post-hospitalization smoking cessation program

a low-key, low-cost post-hospital smoking cessation program had pretty impressive results (see smoking cessation hosp pts jama 2104 in dropbox, or doi:10.1001/jama.2014.9237​). in this randomized controlled trial, 397 hospitalized daily smokers (at least 1 cigarette/d) who wanted to quit smoking were randomized to either "sustained care", which consisted of automated interactive voice response telephone calls for the first 3 months, promoting smoking cessation, medication management, problem-solving approaches, and the option for additional counseling, along with their choice of free smoking cessation medications for up to 90 days, vs. "standard care", which involved recommendations for post-discharge pharmacotherapy and advice through a free telephone quit line.  primary outcome was biochemically-confirmed (saliva cotinine analysis) past 7-day abstinence at 6-month followup.  results:
--mean age of participants was 53, 48% male, 81% non-Hispanic whites. mean smoking of 16.7 cigs/d. 45% of primary discharge diagnosis were for a smoking-related disease
--sustained care patients used more counseling (37% vs 23%) and pharmacotherapy (79% vs 59%) during the month post-discharge. the sustained care group received a median of 4 interactive voice response calls. primary medication used was combination of nicotine replacement therapies (patch plus short-acting), with only <5.5% put on either bupropion or varenicline
--biochemically-validated 7-day abstinence rates at 6 months were 26% in sustained care group vs 15% with standard care [RR=1.71 (1.14-2.56)], with number-needed-to-treat=9.4. the results were at least as impressive in those who had been smoking >10 cigs/d
so, there are a couple of possible lessons here (in dealing with the leading preventable cause of death in the US!!):
    --providing free medications with telephonic counseling seems to improve long-term smoking cessation pretty impressively (often these meds cost money and provides a patient disincentive, though the Affordable Care Act requires insurers to cover all smoking cessation meds approved by the FDA)
    ​--there may be advantages to starting medications in the hospital. in part because there is a direct, palpable connection between disease and smoking cessation (which i would think would be true even if the hospitalization were not clearly related to smoking ... just the vulnerability and sickness associated with the hospitalization itself might prove important). also, such a program set up as a routine part of hospitalization would ensure that smoking cessation were addressed (similar to prescribing statins when patients are being discharged for an MI -- it happens. and the primary care provider may be too caught up with a myriad of issues to prescribe and reinforce the importance of statins).
​it also might be that giving other combinations of meds (eg nicotine replacement plus bupropion, varenicline plus patches -- will append below a recent blog on that) might be even more effective than the combo nicotine replacement therapies. the above study was done in only one institution, so should be validated more broadly.

Comments

Post a Comment

if you would like to receive the near-daily emails regularly, please email me at gmodest@uphams.org

Popular posts from this blog

cystatin c: better predictor of bad outcomes than creatinine

  another article found significant discordance between creatinine and cystatin C in assessing renal function,  finding that the latter correlated most strongly with both renal and non-renal adverse clinical outcomes (see   ckd cystatin c better than creat AJKD2023  in  dropbox or doi: 10.1053/ j.ajkd.2023.04.002)   Details: -- 158,601 adults who were in the Stockholm Creatinine Measurements (SCREAM) project and had testing of creatinine and cystatin C on the same day during a healthcare encounter, from 2010-2018     -- >400,000 outpatient tests were done for both creatinine and cystatin C levels -- mean age 62, 48% female -- mean eGFR by creatinine (   eGFR cr ) 80; mean eGFR by cystatin C ( eGFR cys  ) 73 -- mean stage of renal insufficiency: 39%  eGFR cr   90+; 38%  eGFR cr  60-89; 12%  eGFR cr  45-59; 7.1%  eGFR cr  30-44; 3.2%  eGFR cr  15-29, 0.7%  eGFR cr ...
Read more

diabetes DPP-4 inhibitors and the risk of heart failure

the FDA just came out with a safety alert about 2 DPP-4 inhibitors and the increased risk of heart failure (released 04/05/2016)(see  http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm494252.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery ​ ). details: --saxagliptin and alogliptin were singled out because of 2 clinical trials in diabetic patients with heart disease. in each trial more patients taking these meds were hospitalized for heart failure vs those on placebo     --in the saxagliptin trial: 3.5% were hospitalized for heart failure (vs 2.8% on placebo). risk factors included prior heart failure or kidney disease     --in the alogliptin trial: 3.9% were hospitalized for heart failure (vs 3.3% on placebo) --recommendation by the FDA:     -- we should consider stopping these drugs if the patient develops heart failure ...
Read more

UPDATE: ASCVD risk factor critique

I decided to do an extensive update of my prior ASCVD (atherosclerotic cardiovascular disease) risk analysis and critique of risk calculators, with much more information about the “non-traditional” risk factors. I felt that there should be more data/clarification, since I think we are really undertreating/not preventing the most common cause of death by relying on the current ASCVD risk calculators   -- Cardiovascular risk models:      -- many of us rely on the various cardiovascular risk models to determine the appropriate approach to patients, and these are often integrated into the electronic medical records      -- these risk models have several very important limitations:          -- they are typically based on community data, eg from the Framingham study etc. But, in clinical practice, we are dealing with the individual and not the community:          ...
Read more