Hospitals telling smokers that 'it's time to quit'
Patients hospitalized at University of Rochester (NY) Medical Center might not be able to kick the habit during their hospitalization, but staff will no longer be aiding their addiction.
The hospital recently joined many others in becoming an entirely smoke-free campus, so that medical staff "can get out of the mode of helping people to the front door so they can have a smoke," says Robert J. Panzer, MD, FACP, chief quality officer for the medical center.
Hospitalized patients who are smokers present a number of practical challenges, from merely being ill tempered and nervous to unhooking themselves from monitors and making their way outside to smoke, heedless of their recovery and the smoke-free campus the hospital might have created.
Do most cardiac patients who smoke know, deep down, that they should quit? Do their doctors and nurses urge them to stop smoking, and does the hospital make it abundantly clear that smoking is not permitted in the building and, in more and more cases, anywhere on hospital property?
The answer to all those questions is, of course, "yes," but while a health crisis and hospital stay might be a wake-up call to some smokers, many others are not able to make the break. Coming down hard on the patient in that situation, a patient educator says, is unlikely to accomplish anything.
So what can health care providers do to prevent their patients from smoking while in the hospital? According to some smoking cessation educators, the answer sometimes is nothing.
"Patients are not allowed to smoke in our hospital," points out Rafael Maldonado, health educator for University Hospital in San Antonio. "But they do."
That's the reality, Maldonado says — even thought they know they should not smoke, and everyone around them and treating them tells them to stop, the simple fact of being hospitalized does not mean the end of smoking for some patients.
In those cases, Maldonado says, the most ethical approach is the connection with the patient at the point where he or she is on the "change scale," the spectrum that ranges from complete unwillingness to change all the way to absolute readiness and motivation to change.
"I strongly believe it's far more important to just say, 'If you're ready to quit, I can coach you through it,' as opposed to saying, 'You have to quit' and trying to kind of slap them on the hand," he explains.
Health crisis might not be enough to quit
For many patients, particularly cardiac or cancer patients, hospitalization is a wakeup call, alerting them to the need to make serious lifestyle changes. Those patients, Maldonado says, are ready to begin the process of quitting. For others, the lifelong habit might be shaken by a health crisis, but not enough to prepare them to quit.
"We have a few patients who, even if they are on monitors, and even though we do not have any smoking areas on the hospital grounds, will unhook themselves from the monitors, and go outside to the farthest point they can — which might be 3 feet from the door — and they will smoke," Maldonado says. "They have been smoking so many years, and now they're confronted with physicians telling them they can't smoke. They're going through withdrawals, and on top of everything else they're coping with [during their hospitalization], they can't cope with the withdrawal."
Hospitals across the United States address smoking with their patients, typically at admission. In some cases, there is continued contact with patient educators throughout the stay; in others, the patient receives printed materials and initiating contact with smoking cessation advisors is left to the patient.
Panzer says University of Rochester Medical Center chose the date of the Great American Smokeout to implement its campus-wide no smoking policy.
"We are not going to permit patients to smoke while they're inpatients, period," he says. "We can't control what they do when they leave, but we're not going to give them leave to go out there [and smoke] while they are inpatients."
University Hospital-San Antonio is trying a new initiative, funded by a Robert Wood Johnson Foundation grant. Maldonado and other educators in the four-hospital system are trying to identify as many smokers as possible, and maintain direct contact with them throughout their hospitalization.
The health educators rely heavily on the medical and nursing staff — particularly nurses — to work with each patient who smokes, at whatever point on the change continuum he or she might be.
Every contact can be an opportunity for teaching, Maldonado explains.
"We identify smokers when they are admitted, and begin treatment and a quit plan for them while they are in the hospital," he says.
Under the grant, the educators are targeting heart patients. The first step — identifying smokers — is deceptively difficult, he points out.
Many smokers will answer "no" when asked if they use tobacco products — some to avoid saying "yes," and some because, at that particular moment of a health crisis, consider that they have stopped.
"When they arrive at the hospital, we get patients from all levels of the stages of change, from ready to not ready, to those who aren't sure," Maldonado continues. A large number of patients consider themselves as having quit at the point of admission, but realistically and statistically, their percentage of relapse is very high.
University of Rochester Medical Center's program screens patients for tobacco use within the year prior to admission, and then steers them to a nicotine replacement therapy pathway.
"The best way to handle cigarette addiction is to move [the smoker] toward cessation with nicotine replacement, if suitable," Panzer says.
Take advantage of all teachable moments
No matter where the patient is in willingness to quit, Maldonado and the hospital education staff address that person's individual needs.
If a patient is ready to quit, he or she begins cessation therapy in the hospital. (Patients or their insurers pay for the smoking cessation therapy, and grant monies cover those who can't pay.)
"Those who aren't ready, we still address them," Maldonado says. "We give them information and educate them as much as possible. We can start getting them to at least think about why they should quit."
A study published in 2000 in Preventive Medicine examined patient compliance with hospital smoking policies and the effects of hospitalization on patients' subsequent smoking.1 Hospitalization can precipitate nicotine withdrawal, the authors noted, but also offers willing quitters an opportunity to stop smoking.
In that study, the authors found that one-quarter of smokers admitted to smoke-free hospitals said they smoked during their hospital stay; 55% reported nicotine cravings within 48 hours of admission. Abstaining from tobacco during the hospital stay was a strong indication that abstinence would continue after discharge, the authors added.
Patients wrestling with nicotine withdrawal are very vulnerable to relapse, so it is important to help them understand what is happening and why their bodies are reacting in that way.
"We try to help them understand, too, where the physician is coming from, that he or she is not just this person ordering you to stop smoking," Maldonado explains. "Most doctors want patients to have stopped smoking two weeks before an incision is made, because they want the patient to be at their healthiest status ever."
An inpatient smoking cessation program, such as the one at University Health, starts with educating the clinical and support staff, with an eye toward making whatever the method be easy and efficient.
"We understand that nurses are overloaded with work, so all we ask is that they help us identify patients who smoke, and then turn them over to me," Maldonado explains. "Then, we take every opportunity to educate the patients as much as possible.
"Every moment is a teachable moment, regardless of what stage of change they are."
1. Rigotti NA, Arnsten JH, McKool KM, et al. Smoking by patients in a smoke-free hospital: Prevalence, predictors, and implications. Prevent Med 2000; 31:159-166.
For more information, contact:
- Robert J. Panzer, MD, FACP, chief quality officer, professor of medicine and community & preventive medicine, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Phone: (585) 273-4438.
- Rafael Maldonado, health educator, University Health System, 4502 Medical Drive, San Antonio, TX 78229. E-mail: email@example.com.