse, there is also evidence that such smokers can be helped by smoking cessation treatments (Breckenridge, 1990; Burling, Marshall, and Seidner, 1991; Hall, Munoz, and Reus, 1994; Hartman, Jarvik, and Wilkins, 1989; Hartman, Leong, Glynn, et al., 1991). There is currently too little evidence to determine whether smokers with psychiatric comorbidity benefit more from specialized or tailored cessation treatments than from standard treatments (e.g., Hall, Munoz, and Reus, 1994; Zelman, Brandon, Jorenby, et al., 1992). Even though some smokers may experience exacerbation of a comorbid condition upon quitting smoking, most evidence suggests that cessation entails little adverse impact. For instance, patients in inpatient psychiatric units are able to stop smoking with few adverse effects (e.g., little increase in aggression, or nonadherence to treatment; Hurt, Eberman, Slade, et al., 1993; Resnick, 1993). Additionally, there is little evidence that patients with other chemical dependencies relapse to other drug use when they stop smoking (Hurt, Eberman, Slade, et al., 1993). Finally, stopping smoking may affect the pharmacokinetics of certain psychiatric agents (e.g., Hughes, 1993). Therefore, clinicians may wish to monitor closely the actions or side effects of psychiatric medications in smokers making a quit attempt. Weight Gain After Smoking Cessation Recommendation: The clinician should inform smokers that they are likely to gain weight when they stop smoking. The clinician should recommend that smokers not take strong measures (e.g., strict dieting) to counteract weight gain during a quit attempt. Moreover, ex-smokers should wait until they are confident that they will not return to smoking before trying to reduce their weight. (Strength of Evidence = C) Recommendation: For smokers who are greatly concerned about weight gain, the clinician may prescribe or recommend nicotine gum, which has been shown to delay weight gain after quitting. (Strength of Evidence = A) Key facts about smoking, smoking cessation, and weight gain follow: The majority of smokers who quit smoking gain weight. Most will gain fewer than 10 pounds, but there is a broad range of weight gain, with as many as 10 percent of quitters gaining as much as 30 pounds (Williamson, Madans, Anda, et al., 1991). Women tend to gain slightly more weight than men, and for both sexes, African Americans, people under age 55, and heavy smokers (those smoking more than 25 cigarettes/day) are at elevated risk for major weight gain (Emont and Cummings, 1987; Williamson, Madans, Anda, et al., 1991). For many smokers, especially women, concerns about weight or fears about weight gain are motivators to start smoking or continue smoking (Gritz, Klesges, and Meyers, 1989; Klesges and Klesges, 1988; Klesges, Meyers, Klesges, et al., 1989). Weight gain that follows smoking cessation is a negligible health threat compared with the risks of continued smoking (DHHS, 1990; Williamson Madans, Anda, et al., 1991). No experimentally validated strategies or treatments are effective in preventing postcessation weight gain. In fact, some evidence suggests that attempts to prevent weight gain (e.g., strict dieting) may undermine the attempt to quit smoking (Hall, Tunstall, Vila, et al., 1992; Perkins, 1994; Pirie, McBride, Hellerstedt, et al., 1992). Nicotine replacement-in particular, nicotine gum-appears to be Postcessation weight gain appears to be caused both by increased The research evidence reviewed above illustrates why weight gain is an important impediment to smoking cessation. Many smokers (especially women) are very concerned about their weight and fear that quitting will produce weight gain. Many also believe that they can do little to prevent postcessation weight except to return to smoking. These beliefs are especially difficult to address clinically because they are congruent with research findings; that is, the beliefs have some basis in fact. Recommendations To Address Weight Gain How should the clinician deal with concerns about weight gain? First, the clinician should neither deny the likelihood of weight gain nor minimize its significance to the patient. Rather, the clinician should inform the patient about the likelihood of weight gain and prepare the patient for its occurrence. However, the clinician should counter exaggerated fears about weight gain given the relatively moderate weight gain that typically occurs. Certain types of information may help prepare the patient for postcessation weight gain (see General Strategy 10). Second, before and during the quit attempt the clinician should stress that quitting smoking is the patient's primary, immediate priority, and that the patient will be most successful in the long run if he or she does not take strong measures (e.g., strict dieting) to counteract weight gain during a quit attempt (see General Strategy 10). Third, during the quit attempt, the clinician should offer to help the patient address weight gain (either personally or via referral) once the patient |