Smoking Cessation Drugs: Missed Opportunity for Patients Hospitalized for CHD

Fewer than one-quarter of patients hospitalized for a cardiac event in the United States receive smoking cessation pharmacotherapy to help them quit smoking, according to a research letter published online yesterday in JAMA Internal Medicine. This is despite the fact that the Joint Commission considers such aids to be standard of care, authors of the new analysis point out.

“Most smokers do want to quit,” lead author Quinn R. Pack, MD (Baystate Health, Springfield, MA), told TCTMD. The percentage is around 70% among outpatients, “and about a third of them make an honest quit attempt every year.”

When individuals are hospitalized, that number rises even higher, Pack reported. Around 85% of patients seen at his center are “intent on doing it. They’re ready and willing, and [say], ‘Yeah, I know it. This is the time.’” Beyond having a moment of clarity about their health and positive reinforcement from concerned family members, “they also get a 3- or 4-day head start on quitting smoking, because all hospitals are essentially smoke-free in America,” he said.

“The moment is right there and they’re ready to launch, and I think we fail them,” Pack observed. “I think we could be doing a lot more.”

They’re ready to launch, and I think we fail them. Quinn R. Pack

For their study, Pack and colleagues reviewed data from the Premier Alliance database on 36,675 smokers (mean age 58; 69% men) who were treated at 282 US hospitals in 2014. Approximately two-thirds presented with MI.

Slightly more than one in five patients (22.7%) received some form of smoking cessation pharmacotherapy, be it varenicline tartrate, bupropion hydrochloride, or nicotine replacement therapy. The nicotine patch (median dosage 21 mg/day) was the most commonly used at 20.4% of patients.

The therapies tended to be given more often to patients with chronic lung disease (OR 1.64; 95% CI 1.55-1.73), depression (OR 1.51; 95% CI 1.40-1.64), or signs of alcohol abuse (OR 1.71; 95% CI 1.56-1.87). Other patient-level predictors of smoking cessation pharmacotherapy were drug abuse, psychosis, weight loss, and peripheral vascular disease. Conversely, those with renal failure, paralysis, or lymphoma were less likely to receive the drugs.

Hospitals varied in their use of smoking cessation drugs, with a median treatment rate of 22.3%. Those in the 10th percentile gave only 9.6% of patients pharmacotherapy, whereas the rate was 36.7% in the 90th percentile. Overall, the strongest factor associated with use was the hospitals themselves (median OR 1.91; 95% CI 1.77-2.04). Further calculations showed this link could not be traced to characteristics such as hospital size, urban location, teaching status, or US region, the researchers report.

“More than 40% of hospitals administered [smoking cessation pharmacotherapy] to fewer than 20% of eligible patients,” they note. “These findings may reflect differences in hospital policies, physician inexperience with prescribing [the medications], or lingering concerns about the safety of [their use] in patients with CHD."

There were some gains in pharmacotherapy use over time. The mean rate among hospitals rose by 6% from 2004 to 2011 and by 2% from 2011 to 2014.

Part of the Culture, or Not

Asked why some hospitals prescribed the drugs more than others, Pack acknowledged, “We don’t know. . . . This is speculating, but I think it has to do with the culture and the attitudes toward smoking cessation in the hospital.”

What happens, he said, is “everyone passes the buck, and nobody really takes [ownership of] it.”

Individual providers may not see it as their responsibility, Pack explained. “Cardiologists tend to be pretty gadget and tech savvy. They’re really interested in the latest bioresorbable stents and the most expensive drug, and smoking cessation they tend to dismiss as something that primary care providers should be doing.” Meanwhile, he added, hospitalists and primary care physicians often each think the other should be responsible.

What it seems to take is a “champion” who leads the effort to formalize a smoking cessation at each hospital, Pack said. “They go to work and they educate people and they bring enthusiasm to it. They put in protocols and procedures and add things to pathways. And suddenly it becomes part of the culture.”

Use of these medicines isn’t hard, he said. In the course of caring for patients, “we prescribe medicines that are much more dangerous than these. Most of these medicines are available over the counter. So there are not real safety issues. It’s a matter of attention and caring enough to help support a cessation attempt.” Daily check-ins with patients during their hospital stay are key, Pack advised.

Beyond medications, counseling and cardiac rehab both give patients extra support in quitting, he added. Cardiologists can also spread the word that information on local resources for cessation can be found by calling 1-800-QUIT-NOW, Pack said. “Referring patients to the quit line can be quite helpful.”