Identify smokers, then you educate

Smoking cessation intervention upon admission

Identifying smokers when they are admitted to the hospital and offering information on how to quit is good practice, says Connie Graff, RCP, AE-C, a respiratory therapist at Lake Region Healthcare Corporation in Fergus Falls, MN.

"This is an opportune time to reach patients because they are thinking about their health and no one can deny that smoking does not affect your health," says Graff. Their hospitalization may be a direct result of smoking; and if not, it still gets them in the frame of mind to consider their health. In addition, they go through days of not smoking while hospitalized so they might as well make it a permanent quit time, she says.

Smoking cessation intervention upon hospital admission is recommended by many professional organizations, says Jennifer Robinson, RN, MHS, patient education coordinator at Roper St. Francis Healthcare in Charleston, SC. "Often when your health is compromised, it is a wake-up call that you need to make a change in your lifestyle," she says.

Good opportunity to teach

While patients can’t be forced to quit, it is important to at least provide the information and help if they choose to take the step, says Graff.

"While it doesn’t work to nag people, if the health care professional doesn’t say anything that sends a bigger message," she explains. "That bigger message is, my smoking must not be so bad if no one said anything to me about it.’"

To identify smokers, during the admitting process many health care institutions ask whether or not the patient smokes. A positive response will then trigger an educational intervention.

While some health care institutions are including smoking cessation interventions voluntarily to achieve best practice, others are participating in programs that mandate it. For example, hospitals that have elected to participate in one of three core measure sets (acute myocardial infraction, heart failure, or community acquired pneumonia) implemented by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, must include smoking cessation intervention with certain patient groups, says Virginia Reichert, NP, director of the Center for Tobacco Control for the North Shore-Long Island Jewish Health System in Manhasset, NY.

To make sure that nurses document whether the patient smokes, the computerized admission system at this health care institution locks up and the nurse is unable to finish the admission process if information on the patients smoking habits have not been entered into the computer within eight hours after hospitalization, says Reichert.

Patients who smoke are given a self-help brochure on how to quit smoking that includes information on how to set a quit date and how to deal with the signs and symptoms of withdrawal. The pamphlet also includes information about the free smoking cessation program offered at the Center for Tobacco Control.

Further intervention

In addition, if the patient was admitted to the hospital for congestive heart failure, acute myocardial infarction, or community acquired pneumonia the computer automatically triggers a printout on the patient at the Center for Tobacco Control. Reichert waits until the patient is stable and then visits him or her to discuss smoking cessation.

"Many are still not ready to quit. They swear they will call us when they get home and then they don’t. However, we often find that they will call four months later," says Reichert.

When they do call they are enrolled in a six-week smoking cessation class that includes lessons on preparing for the quit date as part of the smoking cessation plan and nicotine replacement to help the smokers deal with withdrawal symptoms.

In addition to the general smoking cessation classes, the Center for Tobacco Control offers smoking cessation classes for cancer patients, pregnant women, and adolescents.

At Lake Region Healthcare, nurses document if the patient is a smoker upon admission and the unit clerk enters the information into the computer system. Respiratory care retrieves the list from the computer and therapists visit these patients. During the visit, the respiratory therapist assesses the patient’s need for nicotine replacement and initiates the process for prescriptions if the patient is having withdrawal symptoms.

Also, the respiratory therapist provides the patient with information on the institution’s smoking cessation program and leaves a business card with contact information.

The program entails individual counseling appointments with the patient returning for as many sessions as needed. During the first visit, the patient is assessed to determine where he or she is at in the process of quitting. Maybe the smoker has not had a cigarette since discharge from the hospital, or he or she may have started smoking again after returning home. A quit date is selected if needed and a plan is made with specific strategies for success.

For example, if the smoker is used to having a cigarette after dinner and the conversation following the meal triggers an urge to smoke, he or she will commit to leaving the table immediately after dinner and walking out to the mailbox and back.

After the initial visit, counseling sessions can take place either in person or over the telephone.

When patients admitted to Roper St. Francis Healthcare are identified as having smoked within the past year, the nurse asks if they would like education on smoking cessation. If the patient is interested, the nurse has the option of showing one of two videos on the closed-circuit television system or providing the patient with a one-page handout with steps for quitting, which was produced in house. The handout was compiled from several resources and can be printed from the computer.

Patients are asked if they would like to receive education as part of the assessment for their readiness to learn. "Timing can be everything for some people. Quitting smoking has to be their goal; it can’t just be ours," says Robinson.

At discharge, patients are given the web site address ( for the American Lung Association’s "Freedom from Smoking" program and also the association’s toll-free number [(800) 586-4872] for continuing support. Shortly, the health care institution will be offering a smoking cessation program as well. In August 2003, several staff members attended a training program for QuitSmart, which was developed by Robert Shipley, PhD, at Duke University Medical Center in Durham, NC. This smoking cessation program consists of three one-hour classes offered during a three-month period.

According to the 2003 JCAHO Core Measure Comparative Report for Heart Failure, Roper St. Francis Healthcare is scoring 10% above national standards for smoking cessation advice or counseling for at risk patients, says Robinson.

"The goal of our organization is that 100% of at-risk patients will receive smoking education if they are receptive to it," she says.


For more information about initiating smoking cessation education by the admission process, contact:

  • Connie Graff, RCP, AE-C, Respiratory Therapist, Respiratory Department, Lake Region Healthcare Corporation, 712 Cascade St. S., Fergus Falls, MN 56537. E-mail: (department manager).
  • Virginia Reichert, NP, Director, Center for Tobacco Control, North Shore-Long Island Jewish Health System, 225 Community Drive, South Entrance, Great Neck, NY 11021. E-mail:
  • Jennifer Robinson, RN, MHS, Patient Education Coordinator, Roper St. Francis Healthcare, 316 Calhoun St. Charleston, SC 29401. Telephone: (843) 724-2130. E-mail: