7.12 Cessation interventions for people with serious health conditions

Last updated: July 2022

Suggested citation: Greenhalgh, EM., Jenkins, S, Stillman, S., & Ford, C. 7.12 Cessation interventions for people with serious health conditions. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-12-cessation-interventions-for-people-with-serious-health-conditions 

 

Health concerns are a major motivator for smoking cessation.1   Diagnosis of a smoking-related illness, especially if it results in a period of hospitalisation or intensive treatment, is a good opportunity to promote smoking cessation.2 Treatment of some health problems is substantially improved if patients stop smoking. For example, quitting after a heart attack improves recovery and reduces the risk of recurrence.3, 4 Cancer patients show improved response to treatment if they quit, and have a lower rate of recurrence.4, 5 The management and progression of many chronic and acute diseases, including diabetes, asthma, peripheral vascular disease and emphysema, is improved after quitting,6 and intervention is worthwhile.4, 6-13 Smoking is a serious problem after orthotopic liver transplantation and increases the risk for malignancy.14 There has been a vigorous debate in the medical profession about the ethics, economics, and health effects of refusing some hospital treatments for patients who fail to stop smoking.15

A review of interventions for smoking cessation in hospitalised patients concluded that high intensity behavioural interventions that begin during a hospital stay and include at least one month of supportive contact after discharge promote smoking cessation.2 Smoking cessation advice and/or counselling given by nurses also appears to be effective.16 Oncology nurses play a pivotal role in supporting cessation among cancer survivors.17 For smokers receiving outpatient treatment, brief or intense interventions by their physician will increase quit rates,18 which may include referral of those interested in quitting to appropriate services. A randomised clinical trial found that a post-hospital discharge intervention comprising automated telephone calls and free medication resulted in higher rates of smoking cessation at 6 months compared with a standard recommendation to use counselling and medication.19  In hospital, people are likely to be more open to receiving help, and they are likely to find it easier to quit in a place where smoking is prohibited.2 At the very least, there is a need to encourage abstinence, provide nicotine replacement therapy (NRT) to manage withdrawal symptoms, and/or explain the necessity of smoking offsite or in a designated area if available. More intensive programs are likely to have greatest success.20 For example, referral to the Quitline or in-house support staff for cessation may help improve outcomes, as may consideration of smoking status and intentions for discharge planning, and providing support for continued abstinence or encouragement to consider quitting in the future. New South Wales Health has developed a good example of a comprehensive policy approach for all inpatient facilities.21

Current practice falls well short of potential.22 For example, healthcare providers working with cancer survivors do not always take advantage of opportunities to provide cessation advice and interventions.23 Another study found that the majority of smokers continued to smoke five years after stroke, and few recalled smoking cessation advice from their health professionals.24

This section summarises research on interventions tailored and targeted for:

Surgical patients

People with cardiovascular disease

People with respiratory diseases

People with cancer

People with Diabetes

People with HIV/AIDS

People with other conditions

For a detailed discussion of interventions for people with mental illness, see Section 9A.6. For more information on the role of healthcare professionals in supporting cessation, see Section 7.10.

7.12.1 Surgical patients

For people undergoing surgery, smoking cessation decreases postoperative complications. A systematic review published in 2012 concluded that at least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications.25 The Australian and New Zealand College of Anaesthetists recommend that, based on the current available evidence, anaesthetists and surgeons should not be dissuaded from advising patients to quit at any time before surgery.26 A Cochrane review of interventions for preoperative smoking cessation concluded that preoperative smoking interventions providing behavioural support and offering NRT increase short-term smoking cessation and may reduce postoperative morbidity. One trial of varenicline found a benefit on long-term cessation but did not detect an effect on early abstinence or on postoperative complications.27  Another systematic review and meta-analysis found that preoperative smoking cessation programs will likely precipitate long-term cessation, highlighting the additional benefits of cessation support at this time.28

7.12.2 Cardiovascular disease

Quitting smoking is the single greatest lifestyle change people with cardiovascular disease (CVD) can make to reduce their morbidity and mortality risk; however, many continue to smoke, even after experiencing a major cardiac event.29 While many smokers hospitalised with CVD report being prepared to quit smoking, many who do try do not use effective methods.30 There is also high underreporting of smoking status among cardiac patients who participate in smoking cessation programs.31 Factors such as higher income, fewer household smokers, having a partner, and being a lighter smoker are associated with successful quitting among people with CVD32 33 Alternatively, the inability to engage in previously valued activities may contribute to depressed mood and failure to quit smoking in people with heart conditions.34 Understanding the relationship between depressive symptoms often experienced by patients hospitalised for acute CVD and relapse following discharge may assist the development of more effective interventions.35 One study found that those with stroke/transient ischaemic attack do not necessarily associate their illness with smoking and boredom and lack of social support were cited as additional barriers to quitting. Pharmacotherapy and vocational and rehabilitation programs were perceived positively as resources to assist quitting.36

A review of smoking cessation for cardiovascular patients concluded that there are promising approaches for enhancing quit rates with existing cessation medications, such as combination treatment, extended use of pharmacotherapy, reduce-to-quit strategies, and tailored treatments. The use of cytisine appears promising, and despite its relatively low use, the Quitline is also effective.37 The safety of pharmacotherapy for smoking cessation in cardiovascular patients has been demonstrated by a network meta-analysis.38 Another review highlighted the importance of a systematic approach with focus on the 5A's (Ask, Advise, Assess, Assist, and Arrange), as well as the efficacy of pharmacotherapies, NRT, and counselling for smoking cessation in patients with vascular disease.11 A Cochrane review of psychosocial interventions for smoking cessation in patients with coronary heart disease concluded that such interventions are effective in promoting long-term abstinence, as long as they are sufficiently intensive.29

Providing intensive smoking cessation programs for patients hospitalised for CVD increases abstinence.39 In the UK, a nurse-led preventive cardiology program in high CVD risk smokers using optional varenicline substantially increased smoking abstinence over 16 weeks and also reduced overall cardiovascular risk compared with usual care.40 A systematic review and meta-analysis of bupropion for cessation in patients hospitalised with cardiovascular disease found that while bupropion improved abstinence over placebo at the end of treatment, this effect did not persist at 12 months.41  German research found that a low-intensity smoking intervention embedded in an adherence program for patients with an increased risk for cardiovascular disease promoted smoking cessation, although the intervention effect diminished over time.42 There is some evidence that intensive outpatient cessation intervention is effective for patients with peripheral vascular disease.43 A small study found support for the use of phone counselling and text messaging for smoking cessation and lifestyle changes among patients who had undergone percutaneous coronary intervention.44

7.12.3 Respiratory diseases

Smoking has detrimental effects on asthma.45 There is a significant association between asthma and early smoking,46, 47 and adolescents with asthma who smoke are more likely to be girls, have a relatively higher body mass index, be in higher school levels, use marijuana or alcohol, have minor to severe depressive symptoms, not live with both biological parents, be exposed to environmental tobacco smoke at home, and have friends who smoke. Cessation interventions are more likely to assist this group if they address such psychosocial and environmental factors.48 49 A qualitative study found that most patients understood that smoking exacerbates asthma. Fear of asthma-related exacerbations and poor self-control appeared to be the major triggers for quitting smoking. Most patients wanted quit smoking; however, motivation often needed to be combined with public, social, professional, and therapeutic support to achieve and maintain abstinence.50 Counselling and use of pharmacological treatments is a good approach for smoking cessation in asthma patients; however, there is a lack of smoking cessation trials in this patient population.45 Further research is warranted in this area.46

Smoking cessation is the most effective measure for controlling the progression of chronic obstructive pulmonary disease (COPD).45 A 2016 Cochrane review concluded that there is high-quality evidence that smokers with COPD who receive a combination of high-intensity behavioural support and medication are more than twice as likely to quit as those who receive behavioural support alone. There was no clear evidence that one particular form of behavioural support or medication is better than another.51 First-line drugs licensed to aid smoking cessation (nicotine replacement therapy, bupropion, and varenicline) are effective in patients with COPD.52 A combination of two or more NRT products, higher than usual dosing, extended use prior to quitting and extended use post-quitting can improve treatment efficacy. Extended use of varenicline prior to and after the target quit date, and the combination of varenicline with nicotine patches or bupropion can improve treatment outcomes.45 A meta-analysis of behaviour change techniques in cessation interventions for people with COPD concluded that such interventions appear to benefit from focusing on forming detailed plans and self-monitoring.53

For smokers with either COPD or asthma, an intensive smoking cessation program with regular and long-term follow-up can help them to achieve high abstinence rates and prevent relapse.54 Several studies have called for the development of tailored interventions for people with COPD, taking into account both inter- and intragroup differences.55, 56 COPD patients express motivation to quit and often make multiple quit attempts; however, boredom, mood disturbances, the strong sense of identity as a smoker, peer reinforcement, irritability, cravings, hunger, and weight gain can act as barriers to quitting,57 along with patient misinformation, levels of motivation, health beliefs and poor communication with health professionals.58 Depression also appears to decrease the likelihood that patients with chronic respiratory conditions will quit smoking.59 Qualitative research found that smokers with COPD often trivialise the health consequences of smoking, and may be less knowledgeable about its health effects. Autonomy was very important among participants, and many were indignant about a perceived lack of empathy from doctors. There was little faith in the efficacy of smoking cessation aids.60 Some patients may inaccurately report their smoking status, which hampers effective intervention.61 62

The prevalence of smoking among people with tuberculosis (TB) is higher than in the general population, and smoking leads to worse TB outcomes. Smoking cessation strategies for TB patients include: a combination of counselling (brief behavioural intervention at diagnosis followed by monthly behavioural support throughout the TB treatment course) and pharmacological treatment (nicotine replacement therapy, bupropion and varenicline).45 Motivational interviewing also appears to increase self-efficacy and abstinence rates among tuberculosis patients.63, 64

7.12.4 Cancer

A diagnosis of cancer, even a cancer not strongly related to smoking and with a relatively good prognosis, may be associated with increased quitting that is sustained well after diagnosis.65 Motivation and interest in smoking cessation appear to greatly increase following cancer diagnosis, therefore this could be an effective time for encouraging and supporting quitting.46 66 However, many patients and family members continue to smoke following cancer diagnosis, and feelings of guilt can lead to the concealment of smoking status from health care professionals.67 Continued tobacco use limits the effectiveness of major cancer treatments and increases the risk of complications and of developing secondary cancers.68

There is limited research regarding smoking consumption, smoking cessation interventions and relapse prevention strategies among cancer patients.66 A systematic review concluded that interventions combining non-pharmacological and pharmacological approaches have resulted in an improvement in smoking cessation rates compared to usual care.69 Bupropion may have advantages for cancer patients, including low risk for nausea.70 A systematic review and meta-analysis of smoking cessation counselling for patients with head and neck cancer found that patients who received counselling supplemented with NRT achieved cessation considerably more often that those who received usual care.71 The US National Comprehensive Cancer Network clinical practice guidelines recommend that treatment plans for all smokers with cancer include evidence-based pharmacotherapy, behaviour therapy, and close follow-up with retreatment, as needed.72 However, a lack of appropriate resources and provider training has been cited as a major barrier to integrating tobacco treatment in healthcare systems.68

Among childhood and young adult cancer survivors, factors such as self-efficacy, social support, fear of recurrence, perceived vulnerability and depression are associated with smoking73 Web-, print-, and telephone-based interventions appear to be equally effective for this group,74 and educational and behavioural risk-counselling interventions may also be beneficial in reducing smoking risk up to 12 months after intervention.66

Cigarette smoking causes most cases of lung cancer, and adversely impacts prognosis once lung cancer is diagnosed (see Chapter 3, Section 3.4). However, most smokers with lung cancer continue to smoke post-diagnosis, or fail to maintain abstinence following quit attempts. A recent Cochrane review aimed to examine smoking cessation interventions for people diagnosed with lung cancer, which represents an important factor in improving their prognosis. The review found no randomised controlled trials that met selection criteria, therefore the efficacy of cessation interventions could not be evaluated. These authors call for further research in this area.75 Limited research suggests that smoking cessation strategies for lung cancer patients should include counselling and use of pharmacological treatment (nicotine replacement therapy, bupropion and varenicline).45 Screening programs for lung cancer might also benefit from the inclusion of cessation interventions.76 Lung cancer survivors who are exposed to secondhand smoke, particularly those exposed in multiple settings, are less likely to quit.77

In general, because each patient with cancer has unique medical, psychological, and social circumstances, cessation treatment needs to be individualised.78 Patient age, gender and type of cancer may be important factors to consider when developing and implementing smoking cessation interventions for cancer patients. Persistent smoking post-diagnosis is associated with younger age, lower education and income, greater alcohol consumption,79 the presence of household members who smoke, high body mass index, and a longer duration of smoking.80 . Pain may also be a barrier to quitting among cancer patients who smoke.81 People who continue smoking subsequent to a cancer diagnosis often perceive fewer health risks from smoking and fewer benefits of quitting.82, 83   Other challenges for people with cancer can include long histories of smoking, pressure for immediate quitting, high levels of stress and distress, delayed relapse, and medical contraindications to certain pharmacotherapies.46 84

7.12.5 Diabetes

People with diabetes who quit smoking have a lower risk of death and cardiovascular events compared with those who continue to smoke.85  However, recent research has shown while quitting generally decreases the risk of diabetes overall, smoking cessation is associated with an increased risk and deterioration in blood glucose control in the first 2–3 years of abstinence.86, 87 A recent review similarly found that cessation can cause weight gain and can be associated with diabetes or obesity onset.88 Therefore, it is important that quit attempts are accompanied by preparation, extra care, and careful monitoring to keep the person’s blood glucose well controlled during this time.86, 89 Additional challenges to achieving abstinence for people with diabetes include early uptake of smoking, difficulty with weight management, negative affect, and low motivation for quitting at the time of hospitalisation.46 Lower education level is also associated with smoking in young people with diabetes.90

There is a dearth of evidence to inform treatment strategies for smoking cessation in type 2 diabetes. A randomised controlled trial found that an intensive, individualised intervention using motivational interviewing, therapies, and medications adapted to the patient's stage of change delivered to people with diabetes in primary care was feasible and effective, with a smoking cessation rate of 26.1% after 1 year.91 One program partnership in California that aimed to promote referrals to the quitline by diabetes educators resulted in an increase in the percentage of quitline calls from people with diabetes and the proportion of callers referred by healthcare providers.92

A systematic review of randomised trials of smoking cessation interventions in diabetes published in 2014 identified only a small number of trials, which tested interventions similar to those used in the general population, comprising counselling, referral and advice, and for some, the addition of diabetes-specific education. The results did not provide evidence of efficacy for the interventions. Only one trial reported data on glycaemic outcomes, which were not significantly different between intervention groups.93 A more recent review of randomized, placebo-controlled studies of varenicline in smokers with diabetes concluded that it was an effective and well-tolerated aid for smoking cessation, and safety was comparable with participants without diabetes.94 Bupropion should be used with great caution among people with diabetes, as the risk of seizures is greater in individuals taking insulin or oral diabetes medication.95

7.12.6 HIV/AIDS

Adults with HIV are more likely to smoke and less likely to quit than the general population.96 Data from the Australian HIV Futures 6 study show that 42.3% of people living with HIV/AIDS smoke.97 HIV infection appears to confer an increased susceptibility to the harmful effects of smoking,98   including non-AIDS-defining cancers, cardiovascular disease, and pulmonary disease.99 Smoking also adversely affects the health-related quality of life of people living with HIV/AIDS.99 Cessation may result in better disease management and increased length of survival.99 When asked, as many as two-thirds of smokers with HIV report being interested in or considering quitting.100 Diagnosis of HIV may be an effective time for intervention.99

Successful quitting among people with HIV is influenced by a complex range of social, economic, psychiatric, and medical factors.99, 101, 102 Research in the US found that among people with HIV, current smokers had higher unemployment and increased rates of other substance use than former smokers or never smokers. Being unemployed and having used inhalant drugs were also associated with current smoking. Lower education was associated with decreased readiness to quit.103  National surveys in the US have found that people with HIV who binge drink or who have been treated for drug or alcohol use are more than 5 times more likely to be current smokers than never smokers.104 Another study found that older age and lifetime use of NRT/medications were associated with interest in quitting smoking, while older age and having a supporter who had used NRT/medications for cessation were associated with lifetime NRT/medications use.105 Surveys in the US found that people with HIV cite cost and a belief that they can quit unassisted as the main reasons for not using pharmacotherapy. Physician assistance was the strongest correlate of prior use. Willingness to use pharmacotherapy was associated with perceived benefits and self-efficacy.106 Self-efficacy plays an important role in outcomes of smoking cessation interventions107 and cessation medication adherence,108 and measures aimed at increasing self-efficacy to abstain may enhance the effect of targeted tobacco treatment strategies.109 Social support can also promote NRT use adherence.110

Limited evidence shows that interventions for this group are potentially effective, can significantly decrease smoking rates, and can be incorporated within HIV clinics.46, 99, 101, 111, 112   A review published in 2013 found that smoking cessation rates ranged from 6% to 50% across studies employing pharmacologic and behavioural approaches. However, the studies were often small and the effect was often not sustained over time. Smoking was associated with emotional distress, which may be a barrier to successful cessation. Declining adherence to pharmacologic therapy also may have contributed to low cessation rates. Nicotine replacement therapy combined with a mobile phone-delivered intensive counselling intervention appears to be a promising intervention. The authors highlight need for innovative and effective interventions tailored to this population.100 Preliminary findings from a recent randomised controlled trial suggest that web-based treatment is a feasible and effective cessation strategy for smokers with HIV.113

A meta-analysis published in 2016 concluded that targeted behavioural smoking cessation interventions are effective for people with HIV, with interventions consisting of eight sessions or more having the greatest treatment efficacy.114 Another 2016 review also found evidence (albeit sparse and mixed) for the efficacy of behavioural interventions.115 A Cochrane review published in 2016 found very low quality evidence that combined cessation interventions (behavioural support and pharmacotherapy) were effective in helping achieve short-term abstinence among people living with HIV/AIDS, and moderate quality evidence that the effects were not sustained. Despite this, the authors recommend that interventions be offered to this group, given the benefits of short-term cessation.116

While health professionals working with patients living with HIV/AIDS agree on the importance of smoking cessation, they often fail to implement interventions.117 Healthcare professionals should actively pursue smoking cessation as a major objective in the clinical care of people with HIV.118 Future cessation interventions for HIV-infected smokers may be enhanced by the inclusion of medical adherence and depression as components of the program.102, 119

7.12.7 Other conditions

Research related to smokers who are hearing or sight impaired is scarce. Access to smoking cessation programs for those who are deaf is limited due to cultural, linguistic and geographic barriers. Internet-based interventions may provide greater access to cessation assistance, but research is very limited. One pilot study of an interactive website has been positively evaluated by deaf community members.120

Little is known about the smoking rates of adults with intellectual disability or about effective interventions for this population. UK data suggest that those not using disability services are more likely to smoke.121 Limited research supports the use of mindfulness-based cessation programs.122, 123 A systematic review concluded that the body of evidence on the feasibility, appropriateness, meaningfulness, and effectiveness of tobacco-related interventions for people with intellectual disability is small, and the evidence that does exist is of poor/moderate quality. The strongest study developed materials that educated people with intellectual disabilities about smoking, which led to significantly lower rates of smoking.124

 

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