Health counselling has been shown to be effective for helping hospitalized smokers to quit. Counselling, which may vary in intensity and duration, should clearly explain the benefits associated with giving up smoking and discuss the risks. In general, the greater the intensity, duration and frequency of counselling, the more effective the intervention.

It also seems that counselling provided in the hospital by different healthcare professionals, along with self-help materials, is more effective than standard treatment, particularly when it continues for at least 1 month after hospital discharge (relative risk [RR] 1.7, 95% CI 1.27–1.48).10,11 A metaanalysis found that when the intervention was conducted by 2 types of healthcare professionals, rates of abstinence increased compared to when it was conducted by only 1 (RR 2.5; 95% CI 1.9–3.4). Efficacy increased even further when the intervention was conducted by 3 healthcare professionals (RR 2.4; 95% CI 2.1–2.9).12

Different activities that prolong the healthcare intervention beyond the period of hospitalization have been proposed, the most important being personal contact between the healthcare professional and the patient, sending letters, SMS, emails, proactive telephone contact, etc., all of which help increase the efficacy of the interventions offered during the hospital stay.11–13

Other studies have analyzed the efficacy of combining pharmacological treatment with health counselling in hospitalized smokers. The results of a metaanalysis of 6 studies indicate that the efficacy of intensive health counselling (counselling during the hospital stay that continues for at least 1 month after discharge) increases significantly with the addition of nicotine replacement therapy (NRT) (RR 1.54; 95% CI 1.34–1.79).10 One of the advantages of NRT in hospitalized smokers is its rapid onset of action.

Three studies compared the efficacy of varenicline and health counselling compared to counselling alone.13–15 One of these reported greater efficacy in the group that received varenicline compared to the control group (31.1 vs 21.4%; RR 1.45; 95% CI 1.03–2.03; P=.03).13 Another found no significant differences,14 while the third, which analyzed a group of 302 patients admitted for acute coronary syndrome, found greater efficacy in the group that received varenicline compared to the control group (47.3 vs 32.5%, P=.012).15

It is also important to point out that the use of varenicline in hospitalized patients, some of whom have chronic diseases, is as safe as placebo, and nausea was the only event that appeared more frequently in the active treatment group (16.3 vs 1.5%).14,16 Even in the group of subjects admitted for acute coronary syndrome, varenicline was shown to be as safe as placebo. The rate of severe cardiovascular adverse effects 30 days after completing the treatment period was similar in both groups: 4% for varenicline and 4.6% for placebo.15

Three studies have compared the efficacy of the combination of bupropion and intensive health counselling in hospitalized patients, compared to the usual interventions for helping individuals to stop smoking. None of these studies found that this medication was useful for helping patients to quit.17–19 A metaanalysis of these 3 studies was also performed, which also failed to demonstrate efficacy (RR 1.04; 95% CI 0.75–1.45). Interestingly, 2 of these studies were performed in patients who had been admitted for acute cardiovascular disease (myocardial ischaemia), and no short or long-term adverse cardiovascular effects appeared in the group of subjects that used bupropion, compared to the group that received standard care.18,19 These data were confirmed in a recent metaanalysis and in a new randomized, controlled clinical trial.20,21

A recent randomized, double-blind, controlled clinical trial examined the efficacy of a smoking treatment programme in a group of smokers who received intensive counselling for smoking cessation during admission, followed by continued counselling with automated interactive voice response telephone calls after discharge, as well as the treatment of their choice for a period of 3 months (NRT, bupropion or varenicline). The results showed that this programme after 6 months of follow-up was significantly more effective than standard care (27 vs 16%, RR 1.70; 95% CI 1.15–2.51; P=.007).22

Of note is a Spanish study which included a total of 2560 hospitalized smokers. The authors reported that intensive psychological counselling was more effective than minimal counselling, and that its efficacy increased even further when combined with NRT.23

In their meta-analysis, Rigotti et al. included a total of 14 clinical trials conducted in patients admitted for acute cardiovascular problems in which the efficacy of an intensive intervention to quit smoking in the hospital was compared with standard care.10 The results showed that the intensive intervention was more effective than standard care (RR 1.42; 95% CI 1.29–1.56).10 Moreover, one of the studies also analyzed all-cause mortality and readmission rates over a 2-year period. The results showed that the intervention in patients with cardiovascular disease led to a reduction in the RR of all-cause mortality (RR 0.77; 95% CI 0.27–0.93; P=.014) and readmission (RR 0.44; 95% CI 0.16–0.63; P=.007).24

Five studies have analyzed the efficacy of the interventions for smoking cessation in patients admitted with respiratory diseases.25–29 In 2 of these, NRT (chewing gum in 1, patches in the other) was offered in addition to smoking cessation counselling.25,26 The study that offered patches found that in the active group, rates of continuous abstinence between months 3 and 12 were higher than in the placebo group (21% vs 14%, respectively), although the difference was not significant.25 The other 3 studies compared the efficacy of intensive counselling interventions without the use of medication, compared to standard care in patients with chronic obstructive pulmonary disease.27–29 One of the studies found that, after 1 year of follow-up, patients who had received intensive interventions showed an almost 3-fold increase in abstinence compared to those who had received standard care (RR 2.83; 95% CI 1.40–5.74).29 No significant differences were found in the other 2.27,28 However, it must be taken into account that the intervention received by the active group was not very intensive.27,28

A recent study reported that a hospital intervention consisting of cessation counselling during admission, pharmacological treatment, and follow-up after discharge had a cost per quality-adjusted life year of 1386 Canadian dollars, and that providing this type of treatment to 15,326 hospitalized smokers would lead to 4689 individuals giving up, which would help avoid 116 readmissions, 923 days of hospital stay, and 119 deaths.30

Intervention in hospitalized smokers consists of 2 parts: a diagnostic intervention and a therapeutic intervention.

Diagnostic Intervention

The diagnostic intervention will investigate the following aspects10–12 (Fig. 2):

• A)

  Quantification of accumulated tobacco use: the pack-year index will be calculated.

• B)

  Analysis of motivation and self-efficacy for quitting smoking: the use of a visual analogue scale for measuring these variables is recommended.

• C)

  Analysis of physical nicotine dependence: the Fagerström test is highly recommended for quantifying this variable. In cases in which it is assumed that the nature of the disease that brought the individual to hospital will prevent them from smoking a large number of cigarettes a day, it is of particular value to assess the response to the question “how soon after waking do you smoke your first cigarette of the day?”.

• D)

  Previous attempts to quit during which the subject went at least 24h without smoking will be investigated. This investigation will determine the number of previous attempts, the time that the patient went without smoking during those attempts, treatments used, and particularly, the withdrawal symptoms experienced during those attempts.

• E)

  Determination of CO levels in expired air: this is a simple, non-invasive, inexpensive and highly useful test that should be obligatory in all smokers admitted to hospital.

Fig. 2.

Algorithm 2: diagnostic intervention in hospitalized smokers.

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However, it is important to note that evaluating these aspects should not be a pre-requisite for offering treatments for smoking, since the treatment of smoking is effective and should be administered even if specialized evaluations are unavailable or not performed.12

Therapeutic Intervention

Fig. 3 shows the healthcare intervention that should be given to a smoker who is admitted to hospital. This intervention consists of counselling on smoking cessation, the prescription of pharmacological treatment, and a follow-up regimen.

Fig. 3.

Algorithm 3: therapeutic intervention in hospitalized smokers. FT: Fagerström test score; NRT: nicotine replacement therapy.

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Counselling on Smoking Cessation

The healthcare professional should warn the patient that they will not be able to smoke during their hospital stay. The main reasons for not smoking will be explained. These reasons are listed in Table 2. All these warnings should be given with empathy, respect, and understanding.

Recommendation: all smokers must receive counselling on smoking cessation during hospitalization, given by all the healthcare professionals who see the patient during their hospital stay. Counselling must also be accompanied by the provision of self-help materials, and it must also continue for at least 1 month after hospital discharge. This is a consistent recommendation. Quality of evidence: high.

Pharmacological Treatment

Health counselling for smoking cessation offered to hospitalized smokers must be combined with the use of medication.

Three types of drugs have been used: NRT, bupropion and varenicline. Recommendations on the use of each of these products are listed below. For more information, please see the complete version of these guidelines, available at www.separ.es.

Nicotine Replacement Therapy

The use of any type of NRT, particularly chewing gum, lozenges, mouth sprays or patches, is highly recommended for hospitalized smokers.10,22 Prescription of these medications will help control any withdrawal symptoms and help the patient abstain from smoking during their hospital stay.

In smokers with a low degree of physical dependence on nicotine (less than 4 points on the Fagerström test), the prescription of 2mg nicotine in chewing gum, or 1mg in lozenges, or 16- or 24-hour patches at doses of 15 or 21mg/day, respectively, is useful. In smokers with a moderate or high degree of physical dependence on nicotine (4 or more points on the Fagerström test), the use of nicotine patches in combination with nicotine chewing gum, lozenges or mouth spray is required.31

The use of NRT in hospitalized smokers has significant advantages, namely, its rapid onset of action − it is effective from the first administration − and its lack of adverse effects. There are very few contraindications to its use and very few interactions with other drugs that the hospitalized patient may be receiving.12

Although acute coronary syndrome has traditionally been cited as a contraindication for NRT, this is now very controversial. A recent study carried out in hospitalized smokers treated with NRT, some of whom had acute coronary syndrome, showed that this intervention in these patients was effective and safe.24 The American College of Cardiology/American Heart Association also recommends the use of NRT in this group of patients.32

Recommendation: nicotine patches, chewing gum, mouth spray, or lozenges are recommended to help hospitalized patients stop smoking. To obtain the greatest efficacy, they should be prescribed in combination with counselling that should continue for at least 1 month after hospital discharge. This is a consistent recommendation. Quality of evidence: high.

Bupropion

Bupropion has not been shown to be effective for helping hospitalized smokers to quit smoking,10,17–19,22 although this medication has been shown to be safe in this patient group, even those with cardiovascular disease.18,19

The main disadvantages of this medication in hospitalized smokers are its 7–14 day response time. In addition, it is metabolized by the liver, via the enzymatic P450 complex, so may be associated with significant interactions with other medications.

Recommendation: bupropion is not recommended for helping hospitalized patients stop smoking. This is a consistent recommendation. Quality of evidence: high.

Varenicline

The efficacy and safety of varenicline in helping hospitalized patients stop smoking, even in those with acute coronary syndrome, has been clearly demonstrated in 3 out of 4 clinical trials.13–15,22

Varenicline should be used at the standard dose for a period of 12 weeks.12,33,34 In patients with a high degree of dependence or chronic respiratory diseases, it is highly advisable to use it at the dose and for the duration indicated by scientific societies such as the Spanish Society of Pulmonology and Thoracic Surgery and the European Respiratory Society.33,34

The major drawback for the use of varenicline in hospitalized patients is the need to administer it for 1 week before it becomes fully effective. Nevertheless, its metabolic profile − it is eliminated via the urine with no hepatic involvement – rules out potential drug interactions, and it can be easily used in many polymedicated hospitalized patients.12,33,34

Recommendation: varenicline is recommended for helping hospitalized patients stop smoking. To obtain the greatest efficacy, it should be prescribed in combination with counselling that should continue for at least 1 month after hospital discharge. This is a consistent recommendation. Quality of evidence: high.

Follow-up

An essential aspect of treatment of smoking in hospitalized smokers is the follow-up period. To obtain the greatest efficacy, follow-up should continue for at least 1 month after hospital discharge. The longer the follow-up, the greater the efficacy.

Recommendation: follow-up after hospital discharge must always be prescribed to monitor the progress of smokers who have tried to stop smoking during their hospital stay. Follow-up should last at least 4 weeks. This is a consistent recommendation. Quality of evidence: high.

The Clinical Practice Guideline of the US Department of Health and Human Services recommends that intervention in these patients include the following12 (Fig. 1):

• 1.

  Congratulations: patients should be warmly congratulated on their decision to stop smoking by all attending healthcare professionals.12

• 2.

  Offer of support: all healthcare professionals must offer support to the former smoker to help them remain abstinent during their hospital stay.12

• 3.

  Evaluation of withdrawal symptoms: if the patient stopped smoking less than 3 months previously, they may still have withdrawal symptoms. In these cases, withdrawal symptoms should be carefully evaluated and medication should be prescribed, if necessary.12

• 4.

  Depression or negative mood: these symptoms can appear in up to 25%–30% of former smokers who have given up less than 6 months previously. If they occur, they should be diagnosed and treated appropriately.12

• 5.

  Weight gain: around 85% of smokers gain weight on quitting the habit. The amount gained is generally between 2 and 5kg in approximately 4–6 months.35

• 6.

  Monitor relapses: most relapses among smokers who have quit occur during the first 6 months after giving up smoking. Hospitalized smokers who are in this situation must be monitored for the early detection of relapse.

Recommendation: healthcare intervention in hospitalized former smokers who have given up less than 6 months previously should include the following actions: congratulate the patient for having given up smoking, provide support so that they continue to abstain during their hospital stay, and monitor the appearance of withdrawal symptoms, depression, weight gain, and relapse. If any of these develop, the patient must be treated promptly and appropriately. This is a consistent recommendation. Quality of evidence: high.

Interventions in individuals who state that they have never smoked or who stopped smoking more than 6 months previously are limited to congratulating the patient and encouraging them to continue (Fig. 1).