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.

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