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Stopping smoking after myocardial infarction

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... Several randomised studies have investigated whether a smoking cessation programme with 3-6 months of intervention is able to increase the quit rates (24,(37)(38)(39)(40). Two studies showed an approximately 20% increase in cessation rates at 1-year follow-up after delivering the social learning theory and the transtheoretical model, respectively, by especially trained personnel (39,40). ...
... Two other investigations used simpler intervention principles (24,37). A Lancet paper showed 62% abstainers in the intervention group compared to 28% in the usual care group after telling the patients that continued smoking could lead to further heart attacks because it would narrow the arteries in a manner similar to furring in a pipe, sometimes with complete blockage (37). ...
... Two other investigations used simpler intervention principles (24,37). A Lancet paper showed 62% abstainers in the intervention group compared to 28% in the usual care group after telling the patients that continued smoking could lead to further heart attacks because it would narrow the arteries in a manner similar to furring in a pipe, sometimes with complete blockage (37). A similar fear arousal message was delivered in an investigation of 250 patients admitted for acute myocardial infarction, unstable angina or coronary bypass surgery (24). ...
Article
Approximately one-third of the adult population in industrial countries and 70% in several Asian countries are daily smokers. Tobacco is now regarded as the world's leading cause of death. Approximately two-thirds of lifelong smokers eventually die because of smoking. Smoking cessation is the most effective action to reduce mortality in patients with chronic obstructive pulmonary disease (COPD) and coronary heart disease. The aim of this study was to determine the effectiveness of smoking cessation programmes in patients with smoking-related disorders. Medline was searched for studies of interventions for smoking cessation in patients. In patients with cardiovascular diseases and COPD, smoking cessation programmes with behavioural support over several months significantly increase quit rates. The intensity of the programmes seems to be proportional to the effect. A long follow-up period is probably the most important element in the programmes. Even the most intensive programmes are very cost-effective in terms of cost per life-year gained. Effective programmes can be delivered by personnel without special education in smoking cessation using simple intervention principles. In patients with smoking-related disorders, smoking cessation interventions with several months of follow-up are effective and easily applicable in clinical practice. Wider implementation of such programmes would be a cost-effective way of saving lives.
... 36 Almost 50 years ago, it was noted that hospitalisation following myocardial infarction afforded a unique opportunity to successfully assist with smoking cessation. 37 The substantial role that tobacco addiction plays in cardiac morbidity and mortality has been recognised for decades. 38 Multiple investigators have identified the very significant clinical benefits that follow the delivery of smoking cessation in cardiac settings. ...
Article
The systematic integration of evidence-based tobacco treatment has yet to be broadly viewed as a standard-of-care. The Framework Convention on Tobacco Control recommends the provision of support for tobacco cessation. We argue that the provision of smoking cessation services in clinical settings is a fundamental clinical responsibility and permits the opportunity to more effectively assist with cessation. The role of clinicians in prioritising smoking cessation is essential in all settings. Clinical benefits of implementing cessation services in hospital settings have been recognised for three decades—but have not been consistently provided. The Ottawa Model for Smoking Cessation has used an ‘organisational change’ approach to its introduction and has served as the basis for the introduction of cessation programmes in hospital and primary care settings in Canada and elsewhere. The significance of smoking cessation dwarfs that of many preventive interventions in primary care. Compelling evidence attests to the importance of providing cessation services as part of cancer treatment, but implementation of such programmes has been slow. We recognise that the provision of such services must reflect the realities and resources of a particular health system. In low-income and middle-income countries, access to treatment facilities pose unique challenges. The integration of cessation programmes with tuberculosis control services may offer opportunities; and standardisation of peri-operative care to include smoking cessation may not require additional resources. Mobile phones afford unique opportunities for interactive cessation programming. Health system change is fundamental to improving the provision of cessation services; clinicians can be powerful advocates for such change.
... Sensitivity analysis: A sensitivity analysis excluding four studies that reported the use of NRT within the highest intervention intensity 8-10 16 did not suggest that the eYcacy of these interventions was due to the use of NRT (POR 1.61, 95% CI 1.26 to 2.06). Only one study that delivered a minimal intensity intervention Allen (1998) 17 Not inpatients (delivered at outpatient clinic) BTS (1983) 18 Inpatient and outpatient data not reported separately Burt (1974) 19 Not randomised Colby (1998) 20 Short follow up (3 months). Only investigated adolescent smokers Dale (1995) 21 Not inpatients (some participants admitted to inpatients unit for smoking intervention) Gritz (1993) 22 Not inpatients (only recruitment carried out in hospital setting) Johnson (1999) 23 Not randomised Meenan (1998) 24 Not randomised Schmitz (1999) 25 No control/usual care group Strecher (1985) 26 Not randomised Wewers (1994) 27 Short follow up (5 weeks) with follow up (intensity 3) reported the use of NRT, 30 but this was in only about 4% of participants so a sensitivity analysis was not possible. ...
Article
BACKGROUND An admission to hospital provides an opportunity to help people stop smoking. Individuals may be more open to help at a time of perceived vulnerability, and may find it easier to quit in an environment where smoking is restricted or prohibited. Providing smoking cessation services during hospitalisation may help more people to attempt and sustain an attempt to quit. The purpose of this paper is to systematically review the effectiveness of interventions for smoking cessation in hospitalised patients. METHODS We searched the Cochrane Tobacco Addiction Group register, CINAHL, and the Smoking and Health database for studies of interventions for smoking cessation in hospitalised patients. Randomised and quasi-randomised trials of behavioural, pharmacological, or multi-component interventions to help patients stop smoking conducted with hospitalised patients who were current smokers or recent quitters were included. Studies of patients admitted for psychiatric disorders or substance abuse, those that did not report abstinence rates, and those with follow up of less than 6 months were excluded. Two of the authors extracted data independently for each paper, with assistance from others. RESULTS Intensive intervention (inpatient contact plus follow up for at least 1 month) was associated with a significantly higher cessation rate compared with controls (Peto odds ratio (OR) 1.82, 95% CI 1.49 to 2.22). Any contact during hospitalisation followed by minimal follow up failed to detect a statistically significant effect on cessation rate, but did not rule out a 30% increase in smoking cessation (Peto OR 1.09, 95% CI 0.91 to 1.31). There was insufficient evidence to judge the effect of interventions delivered only during the hospital stay. Although the interventions increased quit rates irrespective of whether nicotine replacement therapy (NRT) was used, the results for NRT were compatible with other data indicating that it increases quit rates. There was no strong evidence that clinical diagnosis affected the likelihood of quitting. CONCLUSIONS High intensity behavioural interventions that include at least 1 month of follow up contact are effective in promoting smoking cessation in hospitalised patients.
... In the setting of recent myocardial infarction, 70% of smokers could be persuaded to quit. 61 Smoking increases risk of stroke six-fold, while quitting smoking greatly reduces that risk. 62 A crucial role of successful management of smoking as a serious health problem is to understand how difficult sometimes for the patient to quit. ...
Article
Full-text available
Cigarette smoking is a major modifiable risk factor for cardiovascular disease (CVD), including coronary artery disease (CAD), heart attacks, stroke, peripheral vascular disease, and congestive heart failure. The hazardous effects of smoking on the cardiovascular system are multiple and synergistic. Mechanisms include mainly vascular endothelial and smooth cell dysfunction, enhanced platelet aggregability, disturbed lipid profile, thrombosis, and hemodynamic changes. These effects, both, increase the likelihood of an acute event as well as contribute to longterm development of CAD. Tobacco smoke may also cause insulin resistance, a risk factor for diabetes and CVD. The same mechanisms responsible for CVD in active smokers are nearly as large in passive smokers. The specific ingredients of cigarette smoke responsible for its cardiovascular effects include mainly the polycyclic aromatic hydrocarbons, nicotine, oxidizing agents and particulate matter. Although smoking has been well clarified as the leading cause of cardiovascular morbidity and mortality worldwide, still a large scale of population continues to smoke while others start to smoke adding more victims to this bad habit. The death toll from tobacco is expected to climb to about 10 million people per year within next 25 years. 70% of victims will be in low- and middle income countries. It is estimated that eventually 50% of all smokers will be killed by direct or indirect effects of tobacco. This review highlights atherosclerosis as one of the serious complications of smoking with discussion of its mechanisms and detrimental consequences particularly peripheral arterial disease, stroke and coronary artery disease.
... The threat posed by a recent TIA or stroke presents a special " teachable moment " for smokers who may not previously have been ready to quit. Burt et al. [22] showed that, in the setting of recent myocardial infarction, 70% of smokers could be persuaded to quit. I use a parable borrowed from a Lancet article on weight loss [23]: " Yes, quitting smoking is very difficult. ...
Article
Full-text available
Stroke prevention is an urgent priority because of the aging of the population and the steep association of age and risk of stroke. Direct costs of stroke are expected to more than double in the US between 2012 and 2030. By getting everything right, patients can reduce the risk of stroke by 80% or more; however, getting everything right is a tall order. Roughly in order of importance, this requires smoking cessation, maintenance of a healthy weight, a Cretan Mediterranean diet, blood pressure control, lipid-lowering drugs, appropriate use of antiplatelet agents and anticoagulants, and appropriate carotid endarterectomy and stenting. A new approach called "treating arteries instead of targeting risk factors" appears promising but requires validation in randomized trials.
... A study showed that if 36% of cardiac patients stop cigarette smoking, it results in a 30% reduction in cardiovascular mortality. 26 Lack of exercise is also an important risk factor for coronary and all-cause mortality. However, reliable trials on the health effects of exercise in cardiac patients have not been performed. ...
Article
Research on the cause of coronary heart disease has been ongoing for approximately a century.1 From the beginning, diet played a prominent role in research on the origin of coronary heart disease. The original diet-heart hypothesis was very simple. Cholesterol is a constituent of the atherosclerotic plaque. Therefore, it was thought that there was a direct relation between cholesterol in the diet (ie, eggs), cholesterol in the blood, cholesterol in the plaque, and its clinical complications, such as myocardial infarction. In the second part of the past century, it became clear that dietary cholesterol played a minor role in regulating serum cholesterol levels. It was also shown that dietary fatty acids are the major determinants of serum cholesterol.2 The study of lipoprotein metabolism showed that the cholesterol-rich LDL fraction, not total cholesterol, was most strongly related to the development of atherosclerosis and its sequelae.3 Experimental research was essential to understand the mechanisms by which genes, hormones, and diet interact to regulate the serum cholesterol level.4 LDL cholesterol levels can be increased by saturated fatty acids, especially those with 12 to 16 carbon atoms, and by trans fatty acids.5 Several hypotheses have been proposed to explain the initiating events in atherogenesis, eg, the response-to-injury, response-to-retention, and oxidation hypotheses.6–8⇓⇓ These hypotheses are not mutually exclusive and may even be compatible with each other. The oxidation hypothesis emphasizes the importance of oxidative modification in the atherosclerotic process, because compared with native LDL, oxidized LDL is preferentially taken up in the arterial wall.8 This hypothesis makes a role of diet and lifestyle in atherogenesis likely, because LDL can be oxidized by smoking, for example, and oxidation can be prevented by dietary antioxidants, eg, vitamins and polyphenols. There is overwhelming evidence that smoking, alcohol, and physical …
... Sensitivity analysis: A sensitivity analysis excluding four studies that reported the use of NRT within the highest intervention intensity 8-10 16 did not suggest that the eYcacy of these interventions was due to the use of NRT (POR 1.61, 95% CI 1.26 to 2.06). Only one study that delivered a minimal intensity intervention Allen (1998) 17 Not inpatients (delivered at outpatient clinic) BTS (1983) 18 Inpatient and outpatient data not reported separately Burt (1974) 19 Not randomised Colby (1998) 20 Short follow up (3 months). Only investigated adolescent smokers Dale (1995) 21 Not inpatients (some participants admitted to inpatients unit for smoking intervention) Gritz (1993) 22 Not inpatients (only recruitment carried out in hospital setting) Johnson (1999) 23 Not randomised Meenan (1998) 24 Not randomised Schmitz (1999) 25 No control/usual care group Strecher (1985) 26 Not randomised Wewers (1994) 27 Short follow up (5 weeks) with follow up (intensity 3) reported the use of NRT, 30 but this was in only about 4% of participants so a sensitivity analysis was not possible. ...
Article
BACKGROUND An admission to hospital provides an opportunity to help people stop smoking. Individuals may be more open to help at a time of perceived vulnerability, and may find it easier to quit in an environment where smoking is restricted or prohibited. Providing smoking cessation services during hospitalisation may help more people to attempt and sustain an attempt to quit. The purpose of this paper is to systematically review the effectiveness of interventions for smoking cessation in hospitalised patients. METHODS We searched the Cochrane Tobacco Addiction Group register, CINAHL, and the Smoking and Health database for studies of interventions for smoking cessation in hospitalised patients. Randomised and quasi-randomised trials of behavioural, pharmacological, or multi-component interventions to help patients stop smoking conducted with hospitalised patients who were current smokers or recent quitters were included. Studies of patients admitted for psychiatric disorders or substance abuse, those that did not report abstinence rates, and those with follow up of less than 6 months were excluded. Two of the authors extracted data independently for each paper, with assistance from others. RESULTS Intensive intervention (inpatient contact plus follow up for at least 1 month) was associated with a significantly higher cessation rate compared with controls (Peto odds ratio (OR) 1.82, 95% CI 1.49 to 2.22). Any contact during hospitalisation followed by minimal follow up failed to detect a statistically significant effect on cessation rate, but did not rule out a 30% increase in smoking cessation (Peto OR 1.09, 95% CI 0.91 to 1.31). There was insufficient evidence to judge the effect of interventions delivered only during the hospital stay. Although the interventions increased quit rates irrespective of whether nicotine replacement therapy (NRT) was used, the results for NRT were compatible with other data indicating that it increases quit rates. There was no strong evidence that clinical diagnosis affected the likelihood of quitting. CONCLUSIONS High intensity behavioural interventions that include at least 1 month of follow up contact are effective in promoting smoking cessation in hospitalised patients.
... These RCTs enrolled a total of 2105 patients. Six additional behavioural studies were identified, but were excluded because patients were not randomly assigned or follow-up was insufficient (12)(13)(14)(15)(16)(17). The 11 behavioural RCTs retained involved a broad range of cardiac patients (Table 1). ...
Article
Several meta-analyses have examined the efficacy of smoking cessation therapies in the general population. However, little is known about the efficacy of these therapies in cardiac patients. Therefore, a meta-analysis of randomized controlled trials (RCTs) was performed to determine the efficacy of behavioural therapy and pharmacotherapy for smoking cessation in cardiac patients. The medical literature was systematically reviewed to identify smoking cessation RCTs in cardiac patients. Only RCTs that reported smoking abstinence at six or 12 months were included. Smoking abstinence was examined based on the 'most rigorous criterion', defined as the most conservative outcome reported in any given RCT. Eleven behavioural therapy RCTs that enrolled 2105 patients and four pharmacotherapy RCTs that enrolled 1542 patients were identified. RCTs differed in the type of behavioural therapy administered as well as the total length and duration of the intervention. RCTs differed in the type of pharmacotherapy administered (one nicotine patch RCT, one nicotine gum RCT and two bupropion RCTs). Behavioural therapy was associated with a significantly higher proportion of smoking abstinence than usual care (OR 1.97 [95% CI 1.37 to 2.85]). Pharmacotherapies were more efficacious than placebo (pooled OR 1.72 [95% CI 1.15 to 2.57]). Both behavioural therapy and pharmacotherapy are more efficacious than usual care for smoking cessation in cardiac patients. The present meta-analysis highlights the need for head-to-head RCTs to identify which smoking cessation therapy is preferred in cardiac patients as well as RCTs examining the efficacy of combined behavioural and pharmacotherapies.
Article
Background: Healthcare professionals frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions. Objectives: The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality. Search methods: We searched the Cochrane Tobacco Addiction Group trials register in January 2013 for trials of interventions involving physicians. We also searched Latin American databases through BVS (Virtual Library in Health) in February 2013. Selection criteria: Randomised trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided. Data collection and analysis: We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomisation and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. People lost to follow-up were counted as smokers. Effects were expressed as relative risks. Where possible, we performed meta-analysis using a Mantel-Haenszel fixed-effect model. Main results: We identified 42 trials, conducted between 1972 and 2012, including over 31,000 smokers. In some trials, participants were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics.Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow-up. Authors' conclusions: Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.
Article
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Meta-analysis was used to examine 108 intervention comparisons in 39 controlled smoking cessation trials. Type of intervention (face-to-face advice being better than all others), type of intervenor (both physician and nonphysician counselors better than either alone), the number of reinforcing sessions, and the duration of reinforcing sessions were related to success six months after the initiation of intervention. The number of modalities used by the intervention predicted success with borderline statistical significance. Multivariate analysis predicted that a team of physicians and nonphysicians using multiple intervention modalities to deliver individualized advice on multiple occasions would produce the best result. Program success 12 months after the initiation of intervention was related to the type of intervention session (group and individual sessions combined better than either alone), the number of intervention modalities, and the number of reinforcing sessions. With multivariate adjustment for confounding, the number of intervention modalities alone had a positive association with intervention success. (JAMA 1988;259:2882-2889)
Article
Objective: To test the efficacy of a smoking cessation program for inpatients recovering from coronary artery bypass graft surgery and to identify predictors of cessation. Design: Randomized, controlled clinical trial. Setting: Postoperative cardiac surgery unit of a large teaching hospital. Patients: Patients scheduled for coronary artery bypass surgery by participating surgeons between 1 July 1986 and 1 July 1987 who had smoked 1 or more packs of cigarettes in the 6 months before admission. Of 120 eligible patients, 93 enrolled and 87 were discharged alive. All survivors were followed for at least 1 year; 94% were followed for a median of 5.5 years
Article
Although identified as a clinical priority, smoking cessation has been addressed minimally in the literature in the context of physical therapy practice. Smoking cessation advice delivered by a health professional can help smokers quit. The salient components of such advice however warranted elucidation to enable physical therapists to integrate this clinical competence into their practices. Therefore, we conducted a systematic review to elucidate the effectiveness of advice by a health professional and its components to optimize smoking cessation instituted in the context of physical therapy practice. Thirty source articles were identified. A random-effects model meta-analysis was used to assess the effectiveness of the advice parameters. Risk ratios (RRs) were used to estimate pooled treatment effects. RRs for brief, intermediate, and intensive advice were 1.74 (95% CI=1.37, 2.22), 1.71 (95% CI=1.39, 2.09), and 1.60 (95% CI=1.13, 2.27), respectively. Self-help materials, follow-up, and interventions based on psychological or motivational frameworks were particularly effective components of intermediate and intensive advice interventions. Advice can be readily integrated into physical therapy practice and used to initiate or support ongoing smoking cessation in clients irrespective of reason for referral. Incorporating smoking cessation as a physical therapy goal is consistent with the contemporary definition of the profession and the mandates of physical therapy professional associations to promote health and wellness, including smoking cessation for both primary health benefit and to minimize secondary effects (e.g., delayed healing and recovery, and medical and surgical complications). Thus, advice is an evidence-based strategy to effect smoking cessation that can be exploited in physical therapy practice. Further research to refine how best to assess smokers and, in turn, individualize brief smoking cessation advice could augment positive smoking cessation outcomes.
Article
Approaches to helping tobacco smokers to give up are reviewed. Motivational interventions are valuable for increasing desire and intention to quit, but have limited success in enhancing the outcome of a cessation attempt. Dependence on nicotine is the main factor underlying maintenance of smoking, and nicotine withdrawal is a major block to successful cessation. Nicotine replacement treatment improves outcomes from intensive group support and has the potential to be combined with specific behavioural interventions. But the scope for intensive treatments is limited. Brief interventions delivered by health professionals through their contacts with patients in primary care could have a much greater effect in reducing prevalence. Such interventions have been shown to be effective in one-off research studies, but need to be incorporated into everyday routines on a sustained basis.
Article
To synthesize the evidence on the effectiveness of smoking-cessation interventions by type of provider.
Article
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Hypertension is a highly prevalent risk factor for stroke and dementia, and is the greatest risk factor for small-vessel disease-a frequent cause of lacunar infarction and intracerebral haemorrhage. Lacunar and cortical strokes contribute to the development of dementia in patients with, and in those without, Alzheimer disease pathology; this relationship between stroke and dementia is probably mediated by ischaemia-induced neuroinflammation. Antihypertensive treatment can reduce the risk of stroke and dementia, but requires optimal blood pressure targets to be established for individual patients. Although the rate of treatment and control of hypertension has improved markedly over the past two decades, many physicians remain reluctant to prescribe antihypertensive medication to elderly patients owing to potential adverse events such as cardiovascular morbidity and postural hypotension. In this article we argue that, in patients of all ages, not treating hypertension is a missed opportunity to prevent some of the most prevalent brain diseases.
Article
•The aim of this small-scale study was to assess the feasibility and impact of an individualized smoking cessation intervention among clients admitted to a coronary care unit with severe angina or a first time myocardial infarction.•The intervention involved in-depth nursing assessment interviews related to client beliefs, motivation and experiences of smoking, culminating in an individualized cessation plan. Participants were offered follow up support during the first year post-intervention.•The findings are highly encouraging with a 77% smoking cessation rate for surviving clients within the intervention group at the end of the first year, and with 75% continued successful smoking cessation amongst surviving clients 2 years post-intervention.
Article
This systematic review aimed to assess the effectiveness of psychoeducational smoking cessation interventions for coronary heart disease (CHD) patients; and to examine behaviour change techniques used in interventions and their suitability to change behavioural determinants. Multiple bibliographic databases and references of retrieved articles were searched for relevant randomized controlled studies. One reviewer extracted and a second reviewer checked data from included trials. Random effects meta-analyses were conducted to estimate pooled relative risks for smoking cessation and mortality outcomes. Behaviour change techniques used and their suitability to change behavioural determinants were evaluated using a framework by Michie, Johnston, Francis, Hardeman, and Eccles. A total of 14 studies were included. Psychoeducational interventions statistically significantly increased point prevalent (RR 1.44, 95% CI, 1.20-1.73) and continuous (RR 1.51, 95% CI, 1.18-1.93) smoking cessation, and statistically non-significantly decreased total mortality (RR 0.73, 95% CI, 0.46-1.15). Included studies used a mixture of theories in intervention planning. Despite superficial differences, interventions appear to deploy similar behaviour change techniques, targeted mainly at motivation and goals, beliefs about capacity, knowledge, and skills. Psychoeducational smoking cessation interventions appear effective for patients with CHD. Although questions remain about what characteristics distinguish an effective intervention, analysis indicates similarities between the behaviour change techniques used in such interventions.
Article
Background: Smoking contributes to reasons for hospitalisation, and the period of hospitalisation may be a good time to provide help with quitting. Objectives: To determine the effectiveness of interventions for smoking cessation that are initiated for hospitalised patients. Search methods: We searched the Cochrane Tobacco Addiction Group register which includes papers identified from CENTRAL, MEDLINE, EMBASE and PsycINFO in December 2011 for studies of interventions for smoking cessation in hospitalised patients, using terms including (hospital and patient*) or hospitali* or inpatient* or admission* or admitted. Selection criteria: Randomized and quasi-randomized trials of behavioural, pharmacological or multicomponent interventions to help patients stop smoking, conducted with hospitalised patients who were current smokers or recent quitters (defined as having quit more than one month before hospital admission). The intervention had to start in the hospital but could continue after hospital discharge. We excluded studies of patients admitted to facilities that primarily treat psychiatric disorders or substance abuse, studies that did not report abstinence rates and studies with follow-up of less than six months. Both acute care hospitals and rehabilitation hospitals were included in this update, with separate analyses done for each type of hospital. Data collection and analysis: Two authors extracted data independently for each paper, with disagreements resolved by consensus. Main results: Fifty trials met the inclusion criteria. Intensive counselling interventions that began during the hospital stay and continued with supportive contacts for at least one month after discharge increased smoking cessation rates after discharge (risk ratio (RR) 1.37, 95% confidence interval (CI) 1.27 to 1.48; 25 trials). A specific benefit for post-discharge contact compared with usual care was found in a subset of trials in which all participants received a counselling intervention in the hospital and were randomly assigned to post-discharge contact or usual care. No statistically significant benefit was found for less intensive counselling interventions. Adding nicotine replacement therapy (NRT) to an intensive counselling intervention increased smoking cessation rates compared with intensive counselling alone (RR 1.54, 95% CI 1.34 to 1.79, six trials). Adding varenicline to intensive counselling had a non-significant effect in two trials (RR 1.28, 95% CI 0.95 to 1.74). Adding bupropion did not produce a statistically significant increase in cessation over intensive counselling alone (RR 1.04, 95% CI 0.75 to 1.45, three trials). A similar pattern of results was observed in a subgroup of smokers admitted to hospital because of cardiovascular disease (CVD). In this subgroup, intensive intervention with follow-up support increased the rate of smoking cessation (RR 1.42, 95% CI 1.29 to 1.56), but less intensive interventions did not. One trial of intensive intervention including counselling and pharmacotherapy for smokers admitted with CVD assessed clinical and health care utilization endpoints, and found significant reductions in all-cause mortality and hospital readmission rates over a two-year follow-up period. These trials were all conducted in acute care hospitals. A comparable increase in smoking cessation rates was observed in a separate pooled analysis of intensive counselling interventions in rehabilitation hospitals (RR 1.71, 95% CI 1.37 to 2.14, three trials). Authors' conclusions: High intensity behavioural interventions that begin during a hospital stay and include at least one month of supportive contact after discharge promote smoking cessation among hospitalised patients. The effect of these interventions was independent of the patient's admitting diagnosis and was found in rehabilitation settings as well as acute care hospitals. There was no evidence of effect for interventions of lower intensity or shorter duration. This update found that adding NRT to intensive counselling significantly increases cessation rates over counselling alone. There is insufficient direct evidence to conclude that adding bupropion or varenicline to intensive counselling increases cessation rates over what is achieved by counselling alone.
Article
The North Karelia project was established to carry out a comprehensive community program for control of cardiovascular diseases (CVD) in North Karelia (NK), a county in eastern Finland. After a 5-year intervention period, a survey was taken of physicians, public health nurses, and local decision makers in the county, and those in a matched reference area, in order to assess their experiences concerning CVD control. Questionnaire data were obtained from 354 physicians (76% of total), 340 nurses (94% of total), and 1,229 decision makers (89% of total). The results generally confirmed the effectiveness of the more active work in CVD control of the health personnel in NK compared with the reference area. The decision makers in NK had not personally initiated more CVD control activities, but had been more frequently subjected to them. All these groups showed much greater satisfaction concerning the adequacy of CVD control activities in NK compared with those in the reference area.
Article
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Hospitalization may be an opportune time to change smoking behavior because it requires smokers to abstain from tobacco at the same time that illness can motivate them to quit. A hospital-based intervention may promote smoking cessation after discharge. We tested the efficacy of a brief bedside smoking counseling program in a randomized controlled trial at Massachusetts General Hospital, Boston. The 650 adult smokers admitted to the medical and surgical services were randomly assigned to receive usual care or a hospital-based smoking intervention consisting of (1) a 15-minute bedside counseling session, (2) written self-help material, (3) a chart prompt reminding physicians to advise smoking cessation, and (4) up to 3 weekly counseling telephone calls after discharge. Smoking status was assessed 1 and 6 months after hospital discharge by self-report and validated at 6 months by measurement of saliva cotinine levels. One month after discharge, more intervention than control patients were not smoking (28.9% vs 18.9%; P=.003). The effect persisted after multiple logistic regression analyses adjusted for baseline group differences, length of stay, postdischarge smoking treatment, and hospital readmission (adjusted odds ratio, 2.19; 95% confidence interval, 1.34-3.57). At 6 months, the intervention and control groups did not differ in smoking cessation rate by self-report (17.3% vs 14.0%; P=.26) or biochemical validation (8.1% vs 8.7%; P=.72), although the program appeared to be effective among the 167 patients who had not previously tried to quit smoking (15.3% vs 3.7%; P=.01). A low-intensity, hospital-based smoking cessation program increased smoking cessation rates for 1 month after discharge but did not lead to long-term tobacco abstinence. A longer period of telephone contact after discharge might build on this initial success to produce permanent smoking cessation among hospitalized smokers.
Article
Secondary stroke prevention can reduce the risk of recurrent stroke by approximately 90%. To achieve such a reduction, early implementation of preventative measures and administration of therapy appropriate to the underlying cause of the presenting transient ischemic attack or stroke are crucial. Smoking cessation and a Cretan Mediterranean diet are each more effective than any single medication in reducing the risk of recurrent stroke. Control of resistant hypertension can markedly reduce the risk of intracerebral hemorrhage and lacunar infarction but might require therapy that is specific to the underlying cause. New antiplatelet agents have been developed or are in development that might avoid the issues of resistance and drug interactions that prevail with established agents of this type. Furthermore, new anticoagulants in development offer promise of replacing warfarin, and devices to occlude the atrial appendage are on the horizon for patients with atrial fibrillation. Carotid endarterectomy is appropriate for severe symptomatic carotid stenosis, while stenting might be appropriate for symptomatic stenosis where the surgical risk is high. Most patients with asymptomatic stenosis, however, should be treated with medical therapy, unless indicators of high stroke risk are present. In this narrative Review, I discuss recent advances in secondary stroke prevention.
Article
We have surveyed the health promotion efforts of dentists and dental hygienists in general dental practice in Chittenden County, Vermont, in relation to smoking. The response rate was 61 percent. Smoking issues were addressed by 76 percent of dentists and 81 percent of dental hygienists in approximately one quarter of their smoking patients. Although the majority of both dentists and dental hygienists advised their patients to change their smoking behavior, their advice was usually to cut down rather than to quit. Most of the respondents—78 percent of dentists and 93 percent of dental hygienists—considered it appropriate to give advice about smoking during visits for routine dental care and 68 percent and 89 percent, respectively, were willing to learn brief methods of advising their patients about smoking. Experience with giving advice about smoking and agreement that it was appropriate to give such advice were both strongly related to willingness to learn brief methods of giving such advice. In individual dental practices, there were virtually no correlations between the dentist's and the dental hygienist's behaviors as far as the proportion of patients from whom a smoking history was taken, the proportion of smokers advised about smoking, the content of the advice, or the nature of the advice. Only nine percent of dentists and 11 percent of dental hygienists were current smokers.
Article
This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required. This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification. The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied. Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months. Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI). We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status). Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.
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Manual clínico para la prevención, diagnóstico y tratamiento del tabaquismo en la práctica clínica diaria.
Chapter
Coronary heart disease (CHD) is a chronic, progressive disease widely prevalent in industrial societies, including the United States. More than 3,400 Americans suffer myocardial infarctions each day, incurring an annual estimated economic cost of $60 billion. A first step in the prevention of this disease has been the identification of characteristics, or risk factors, that are present in individuals prone to develop CHD. Epidemiological studies have found these factors to include a family history of heart disease, elevations in blood pressure and serum cholesterol, cigarette smoking, obesity, a sedentary lifestyle, and the Type A behavior pattern.
Chapter
Smoking cessation should be the prime objective of medical treatment for people who smoke, particularly since most smokers who require treatment are dependent on tobacco. Statistics on readiness to quit smoking show wide variations. For some 20–30% of smokers, an external event marks the starting point for giving up. Further undecided smokers – the figures vary between 25 and 40% – may possibly be persuaded to quit by extensive education campaigns directed at the smoking public [1, 2]. Besides techniques employed worldwide in which patient education is combined chiefly with the pharmacological approach (see Chap. 11), a wide range of counselling methods have found application, ranging from physician advice through to psychological withdrawal programmes, such as those used in other forms of dependence. Scientific assessment of these techniques is only possible if they also adhere to defined standards. The technique used must, therefore, also be scientifically justified or justifiable and the success of treatment must be quantifiable by measuring biochemical markers (e.g. CO in expired air or, preferably, cotinine levels in plasma, urine or saliva). In addition, the consensus definition of cessation is that the smoker remains abstinent for at least 6 (or preferably 12) months after the start of treatment, i.e. the ex-smoker should no longer smoke any cigarettes. A reduction in cigarette smoking (e.g. by 20 cigarettes/day) may be termed a partial success, but does not qualify as smoking cessation in the sense defined above. Given the millions of smokers who are potentially willing to quit, the techniques employed must be practicable and economically viable, and this explains the dominant position of nicotine replacement therapy (NRT) worldwide [3].
Article
This article discusses the addictiveness of tobacco and the health consequences of chronic tobacco use. Personality, environmental, and behavioral factors that promote the initiation of cigarette smoking by adolescents are identified.Age-specific interventions are suggested.
Article
Full-text available
Tobacco smoking can be considered an old and a new challenge for public health. The aim of this review was to analyse different smoking cessation interventions aiming at health care workers.Methods: A literature search of electronic journal databases for studies on smoking cessation interventions among health care workers was performed according to PRISMA criteria, using the MEDLINE and Scopus databases.Results: Smoking restriction policies shouldn’t be considered as actual interventions, being ineffective, unpopular and reducing willingness to quit smoking in many subjects. Even though pharmacological therapies based on bupropion SR and transdermal nicotine patches grant significant results on the short-term (weeks and months), smoking recurrence rates are high and individualised interventions should be preferred or integrated since they seem to grant better results on the longterm (years).Conclusions: There is evidence that smoking cessation interventions among health care workers can be effective. This is of particular interest both for reducing tobacco smoking prevalence among this type of workers and for helping them to be useful model for the general population.
Chapter
Smoking cessation should be the prime objective of medical treatment for people who smoke, particularly since most smokers who require treatment are dependent on tobacco. Statistics on readiness to quit smoking show wide variations: for some 20– 30% of smokers an external event marks the starting point for giving up. Further undecided smokers — the figures vary between 25% and 40% — may possibly be persuaded to quit by extensive education campaigns directed at the smoking public [1,2].
Chapter
Health care in the UK has reached a watershed and a fundamental shift in emphasis is required in order to ensure that health and nursing continue to be valued. Health care has been manoeuvred into the market place and the principles of cost effectiveness, audit and economies of scale now dominate. The effects of a growth in consumerism and the welcome pressure for enhanced lay participation in health care are also making themselves felt. At the same time, changing patterns of health and illness and demographic shifts are strongly impacting on the demands being made on nursing and health care services.
Chapter
At the turn of the 20th century, life expectancy for humans was 47 years. Few individuals lived into their 70s, and only 1 in 10 individuals lived past the age of 65. Today, at the turn of the 21st century, life expectancy has reached the mid-70s. Many individuals, however, are living well past that point; over 8 in 10 can now expect to live into their late 70s. Today, approximately 1 in 8 Americans is over the age of 65 (13%). By the year 2030, it is estimated that 1 in 5, or 20% of the population, will be age 65 or older.
Chapter
This chapter discusses compliance in health-seeking behavior. Compliance is a continuous and dynamic process in most instances instead of a one-time event. Continuous decision making about adherence is involved and compliance needs to be reassessed periodically. If a patient is on medication for long periods or even a lifetime, his compliance will change for better or worse as different events occur in his life. The complex of recommendations for health ranges from advice about periodic health examinations to making radical changes in daily habits, such as abstinence from alcohol. With a little reflection, one would expect compliance with some recommendations to be higher than with others. Compliance varies according to the type of health recommendation: (1) making a contact with a health provider, (2) adhering to a drug regimen, or (3) making life-style changes. A patient always has the right not to comply with health recommendations; the choice to comply should remain his under all possible circumstances. However, health providers need to know as much as possible about compliance to help those patients who wish to comply but have difficulty in doing so.
Article
Cigarette smoking is a major modifiable risk factor for cardiovascular disease (CVD), including coronary artery disease (CAD), heart attacks, stroke, peripheral vascular disease, and congestive heart failure. The hazardous effects of smoking on the cardiovascular system are multiple and synergistic. Mechanisms include mainly vascular endothelial and smooth cell dysfunction, enhanced platelet aggregability, disturbed lipid profile, thrombosis, and hemodynamic changes. These effects, both, increase the likelihood of an acute event as well as contribute to long-term development of CAD. Tobacco smoke may also cause insulin resistance, a risk factor for diabetes and CVD. The same mechanisms responsible for CVD in active smokers are nearly as large in passive smokers. The specific ingredients of cigarette smoke responsible for its cardiovascular effects include mainly the polycyclic aromatic hydrocarbons, nicotine, oxidizing agents and particulate matter. Although smoking has been well clarified as the leading cause of cardiovascular morbidity and mortality worldwide, still a large scale of population continues to smoke while others start to smoke adding more victims to this bad habit. The death toll from tobacco is expected to climb to about 10 million people per year within next 25 years. 70% of victims will be in low-and middle-income countries. It is estimated that eventually 50% of all smokers will be killed by direct or indirect effects of tobacco. This review highlights atherosclerosis as one of the serious complications of smoking with discussion of its mechanisms and detrimental consequences particularly peripheral arterial disease, stroke and coronary artery disease.
Chapter
The area of behavioral aspects of physical illness is a vast one: it includes the old definition of psychosomatic disorders, but is broader, in the sense of comprehending all psychological factors contributing to the etiology, maintenance, treatment, and prevention of illness. According to Engel (1986) behavior is defined as “All responses (physical, cognitive, overt behavior) on illness, leading to or prior to illness.”
Article
Factors associated with outcome were investigated in the British Thoracic Society's study of smoking withdrawal in 1550 patients attending hospital with smoking related diseases. A long term abstinence rate of 9.7% was found. Men did better than women, 12.2% of them succeeding in stopping smoking compared with 5-3% of the women. Success rate increased with age, and people with heart disease did better than those with any other diagnosis. The success rate of the best group, men with heart disease, was 21%. Sex, age, and diagnosis appeared to act independently. If the most important other person in the patient's life was a non-smoker success was more likely. Weight increased by an average of 5-9 kg over a year in those who stopped smoking.
Article
Four methods of smoking withdrawal were compared in patients with smoking related diseases attending a hospital or chest clinic. Reinforcing verbal advice with a booklet or with a booklet together with nicotine or placebo chewing gum did not result in greater success than verbal advice alone. Roughly a quarter of those patients who denied smoking had carboxyhaemoglobin and plasma thiocyanate concentrations typical of smokers. At the end of a year 150 out of 1550 patients (9.7%) had successfully stopped smoking.
Chapter
Harm to SmokersMechanisms of HarmHarm to Non-SmokersStopping SmokingSafer CigarettesSmoking and WeightSmoking in the WorkplaceChildren and SmokingSmoking and the Developing WorldReferencesAcknowledegement
Article
Implementation of best medical treatment (BMT) is the cornerstone of the management of patients with either asymptomatic or symptomatic carotid artery stenosis. We review the literature to define the components of BMT. Smoking cessation, maintaining a healthy body weight, moderate exercise, and a Mediterranean diet are essential lifestyle measures. Moderate alcohol consumption may also be beneficial but recommending it to patients may be hazardous if they consume too much. The importance of lifestyle measures is largely underestimated by both physicians and patients. Blood pressure and diabetes control, antiplatelet agents, and lipid-lowering treatment with statins/ezetimibe comprise the pharmacological components of BMT. Initiation of an intensive regimen of BMT is a sine qua non for patients with carotid artery stenosis whether or not they are offered or undergo an invasive revascularization procedure.
Article
The effects of various smoking cessation strategies were studied in two multicentre trials with new patients attending hospital or a chest clinic because of a smoking related disease. In the first trial (study A, 1462 patients) the effect of the physician's usual advice to stop smoking was compared with the effect of the same advice reinforced by a signed agreement to stop smoking by a target date within the next week, two visits by a health visitor in the first six weeks, and a series of letters of encouragement from the physician. The second trial (study B, 1392 patients) compared (1) advice only, (2) advice supplemented by a signed agreement, (3) advice supplemented by a series of letters of encouragement, and (4) advice supplemented by a signed agreement and a series of letters of encouragement. Patients were reviewed at six months and those claiming to have stopped smoking were seen again at 12 months. Claims of abstinence were checked by carboxyhaemoglobin measurement. In study A 9% of the intervention group had succeeded in stopping smoking at six months compared with 75 of the 'advice only' patients (p = 0.17). In study B success rates were 5.2%, 4.9%, 8.5%, and 8.8% respectively. The signed agreement did not influence outcome, whereas postal encouragement increased the effect of the physician's advice. In both studies patients reviewed clinically between the initial and the six month visit were more likely to stop smoking than those not reviewed. Success rates increased with age and men tended to do better than women. The studies suggest that physicians' advise alone will persuade 5% of outpatients with a smoking related disease to stop smoking. Subsequent postal encouragement will increase the cessation rate by more than half as much again. Such small improvements in success rates are worth while, especially if they can be achieved cheaply and on a wide scale.
Article
La intervencion minima (IM) sobre el tabaquismo se ha mostrado como una forma eficaz de conseguir el abandono del habito tabaquico en la poblacion general. Se fundamenta en el consejo medico a cada paciente fumador, con informacion complementaria de los efectos del tabaquismo sobre el organismo y las formas de abandonar el habito tabaquico. La poblacion de pacientes que consulta por enfermedad neumologica puede ser especialmente receptiva a la IM, ya que la frecuente relacion entre su sintomatologia y el habito tabaquico puede aumentar la motivacion para el abandono. Se ha aplicado un protocolo de IM sobre el tabaquismo en 285 fumadores visitados en una consulta extrahospitalaria de neumologia. 208 fumadores (grupo A) recibieron consejo medico y educacion sanitaria, con ofrecimiento de seguimiento ulterior. Setenta y siete fumadores (grupo B) recibieron la misma IM suplementada con el ofrecimiento de terapia farmacologica de soporte con chicle de nicotina 2 mg, y explicacion de su forma de utilizacion. Al ano de la IM los pacientes fueron contactados telefonicamente para precisar el numero de abstinentes, y se corrigio la cifra obtenida segun el indice de veracidad de la respuesta telefonica positiva a abstinencia (71,4%). Un total de 71 (24,9%) fumadores no fueron localizados telefonicamente por cambio de domicilio, telefono erroneo, fallecimiento o ausencia de telefono en el propio domicilio. El numero estimado de abstinentes en el grupo A fue de 31,5/160 (19,7%), y en el grupo B de 8,6/54 (15,9%) (diferencia no significativa, test de la χ2). El grupo B solo utilizo el chicle de nicotina de forma terapeuticamente significativa en un 11,0% de los casos. Se concluye que la eficacia de la IM en la consulta extrahospitalaria de neumologia es elevada. El grado de utilizacion de la terapia de soporte con chicle de nicotina en una poblacion no seleccionada es bajo, lo que sugiere que la utilizacion de chicle de nicotina probablemente debe reservarse para los fumadores con elevada motivacion/dependencia.
Chapter
Smoking and exposure to secondhand smoke are the most important preventable risk factors that contribute to premature death from coronary heart disease (CHD). The US adult smoking prevalence rates decreased from 24% in 1998 to 21% in 2008 (Dube, Asman, Malarcher, & Carabollo, 2009), but during the past 5 years, smoking rates have not changed. Men are more likely to smoke than women, and American Indians/Alaska Natives have the highest smoking rate of all ethnicities. Smoking is more prevalent in adults with low educational attainment and in those from lower socioeconomic strata. Clinicians should offer and provide effective smoking cessation interventions to reduce these numbers in developing countries, especially in subpopulations which can obtain maximum benefits from quitting smoking. © 2012 Springer Science+Business Media, LLC. All rights reserved.
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