In-hospital smoking cessation programs: what do VA patients and staff want and need?

Abstract

In preparation for delivering an inpatient smoking cessation intervention, surveys and interviews of general inpatients and staff were conducted in two Veterans Affairs (VA) hospitals to determine the motivation of veterans to quit smoking and to identify facilitators and barriers to inpatient staff delivery of inpatient cessation services. Seventy percent of inpatients were “motivated smokers” (thinking of quitting in the next 30 days), yet only 17% stated that they received cessation services during their hospitalization. Most staff said that VA should do more to assist patients to quit, yet less than half said that they personally provided cessation services due to lack of confidence/training and hesitancy to upset patients. Given the high motivation to quit among hospitalized veterans and the lack of knowledge about providing cessation services among nurses, training health professionals may facilitate and overcome barriers to the provision of these services. As frontline providers, nurses are ideally positioned to deliver inpatient smoking cessation services to hospitalized veterans.

Introduction

Tobacco use is the leading cause of mortality in the United States, with an estimated 18.1% of total deaths in the year 2000 attributed to tobacco (Mokdad, Marks, Stroup, & Gerberding, 2004). Smoking rates are higher in the veteran population (33% vs. 22% of nonveterans) (Centers for Disease Control, 2003, Office of Quality and Performance, 2001). Psychiatric comorbidities, which are associated with smoking and are common among veterans, may contribute to elevated mortality rates from cancer, cardiovascular disease, and hepatic disorders (Lambert, LePage, & Schmitt, 2003).

Compared to nonsmokers, smokers have twice as many hospital stays, have longer hospitals stays, and incur greater expenses per admission (Haapanen-Niemi, Miilunpalo, Vuori, Pasanen, & Oja, 1999). The total cost of annual medical services for smokers is estimated at US$75.5 billion, with another US$92 billion estimated in lost productivity (Centers for Disease Control, 2005). Treatment of heart attacks and strokes is expensive, especially in the Veterans Affairs (VA) system where patients have less economic resources (Agha, Lofgren, VanRuiswyk, & Layde, 2000). Compared with other preventive and invasive interventions, smoking cessation programs represent one of the most cost-effective chronic disease prevention interventions (Cromwell, Bartosch, Fiore, Hasselblad, & Baker, 1997).

The majority of smoking services in the VA are provided by outpatient programs. Although efficacious, outpatient smoking cessation programs are poorly attended, and few smokers are reached (Cromwell et al., 1997). In contrast, inpatient programs, compared to outpatient programs, enroll a higher percentage of patients who smoke and result in higher cessation. Hospitalization provides an excellent opportunity for patients to quit smoking as they are a captive audience, are removed from daily cues to smoke, are often motivated to quit due to illness, and have often quit temporarily due to hospital smoking bans, and many will have undergone the worst withdrawal during hospitalization (Orleans & Ockene, 1993). However, inconsistent or minimal cessation services are provided to inpatients in the VA system. Health care providers, particularly nurses, can use this window of opportunity to provide smoking cessation services when patients are most receptive to this information.

Although nurses generally favor the provision of cessation services, several studies have shown that nurses are unlikely to provide cessation services (Braun et al., 2004, Gomm et al., 2002, McCarty et al., 2001, McCarty et al., 2001). One of the most often cited reasons for nurses failing to provide cessation services is lack of confidence and training (Braun et al., 2004, Gomm et al., 2002, McCarty et al., 2001, Sarna et al., 2001, Willaing & Ladelund, 2004). Other barriers to nurses' provision of cessation services include the following: perception that a patient was not motivated, not wanting to make a patient feel guilty, perception that it will not make a difference in a patient's prognosis, lack of recognition for providing these services, and other more pressing issues such as substance abuse, invasion of privacy, risk of alienating patient, and lack of time (McCarty et al., 2001, Sarna et al., 2001). Nurses who smoke are less likely to feel that providing services is important and, thus, are less likely to provide cessation counseling (Braun et al., 2004, Willaing & Ladelund, 2004).

In preparation for delivering an inpatient smoking cessation intervention, veteran inpatient smokers and their staff caregivers at two Michigan VAs were surveyed and interviewed. The objectives of the study were to: (1) determine the motivation of inpatient veterans to quit smoking and the types of services they would prefer; (2) determine facilitators and barriers to inpatient staff delivery of inpatient cessation services; and (3) seek suggestions and insight from inpatients and staff about what would be important to include in an inpatient smoking cessation program.