Nicotine Withdrawal and Smoking Status in Hospitalized Veterans

Kamath AS, Vander Weg MW, Fu S, Grant K, Prochazka A, Katz DA. Nicotine Withdrawal and Smoking Status in Hospitalized Veterans. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 6; Phoenix, AZ.

Related HSR&D Project(s)

• IIR 07-113 – Improving the Delivery of Smoking Cessation Guidelines in Hospitalized Veterans

BACKGROUND: Veterans Administration (VA) hospitals have mandated that patients abstain from smoking while in-hospital, but have created facilities on hospital grounds where inpatients may smoke. Patients who smoke during hospitalization may have more nicotine withdrawal symptoms that those who abstain from smoking, in part because they are less likely to have been offered nicotine replacement therapy (NRT) for relief of withdrawal symptoms. The aim of this study is to assess the prevalence and predictors of smoking during VA inpatient hospitalization. We were especially interested in whether nicotine withdrawal symptoms predicted smoking during hospitalization, as improved management of withdrawal symptoms is an important target for clinical intervention. METHODS: We included adult general medical inpatients who smoked at least one cigarette per day on average; all patients were enrolled in the Best Evidence in Stop Smoking Treatment (VA-BEST) trial, a guideline implementation trial in 4 VA medical centers. At the initial interview, a study site research assistant (RA) collected information on smoking-related variables (Fagerstrom Test for Nicotine Dependence (FTND), readiness to quit (Contemplation Ladder), presence of a smoking-related condition (patient-reported), Minnesota Nicotine Withdrawal Scale (MNWS), and other psychological measures (Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale (PSS)), and receipt of smoking cessation counseling (including whether any inpatient clinician had discussed or offered NRT for relief of nicotine withdrawal symptoms). Demographics and smoking-related comorbidities were abstracted from the electronic medical record. We used generalized estimating equations (PROC Genmod with binomial distribution and logit link) to explore predictors of smoking during hospitalization, and adjusted for age, education, smoking-related variables, psychological variables, smoking cessation counseling (discussion of NRT for relief of nicotine withdrawal symptoms), and study period (intervention versus usual care). RESULTS: Mean age of the study sample was 59 years (SD 9.5); 96% and 93% were male and Caucasian, respectively. Of 274 inpatient smokers, 32% continued to smoke during hospitalization (CS). 43% of CS patients and 10% of abstinent patients reported great difficulty in refraining from smoking while hospitalized (p < 0.001); mean (SD) MNWS was 15 (10.4) and 11.5 (8.6) in each group, respectively. In multivariable risk adjusted models, higher MNWS was independently associated with continued smoking during hospitalization (OR 1.05 per one point increase in MNWS score, 95% Cl = 1.01-1.1). Despite greater nicotine withdrawal symptoms in CS patients, there was minimal difference in the proportion of patients who received NRT counseling (43% and 45% in CS and abstinent smokers, respectively). Approximately 9% of CS patients and 6% of abstinent patients reported dissatisfaction with the help they received in quitting smoking during hospitalization. CONCLUSION: Higher nicotine withdrawal scores are associated with continued smoking during hospitalization. Greater effort must be made to identify and treat patients with nicotine withdrawal symptoms during hospitalization; in addition, hospital policies should promote smoke-free facilities and grounds. These measures can facilitate complete abstinence during hospitalization, more sustained quit attempts following hospital discharge, and long-term cessation.