Cost-effectiveness of point of care smoking cessation interventions in oncology clinics.

BACKGROUND: We examined the cost-effectiveness of providing systematic smoking cessation interventions to oncology patients at point-of-care. METHODS: A decision analytic model was completed from the healthcare payer's perspective and included all incident cancer cases involving patients who smoke in New Brunswick, Canada (n = 1040), cancer site stratifications, and risks of mortality, continued smoking, and cancer treatment failure over one year. Usual care (no cessation support) was compared to the standard Ottawa Model for Smoking Cessation (OMSC) intervention, and to OMSC plus unlimited cost-free stop smoking medication (OMSC + SSM), including nicotine replacement therapy, varenicline, or bupropion. Primary outcomes were incremental cost per quit (ICQ) and incremental cost per cancer treatment failure avoided (ICTFA). RESULTS: The ICQ was $C143 and ICTFA $C1193 for standard OMSC. The ICQ was $C503 and ICTFA was $C5952 for OMSC + SSM. The number needed to treat (NNT) to produce one quit was 9 for standard OMSC and 4 for OMSC + SSM, and the NNT to avoid one first-line treatment failure was 78 for OMSC and 45 for OMSC + SSM. Both were cost-effective in 100% of 1000 simulations. CONCLUSIONS: Given the high clinical benefits and low incremental costs, systematic smoking cessation interventions should be a standard component of first-line cancer treatment.

Nicotine replacement therapy 'gift cards' for hospital inpatients who smoke: a prospective before-and-after controlled pilot evaluation.

INTRODUCTION: A common barrier identified by individuals trying to quit smoking is the cost of cessation pharmacotherapies. The purpose of this evaluation was to: (1) Assess the feasibility of offering nicotine replacement therapy (NRT) 'gift cards' to hospitalised smokers for use posthospitalisation; and, (2) Estimate the effect of providing NRT gift cards on 6-month smoking abstinence. METHODS: A prospective, quasi-experimental, before-and-after controlled cohort design with random sampling was used to compare patients who had received the Ottawa Model for Smoking Cessation (OMSC) intervention ('control') with patients who received the OMSC plus a $C300 Quit Card ('QCI'), which they could use to purchase any brand or form of NRT from any Canadian pharmacy. RESULTS: 750 Quit Cards were distributed to the three participating hospitals of which 707 (94.3%) were distributed to patients. Of the cards received by patients, 532 (75.2%) were used to purchase NRT. A total of 272 participants completed evaluation surveys (148 control; 124 QCI).Point prevalence abstinence rates adjusted for misreporting among survey responders were 15.3% higher in the QCI group, compared with controls (44.4% vs 29.1%; OR 1.95, 1.18-3.21; p=0.009). Satisfaction was high among participants in both groups, and among staff delivering the QCI. QCI participants rated the intervention as high in terms of motivation, ease of use and helpfulness. CONCLUSIONS: The NRT gift card appears to be a feasible and effective smoking cessation tool that removes a primary barrier to the use of evidence-based smoking cessation pharmacotherapies, while motivating both patients and health providers.

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking.

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

The INITIATE trial protocol: a randomized controlled trial testing the effectiveness of a "quit card" intervention on long-term abstinence among tobacco smokers presenting to the emergency department.

BACKGROUND: Smoking cessation interventions implemented in emergency department (ED) settings have resulted in limited success, owing to factors such as lack of time, motivation, and incentives. A dynamic yet simple and effective approach that addresses the fast-paced nature of acute-care ED settings is needed. This study proposes a multi-center randomized controlled trial (RCT) to compare the effectiveness of an easy to deliver proactive, multi-component tobacco treatment intervention to usual care in the ED setting. METHODS: This will be a prospective four-site, single-blind, blinded-endpoint (PROBE) RCT. Participants will be recruited directly in the ED and will be approached strictly in order of arrival time. Those randomized to the Quit Card Intervention (QCI) group will receive a "quit kit" which will include: a "Quit Card" worth $300 that can be used at any Canadian pharmacy to purchase any form of nicotine replacement therapy (NRT); a self-help booklet; and proactive enrolment in 6 months of telephone follow-up counseling. The usual care (UC) group will receive a "quit kit" which will include a brochure for a local smoking cessation program. Quit kits for both groups will be delivered in opaque, sealed envelopes, and identical in size and weight so to conceal group allocation from the blinded research coordinator. Randomization will be stratified by site and by the Canadian Triage Acuity Scale (CTAS), a value assigned to each ED patient based on the severity of the condition. An equal number of quit kits will be prepared for each CTAS level. The primary outcome will be bio-chemically verified smoking abstinence at 26 weeks. Secondary outcomes include smoking behavior at weeks 4, 52, and 104 as well as mortality and health care utilization outcomes. Investigators, outcome assessors, and data analysts will be blinded to group allocation until after primary analyses are completed. It is hypothesized that the QCI group will have higher a abstinence rate, improved health outcomes, and decreased healthcare utilization. DISCUSSION: There are few examples of hospital EDs in Canada that systematically initiate tobacco cessation interventions for patients who smoke. Given the high smoking prevalence among ED patients and the relation of tobacco smoking to the majority of ambulatory care sensitive conditions, EDs are a missed opportunity in the initiation of tobacco treatment interventions. We have designed and will test an evidence-based tobacco treatment intervention that is simple and highly scalable. TRIAL REGISTRATION: ClinicalTrials.gov NCT04163081 . Registered on November 14, 2019.

Performance Obligations to Improve Delivery of Hospital-Initiated Smoking Cessation Interventions: A Before-and-After Evaluation.

INTRODUCTION: This study evaluated whether introducing performance obligations (a policy intervention) to service agreements between hospitals (n = 15) and their local health authority: (1) improved provision of an evidence-based tobacco cessation intervention (the "Ottawa Model" for Smoking Cessation) and (2) changed the quality of the cessation intervention being delivered. METHODS: Interrupted time series analysis was used to evaluate the change in the proportion of smoker patients provided the Ottawa Model 3 years before and 3 years after introducing the performance obligations. Changes in secondary outcomes related to program quality were described using mean differences, risk differences, and risk ratios, as appropriate. RESULTS: The proportion and number of patients provided the Ottawa Model doubled in the 3-year period following introduction of the new policy-from 3453 patients (33.7%) in the year before to 6840 patients (62.8%) in the final assessment year. This resulted in a signification slope change (+9.2%; 95% confidence interval [CI] 4.5%, 13.9%; p = .01) between the pre- and post-obligation assessment periods, signifying the policy had a positive impact on performance. Quality and effectiveness of the in-hospital intervention remained steady. CONCLUSIONS: Implementation of performance obligations by a healthcare funder increased delivery of an evidence-based smoking cessation intervention across multiple hospitals. Given the known health and economic impacts of smoking cessation interventions, health authorities and hospitals should consider pairing adoption of systematic interventions, like the Ottawa Model, with policy to enhance reach and impact. IMPLICATIONS: • The hospital-based Ottawa Model for Smoking Cessation (OMSC) intervention has been shown to increase smoking abstinence, while reducing mortality and healthcare utilization.• The uptake of systematic, evidence-based interventions, like the OMSC, by hospitals has been relatively low despite the known positive impacts.• The introduction of smoking cessation performance obligations by a healthcare funder resulted in more patients receiving an OMSC intervention while in hospital, with no corresponding change in intervention quality or effectiveness.• Healthcare funders and hospitals should consider pairing the adoption of effective, systematic interventions, like the OMSC, with policy to enhance reach and impact.

Implementation of a Pharmacist-Led Inpatient Tobacco Cessation Intervention in a Rehabilitation Hospital: A Before-and-After Pilot Study.

BACKGROUND: Inpatient rehabilitation presents a unique opportunity for smoking interventions, given the typical lengths of stay, the relevance of smoking to the admission diagnosis of many patients, and the occurrence of nicotine withdrawal during the hospital stay. OBJECTIVE: To evaluate the feasibility of implementing a pharmacist-led version of the Ottawa Model for Smoking Cessation (OMSC) program at a rehabilitation hospital, using the indicators of reach, effectiveness, adoption, and implementation. METHODS: A before-and-after pilot study was conducted. Smoking cessation data were collected from 2 cohorts of eligible smokers identified during 4-month periods before (control) and after (intervention) implementation of the OMSC program. Control participants received usual care (i.e., no cessation intervention). Intervention participants received initial in-hospital smoking cessation support (counselling and nicotine replacement therapy), inpatient follow-up during the hospital stay, and 3 months of postdischarge follow-up calls, with all aspects led by hospital pharmacists. RESULTS: Among all patients admitted to participating inpatient rehabilitation units during the 2 study periods, smoking prevalence was 7.8% (127/1626). After exclusions, deaths, and withdrawals, 111 patients were retained for analysis: 55 in the control group and 56 in the intervention group. The overall mean age of participants was 64.9 (standard deviation [SD] 14.3) years, with a mean smoking history of 35.0 (SD 24.8) pack-years. There were no significant differences between groups in terms of baseline characteristics. Self-reported abstinence rates (determined 3 months after discharge) were higher after compared with before implementation of the OMSC program: for continuous abstinence, 16/56 (28.6%) versus 9/55 (16.4%), χ2 = 4.462, p = 0.035; for 7-day point prevalence abstinence, 21/56 (37.5%) versus 10/55 (18.2%), χ2 = 6.807, p = 0.009. CONCLUSIONS: Implementation of the OMSC program at a large rehabilitation hospital was feasible and led to an increase in 3-month smoking abstinence. This study provides preliminary evidence to support inclusion of smoking interventions as part of inpatient rehabilitation care.

CONTEXTE: La réadaptation des patients hospitalisés représente une occasion unique de procéder à des interventions de désaccoutumance du tabac, notamment en raison de la durée habituelle des séjours, du rapport entre le tabagisme et le diagnostic posé à l'admission, et de la survenue du syndrome de sevrage de la nicotine durant le séjour. OBJECTIF: Étudier la possibilité de mettre en oeuvre une version dirigée par des pharmaciens du programme Modèle d'Ottawa pour l'abandon du tabac (MOAT) dans un centre de réadaptation en employant les indicateurs pour la portée, l'efficacité, l'adoption et la mise en oeuvre. MÉTHODES: Une étude pilote avant-après a été menée. Des données sur la désaccoutumance ont été recueillies auprès de deux cohortes de fumeurs admissibles qui ont été repérés pendant des périodes de quatre mois avant (groupe témoin) et après (groupe expérimental) la mise en oeuvre du programme du MOAT. Les participants du groupe témoin ont reçu les soins habituels (c.-à-d. sans intervention de désaccoutumance). Les participants du groupe expérimental ont reçu un soutien initial à l'hôpital pour la désaccoutumance du tabac (des conseils et un traitement de remplacement de la nicotine), un suivi pendant le séjour à l'hôpital, et des appels de suivi pendant les trois mois suivant le congé, le tout sous la direction de pharmaciens d'hôpitaux. RÉSULTATS: Parmi l'ensemble des patients admis dans les unités de réadaptation participantes au cours des deux périodes de l'étude, la prévalence du tabagisme était de 7,8 % (127/1626). Mis à part les exclusions, les décès et les abandons, 111 patients ont été retenus pour l'analyse : 55 dans le groupe témoin et 56 dans le groupe expérimental. L'âge moyen des participants était de 64,9 (écart-type de 14,3) ans et leur antécédent de tabagisme moyen était de 35,0 (écart-type de 24,8) paquets-années. Aucune différence significative n'a été relevée entre les groupes en ce qui touche aux caractéristiques de base. Les taux d'abstinence autodéclarée (déterminée 3 mois après le congé) étaient plus élevés après la mise en oeuvre du programme du MOAT : pour une abstinence continue, 16/56 (28,6 %) contre 9/55 (16,4 %), χ2 = 4,462, p = 0,035; pour une abstinence ponctuelle de sept jours consécutifs, 21/56 (37,5 %) contre 10/55 (18,2 %), χ2 = 6,807, p = 0,009. CONCLUSIONS: La mise en oeuvre du programme du MOAT dans un important centre de réadaptation a été possible et a mené à une amélioration de l'abstinence du tabac à trois mois. Cette étude donne des résultats préliminaires en appui à l'inclusion d'interventions de désaccoutumance du tabac aux soins de réadaptation de patients hospitalisés.

Effectiveness of a hospital-initiated smoking cessation programme: 2-year health and healthcare outcomes.

BACKGROUND: Tobacco-related illnesses are leading causes of death and healthcare use. Our objective was to determine whether implementation of a hospital-initiated smoking cessation intervention would reduce mortality and downstream healthcare usage. METHODS: A 2-group effectiveness study was completed comparing patients who received the 'Ottawa Model' for Smoking Cessation intervention (n=726) to usual care controls (n=641). Participants were current smokers, >17 years old, and recruited during admission to 1 of 14 participating hospitals in Ontario, Canada. Baseline data were linked to healthcare administrative data. Competing-risks regression analysis was used to compare outcomes between groups. RESULTS: The intervention group experienced significantly lower rates of all-cause readmissions, smoking-related readmissions, and all-cause emergency department (ED) visits at all time points. The largest absolute risk reductions (ARR) were observed for all-cause readmissions at 30 days (13.3% vs 7.1%; ARR, 6.1% (2.9% to 9.3%); p<0.001), 1 year (38.4% vs 26.7%; ARR, 11.7% (6.7% to 16.6%); p<0.001), and 2 years (45.2% vs 33.6%; ARR, 11.6% (6.5% to 16.8%); p<0.001). The greatest reduction in risk of all-cause ED visits was at 30 days (20.9% vs 16.4%; ARR, 4.5% (0.4% to 8.7%); p=0.03). Reduction in mortality was not evident at 30 days, but significant reductions were observed by year 1 (11.4% vs 5.4%; ARR 6.0% (3.1% to 9.0%); p<0.001) and year 2 (15.1% vs 7.9%; ARR, 7.3% (3.9% to 10.7%); p<0.001). CONCLUSIONS: Considering the relatively low cost, greater adoption of hospital-initiated tobacco cessation interventions should be considered to improve patient outcomes and decrease subsequent healthcare usage.

Systematic approaches to smoking cessation in the cardiac setting.

PURPOSE OF REVIEW: Constituents of tobacco smoke are prothrombotic and atherogenic and causative factors in the development of coronary heart disease (CHD). Smoking cessation is the single most important intervention to reduce morbidity and mortality in smokers with CHD. This review presents contemporary information regarding treatments for smoking cessation in the setting of CHD. RECENT FINDINGS: The beneficial effects of smoking cessation may be mediated by improvements in endothelial function. Failure to quit smoking in those with CHD is a typical consequence of nicotine addiction. Practical counseling and pharmacotherapy [nicotine replacement therapy (NRT), bupropion, and varenicline] are well tolerated and effective treatments for CHD patients attempting to quit smoking. Treatments initiated in hospital following a CHD-related event or procedure are more effective than those initiated outside the hospital setting. Extending medication use beyond the initial treatment phase is the most promising means of preventing relapse. Financial coverage for smoking cessation pharmacotherapy improves quit rates. The routine provision of pharmacotherapy and practical counseling in the CHD setting can be assured by implementing proven, systematic approaches to smoking cessation treatment. SUMMARY: Smoking cessation is a fundamental priority in smokers with CHD. Systematic approaches to ensure that cessation assistance is provided by clinicians and to improve cessation outcomes for smokers are effective and available.