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Tobacco use cessation in hospitals in ontario




NG THE UPTAKE OF HOSPITAL-BASED TOBA SUPPORTS ACROSS McMaster Health Forum Evidence Brief:
Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario
Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario McMaster Health Forum For concerned citizens and influential thinkers and doers, the McMaster Health Forum strives to be a leading hub for improving health outcomes through collective problem solving. Operating at the regional/provincial level and at national levels, the Forum harnesses information, convenes stakeholders, and prepares action-oriented leaders to meet pressing health issues creatively. The Forum acts as an agent of change by empowering stakeholders to set agendas, take wel -considered actions, and communicate the rationale for actions effectively. Authors Stephanie Montesanti, Co-Lead, Evidence Synthesis and Evaluation, McMaster Health Forum, and Doctoral Student, Health Policy PhD Program, McMaster University John N. Lavis, MD PhD, Director, McMaster Health Forum, and Professor, McMaster University Michael G. Wilson, PhD, Assistant Director, McMaster Health Forum, and Assistant Professor (part- time), McMaster University Funding The evidence brief, and the stakeholder dialogue it was prepared to inform, were both funded by the Ontario Ministry of Health and Long-Term Care. The McMaster Health Forum receives both financial and in-kind support from McMaster University. The views expressed in the evidence brief are the views of the authors and should not be taken to represent the views of the ministry or Conflict of interest The authors declare that they have no professional or commercial interests relevant to the evidence brief. The funders played no role in the selection, assessment, synthesis or presentation of the research evidence profiled in the evidence brief. The evidence brief was reviewed by a smal number of policymakers, stakeholders and researchers in order to ensure its scientific rigour and health system relevance. Acknowledgements The authors wish to thank Piyumi Galappatti and Margherita Cina for their assistance with identifying, selecting and assessing systematic reviews and single studies for use in the evidence brief. We are grateful to Steering Committee members for providing feedback on previous drafts of the brief. We are especial y grateful to Fides Coloma, Robert D. Reid and Sharon Campbel for the insightful comments and suggestions. The views expressed in the evidence brief should not be taken to represent the views of these individuals. Citation Montesanti S, Lavis JN, Wilson MG. Evidence Brief: Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Hospitals in Ontario. Hamilton, Canada: McMaster Health Forum, 18 January 2012.
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ISSN 1925-2269 (print) ISSN 1925-2277 (online) Evidence >> Insight >> Action McMaster Health Forum
Table of Contents
Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario vidence >> Insight >> Action McMaster Health Forum KEY MESSAGES

What's the problem?
• Ontario hospitals lack a common, feasible, cost-effective and sustainable approach to delivering tobacco- use cessation supports. The problem can be understood at a number of levels:
o Tobacco-related il ness affects many Ontarians and is a key driver of healthcare costs.
o There is no agreed minimum standard of support for tobacco users across Ontario hospitals. Few
hospitals have in place the necessary range of systems, policies and environmental prompts that encourage and enable consistent and effective support to tobacco users. Few studies have examined the sustainability of tobacco-use cessation programs beyond the program-implementation phase. o Gaps in existing health system arrangements constrain hospital-based tobacco-use cessation supports. What do we know (from reviews) about three elements of an approach to address the problem?
• Element 1 – Establishing and institutionalizing a common approach to identifying tobacco users upon admission to hospital o A limited number of systematic reviews were identified that addressed this element. One high-quality review found benefits for providing financial incentives to healthcare providers (albeit in primary care) and medium-quality reviews found benefits for providing smoking-cessation training to healthcare providers and for using reminder systems to increase the provision of assistance and counsel ing. No reviews were found about engaging staff in tobacco-use cessation, developing or adapting policies, procedures and care pathways, or establishing indicators for successful tobacco-user identifications. • Element 2 – Providing tobacco users with assistance in quitting and continuing support for nicotine withdrawal while in hospital o Several high-quality reviews found benefits for: several smoking-cessation interventions (including behavioural and nicotine-replacement therapies); follow-up contact after the delivery of an intervention; and interventions delivered by a range of providers. While high-quality reviews were identified as being relevant to three other components (developing or adapting policies, procedures and care pathways; providing targeted funding and/or financial incentives; and establishing accountability within hospitals), none of the reviews provided clear messages related to this element based on the findings from included studies. • Element 3 – Ensuring follow-up counsel ing once tobacco users leave hospital to assist them in remaining tobacco-free o Several high-quality reviews found benefits for: following-up with patients after the delivery of hospital-based interventions; intensive behavioural interventions; using trained community pharmacists to provide counsel ing; and using financial incentives. Medium-quality reviews also found benefits for physical therapists providing smoking-cessation advice and using reminder systems for delivering preventive services. No reviews were found for: providing additional training, certification and/or oversight of community providers; establishing indicators for successful tobacco-use cessation, data collection and feedback mechanism for organizations or providers; or establishing accountability within community-based organizations and among community-based physicians. What implementation considerations need to be kept in mind?
• Potential barriers to the implementation of a comprehensive approach to hospital-based tobacco-use cessation supports across Ontario can be identified at the level of patients (e.g., fear of treatment denial, resistance to a one-size-fits-all approach, and concern about affordability), providers (e.g., lack of resources, knowledge/skil s and support systems, as wel as concerns about professional autonomy), organizations (e.g., lack of resources and agreed indicators and concerns about organizational autonomy), and system level (e.g., budget constraints during a difficult economic period). • Three types of implementation strategies warrant deliberation: 1) a participatory approach to developing new communication channels; 2) a process for identifying and working with champions drawn from the senior executive ranks of Ontario hospitals; and 3) the development of a business case. Evidence >> Insight >> Action McMaster Health Forum Box 1: Background to the evidence brief
Tobacco use remains the number one preventable cause This evidence brief mobilizes both global and local of death and disease in Canada.(3) Tobacco-related research evidence about a problem, three elements of a comprehensive approach for addressing the illness can boost a tobacco user's motivation to quit problem and key implementation considerations. using tobacco, presumably by increasing their perceived Whenever possible, the evidence brief summarizes vulnerability to the health hazards of tobacco use.(4) research evidence drawn from systematic reviews Tobacco-related illness also brings tobacco users into of the research literature and occasional y from single research studies. A systematic review is a healthcare settings where providers have an opportunity summary of studies addressing a clearly to encourage and enable tobacco cessation (as do formulated question and using systematic and il nesses caused by other factors). The traditional explicit methods to identify, select and appraise approach of most tobacco-cessation programs is to rely research studies and to synthesize data from the on tobacco users self-identifying the need to quit and included studies. The evidence brief does not contain recommendations. seeking out supports to do so. A complementary approach is to identify and work with tobacco users The preparation of the evidence brief involved when they visit a healthcare setting. In this evidence brief we focus on circumstances where tobacco users 1) convening a Steering Committee comprised of representatives from the partner organization are admitted to hospital. and the McMaster Health Forum; 2) developing and refining the terms of reference Tobacco-use cessation is the process of discontinuing for the evidence brief, particularly the framing the use of tobacco, and thereby reducing the harm of the problem and three elements of a caused by tobacco use. Hospitalization provides a comprehensive approach for addressing it, in consultation with the Steering Committee and unique opportunity to identify and engage tobacco with the aid of several conceptual frameworks users, initiate cessation supports, and facilitate that organize thinking about ways to approach appropriate follow-up. A recent Cochrane review has demonstrated that intensive smoking-cessation 3) identifying, selecting, appraising and synthesizing relevant research evidence about interventions that begin during hospitalization and the problem, elements of an approach to continue for at least one month post-discharge can be addressing the problem, and implementation effective, compared to brief interventions.(4) 4) drafting the evidence brief in such a way as to Hospital-based tobacco-use cessation programs are present concisely and in accessible language the global and local research evidence; and implemented in the hospital setting to identify and offer 5) finalizing the evidence brief based on the input a range of treatment and support services to every of several merit reviewers. admitted tobacco user.(5) This evidence brief defines hospital-based tobacco-use cessation programs as The evidence brief was prepared to inform a stakeholder dialogue at which research evidence is inpatient tobacco-use cessation interventions that can one of many considerations. Participants' views involve: 1) identifying tobacco users on admission; 2) and experiences and the tacit knowledge they providing counsel ing to patients; 3) providing bring to the issues at hand are also important medication during hospitalization; 4) linking the patient inputs to the dialogue. One goal of the stakeholder back to community resources; and 5) providing follow- dialogue is to spark insights – insights that can only come about when al of those who wil be up after discharge from hospital. Such programs may involved in or affected by future decisions about have two areas of focus: 1) managing nicotine the issue can work through it together. A second withdrawal; and 2) maximizing the opportunity posed goal of the stakeholder dialogue is to generate by hospitalization to support quitting and remain action by those who participate in the dialogue and by those who review the dialogue summary and the video interviews with dialogue participants. Hospital-based interventions can include many elements • use of clinical information systems (e.g., documentation and monitoring of tobacco use); Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario • provision of healthcare provider supports (e.g., Box 2: Equity considerations
education support tools for physicians and nurses to A problem may disproportionately affect some assist with the tobacco-use assessment of patients); groups in society. The benefits, harms and costs of • introduction of broader healthcare system changes the elements of a comprehensive approach to (e.g., creating a culture, organization and mechanism address the problem may vary across groups. that promote the adoption of hospital-based Implementation considerations may also vary tobacco-use cessation programs in Ontario); and • linkages to community-based resources for patients One way to identify groups warranting particular (e.g., identification of community-based tobacco-use attention is to use "PROGRESS," which is an acronym formed by the first letters of the following cessation support programs for patients referred to eight ways that can be used to describe groups†: by providers in the hospital doing tobacco-use • place of residence (e.g., rural and remote assessments), which ideally include linkages to patients' primary healthcare providers upon • race/ethnicity/culture (e.g., First Nations and discharge to ensure continuation of treatment and Inuit populations, immigrant populations, and linguistic minority populations); occupation or labour-market experiences more general y (e.g., those in "precarious work" Several studies have shown that hospital-based tobacco- use cessation programs are feasible and effective in improving patient outcomes, but continuation beyond the program-implementation phase has not been • educational level (e.g., health literacy); careful y examined.(4;6;7) There are few evaluations of • socio-economic status (e.g., economical y the impact of implementing cessation interventions into disadvantaged populations); and routine hospital practice.(8) Understanding how • social capital/social exclusion. programs are best embedded in the hospital setting is This evidence brief strives to address al people, important to avoid losing the overal benefit these but (where possible) it also gives particular programs can have on the burden of tobacco-related attention to two groups: illness, hospitalization and the health status of tobacco • people with low socio-economic status; and users.(9) This evidence brief defines sustainability of • people with one or more chronic conditions. tobacco-use cessation programs as the continuation of Many other groups (such as youth, those living in rural communities and pregnant women) warrant tobacco-use cessation supports over a defined period of serious consideration as well, and a similar time. While there is no commonly accepted definition of approach could be adopted for any of them. In this period of time, it is likely that a program that had addition to the two groups of individuals, the continued over a period of five years would be evidence brief also gives attention to rural hospitals considered a sustained program given it may have and hospitals for the mental y il . survived changes in government administrations and The groups that are the focus of commentary about turn-over in both the organization's senior management equity include two of the three groups with the team and the program-delivery team. A recent study on highest prevalence of tobacco use, which are the sustainability of tobacco-use cessation programs in individuals in trade occupations (34%), Aboriginals (40%), and individuals with mental health and Ontario demonstrated that program sustainability addiction problems (45%).(1) Giving attention to depends on several factors, including integrating the prevalence, however, masks variation within groups. intervention into clinical pathways, integrating outcomes For example, the proportion of pregnant women who for evaluation into program delivery, and partnering smoke in Ontario ranges from 5% in Toronto to 9% with community programs (e.g., the Smokers' Helpline) in the central east region, 15% in the central west region and in the eastern region, 18% in the south for patient follow-up and ongoing provision of patient west region, 29% in the north east region, and 34% in the north west region.(2) It is important to recognize that responses to offers of † The PROGRESS framework was developed by Tim Evans and Hilary Brown (Evans T, Brown H. Road tobacco-use cessation supports may vary between traffic crashes: operationalizing equity in the context of patients who are hospitalized for conditions that may be health sector reform. Injury Control and Safety Promotion 2003;10(1-2): 11–12). It is being tested by the Cochrane tobacco-related and patients who are hospitalized for Collaboration Health Equity Field as a means of other reasons. In a recent randomized-controlled trial evaluating the impact of interventions on health equity. Evidence >> Insight >> Action McMaster Health Forum conducted in northwest Ontario, one-year abstinence rates from tobacco-cessation treatment were significantly higher for patients with cardiovascular disease receiving intensive tobacco-use cessation support in hospital, compared to patients with other diseases receiving similar support.(10) An older randomized controlled trial found that patients hospitalized because of cancer, cardiovascular disease or pulmonary disease were more likely to enrol in an inpatient tobacco-use cessation program and had higher self-reported cessation rates than patients hospitalized for other reasons.(11) The aim of the evidence brief, which will be used to inform a stakeholder dialogue that brings stakeholders' views and experience to bear on the issue of expanding the uptake of hospital-based tobacco-use cessation supports in Ontario, is to examine the missed opportunities for tobacco-use cessation efforts in Ontario's hospitals, and to support the development of a common, feasible, cost-effective and sustainable minimum standard of care for delivering tobacco-use cessation supports in all hospitals in Ontario, which could include standards targeted to specific patient groups. A standard of care approach can include support tools, clinical forms, treatment pathways, care pathways, workshops and other resources to assist healthcare providers with providing tobacco-use cessation supports to patients admitted to hospital. Examining existing hospital-based tobacco-use cessation protocols in Ontario can support the development of a common standard of care for tobacco-use cessation. This evidence brief does not address community-based interventions for tobacco cessation per se, however, hospital-based tobacco-use cessation programs cannot be sustained if they are not linked to community-based resources for post-discharge support. A number of commitments have been made at the national level in Canada to reduce tobacco-related illness through prevention and cessation efforts. For example, Health Canada leads the Federal Tobacco Control Strategy, the goal of which is to reduce overal smoking prevalence from 19% (in 2006) to 12% by 2011. Moreover, several health professional associations, including the Canadian Medical Association, the Canadian Nurses Association, the Canadian Pharmacists Association, the Canadian Dental Hygienists Association, the Canadian Association of Respiratory Therapists, and the Canadian Psychological Association, have issued individual or joint position statements highlighting the role of health professionals in the control of tobacco At the provincial level, the Ontario government has supported tobacco users to quit by sponsoring and funding a variety of tobacco-use cessation initiatives and programs: • the Ontario government developed (and renewed for 2010-2015) the Smoke-free Ontario Strategy, which focuses on initiatives aimed at preventing young people from taking up tobacco-use, protecting individuals from exposure to second-hand smoke through the Smoke-Free Ontario Act, and helping smokers to • the Ontario government funds: o the Ontario Tobacco Research Unit to conduct research, monitoring and evaluation on tobacco o the Centre for Addiction and Mental Health's Smoking Treatment for Ontario Patients (STOP), a research study and program that aims to discover and deliver the most effective smoking-cessation medication and counselling support to smokers across Ontario through a variety of channels, including STOP-on-the-Road workshops (some of which take place in hospitals), activities in collaboration with Family Health Teams, and activities in Aboriginal Health Access Centres and Community Health Centres; o the University of Ottawa Heart Institute's Ottawa Model for Smoking Cessation (under the Smoke- free Ontario Strategy), which helps hospitalized smokers with nicotine withdrawal as well as smoking cessation and now involves 22 Champlain LHIN-affiliated hospitals and 34 additional Ontario hospitals in 10 other LHINs; o the Canadian Cancer Society's Smoker's Helpline and Smokers' Helpline Online to provide support, advice and community referrals for individuals who want to quit; Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario o community pharmacists (through the Pharmacy Smoking Cessation Program) to provide a smoking- cessation program to Ontario Drug Benefit recipients;(14) o seven regional Tobacco Control Area Networks that range in size from one to nine public health departments and that facilitate coordination at the local and regional levels, ensure that the needs of public health departments are met, and maximize the effective use of limited resources; and o Brock University's Leave the Pack Behind, a program that delivers prevention and cessation programs across all Ontario universities and colleges. As wel , the Ontario government has funded the development of best practice guidelines targeted at single health professions and capacity-building initiatives targeted at all health professions, including: • a best practice guideline for tobacco-use cessation support by physicians that follows the "5 As" strategy – 1) ask patients if they use tobacco; 2) advise them to quit; 3) assess readiness to quit; 4) assist with quitting (using counselling, cessation materials and first-line pharmacotherapy); and 5) arrange follow-up) – and that was developed by the Ontario Ministry of Health and Long-Term Care and Ontario Medical Association, although this initiative no longer receives dedicated funding from the Ontario government; • a best practice guideline for smoking cessation for registered nurses using an "ask, advise, assist, arrange" (4 As) protocol, which was developed as part of the Registered Nurses Association of Ontario's Best Practice Guidelines program;(15) and • the Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counsel ing and Health (TEACH) program, which supports capacity building related to tobacco cessation among healthcare providers in Ontario.(16) In addition to the above tobacco-control initiatives, there are a number of best practice models and guidelines that support or could support tobacco cessation, including: • Public Health Ontario uses a best-practices model to spur a broad range of quality improvements in hospitals and other healthcare institutions and in healthcare practices, however, as of yet it has not used this model to support tobacco cessation in hospitals; • Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN ADAPTT) develops clinical practice guidelines both for all citizens and for specific priority populations (e.g., Aboriginal people, hospital-based populations, mental health and addictions, pregnancy and breast-feeding women, and youth), and its Practice-Based Research Network facilitates research and knowledge exchange among researchers, practitioners and policymakers in the area of smoking cessation;(17) and • U.S. Department of Health and Human Services' Treating Tobacco Use and Dependence clinical practice guideline is a widely accepted strategy for smoking cessation that has been recommended by Ontario's Guidelines Advisory Committee, promotes the "5 As" strategy, and advocates for important clinical interventions such as counsel ing with the use of tools such as nicotine-replacement therapy.(18) The latter guideline informed the development of the Registered Nurses Association of Ontario best practice guidelines for smoking cessation.(15) The following key features of the health policy and system context in Ontario that affect the provision of hospital-based tobacco-use cessation supports were also taken into account in preparing this evidence brief: • the Ontario Ministry of Health and Long-Term Care acts as a steward of the healthcare system and in doing so it oversees legislation that governs the healthcare system (e.g., Public Hospitals Act), establishes accountability agreements with and funds the provinces 14 Local Health Integration Networks (LHINs), negotiates agreements with and funds physicians and physician groups, and administers and funds prescription drug benefits programs, among other responsibilities; • the LHINs have responsibility for the planning, funding and integration of healthcare within their regions, and they establish accountability agreements with hospitals and other healthcare facilities in their regions; Evidence >> Insight >> Action McMaster Health Forum • hospitals have the authority to make decisions about how they operate in any domain not explicitly addressed through the Public Hospitals Act or accountability agreements with LHINs, and more specifically o hospital-based medical care is typical y delivered by physicians working in private practice and receiving first-dollar (i.e., no deductibles or cost sharing) public payment, with the private practice element of this agreement between government and physicians typical y meaning that physicians have been wary of potential infringements on their professional autonomy (e.g., directives about the nature of the care they deliver or the way in which they organize and deliver that care) and with the public payment element typical y taking the form of fee-for-service payment or some form of salary if the physicians are enrolled in an alternative payment plan; o other health professionals working in hospitals are typical y paid a salary (out of the hospital's global budget) as part of a formal employment relationship; o hospitals participate in accreditation processes organized by Accreditation Canada; • prescriptions receive partial public coverage in Ontario, but not with the same type of first-dollar coverage provided for hospital-based and physician-provided care (e.g., co-payment is required for prescription drugs for those 65 years of age and older) and with many Ontarians having no coverage through either public or private plans; • there are a variety of legislation and/or policies governing public health that can have an impact on hospital-based efforts, as wel as a general climate that supports the use of health promotion and disease prevention efforts that reduce the burden on hospitals and other parts of the healthcare system; and • the Ontario provincial government recently passed legislation, cal ed the Excel ent Care for All Act, that gives significant attention to enhancing quality of care across the healthcare system (not just in the hospital THE PROBLEM
Box 3: Mobilizing research evidence about the
Tobacco-related il ness kills more than 16,000 Ontario residents each year.(20) For many tobacco users, both The available research evidence about the problem was sought from a range of published and "grey" tobacco-related and other illnesses frequently result in research literature sources. Published literature that hospitalizations. Ontario hospitals and the Ontario health provided insights into alternative ways of framing system in general lack a common, feasible, cost-effective the problem was sought using the qualitative and sustainable approach to delivering tobacco-use research "hedge" in MedLine. Grey literature was sought by reviewing the websites of a number of cessation supports.(8) The problem can be understood at Canadian and international organizations. a number of levels: 1) tobacco-related illness affects many Ontarians and is a key driver of healthcare costs; 2) there Priority was given to research evidence that was is no agreed minimum standard of care for tobacco-using published more recently, that was local y applicable patients across Ontario hospitals; and 3) gaps in health (in the sense of having been conducted in Canada), and that took equity considerations into account. system arrangements constrain hospital-based tobacco-use cessation supports. The renewal and implementation of the Smoke-free Ontario Strategy will support efforts to address this problem. Tobacco-related il ness affects many Ontarians and is a key driver of healthcare costs
Tobacco use causes a number of health problems leading to hospitalization and premature death, including
cardiovascular disease, respiratory il ness, and many forms of cancer.(20) The current daily smokers and former daily smokers who had quit in the past five years averaged more than twice as many days in hospital as did never-daily smokers.(9) According to the Canadian Institute for Health Information, the greatest proportion of these hospitalizations was for adult patients being treated for chronic disease conditions such as respiratory disease, cardiovascular disease and diabetes in 2004-2005.(21) Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario The burden of tobacco-related il ness has a significant financial impact on the entire healthcare system. Tobacco-related diseases cost the Ontario economy at least $1.7 billion in healthcare annually, results in more than $2.6 billion in productivity losses, and account for at least 500,000 hospital days each year.(20) On an individual level, cessation brings financial benefits to the ex-smoker due to decreased expenditure on cigarettes.(1;22) According to data in 2009 from the Propel Centre for Population Health Research at the University of Waterloo, there are significant variations in smoking prevalence by province. Some findings from the data reported on the province of Ontario in 2009 include:(23) • a smoking prevalence of 15.4%, below the national average of 17.5%; and • the smoking prevalence among youth aged 15-19 was 9%. A report by the Ontario Tobacco Research Unit published in 2010 documented that in Ontario(24): • the highest prevalence of current smoking occurs among moderate or problem gamblers (45%), Aboriginals (40%), 25- to 29-year-old males (37%,) and those in trades occupations (34%); • residents living in rural areas had a slightly higher prevalence of current smoking (21%) than residents living in urban areas (19%); and • the percentage of current smokers is the highest in northern regions of Ontario (for example, in 2007/2008, the percentage of current smoking was 27% in North Bay Parry Sound District Health Unit, 26% in Thunder Bay and 25.5% in Sudbury). According to a recent study of tobacco-use prevalence among emergency-department patients in acute care hospitals in northwest Ontario: • tobacco-use prevalence is double the national and provincial averages for people under the age of 55, and almost 60% higher than the national average for 45–54 year olds; and • tobacco-use prevalence is higher in rural communities than in urban communities, with rates being 15% higher for patients under the age of 30 years, 9% higher among patients aged 30-49, and 7% higher among patients aged 50-69 years.(25) The higher tobacco-use rates in this region are likely reflective of the region's higher proportion of manual labourers (e.g., in the mining, logging and pulp and paper industries), citizens of lower socio-economic status and First Nations individuals.(25) The research evidence demonstrates that health improves after people stop using tobacco. Quitting tobacco has been associated with a 36% decrease in the relative risk of mortality in coronary heart disease patients who are able to quit.(26) Hospitalization for coronary heart disease has been linked to greater intentions to quit smoking. For example, 65% of smokers hospitalized with myocardial infarction reported intentions to quit smoking in the next 30 days as compared to 20% of non-hospitalized smokers.(22;27) That said, the motivation or intention to quit tobacco and remain tobacco-free varies among individuals. Tobacco-related illness might initially motivate a person to quit smoking, however, cases of relapse are common even if the patient has received pharmacotherapy treatment such as nicotine-replacement therapy.(28) There is no agreed minimum standard of support for tobacco-using patients across Ontario
hospitals

Clinical practice guidelines are often considered to represent the minimum standard for regulated health
professionals such as nurses and physicians. The United States Department of Health and Human Services clinical practice guideline on treating tobacco use and dependence recommends clinical interventions based on the 5As (ask, assess, advise, assist, arrange) and six system-level strategies to assist hospitalized tobacco users with quitting.(18) However, the searches for research evidence were conducted more than 4.5 years ago 12 Evidence >> Insight >> Action McMaster Health Forum (in June 2007) and there is no province-wide agreement among hospitals to endorse the system-level strategies and support their implementation. Without an agreed minimum standard of support for tobacco-using patients across Ontario hospitals, standardized, cost-effective and sustainable tobacco-cessation interventions are unlikely to be delivered with a high degree of quality in all of the province's hospitals. Increased coverage rates of these interventions and/or programs can increase utilization of tobacco cessation services, quit attempts, and the number of smokers who quit. Research has shown that if a substantial number of healthcare providers implement minimal smoking cessation interventions, there wil be a significant reduction in the number of tobacco users, a decrease in related tobacco diseases and a lowering of healthcare costs.(9;15) Admission to hospital can often provide the ideal conditions to support and treat tobacco users, which include the smoke-free environment of hospitals and perceived vulnerability to the health effects of smoking (29). Among the 164 hospitals that completed the Ontario Tobacco Research Unit 2011 baseline survey of hospital tobacco-use cessation services in Ontario, approximately 84% reported providing some level of tobacco-use cessation support. The most commonly adopted policies and practices for smoking cessation were documenting patient smoking status upon admission (79%), making smoking-cessation pharmacotherapies available in the hospital formulary (73%), and having standard methodology for the identification of smoking status (69%).(30) However, few Ontario hospitals reported providing counsel ing to inpatients (40% for minimal or brief counselling and 15% for intensive counselling) or referral or fol ow-up one month after discharge (27%). Furthermore, few Ontario hospitals have in place processes to evaluate the degree to which healthcare providers are providing tobacco-use treatment to patients, following up with tobacco users after hospital discharge, or providing feedback to clinicians about performance.(8) As well, additional information is needed about whether hospital-based tobacco-use cessation services are being offered across the entire hospital organization, one hospital site or one department or unit.(30) According to a report by the Ontario Tobacco Research Unit published in 2010, the implementation of effective cessation interventions (such as, nicotine-replacement therapy, physician's advice, and individual behavioural counselling) could save the Canadian healthcare system 33,307 acute care hospital days over a 20- year period (monetary value $37 million).(1). While these initiatives have helped tobacco users to quit, they lack the integration, resources and comprehensiveness that are necessary to tackle the complexity of tobacco addiction in Ontario, and ensure long-term quit rates among tobacco-users.(24) The Ontario Tobacco Research Unit 2011 survey of Ontario hospitals reported common barriers and chal enges include a lack of staff time to provide cessation support, lack of funding, and lack of capacity to monitor or track the implementation of policies and programs.(30) Hospital-based tobacco-use cessation interventions for in-patients can be divided into two categories: 1) minimal contact cessation interventions; and 2) intensive cessation interventions. Minimal contact interventions are brief interventions that involve one-on-one counsel ing with the patients, the healthcare provider (usually a nurse) offering take-home materials to patients such as pamphlets on how to quit and where to find help quitting, and putting a note in each patient's chart to ask the attending physician to deliver a scripted non-smoking message at the bedside during the patient's hospital stay.(31) Brief interventions usually last a few minutes. Intensive cessation programs involve a minimal contact approach in addition to 45–60 minutes of bedside education and counselling, take-home materials for the patient, (possibly) the use of pharmacotherapy treatment, and follow-up after discharge from hospital.(31) In a systematic review on the effectiveness of tobacco-use cessation support for hospitalized patients, interventions were divided into four categories of counselling intensity for in-patients: 1) one contact in hospital, lasting 15 minutes or less and no post-discharge support; 2) one or more contacts in hospital lasting 15 minutes in total and with post-discharge support; 3) any hospital contact plus post-discharge support lasting less than one month; and 4) any hospital contact plus post-discharge support lasting one month or longer.(32) The review found that high-intensity counselling interventions, defined as those that begin during Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario hospital stays and include supportive contact for one month or longer after hospital discharge (i.e., those that would be included in the fourth category described above) increased the odds of smoking cessation by 65% at 6-12 months.(32) Meta-analyses show that simple advice from a physician has a smal but significant effect on tobacco-use cessation.(33;34) In one review of nurse-led tobacco-use cessation interventions, the findings suggest that minimal contact interventions can be as effective as intensive interventions in assisting patients to quit using tobacco (when compared to no tobacco-use cessation intervention).(34) In a minimal contact intervention nurses can provide patients with information about the potential benefits of tobacco cessation and with counselling to motivate patients to quit. However, abstinence after treatment has shown to vary between minimal contact and intensive interventions. In a randomized controlled trial of hospitalized patients with coronary artery disease, more patients in the intensive intervention than in the minimal intervention were abstinent at one year (absolute increase of 19%). The odds of quitting smoking were two times greater for those in the intensive intervention.(31) Clinical practice guidelines for tobacco-use cessation recommend that healthcare providers provide at least brief interventions to in-hospital patients who use tobacco.(35) Brief interventions can be effective, although cessation increases with the intensity and frequency of the interventions provided.(35) There is insufficient evidence on the effectiveness of pharmacotherapy treatment (e.g., bupropion or nicotine- replacement therapy) in combination with behaviour interventions (e.g., counsel ing) for hospitalized patients specifically.(32;36) A hospital-based tobacco-use cessation study reported a significantly lower abstinence rate at 12 months for inpatients in either minimal or intensive interventions who used pharmacotherapy.(36) The lower abstinence rate for inpatients who used pharmacotherapy in combination with a behaviour intervention might be confounded by the extent of the patient's addiction. As of September 2011 the Ontario Drug Benefit program covers two prescription medications that can support patients quitting tobacco – Champix and Zyban – but not nicotine-replacement therapy. The Ontario government is also currently providing free nicotine-replacement therapy through Family Health Teams, Aboriginal Health Access Centres and Community Health Centres. In addition, the Centre for Addiction and Mental Health provides free nicotine-replacement therapy through STOP-on-the-Road programs. To complement the availability of cessation medications, the Ontario government funds community pharmacists to provide a smoking-cessation program to Ontario Drug Benefit recipients. The Canadian Pharmacist Association's Quit Using and Inhaling Tobacco (QUIT) program offers smoking cessation services (e.g., counsel ing and pharmacotherapy) in pharmacies, using the 5 As.(12) There has been recognition among leaders in tobacco-use cessation for the need of an integrated, multi- disciplinary collaborative approach that includes the policies, support tools, and interventions required to optimize hospital-based tobacco cessation as a standard of care.(29). In 2007, the Cessation Task Group, which was part of the then Ontario Ministry of Health Promotion Community Action Working Group, proposed an evidence-based approach for developing a system of cessation to improve quit rates in Ontario. In order to reduce the health and economic burden associated with tobacco use, the group developed and made recommendations for an improved, comprehensive and integrated tobacco-use cessation strategy. More recently, the Tobacco Strategy Advisory Group has issued updated recommendations, one of which is to establish a tobacco-use cessation system. This recommendation is referred to as the ‘no wrong door' recommendation because it advocates for any Ontarian seeking to quit tobacco to be able to access tobacco- use cessation supports through multiple channels.(3) Two models of hospital interventions to tobacco-use cessation in Ontario that incorporate recommendations from the U.S. Department of Health and Human Services' guidelines are the University of Ottawa Heart Institute's Ottawa Model for Smoking Cessation and the northwest Ontario program. The Ottawa Model for Smoking Cessation is a systematic approach for addressing tobacco use among hospitalized patients and which involves a common approach to identifying tobacco users upon admission to hospital, providing them 14 Evidence >> Insight >> Action McMaster Health Forum with assistance in quitting and support for nicotine withdrawal while in hospital, and ensuring follow-up counsel ing once they leave hospital to assist them in remaining tobacco-free. Implementation of the Ontario Model for Smoking Cessation has been found to result in an 11.1% increase (from 18.3% - 29.4%) increase in long-term smoking cessation following hospital discharge.(8) Since 2006, the OMSC has been implemented in a number of hospitals across Canada. The northwest Ontario program involves system-level changes to ensure that al admitted patients and al patients visiting emergency departments are systematical y screened for tobacco use. Most clinical and system-level aspects of the program have been implemented in al 13 northwest Ontario hospitals, with 11 of the 13 hospitals having implemented al key elements of the smoking cessation guidelines. Six of the most highly visible tobacco-use cessation initiatives that involve Ontario hospitals include: 1. Registered Nurses Association of Ontario (RNAO) best practice guideline on integrating smoking cessation into daily nursing practices;(37) 2. Smoking Treatment for Ontario Patients (STOP; 3. Safer Healthcare Now, a program of the Canadian Patient Safety Institute, which features an acute myocardial-targeted intervention that includes tobacco-use cessation supports 4. Stop Smoking for Safer Surgery, which focuses on tobacco-use cessation for surgery candidates 5. northwest Ontario program (as described above); and 6. Ottawa Model for Smoking Cessation (http://www.ottawamodel.ca/). Features of the six initiatives are described in Table 1, and the findings from assessments of these initiatives (much of which come from the Ontario Tobacco Research Unit 2011 survey) are described in Table 2.(30) Descriptions of the first four of the six initiatives were based on information that could be obtained from publicly available documents whereas descriptions of the fifth and sixth programs were based on personal communications with individuals that created or coordinate the initiatives.
Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Table 1: Overview of tobacco-use cessation initiatives that involve Ontario hospitals
Primary focus is Primary focus is research and Primary focus is a single profession out-of-hospital programs within-hospital programs RNAO best practice guideline Smoking Treatment for Ontario Safer Healthcare Now Stop Smoking for Northwest Ontario Best Practice Ottawa Model for (source: information that (source: information that Smoking Cessation could be obtained from (source: information that could could be obtained from (source: information that (source: personal communication (source: personal communication from publicly available documents) be obtained from publicly publicly available could be obtained from Kerri-Anne Mullen) available documents) publicly available documents) Nurses identify tobacco users Patients provide their smoking Healthcare providers Healthcare providers (usually Admitting clerks document tobacco Attending nurses or physicians by asking patients about their history through a web-based identify and document the nurses) identify the smoking use over the previous 30-day period document tobacco-use status on one tobacco-use, and document survey or telephone cal with smoking status (during the status of patients as part of the for inpatients and emergency-room or more of the following intake forms the patient's tobacco-use the cal centre, and based on preoperative assessment, and visits using a no-bypass field on (paper or electronic depending on this assessment they can receive hospitalization) of patients patients are advised to quit for Meditech admitting records. Staff hospital): admission forms, patient free nicotine-replacement with acute myocardial eight weeks before surgery to nurses also document tobacco use history forms, nursing assessment therapy through a range of infarction. No details improve surgical outcomes. as part of the nursing assessment forms or physicians' orders. A providers working in Family identified about the Anaesthetists are also involved using a standardized form on standard question is embedded on Health Teams, Aboriginal healthcare provider in consultations with patients patients' charts. these forms ("Have you used any form Health Centres, Community responsible for identifying of tobacco in the last 6 months"). Health Centres, as wel as settings reached by STOP-on- Nurses implement minimal Healthcare providers receive Healthcare providers are Healthcare providers explain Systems include the integration of a Systems include the transfer of tobacco-use interventions and training on combining given an ‘Improved Care the health risks during and cessation intervention into standard information about tobacco use to the brief counselling (lasting one pharmacotherapy with for AMI' kit, which after surgery; and patients who practice on inpatient nursing applicable practice tool (e.g. care map, to three minutes) using the behavioural interventions (with includes guidelines for are scheduled for surgery are assessments (i.e., pathways), a clinical pathway, and/or Kardex 4As protocol (ask, advice, training offered through healthcare providers on asked when they last smoked standardized tobacco intervention system), a standardized cessation level and at the assist, arrange) TEACH and related programs) smoking-cessation (and, if necessary, surgery is form (which is part of quality chart consult form, standard orders for interventions for patients audits), centralization of patient pharmacotherapy (with first-line materials, standard orders for options on the formulary), and telephone follow-up post-discharge Interventions depend on the Patients are given free nicotine- Patients are given Patients are told about the Patients receive from staff nurses a Patients receive brief, strategic advice, hospital but patients are replacement therapy and tobacco-use cessation risks of smoking before brief 5A intervention, self-help pharmacotherapy to assist with typical y referred to the counsel ing through a variety of counsel ing and tobacco surgery and referred to materials (e.g., Canadian Cancer nicotine withdrawal and long-term Canadian Cancer Society's providers and in a variety of dependence medications smoking-cessation services Society ‘s "One Step at a Time" cessation, enrolment in telephone Smokers' Helpline, and settings as described above (e.g., nicotine- (e.g., Smokers' Helpline or the booklet), pharmacotherapy during follow-up, referrals to community offered support and self-help replacement therapy, Stop Smoking for Safer hospitalization, and Smoker's programs (e.g., Smoker's Helpline), resources in the community bupropion, varenicline) Surgery website) Helpline information and fax and self-help material Nurses schedule follow-up or Follow-up arrangements Patients referred to Patients are referred to the Patients are offered a fax referral to Patients are registered in a telephone refer patients to community depend on the setting cardiac rehabilitation Smokers' Helpline ‘Quit the Smokers' Helpline for up to 12 follow-up system, followed for six cessation programs. No clear during hospitalization. Connection' program and quit sessions months post-discharge (either by nurse guidelines on the duration of No clear guidelines for specialists initiate a call to the counsel ors or by Smokers' Helpline quit specialists), and provided with a list of regional cessation programs Evidence >> Insight >> Action McMaster Health Forum Table 2: Findings from assessments of tobacco-use cessation initiatives that involve Ontario hospitals
Primary focus is Primary focus is research and Primary focus is a single profession out-of-hospital programs within-hospital programs RNAO Best Practice Smoking Treatment for Safer Healthcare Stop Smoking for Northwest Ontario Ottawa Model for Ontario Patients (STOP) Best Practice Guidelines Smoking Cessation (source: information (source: information that (source: information (source: information (source: personal communication (source: personal communication that could be obtained could be obtained from that could be obtained from Patricia Smith) from Kerri-Anne Mul en) from publicly available publicly available documents) from publicly available publicly available Evaluation of the No evaluations identified Intervention forms are completed Regular audits are completed at evaluation (e.g., RNAO clinical at participating hospitals. A review participating hospitals and degree to which practice guidelines of these forms for 10 rural feedback reports are presented to included the fol owing hospitals showed that nurses have front-line staff, unit managers and asked 96% of patients if they use hospital leaders on a quarterly to tobacco, advised 75% of tobacco semi-annual basis. Program audit evaluation: objectives users to quit, assessed 80% for data from a sample of 15 hospitals of the intervention, interest in quitting, assisted 69% to in 2010-2011 revealed that 13,857 the organization, the quit, offered pharmacotherapy to patients were audited, of which provider, the client, 45%, and arranged fol ow-up for 12,650 (91.3%) were asked about and financial cost of their tobacco use, 2,089 tobacco the intervention users were identified, and 1,422 (68.1%) had a consult form No data identified The initiative has been Process and outcome The initiative has All units in 10 of 11 rural hospitals All or select units in 42 Ontario (e.g., number of introduced in institutions such measures are reached more than and the one urban hospital in hospitals have implemented the as the Centre for Addictions reported to be used 38,000 smokers in its northwestern Ontario (LHIN14) cessation program. These units and Mental Health and the to monitor success, have implemented the cessation collectively reached 8,367 smokers Ottawa Heart Institute, as but no data were program. In 2009 and 2010, nurses in 2010-11 and more than 30,000 well as public health units, asked 11,758 patients if they smokers since 2006 community health centres and smoked, among whom 3,907 were pharmacies in Ontario. The smokers and 3,055 received the program has reached close to 70,000 Ontarians since the start of the program in 2006 Quit rates from No data identified At six months post-treatment, No data identified No data identified No data identified, although data An evaluation of the first nine the self-reported quit rates (7- are available from a Canadian hospitals in Ontario to implement day point prevalence) ranged randomized control ed trial that the OMSC revealed an 11.1% from 17% (STOP-on-the- used the same approach as this increase (from 18.3% to 29.4%) in Road) to 33% (primary six-month quit rates fol owing healthcare settings and public hospital discharge. Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario The implementation of tobacco-use cessation programs is also inconsistent across hospital units. Smoking- cessation interventions in cardiac units in Canada were underused, even though cardiovascular disease accounts for a large proportion of hospital admissions and is a leading cause of death.(38) The use of smoking-cessation interventions among those with cardiovascular disease have been argued to be cost- effective because of the life expectancy gains among those who quit using tobacco.(39) The initiatives described in Table 1 also need to be considered in relation to other complementary initiatives: • Canadian hospitals are implementing a "smoke-free" campus policy, which means that tobacco users (whether patients or staff) wil not only need to be at least nine metres away from hospital premises in order to smoke (as is the law now in Ontario), they wil need to leave hospital property entirely.(8) and • the Canadian Cancer Society maintains a Smokers' Helpline, a free, confidential, interactive telephone service for all smokers, as wel as a Smokers' Helpline Online, both of which support smokers who want to quit or are thinking about quitting but want support. A review of the empirical literature demonstrated that tobacco cessation interventions provided to hospitalized smokers improve tobacco abstinence rates, along with healthcare utilization and surgical outcomes. However, few studies have examined the sustainability of these cessation programs.(9)
Gaps in health system arrangements constrain hospital-based tobacco-use cessation supports
A variety of gaps in the delivery, financial and governance arrangements within Ontario's health system likely contribute to a lack of a common, cost-effective and sustainable approach to hospital-based tobacco cessation programs. These gaps likely also contribute more general y to the lack of a sustained approach to supporting patients in the transition from receiving treatment and counsel ing in a hospital to linking them to supports in the community to remain tobacco-free.
An important gap within the category of delivery arrangements is the limited attention given to identifying
(and achieving consensus on) an agreed upon standard of care for hospital-based tobacco cessation programs. Identifying the optimal time when patients should be assessed for their tobacco-use during hospital admission (e.g., during pre-admission or at nursing unit), the type, timing and dose of assistance, and the timing and duration of follow-up after hospital discharge, as wel as the type of fol ow-up provided, have not been wel studied. The readiness of hospitals to implement tobacco-use cessation interventions is another significant gap. Implementing tobacco-use cessation services in hospitals requires embedding tobacco-use cessation services in routine clinical practice by changing organizational roles and responsibilities, introducing new clinical practices, administrative routines, quality assurance and accreditation, and patient safety. One possibility is to begin by raising awareness of the legitimate role of hospitals in providing support to tobacco users among government funders, hospital administration and staff, and other health professionals. A variety of other gaps in delivery arrangements are spoken about (and some al uded to in the previous sub- section) but also not well studied, including: • lack of agreement about the ideal process; • lack of agreement about whether those delivering tobacco-use cessation services should have additional training, certification and/or oversight of whether it's everyone's responsibility; • lack of agreed indicators for successful tobacco-use cessation, data col ection and feedback mechanisms for hospital staff; • lack of clinical information systems to track tobacco status and tobacco-use cessation interventions used; • lack of reminder systems for hospital staff; • lack of documentation of and access to community-based resources; and • lack of tobacco-use cessation interventions in al hospital departments, whereby some hospital departments wil implement tobacco-use cessation programs and others don't. Evidence >> Insight >> Action McMaster Health Forum In 2005, the Canadian Tobacco Use Monitoring Survey included questions to assess self-reported provision of cessation advice by healthcare providers. This report summarizes the results of that survey, which indicate that only half of persons who visited healthcare providers in the preceding 12 months received smoking- cessation advice, suggesting that healthcare providers need to take greater advantage of opportunities to provide such advice to smokers. Regarding advice, counselling and treatment given to tobacco users by type of healthcare provider, the survey found: • 73% of current smokers reported visiting a physician in the preceding 12 months, whereas a smaller proportion reported visiting a pharmacist (38%); • a greater portion of female smokers visited a physician (85%), dentist or dental hygienist (64%), or a pharmacist (44%) compared with male smokers (65%, 57%, and 33%, respectively); and • among the current smokers who reported visiting a physician in the preceding 12 months, approximately half (51%) said that they were advised to reduce or quit smoking. Rates of advice to reduce or quit smoking by a physician were lowest among the youngest smokers (i.e., aged 15 to19 years) (38%) and increased by age group.
Financial arrangements in Ontario's healthcare system contribute to a lack of a sustained approach to
hospital-based tobacco cessation programs. There is a lack of targeted funding for tobacco-use interventions in hospital global budgets and community organizations' budgets, as well as a lack of financial incentives for physicians.(12;40) Funding mechanisms that assign a low priority to preventive care, (e.g., little or no reimbursement for tobacco-use cessation interventions, follow-up or support) creates barriers for healthcare professionals in hospitals to deliver tobacco-use cessation interventions. Pharmacotherapy provides a case in point. It can assist patients in managing nicotine withdrawal in hospital and after discharge from hospital, and thereby promote long-term cessation. The U.S. Department of Health and Human Service guidelines recommend the use of medication (as wel as counsel ing) as tobacco-dependence treatments.(18) A central component of the Ottawa Model for Smoking Cessation is the appropriate use of pharmacotherapy to assist with cessation and to manage withdrawal symptoms in hospitalized patients.(41) Yet there is a lack of funding for nicotine-replacement therapy for many patients after discharge (whereas it is typical y paid for through the hospital drug formulary when needed to manage acute withdrawal). Individuals who are eligible for the Ontario Drug Benefit program can now receive prescription pharmacotherapy for free when they are living at home (and not just when they are hospitalized, which is the case for al Ontarians now). In 2011, the Ontario government introduced free nicotine-replacement therapy through Family Health Teams, Aboriginal Health Access Centres and Community Health Centres. There is a lack of consensus among key informants about how the Ontario government should al ocate targeted funding for tobacco-use cessation programs or interventions in hospitals. There is an expectation among many of these key informants that since the healthcare system provides medical, surgical and rehabilitation services for a number of chronic il ness that are linked to tobacco use, hospitals should already be providing these interventions out of the global budget.
Governance arrangements also contribute to the lack of a sustained, comprehensive approach to tobacco
cessation in Ontario hospitals. Hospitals do not currently have tobacco-use cessation support as a performance measure, which means that there can be no public reporting (and hence public accountability) about hospitals' activity in this domain. There is also a lack of administrative accountability within hospitals for providing tobacco-use cessation supports to inpatients. Accreditation Canada does not currently incorporate a focus on tobacco-cessation supports in its hospital accreditation program. As wel , with one exception, the province's Local Health Integration Networks do not include tobacco-cessation support within their accountability agreements with hospitals. Success on this front has been the expanded uptake of the Ottawa Model for Smoking Cessation in the 22 hospital sites within the remit of the Champlain Local Health Integration Network, and the incorporation of this activity as part of the hospitals' accountability agreement.(29) The North West Ontario Local Health Integration Network has also been successful in implementing smoking-cessation guidelines and systems changes in hospitals in northwest Ontario, and this was accomplished without its inclusion in hospitals' accountability agreements. Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario
The renewal and implementation of the Smoke-free Ontario Strategy can support efforts to address
this problem

The Tobacco Strategy Advisory Group was established in 2009 to advise the government in its development
of a five-year plan to renew the Smoke-Free Ontario Strategy from 2011-2016.(3) The Smoke-Free Ontario Strategy combines public education, policies and legislation to help tobacco users quit, protect non-tobacco users from second-hand smoke, and encourage young people to never start using tobacco. The recommendations made by the Tobacco Strategy Advisory Group support a comprehensive approach to tobacco control in Ontario, which includes both decreasing demand for tobacco (e.g. building a comprehensive cessation system) and decreasing the supply of legal and unregulated tobacco products. The Ontario Agency for Health Protection and Promotion also convened a Scientific Advisory Committee (SAC) of leading researchers in the field of tobacco control. They provided scientific evidence that helped inform many of the recommendations in the Tobacco Strategy Advisory Group report
Additional equity-related observations about the problem

Access to tobacco-use cessation programs, medications and support is not available to all people living in Ontario. People living in remote and rural areas do not have ful access to online supports, smoker's help lines or counselling. Moreover, it is difficult to generalize to all individuals, such as patients with short admissions and patients hospitalized for substance abuse and/or psychiatric co-morbidities whose smoking behaviour and cessation attempts may be attributed to cognitive limitations and the person's social environment (e.g., poverty, low education, and lack of social support).(42) Furthermore, the tobacco-use cessation programs described in Table 1 are clinical interventions. For example, clinical guidelines for the treatment of nicotine dependency encourage brief counselling and the provision of pharmacotherapy to the vast majority of tobacco users. While systematic approaches to addressing tobacco use in hospital may decrease inequalities in terms of identifying tobacco users and offering treatment, such clinical interventions to tobacco-use cessation may not pay particular attention to tobacco use across population groups. Complementary population-based strategies can help to reduce the negative effects of tobacco across the entire population and reduce disparities in the burden of tobacco use borne by sub-groups within populations.(43) Evidence >> Insight >> Action McMaster Health Forum THREE ELEMENTS OF AN APPROACH FOR
ADDRESSING THE PROBLEM
Box 4: Mobilizing research evidence about
the elements of a comprehensive approach
for addressing the problem
Healthcare providers are in a unique position to of er smoking- cessation advice and provide information on smoking-cessation aids to The available research evidence about elements of a comprehensive approach for addressing the their patients; however, the results of this analysis indicate that many problem was sought primarily from Health of these opportunities are being missed (44) Systems Evidence Many starting points could be selected for deliberations continuously updated database containing more than 1,900 systematic reviews of delivery, designed to inform efforts to expand the uptake of financial and governance arrangements within hospital-based tobacco-cessation supports in Ontario health systems and about implementation hospitals. To promote discussion about the pros and cons strategies within health systems. The reviews of potentially viable elements of a comprehensive were identified by first searching the database approach to expanding uptake, we have selected (in for reviews containing the words "hospital" and one of "tobacco cessation," "smoking cessation" consultation with the project steering committee and key or "tobacco-use intervention." Additional informants) three elements which, taken together, reviews were identified by searching the database constitute a comprehensive approach. These elements are for reviews addressing features of the options situated in the context of the "5 As" strategy that were not identified within this sub-category, – ask, advise, as wel as by searching health-evidence.ca, a assess, assist and arrange – and system-level interventions continuously updated database containing to support tobacco cessation in the hospital setting. The reviews about the effects of public health U.S. Department of Health and Human Services guidelines are rooted in the 5 As and they recommend the following The authors' conclusions were extracted from specific interventions for hospitalized patients: 1) the reviews whenever possible. None of the document tobacco use status; 2) list tobacco-use status on reviews contained no studies despite an admission forms; 3) use counsel ing and medication to exhaustive search (i.e., they were no "empty" help tobacco users remain abstinent and treat tobacco reviews), however, others concluded that there was substantial uncertainty about the elements withdrawal symptoms; 4) provide advice and assistance on based on the identified studies. Where relevant, how to quit during hospitalization; and 5) arrange for caveats were introduced about these authors' follow-up regarding smoking status for at least one month conclusions based on assessments of the after discharge.(18) reviews' quality, the local applicability of the reviews' findings, equity considerations, and relevance to the issue. (See the appendices for a While these elements are complementary to each other, complete description of these assessments.) they are presented separately to foster deliberations about their respective components, the relative importance or Being aware of what is not known can be as priority of each, and their feasibility. The three elements important as being aware of what is known. When faced with an empty review (which was include: 1) establishing and institutionalizing a common not the case with any of the reviews contained in approach to identifying tobacco users upon admission to this evidence brief), substantial uncertainty or hospital; 2) providing tobacco users with assistance in concerns about quality and local applicability, or quitting and continuing support for nicotine withdrawal; a lack of attention to equity considerations, primary research could be commissioned or an and 3) ensuring follow-up counsel ing once they leave element could be pursued and a monitoring and hospital to assist them in remaining tobacco-free. evaluation plan designed as part of its implementation. When faced with a review that was published many years ago, an updating of the review could be commissioned if time No additional research evidence was sought beyond what was included in the systematic review. Those interested in pursuing a particular element may want to search for a more detailed description of the element or for additional research evidence about the element. Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Element 1 – Establishing and institutionalizing a common approach to identifying tobacco users
upon admission to hospital
This element is about finding the tobacco users in Ontario's hospitals who could benefit from tobacco-use cessation supports. Components of this element might include: • selecting options for the process (i.e., who does what and in what order?); • providing additional training, certification and/or oversight of those providing the function at admission • engaging all staff in tobacco-use cessation supports; • developing or adapting policies, procedures and care pathways; • establishing indicators for successful tobacco-user identifications, streamlined data collection and feedback mechanism for hospital staff; • implementing reminder systems for hospital staff; • providing targeted funding and/or financial incentives; and • establishing accountability within hospitals for this function (which could include public reporting). A limited number of systematic reviews were identified that addressed these components of element 1. Of the reviews that were identified, one high-quality review found benefits for providing financial incentives to healthcare providers (albeit primary care providers). In addition, medium-quality reviews found benefits for: 1) providing training to healthcare providers in how to deliver smoking-cessation interventions, and 2) using reminder systems as part of a multifaceted strategy or broader clinic systems for increasing the provision of assistance and counselling. While high-quality reviews were identified as being relevant to two other components of element 1 (selecting options for the process and establishing accountability within hospitals), none provided clear messages based on the included studies. No reviews were found about engaging staff in tobacco-use cessation, developing or adapting policies, procedures and care pathways, or establishing indicators for successful tobacco-user identifications. The high- and medium-quality reviews do not provide a clear road map to identifying tobacco users upon admission to hospital, but instead provide insights relevant to the deliberations, which should ideally focus 1) What is the ideal process for doing this? a. How should tobacco users be identified and documented (e.g., when in the course of hospital visit or stay and with what type of documentation)? b. What policies and procedures need to be developed or adapted (e.g., clinic forms)? 2) Who should do what? a. Should nurses, psychologists, physicians or other healthcare providers be involved? b. With what additional training (and frequency of training)? c. With any form of certification? d. With any form of verification that the process is fol owed correctly? e. With any form of incorporation into staff performance reviews? 3) What resources would be needed? a. What, if any, changes to provider payment mechanisms are needed (e.g., fee codes and financial 4) What are the indicators for success? a. What indicators should be monitored (e.g., proportion of patient visits or hospital stays with tobacco status documented)? b. How would these data be captured? c. How would these data be fed back to hospital staff (individually or by unit)? Evidence >> Insight >> Action McMaster Health Forum d. Would these data be publicly reported? 5) What reminder systems are needed to ensure this is done? 6) Who do you hold accountable in hospital to do this? a. What accountabilities are held by al staff, designated service delivery staff and program coordination b. What accountability mechanism is used? For those who want to know more about the systematic reviews contained in Table 3 (or obtain citations for the reviews), a fuller description of the systematic reviews is provided in Appendix 1. Table 3: Summary of key findings from systematic reviews relevant to Element 1 – Establishing and institutionalizing a common approach to identifying tobacco users upon admission to hospital Category of finding
Summary of key findings
Providing additional training, certification and/or oversight of those providing the
function at admission to hospital
o A medium-quality, older review found that training health professionals to provide smoking cessation interventions had a measurable effect in professional performance. There was no strong evidence that it changed smoking behaviour in patients.(45) Implementing reminder systems for hospital staff
o A medium-quality, recent review found that reminders as part of a multifaceted strategy
(most often combined with organizational change strategies or educational meetings and/or written resources) had a significant effect on the provision of assistance and counsel ing to quit, but not for assessment of smoking status, advice to quit, or the provision or discussion of nicotine-replacement therapy.(46) o A medium-quality, older review assessing the effects of computerized clinical decision support systems found benefits for reminder systems for prevention (including rates of screening, counsel ing and identifying at-risk behaviours) in 16 of the 21 studies that were identified (although the one study assessing patient outcomes found no improvements).(47) o A medium-quality, older review reported in a clinical practice guideline found clinic systems designed to increase the assessment and documentation of tobacco use status increased the rate at which clinicians intervened with their patients who smoke. However, while such systems may increase rates of intervention, this does not necessarily produce significantly higher rates of smoking cessation.(35) Providing targeted funding and/or financial incentives
o A high-quality, recent review evaluating the effect of changes in the method and level of payment on the quality of care provided by primary care physicians found three studies examining smoking cessation. The three studies found that financial incentives had a significant impact on the behaviours of primary care physicians by increasing referral rates and recording of smoking status, but not on measures of patients' smoking cessation. (48) Costs and/or cost- effectiveness in relation to Uncertainty regarding Uncertainty because no systematic reviews were identified benefits and potential harms o Engaging al staff in tobacco-use cessation
(so monitoring and o Developing or adapting policies, procedures and care pathways (e.g., hospital
evaluation could be formularies to include required medication, medical directives to support al
warranted if the option were professional staff to administer nicotine-replacement therapy)
o Establishing indicators for successful tobacco-user identification streamlined data
col ection and feedback mechanism for hospital staff
Uncertainty because no studies were identified despite an exhaustive search as part of a systematic review o Not applicable (i.e., no ‘empty' reviews were found) No clear message from studies included in a systematic review o Selecting options for the process (e.g., who does what and in what order?)
A high-quality, recent review found that service organization interventions for ischemic heart disease patients (IHD) that included regular planned appointments, Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario patient education and structured monitoring of medication and risk factors, had no significant effects on smoking cessation.(49) A high-quality, older review found little evidence on the effectiveness of nurse-led interventions for COPD patients on smoking cessation.(50) o Establishing accountability within hospitals for this function (which could include
public reporting)
 A high-quality, recent review including four studies found no consistent evidence that the public release of performance data changes consumer behaviour or improves  A low-quality and a recently published review (date of last search was not reported in the review) about the design and evaluation of public reporting initiatives on the quality of healthcare found limited evidence and were unable to draw conclusions or recommendations based on research evidence.(52) Key elements of the policy Implementing reminder systems for hospital staff
option if it was tried o A medium-quality, older review found that successful reminder systems were reported mainly in ambulatory care settings(47) Stakeholders' views and Evidence >> Insight >> Action McMaster Health Forum Element 2 – Providing tobacco users with assistance in quitting and continuing support for nicotine
withdrawal while in hospital

This element is about the types of tobacco-use cessation supports provided to those patients who are
identified as tobacco users once they are admitted to a hospital in Ontario, both to assist them with quitting and to begin to support them in remaining tobacco-free. Components of this element include: • selecting the types of assistance provided (e.g., balance of counsel ing and pharmacotherapy) and the ‘dose' of assistance (e.g., intensity of counselling); • selecting options for the process (i.e., who does what and in what order?); • providing additional training, certification and/or oversight of those providing the function in hospital; • developing or adapting policies, procedures and care pathways (e.g., hospital formularies to include required medication, medical directives to support all professional staff to administer nicotine-replacement • establishing indicators for successful tobacco-use cessation, streamlined data col ection and feedback mechanism for hospital staff; • implementing reminder systems for hospital staff; • providing targeted funding and/or financial incentives; and • establishing accountability within hospitals for this function (which should include public reporting). Given some of these components overlap with components of element 1, select reviews are included again below if they are also germane to providing assistance in quitting and continuing support for nicotine withdrawal while in hospital. Several high-quality reviews found benefits for: 1) several types of behavioural smoking-cessation interventions (including behavioural and nicotine-replacement therapies) and combinations of nicotine- replacement therapies (as opposed to just one replacement therapy) delivered in different settings (e.g., in preoperative clinics or through the use of technology); 2) follow-up contact after the delivery of an intervention; and 3) interventions delivered by a range of providers, such as nurses, psychologists and physicians. While high-quality reviews were identified as being relevant to three other components (developing or adapting policies, procedures and care pathways; providing targeted funding and/or financial incentives; and establishing accountability within hospitals), none provided clear messages related to this element based on the findings from included studies. The high-quality reviews do not provide a clear road map to supporting tobacco users in hospital, but instead provide insights relevant to the deliberations, which should ideally focus on: 1) What is the ideal process for doing this? a. What assistance needs to be provided to tobacco users (e.g., ‘balance' of counsel ing and pharmacotherapies, ‘dose' of counsel ing, and which (combination of) pharmacotherapies), in what order, and when in the course of a hospital visit or stay? b. What policies and procedures need to be developed or adapted (e.g., clinic forms and treatment pathways/care maps)? 2) Who should do what? a. Should nurses, psychologists, physicians or other healthcare providers be involved? b. With what additional training (and frequency of training)? c. With any form of certification? d. With any form of verification that the process is followed correctly? e. With any form of incorporation into staff performance reviews? 3) What resources would be needed? a. What self-help and service delivery materials are needed and how would their development and dissemination be funded? Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario b. What, if any, patient incentives are needed (e.g., free pharmacotherapies or financial incentives)? c. What, if any, changes to provider payment mechanisms are needed (e.g., fee codes and financial d. What, if any, changes to organizational payment mechanisms are needed (e.g., to cover counselling and pharmacotherapy)? 4) What are the indicators for success? a. What indicators should be monitored (proportion of tobacco users with at least two supports b. How would these data be captured? c. How would these data be fed back to hospital staff (individually or by unit)? d. How would these data be publicly reported? 5) What reminder systems are needed to ensure this is done? 6) Who do you hold accountable in hospital to do this? a. What accountabilities are held by al staff, designated service delivery staff and program coordination b. What accountability mechanism is used? For those who want to know more about the systematic reviews contained in Table 4 (or obtain a citation for the reviews), a fuller description of the systematic reviews is provided in Appendix 2. Table 4: Summary of key findings from systematic reviews relevant to Element 2 - Providing tobacco users with assistance in quitting and continuing support for nicotine withdrawal while in hospital Category of finding
Summary of key findings
Selecting the types of assistance provided (e.g., balance of counsel ing and
pharmacotherapy) and the ‘dose' of assistance (e.g., intensity of counsel ing)
o A high-quality, recent review found that bupropion increases smoking abstinence rates in
smokers with schizophrenia, without jeopardizing their mental state.(53) o A high-quality, recent review found that a combination of nicotine-replacement therapies (e.g., nicotine gum, nicotine patch, oral nicotine, tablet or lozenge, or nicotine spray) is better than one product alone; nicotine-replacement therapies increase the rate of quitting by 50- 70%, regardless of setting (e.g., hospital); and the effectiveness of nicotine-replacement therapy appears to be largely independent of the intensity of additional support provided to the individual.(54) o A high-quality, older review found that high intensity behavioural interventions that include at least one month of fol ow-up contact are effective in promoting smoking cessation in hospitalized patients.(4) o A high-quality, older review found that intensive behavioural interventions result in substantial increases in smoking abstinence compared with minimal clinical interventions (e.g., brief advice from a healthcare provider).(55) o A high-quality, older review found that smoking cessation interventions initiated at the preoperative clinic can increase abstinence rates by up to 60% within a three-to-six-month fol ow-up period.(56) o A high-quality review found that the use of telehealthcare (e.g., people treated by telephones, video cameras and the internet to al ow people to stay at home and communicate with a nurse or doctor when they have a period of increased breathlessness) manage to stay out of hospital longer than people treated by conventional systems of care.(57) o A low-quality, recent review found that enhancing standard of care with the use of reminders, disease monitoring and management, and education through cellphone voice message service can help improve health outcome of patients, and care processes have implications for both patients and providers.(58) o A medium-quality, recent review assessing smoking cessation advice provided by physical therapists found that self-help materials, follow-up, and interventions based on psychological or motivational frameworks were particularly effective components of intermediate and intensive advice interventions.(59) o A medium-quality, older review found evidence that materials which are tailored for individual smokers are more effective than untailored materials.(33) Evidence >> Insight >> Action McMaster Health Forum o A low-quality, older review found that studies incorporating counselling in addition to nicotine-replacement therapy appeared to show greater benefits for supporting smoking Selecting options for the process (who does what and in what order?)
o A high-quality, older review found that high intensity behavioural interventions including at least one month of fol ow-up contact are effective in promoting smoking cessation in hospitalized patients.(4) o A high-quality, older review found that smoking cessation interventions provided by psychologists, physicians, and nurses were more effective with the use of nicotine- replacement therapy compared to no nicotine-replacement therapy provided.(61) o A high quality, older review found that nurse-led smoking cessation interventions significantly increased the likelihood of quitting. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions.(34) o A medium-quality, recent review found that smoking cessation advice provided by physical therapists could result in positive smoking cessation outcomes. Self-help materials, follow- up, and interventions based on psychological or motivational frameworks were particularly effective components of intermediate and intensive advice interventions provided by physical therapists.(59) o A low-quality, recent review examined counsel ing delivered by a trained therapist providing one or more face-to-face sessions, separate from medical care. Individual counsel ing was more effective than minimal behaviour interventions.(62) o A medium-quality, older review reported in a clinical practice guideline suggests that physicians and other clinicians are similarly effective in delivering tobacco cessation counselling. The review also found that treatments delivered by two or more types of clinicians increased abstinence rates as compared to those not delivered through a clinician. The review also notes that the number of contacts may be equal y or more important than the number of clinicians providing treatment.(35) Providing additional training, certification and/or oversight of those providing the
function in hospital
o A medium-quality, older review found that training health professionals to provide smoking cessation interventions had a measurable effect in professional performance. There was no strong evidence that it changed smoking behaviour in patients.(45) Implementing reminder systems for hospital staff
o A medium-quality, recent review found that reminders as part of a multifaceted strategy
(most often combined with organizational change strategies or educational meetings and/or written resources) had a significant effect on the provision of assistance and counsel ing to quit, but not for assessment of smoking status, advice to quit, or the provision or discussion of nicotine-replacement therapy.(46) o A medium-quality, older review assessing the effects of computerized clinical decision support systems found benefits for reminder systems for prevention (including rates of screening, counsel ing and identifying at-risk behaviours) in 16 of the 21 studies that were identified (although the one study assessing patient outcomes found no improvements).(47) o A medium-quality, older review reported in a clinical practice guideline found clinic systems designed to increase the assessment and documentation of tobacco use status increased the rate at which clinicians intervened with their patients who smoke. However, while such systems may increase rates of intervention, this does not necessarily produce significantly higher rates of smoking cessation.(35) Establishing accountability within hospitals for this function (which should include
public reporting)
o A medium-quality, recent review found evidence to suggest that publicly releasing
performance data stimulates quality improvement activity at the hospital level and also found a modest association between public reporting and selection of health plans.(63) No reviews were found Costs and/or cost- Selecting the types of assistance provided (e.g., balance of counsel ing and
effectiveness in relation to pharmacotherapy) and the ‘dose' of assistance (e.g., intensity of counsel ing)
o A low-quality, older review on costs and effects of smoking cessation interventions (e.g., brief advice, counsel ing, nicotine-replacement therapy and bupropion) found that telephone counselling appeared to be the most cost-effective intervention, bupropion appeared to be more cost effective than nicotine replacement therapy, and combined bupropion and nictone-replacement therapy did not appear to be cost effective.(64) o A high-quality review found that there is some data showing that although the use of Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario telehealthcare systems are initial y expensive, they may be cheaper in the long-term given the potential cost savings attained if they are successful at keeping people out of hospital.(57) Uncertainty regarding Uncertainty because no systematic reviews were identified benefits and potential harms Establishing indicators for successful tobacco-use cessation, streamlines data
(so monitoring and col ection and feedback mechanism for hospital staff
evaluation could be Uncertainty because no studies were identified despite an exhaustive search as part of a warranted if the option were systematic review Not applicable (i.e., no ‘empty' review were found) No clear message from studies included in a systematic review o Selecting the types of assistance provided (e.g., balance of counsel ing and
pharmacotherapy) and the ‘dose' of assistance (e.g., intensity of counsel ing)
 A high-quality, recent review found limited evidence of sufficient quality about the effectiveness of biomedical risk assessment as an aid for smoking cessation (i.e., the process of giving smokers feedback on the physical effects of smoking by physiological measurements). Current evidence of lower quality does not however support the hypothesis that biomedical risk assessment increases smoking cessation in comparison with standard treatment.(65)  A high-quality, recent review found that service organization interventions for ischemic heart disease patients (IHD) that included regular planned appointments, patient education and structured monitoring of medication and risk factors, had no significant effects on smoking cessation.(49)  A high-quality, recent review found limited and inconsistent evidence for the effects of internet-based interventions for smoking cessation.(66)  A high quality, older review found limited evidence for the effects of smoking-cessation interventions provided in preoperative clinics on long-term abstinence rates.(56)  A high-quality, older review found limited evidence (due to methodological limitations) that peer support telephone cal s change behavioural health outcomes. (67)  A medium-quality, older review found no evidence that self-help interventions add an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine-replacement treatment.(33)  A medium-quality, older review found a possible impact of community pharmacy advice in smoking cessation in the prevention of heart disease. However, only a few studies were found and the evidence is unclear.(68)  Two studies included in a low-quality, older review that assessed smoking status at six months among surgical patients found no significant difference in abstinence rates between patients who received a smoking cessation intervention prior to surgery and those who had not.(60) o Selecting options for the process (i.e., who does what and in what order?)
 A high-quality, recent review found that service organization interventions for ischemic heart disease patients that included regular planned appointments, patient education and structured monitoring of medication and risk factors, had no significant effects on smoking cessation.(49)  A high-quality, older review found little evidence on the effectiveness of nurse-led interventions for COPD patients on smoking cessation.(50)  A low-quality, recent review found no evidence of greater effect of intensive counselling compared to brief counselling.(62)  Developing or adapting policies, procedures and care pathways (e.g., hospital
formularies to include required medication, medical directives to support al
professional staff to administer nicotine-replacement therapy)
 A high-quality, recent review found insufficient evidence to support the use of any specific behavioural intervention for helping smokers who have successful y quit for a short time, but have relapsed.(69) o Providing targeted funding and/or financial incentives
 A high-quality, recent review evaluating the effect of changes in the method and level of payment on the quality of care provided by primary care physicians found three studies examining smoking cessation. While the three studies found that financial incentives had a significant impact on the behaviours of primary health care providers by increasing referral rates and recording of smoking status, they did not find an impact on measures of patients' smoking cessation.(48) o Establishing accountability within hospitals for this function (which could include
public reporting)
 A high-quality, recent review including four studies found no consistent evidence that Evidence >> Insight >> Action McMaster Health Forum the public release of performance data changes consumer behaviour or improves  A low-quality and a recently published review (date of last search was not reported in the review) about the design and evaluation of public reporting initiatives on the quality of healthcare found limited evidence and were unable to draw conclusions or recommendations based on research evidence.(52) Key elements of the policy Selecting the types of assistance provided (e.g., balance of counsel ing and
option if it was tried pharmacotherapy) and the ‘dose' of assistance (e.g., intensity of counsel ing)
o A high-quality, recent review found ambiguous results on the use of motivational interviewing to assist smokers to quit.(70) Selecting options for the process (who does what and in what order?)
o A high quality, older review of nursing-delivered smoking cessation interventions identified five studies that assessed smoking cessation during a screening health check or as part of general practice and found nursing interventions to have less effect in these settings.(35) Implementing reminder systems for hospital staff
o A medium-quality, older review found that successful reminder systems were reported
mainly in ambulatory care settings.(47) Stakeholders' views and Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario
Element 3 – Ensuring fol ow-up counselling once tobacco users leave hospital to assist them in
remaining tobacco-free
This element is about supporting patients after they have been identified as tobacco users and provided with tobacco-use cessation supports while in an Ontario hospital, with the focus being primarily in supporting them in remaining tobacco-free if they have already quit or in continuing to assist them with quitting. Components of this element include: • providing documentation of and enhancing production and dissemination of community-based resources; • selecting options for the process (i.e., who does what aspect of the referral process and in what order?); • providing additional training, certification and/or oversight of those providing the function in the • establishing indicators for successful tobacco-use cessation, data col ection and feedback mechanisms for community-based organizations and physicians; • implementing reminder systems for community-based organizations and physicians; • establishing targeted funding (e.g., nicotine-replacement therapy, counselling fees) and/or financial • establishing accountability within community-based organizations and among community-based physicians for this function. Several high-quality reviews found benefits for: 1) following-up with patients after the delivery of smoking cessation interventions in hospital settings; 2) intensive behavioural interventions as compared to minimal clinical interventions such as the provision of brief advice from a healthcare provider; 3) using trained community pharmacists to provide counsel ing and a record-keeping support program; 4) using financial incentives to influence the behaviours of providers (e.g., increasing the use of smoking -cessation interventions) and smokers (e.g., increasing rates of continuous abstinence). Medium-quality reviews also found benefits for physical therapists providing smoking-cessation advice and using reminder systems for delivering preventive services. While high-quality reviews were identified as being relevant to two other components (providing documentation of and enhancing production and dissemination of community-based resources; and selecting options for the process) none provided clear messages based on the findings from included studies. No reviews were found for: 1) providing additional training, certification and/or oversight of those providing the function in the community; 2) establishing indicators for successful tobacco-use cessation, data collection and feedback mechanism for community-based organizations and physicians; or 3) establishing accountability within community-based organizations and among community-based physicians for this function. The deliberations about this element of an integrated approach would ideal y focus on: 1) What is the ideal process for doing this? a. What follow-up is needed, by whom should the follow-up be provided, and when and for how long? b. What policies and procedures need to be developed or adapted (clinic forms and treatment pathways/care maps)? 2) Who should do what? a. Should nurses, psychologists, physicians or other healthcare providers be involved in referrals? b. With what additional training (and frequency of training)? c. With any form of verification that the process is followed correctly? d. With any form of incorporation into staff performance reviews? 3) What resources would be needed? a. What referral materials are needed and how would their development and dissemination be funded? b. What, if any, patient incentives are needed (e.g., free pharmacotherapies or financial incentives)? Evidence >> Insight >> Action McMaster Health Forum c. What, if any, changes to provider payment mechanisms are needed (e.g., fee codes and financial d. What, if any, changes to organizational payment mechanisms are needed (e.g., to cover counsel ing, pharmacotherapy and follow-up)? 4) What are the indicators for success? a. What indicators should be monitored (proportion of tobacco users with at least one referral initiated)? b. How would these data be captured? c. How would these data be fed back to hospital staff (individually or by unit)? d. How would these data be publicly reported? 5) What reminder systems are needed to ensure this is done? 6) Who do you hold accountable in hospital to do this? a. What accountabilities are held by al staff, designated service delivery staff and program coordination b. What accountability mechanism is used? For those who want to know more about the systematic reviews contained in Table 5 (or obtain a citation for the reviews), a fuller description of the systematic reviews is provided in Appendix 3. Table 5: Summary of key findings from systematic reviews relevant to Element 3 – Ensuring follow up counsel ing once tobacco users leave hospital to assist them in remaining smoke-free Category of finding
Summary of key findings
Providing documentation of and enhancing production and dissemination of
community-based resources
o A high-quality, older review found that smoking cessation interventions that include at least
one month of fol ow-up contact are effective in promoting smoking cessation in hospitalized patients. Also, there is insufficient direct evidence to conclude that adding nicotine- replacement therapy or bupropion to intensive counselling increases cessation rates over what is achieved by counselling alone.(4) o A high-quality, older review found that intensive behavioural interventions result in substantial increases in smoking abstinence compared with minimal clinical interventions (e.g., brief advice from a healthcare provider).(55) o A low-quality, recent review found that enhancing standard of care with the use of reminders, disease monitoring and management, and education through cellphone voice message service can help improve health outcome of patients, and care processes have implications for both patients and providers.(58) Selecting options for the process (i.e., who does what and in what order?)
o A medium-quality, recent review found that smoking cessation advice provided by physical
therapists could result in positive smoking cessation outcomes. Self-help materials, follow- up, and interventions based on psychological or motivational frameworks were particularly effective components of intermediate and intensive advice interventions provided by physical therapists.(59) o A high-quality, older review found that trained community pharmacists providing counselling and a record keeping support program had a positive effect on smoking o A medium-quality, recent review found that proactive telephone counselling had a statistical y significantly greater effect on point prevalence abstinence (non-smoking at fol ow-up or abstinent for at least 24 hours, seven days before follow-up) at six-to-nine months, but not at 12–15 months after recruitment.(72) o A low-quality, older review found that community interventions for reducing smoking among adults had slightly better results on light to moderate smokers than heavy smokers, but overal rates remained similar between intervention and control communities.(73) Implementing reminder systems for community-based organizations and physicians
o One medium-quality, older review assessing the effects of computerized clinical decision support systems found benefits for reminder systems for prevention (including rates of screening, counsel ing and identifying at-risk behaviours) in 16 of the 21 studies that were identified (although the one study assessing patient outcomes found no improvements).(47) Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Establishing targeted funding (e.g., nicotine-replacement therapy, counselling fees)
and/or financial incentives
o A high-quality, recent review evaluating the effect of changes in the method and level of payment on the quality of care provided by primary care physicians found three studies examining smoking cessation. The three studies found that financial incentives had a significant impact on the behaviours of primary health care providers by increasing referral rates and recording of smoking status, but not on measures of patients' smoking cessation. o A high-quality, recent review of financial interventions directed at smokers found a statistical y favourable effect of financial interventions on continuous abstinence compared with no interventions, and a significant effect of financial interventions when compared with no interventions on the number of participants making a quit attempt. There was a significant effect of financial interventions directed at healthcare providers in increasing the utilization of behavioural interventions for smoking cessation.(74) Costs and/or cost- A high-quality, recent review of financial interventions directed at smokers included a cost effectiveness in relation to comparison of ful , partial and no financial support and found costs per additional quitter ranging from $260 to $1453.(74) Uncertainty regarding Uncertainty because no systematic reviews were identified benefits and potential harms o Providing additional training, certification and/or oversight of those providing the
(so monitoring and function in the community
evaluation could be o Establishing indicators for successful tobacco-use cessation, data col ection and
warranted if the option were feedback mechanism for community-based organizations and physicians
o Establishing accountability within community-based organizations and among
community-based physicians for this function
Uncertainty because no studies were identified despite an exhaustive search as part of a systematic review o Not applicable (i.e., no ‘empty' reviews were found) No clear message from studies included in a systematic review
o Providing documentation of and enhancing production and dissemination of
community-based resources
A high-quality, older review found insufficient direct evidence to conclude that adding nicotine-replacement therapy or bupropion to intensive counselling increases cessation rates over what is achieved by counselling alone.(4) Selecting options for the process (i.e., who does what and in what order?)
A high-quality, older review found limited evidence due to methodological limitations that peer support telephone cal s change behavioural health outcomes.(67) Key elements of the policy Not applicable (i.e., key elements were not addressed in the available systematic reviews) option if it was tried Stakeholders' views and Evidence >> Insight >> Action McMaster Health Forum Additional equity-related observations about the three elements
As this research evidence suggests, very little is known about the three elements in relation to the use of tobacco-use cessation supports in rural hospitals and in hospitals for the mentally ill, as well as among people with low socio-economic status and people with one or more chronic conditions. Rural hospitals with small operating budgets and limited staff may face particular challenges with implementing tobacco- use cessation supports. Hospitals for the mental y il , on the other hand, may be particularly reluctant to be perceived as taking away a coping strategy (tobacco use) at a stressful time in their patients' lives. We found one systematic review that included studies of individuals living with a mental illness either in the community or in an in-patient unit, and it showed that the use of pharmacotherapy (i.e., Bupropion) increases smoking-abstinence rates.(53) People with low socio-economic status or with one or more chronic conditions may face a unique set of challenges with quitting. We found one systematic review that examined the effectiveness of different types of tailored self-help materials for smoking cessation (e.g., such as computer-generated feedback, telephone hotlines and pharmacotherapy) versus non-tailored self-help materials.(33) The review found that approaches tailored to the individual are more effective than non- tailored materials. However, we found no systematic reviews that directly addressed the question as to whether the benefits, harms and costs of any of the elements of a comprehensive approach to tobacco- cessation supports varied according to whether the hospitals were based in rural areas or treated mental y il patients, or whether the patients were of low socio-economic status or living with one or more chronic Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario IMPLEMENTATION CONSIDERATIONS
As suggested by the overview of tobacco-use cessation initiatives that involve Ontario hospitals that was presented in Table 1, there is a significant amount of activity already underway in providing hospital-based tobacco-cessation supports in Ontario hospitals. One key overarching implementation challenge will involve identifying how any minimum standard of care aligns with existing initiatives. In Table 6, we use the same six questions posed in the preceding section and the responses provided by the creator of one initiative, as a way to highlight the types of specificities required in a standard of care. A description of how one initiative addresses questions about the standard of care Responses provided by the creator of the initiative in northwestern Ontario (source: personal communication from Patricia Smith; reproduced verbatim with only copy-edits made) What is the ideal process for doing this?
Centralize the identification and documentation of tobacco use by adding a • How should tobacco users be identified and standardized question (30 day point prevalence) to the electronic admitting records to documented (e.g., when in the course of hospital be asked by admitting staff when patients first register at the hospital. Documentation visit or stay and with what type of should have forced choice answer options and be a no-bypass field on the admission record.(1) Additional y, a tobacco-use item should be added to healthcare provider • What assistance needs to be provided to tobacco assessments (e.g., history and physical) which in turn triggers provision of an users (e.g., ‘balance' of counsel ing and intervention and intervention tracking form for smokers.(1) pharmacotherapies, ‘dose' of counselling, and • Assistance: guidelines recommend both counselling and pharmacotherapy (5) which (combination of) pharmacotherapies), in • Dose of counselling: guidelines recommend a minimum of 1-3 minutes of what order, and when in the course of a hospital intervention fol owing the 5A protocol, but preferably 10+ minutes with 8+ sessions and a total of 90-300 minutes (5) • What fol ow-up is needed, by whom should the • Pharmacotherapy: guidelines recommend first-line therapies and combination fol ow-up be provided, and when and for how nicotine-replacement therapy in combination with bupropion (5) • When in the course of hospitalization: as soon as patients are stabilized (5) • What policies and procedures need to be • Follow-up: meta-analyses recommend a minimum of 1 month post-discharge developed or adapted (e.g., clinic forms and fol ow-up; since acute care cannot always do that, referral to a community treatment pathways/care maps)? resource, such as the Smokers' Helpline or an outpatient clinic (5) • Policies/procedures: standardized tobacco use question and integration into electronic admitting forms; intervention tracking form; standard order forms; clinician training and feedback; integration of intervention into pathways; pharmacotherapy available on formulary; and policy/procedure document (4) Who should do what?
The system for tobacco-use identification and documentation on admission is • Should nurses, psychologists, physicians or other centralized by designating admitting staff to identify/document tobacco use rather healthcare providers be involved? than having a decentralized approach in which al clinicians are responsible for asking • With what additional training (and frequency of and documenting, because there could be thousands of clinicians in a given hospital — the more that are responsible for documenting tobacco use, the more diffuse the responsibility (3) With any form of certification? With any form of verification that the process is For providing tobacco-cessation interventions, hospitals are in the best position to followed correctly? designate what clinicians will provide interventions, and who will centralize patient materials and assess delivery in staff performance evaluations, because this With any form of incorporation into staff performance reviews? becomes a scope of practice, professional practice, and workload issue and oftentimes unions and collective agreements are involved (3) • Training: In-services on the intervention activities provided and management has integrated expectations for interventions into new staff orientation (2) • Additional training: Information on more intensive training is made available (2) • Certification is not mandatory. Nurses are regulated professionals and cessation counselling is an RNAO best practice and is included in their scope of practice. There are >30 RNAO best practices - nurses do not have to be certified for the other best practices. Moreover, mandating certification was not an option from a resource perspective (time/money), and was not feasible due to issues such as who pays for the training, nurses want to do it on company time, and hospitals want nurses to do it on personal time.(2) • Process verification: "Report cards" at the organizational level provide data for hospitals to include in accreditation reports (4) Evidence >> Insight >> Action McMaster Health Forum • Performance reviews: intervention forms are part of quality chart audits, but incorporating into performance reviews is optional and for most, not feasible as there are too many issues involved (e.g., hospitals do not include everything nurses do in their job as line items on a performance evaluation; performance evaluation also has col ective agreement issues) (4) What resources would be needed?
Agreements with Smokers' Helpline for patient materials and post discharge fol ow- • What self-help, service delivery and referral up. No funding is needed because Smokers' Helpline has a mandate to work with materials are needed and how would their acute care; however, time is required to set up the agreements (2) development and dissemination be funded? • Patient incentives: Include counselling and pharmacotherapy as paid or covered • What, if any, patient incentives are needed (e.g., services during hospitalization; continued no-cost counselling and free pharmacotherapies or financial incentives)? pharmacotherapy post-discharge would be an incentive (5) • What, if any, changes to provider payment • No changes are obvious as provider payment: physicians have OHIP bil ing mechanisms are needed (e.g., fee codes and codes; nurses are salaried; however, to provide intensive interventions in hospital financial incentives)? with post discharge fol ow-up, salaries for counsel ors would be needed (4) • What, if any, changes to organizational payment • Organizational payment mechanisms would benefit from salary support for ful - mechanisms are needed (e.g., to cover time counsellors, increased budgets for pharmacotherapy, and mechanisms to counselling, pharmacotherapy, fol ow-up)? provide pharmacotherapy to patients when they are discharged (4) What are the indicators for success?
• Indicators: proportion of: a) al hospitalized patients screened for tobacco use; b) • What indicators should be monitored (e.g., proportion of tobacco users; c) proportion of tobacco users provided with proportion of patient visits or hospital stays with interventions; d) what intervention components are provided (e.g., each step of tobacco status documented and proportion of the 5A protocol) (1, 5) tobacco users with at least two supports provided • Screening and tobacco prevalence are captured at the organizational level through and one referral initiated)? admitting records,(1) while tobacco interventions provided are captured with a • How would these data be captured? standardized form on patients' charts (5) • How would these data be fed back to hospital • Data are provided to hospital staff during in-services and to the organization staff (e.g., individually or by unit)? • Would these data be publicly reported? • Data are available to the public through publications and presentations What reminder systems are needed to ensure this
• Tobacco intervention forms need to be part of patients' charts to trigger clinicians to provide interventions (2) • Regular feedback about tobacco prevalence data and adherence to the 5A guidelines through analysis of intervention forms are integrated into in-service booster sessions Who do you hold accountable in hospital to do
• CEO and senior management team are ultimately accountable because they make the decisions and make changes to clinicians' jobs (4) • What accountabilities are held by all staff, • Staff accountabilities: Al admitting staff are expected to ask al patients about designated service delivery staff and program tobacco use. Feedback is provided (4) coordination staff? • Al staff nurses are expected to provide a brief 5A intervention to smokers (4) • What accountability mechanism is used? • A designated staff person is responsible to ensure that new hires know about tobacco intervention expectations, provide feedback to nursing staff on intervention adherence, and arrange ongoing replenishment of patient materials • Accountability is currently through completion of forms and through coordination responsibilities assigned by senior management (3) Potential barriers to the implementation of a comprehensive approach to hospital-based tobacco-use cessation supports across Ontario can be identified at the level of patients (e.g., fear of treatment denial, resistance to a one-size-fits-all approach, and concern about affordability), providers (e.g., lack of resources, knowledge/skills and support systems, as wel as concerns about professional autonomy), organizations (e.g., lack of resources and agreed indicators and concerns about organizational autonomy), and system level (e.g., budget constraints during a difficult economic period). (The barriers were identified through a combination of two recently published articles,(75;76) key-informant interviews and input from Steering Committee members but not from a systematic review of the research literature.) Additional details about potential barriers to implementing the elements of a comprehensive approach are provided in Table 7. Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Table 7: Potential barriers to implementing a comprehensive approach to tobacco-use cessation supports Element 1 – Establishing and
Element 2 – Providing tobacco users
Element 3 – Ensuring fol ow-
institutionalizing a common approach to
with assistance in quitting and
up counsel ing once tobacco
identifying tobacco users upon admission to continuing support for nicotine
users leave hospital to assist
hospital
withdrawal while in hospital
them in remaining tobacco-
Tobacco users may perceive that they may Tobacco users may resist or not respond Former tobacco users may resist have a coping strategy (tobacco use) taken to a one-size-fits-all-approach that does or not respond to a one-size-fits- away at a stressful time, that they may be not recognize their unique needs, which blamed for their condition or that treatment may vary by reason for admission, socio- might be denied based on their response demographic status and other factors Tobacco users with limited Tobacco users with limited financial financial resources or resources or supplementary insurance supplementary insurance coverage may not be able to afford some coverage may not be able to cessation supports afford some cessation supports Healthcare
Hospital-based healthcare providers may resist Hospital-based healthcare providers may Primary care physicians and provider
the institutionalization of a common approach resist certification or incentives as a form physician groups may not have because of a sense that supporting tobacco-use of infringement on their professional electronic health records or cessation is not their responsibility, or because patient reminder systems to of the resource requirements and added assist with fol ow-up care for responsibilities Hospital-based healthcare providers may not have the knowledge and skil s needed to support links to community-based cessation supports Hospital-based healthcare providers may resist certification or incentives as a form of infringement on their professional autonomy Hospitals
Hospitals may resist a common approach, Hospitals may resist a common Community-based healthcare and other
accreditation and incentives as a form of approach, accreditation and incentives as organizations may not have the healthcare
infringement on their organizational autonomy a form of infringement on their resources to accommodate al organizations and without dedicated funds and an agreement
organizational autonomy and without eligible patients about how adherence and success wil be dedicated funds and an agreement about how adherence and success wil be Rural hospitals may resist an approach that requires a certain organizational scale to be Rural hospitals may resist an approach that requires a certain organizational scale Provincial government may lack the financial Provincial government may lack the Provincial government may lack flexibility to finance/support the necessary financial flexibility to finance/support the the financial flexibility to coordinating structures and processes, as wel as necessary hospital-based tobacco-use finance/support the necessary the monitoring and evaluation, of hospital-based cessation supports during a difficult community-based tobacco-use tobacco-use cessation programs during a cessation supports during a difficult economic time difficult economic time Studying successes and failures in pursuing a similar approach in other provinces and countries may prove useful in identifying strategies to overcome some of these identified barriers. In the meantime, the following types of implementation strategies warrant deliberation: 1) a participatory approach to developing new communication channels for patients and healthcare providers so that they can draw on tobacco-use cessation supports (e.g., use of hospital television as a mechanism); 2) a process for identifying and working with champions drawn from the senior executive ranks of Ontario 3) the development of a business case for a minimum standard of support for tobacco-using patients across Ontario hospitals, and perhaps as wel as for the optimal standard (which might permit a staged approach to implementation that initial y focuses on low-cost early wins across all Ontario hospitals, and later moves on to more costly elements of a comprehensive approach). Evidence >> Insight >> Action McMaster Health Forum REFERENCES

1. Schwartz R, O'Connor S, Minian N, Borland T, Babayan A, Ferrence R et al. Evidence to Inform Smoking Cessation Policymaking in Ontario: A Special Report by the Ontario Tobacco Research Unit. Toronto, Canada: Ontario Tobacco Research Unit. Available online at: [accessed on 5 December 2011]; 2. Echo Advance. Improving Women's Health in Ontario - Smoking Cessation Best Practices for Pregnant Women: Adapting to Local Needs (May 2011). Toronto, Canada: Echo Advance. Available December 2011]; 2011. 3. Tobacco Strategy Advisory Group. Building On Our Gains, Taking Action Now: Ontario's Tobacco Control Strategy for 2011-2016. Toronto, Canada: Ministry of Health Promotion and Sport. Available online at:[accessed on 5 December 2011]; 2010. 4. Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst.Rev. 2007(3):Art. No.: CD001837. DOI: 5. Reid E, Pipe A, Higginson L, Johnson K, D'Angelo MS, Cooke D et al. Stepped care approach to smoking cessation in patients hopsitalized for coronary artery disease. Journal of Cardiopulmonary Rehabilitation 2003;23:176-82. 6. Thomsen T, Tonnesen H, Moller AM. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. British Journal of Surgery 2009;96(5):451-61. 7. Mohiuddin SM, Mooss AN, Hunter CB, Grollmes TL, Cloutier DA, Hilleman DE. Intensive smoking cessation intervention reduces mortality. Chest 2007;131(2):446-52. 8. Reid R, Mullen KA, D'Angelo S, Aitken DA, Papadakis S, Haley P et al. Smoking cessation for hospitalized smokers: An evaluation of the "Ottawa Model". Nicotine & Tobacco Research 2010;12(1):11-8. 9. Campbell S, Pieters K, Mullen KA, Reece R, Reid RD. Examining sustainability in a hospital setting: Case of smoking cessation. Implementation Science 2011;6(108). 10. Smith P, Corso L, Brown KS, Cameron R. Nurse case-managed tobacco cessation interventions for general hospital patients: Results of a randomized clinical trial. Canadian Journal of Nursing Research 2011;43(1):98-117. 11. Smith PM, Reilly KR, Houston-Miller N, DeBusk RF, Taylor CB. Application of a nurse-managed inpatient smoking cessation program. Nicotine and Tobacco Research 2002;4:211-22. 12. Canadian Pharmacists Association. Tobacco: The Role of Health Professionals in Smoking Cessation Joint Statement. Ottawa, Canada: Canadian Pharmacists Association. Available online at: [accessed on 5 December 2012]; 2001. 13. Ontario Ministry of Health and Long- Term Care. Smoke-free Ontario Strategy. Toronto, Canada: Ontario Ministry of Health and Long-Term Care. Available online at: [accessed on 5 December 2012]; 2011. 14. Ontario Ministry of Health and Long- Term Care. Pharmacy Smoking Cessation Program. Toronto, Canada: Ontario Ministry of Health and Long-Term Care. Available online at: Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario December 2012]; 2011. 15. Registered Nurses Association of Ontario. Integrating Smoking Cessation into Daily Nurse Practice: Nuring Best Practice Guideline. Toronto, Canada: Registered Nurses Association of Ontario. Available online at:[accessed on 5 December 2011]; 2007. 16. Centre for Addiction and Mental Health. Training Enhancement in Applied Cessation Counsel ing and Health (TEACH) Program. Toronto, Canada: Centre for Addiction and Mental Health. Available [accessed on 5 December 2011]; 2011. 17. The Canadian Action Network for the Advancement DaAoPTTCA. Smoking Cessation Knowledge Exchange Network and Clinical Practice Guidlines. Toronto, Canada: CAN ADAPTT. Available online at:[accessed on 5 December 2012]; 18. U.S.Department of Health and Human Services PHS. Treating Tobacco Use and Dependence: Clinical Practice Guidelines. U.S. Department of Health and Human Services. Available online at: [accessed on 30 November 19. Ontario Ministry of Health and Long-term Care. The Excel ent Care for All Act. Toronto, Canada: Ontario Ministry of Health and Long-Term Care; 2010. 20. Ontario Ministry of Health Promotion and Sport. Frequently Asked Questions about Ontario's Smoke-free Strategy. Toronto, Canada: Ontario Ministry of Health Promotion and Sport. Available online at:[accessed on 5 December 2011]; 2006. 21. Canadian Institute for Health Information. Highlights of 2009-2012 Inpatient Hospitalizations and Emergency Department Visits. Ottawa, Canada: Canadian Institute for Health Information. Available online [Accessed on 14 December 2011]; 2011. 22. Health Canada. Tobacco Use Monitoring Survey 2003. Ottawa, Canada: Health Canada. Available [accessed on 30 November 2012]; 2010. 23. Propel Centre for Population Health Impact. Tobacco Use in Canada: Patterns and Trends, 2011 Edition. Waterloo,Canada: University of Waterloo. Available online at: December 2011]; 2011. 24. Ontario Tobacco Research Unit. Indicators of Smoke-Free Ontario Progress: Special Report. Toronto, Canada: Ontario Tobacco Research Unit. Available online at: [accessed on 30 November 2012]; 2010. 25. Smith P. Tobacco use among emergency department patients. International Journal of Environmental Research and Public Health 2011;8:253-63. 26. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: A systematic review. Journal of American Medical Association 2003;290:86- Evidence >> Insight >> Action McMaster Health Forum 27. Health Canada. Tobacco Control Programme, Health Canada Supplementary Tables (Canadian Tobacco Use Monitoring Survey). Ottawa, Canada: Health Canada. Available online at: on 30 November 2012]; 2002. 28. Piasecki TM. Relapse to smoking. Clinical Psychology Review 2006;26:196-215. 29. University of Ottawa Heart Institute. Workshop Report: Integrated Approaches to Hospital-based Smoking Cessation. Ottawa, Canada: University of Ottawa Heart Institute; 2005. 30. Babayan A, Yates E, Taylor E, Dubray J, Schwartz R. Smoking Cessation Acitives in Ontario Hospitals: Survey Results. Toronto,Canada: The Ontario Tobacco Research Unit. [Accessed on 4 January 2012]; 2011. 31. Smith P, Burgess E. Smoking cessation initiated during hospital stay for patients with coronary artery disease: A randomized controlled trial. Canadian Medical Association Journal 2009;180(13):1297-303. 32. Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst.Rev. 2008(3):Art. No.: CD001837. DOI: 33. Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Database Syst.Rev. 2005(3):Art. No.: CD001118. DOI: 10.1002/14651858.CD001118.pub2. 34. Rice VH, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst.Rev. 2004(1):Art. No.: CD001188. DOI: 10.1002/14651858.CD001188.pub3. 35. Fiore MC, Jaen CR, Baker TB. Treating Tobacco Use and Dependence, 2008 Update. U.S: Department of Health and Human Services, Public Health Service. Available online at [accessed on 5 December 2012]; 36. Smith P, Burgess E. Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial. Canadian Medical Assocation Journal 2009;180(13). 37. Registered Nurses Association of Ontario (RANO). Integrating Smoking Cessation into Daily Nurse Practice: Nuring Best Practice Guideline. Toronto, Canada: Registered Nurses Association of Ontario (RNAO). Available online at: [accessed on 5 December 2012]; 38. Van Spal HG, Chong A, Tu JV. Inpatient smoking-cessation counseling and all-cause mortality in patients with acute myocardial infarction. The American Heart Journal 2007;154(2):213-20. 39. Goldman L, Garber AM, Grover SA, Hilatky MA. Cost-effectiveness of assessment and management of risk factors. Journal of the American College of Cardiology 1996;27:1020-30. 40. Ontario Ministry of Health and Long-term Care. Pharmacy Smoking Cessation Program. Toronto, Canada: Ontario Ministry of Health and Long-term Care. Available online at: December 2011]; 2011. 41. Pipe A, Reid R, Riley D, Quinlan B. Institutional Approaches to Smoking Cessation: Their Time Has Come. Ottawa, Canada: Minto Prevention Rehabilitation Centre and University of Ottawa Heart Institute. Available online at:[accessed on 14 December 2011]; 2008. 42. Esterberg ML, Compton MT. Smoking behaviour in persons with a schizophrenia-spectrum disorder: A qualitative investigation of the transtheoretical model. Social Science and Medicine 2005;61(2):293-303. Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario 43. McDonald PW. A Recommended Population Strategy to Help Canadian Tobacco Users. Waterloo, Canada: University of Waterloo. Available online at: [accessed on 14 December 2011]; 44. Stevenson J, Snider J, Kaiserman MJ. Smoking-cessation Advice from Healthcare Providers - Canada, 2005. Toronto, Canada: Tobacco Control Programme, Health Canada. Available online at: [accessed on 14 December 2011]; 45. Lancaster T, Silagy C, Fowler G. Training health professionals in smoking cessation. Cochrane Database Syst.Rev. 2000(3):Art. No.: CD000214. DOI: 10.1002/14651858.CD000214. 46. Freund M, Campbell E, Paul C, Sakrouge R, McElduff P, Walsh RA et al. Increasing smoking cessation care provision in hospitals: A meta-analysis of intervention effect. Nicotine and Tobacco Research 2009;11(6):650-62. 47. Garg AX, Adhikari NKJ, McDonald H, Rosas-Arel ano MP, Devereaux PJ, Beyene J et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA 2005;293(10):1223-38. 48. Scott A, Peter S, Ouakrim DA, Willenberg L, Naccerella L, Furler J et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst.Rev. 2011(9):Art. No.: CD008451. DOI: 10.1002/14651858.CD008451.pub2. 49. Buckley BS, Byrne MC, Smith SM. Service organisation for the secondary prevention of ischaemic heart disease in primary care. Cochrane Database Syst.Rev. 2010(3):Art. No.: CD006772. DOI: 50. Taylor SJC, Candy B, Bryar RM, Ramsay J, Vrijhoef HJM, Esmond G et al. Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: Systematic review of evidence. BMJ 2005;331(7515):485-8. 51. Ketelaar N, Faber M, Flottorp S, Rygh LH, Deane K, Eccles MP. Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations. The Cochrane 52. Wallace J, Teare GF, Verrall T, Chan BTB. Public reporting on the quality of healthcare: Emerging evidence on promising practices for effective reporting. Ottawa, Canada: Canadian Health Services Research Foundation; 2007. 53. Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Database Syst.Rev. 2010(6):Art. No.: CD007253. DOI: 54. Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst.Rev. 2008(1):No.: CD000146. DOI: 55. Mottillo S, Filion KB, Belisle P, Joseph L, Gervais A, O'Loughlin J et al. Behavioural interventions for smoking cessation: A meta-analysis of randomized controlled trials. European Heart Journal 2009;30(6):718-30. 56. Zaki A, Abrishami A, Wong J, Chung FF. Interventions in the preoperative clinic for long term smoking cessation: A quantitative systematic review. Canadian Journal of Anaesthesia 2008;55(1):11- Evidence >> Insight >> Action McMaster Health Forum 57. McLean S, Nurmatov U, Liu-Joseph LY, Pagliari C, Car J, Sheikh A. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst.Rev. 2011(7):Art. No.: CD007718. DOI: 58. Krishna S, Boren SA, Balas EA. Healthcare via cel phones: A systematic review. Telemedicine and E-Health 2009;15(3):231-40. 59. Bodner ME, Dean E. Advice as a smoking cessation strategy: A systematic review and implications for physical therapists. Physiotherapy Theory and Practice 2009;25(5-6):369-407. 60. Cropley M, Theadom A, Pravettoni G, Webb G. The effectiveness of smoking cessation interventions prior to surgery: A systematic review. Nicotine and Tobacco Research 2008;10(3):407- 61. Mojica WA, Suttorp MJ, Sherman SE, Morton SC, Roth EA, Maglione MA et al. Smoking-cessation interventions by type of provider: A meta-analysis. American Journal of Preventive Medicine 2004;26(5):391-401. 62. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst.Rev. 2005(2):Art. No.: CD001292. DOI: 10.1002/14651858.CD001292.pub2. 63. Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic review: The evidence that publishing patient care performance data improves quality of care. Annals of Internal Medicine 2008;148(2):111-23. 64. Shearer J, Shanahan M. Cost effectivness analysis of smoking cessation interventions. Australian New Zealand Journal of Public Health 2006;30:428-34. 65. Bize R, Burnand B, Mueller Y, Cornuz J. Biomedical risk assessment as an aid for smoking cessation. Cochrane Database Syst.Rev. 2005(4):Art. No.: CD004705. DOI: 66. Civljak M, Sheikh A, Stead LF, Car J. Internet-based interventions for smoking cessation. Cochrane Database Syst.Rev. 2010(9):Art. No.: CD007078. DOI: 10.1002/14651858.CD007078.pub3. 67. Dale J, Caramlau IO, Lindenmeyer A, Williams SM. Peer support telephone calls for improving health. Cochrane Database Syst.Rev. 2008(4):Art. No.: CD006903. DOI: 68. Blenkinsopp A, Anderson C, Armstrong M. Systematic review of the effectiveness of community pharmacy-based interventions to reduce risk behaviours and risk factors for coronary heart disease. Journal of Public Health Medicine 2003;25(2):144-53. 69. Hajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database Syst.Rev. 2009(1):Art. No.: CD003999. DOI: 70. Lai DTC, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database Syst.Rev. 2010(1):Art. No.: CD006936. DOI: 10.1002/14651858.CD006936.pub2. 71. Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database Syst.Rev. 2004(1):Art. No.: CD003698. DOI: 72. Tzelepis F, Paul CL, Walsh RA, McElduff P, Knight J. Proactive telephone counseling for smoking cessation: Meta-analyses by recruitment channel and methodological quality. Journal of National Cancer Institute 2011;103:922-41. Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario 73. Secker-Walker R, Gnich W, Platt S, Lancaster T. Community interventions for reducing smoking among adults. Cochrane Database Syst.Rev. 2002(2):Art. No.: CD001745. DOI: 74. Reda AA, Kaper J, Filkretler H, Severens JL, Van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database Syst.Rev. 2009(3):Art. No.: CD004305. DOI: 10.1002/14651858.CD004305. 75. Lawn S. Habit or addiction: the critical tension in deciding who should enforce hospital smoke-free policies. Canadian Medical Assocation Journal 2011;183(18):2085-6. 76. Schultz AS, Finegan B, Nykiforuk CIJ, Kvern MA. A qualitative investigation of smoke-free policies on hospital property. Canadian Medical Assocation Journal 2011;183(18):2105. Evidence >> Insight >> Action McMaster Health Forum APPENDICES
The following tables provide detailed information about the systematic reviews identified for each option. Each row in a table corresponds to a particular systematic review and the reviews are organized by each of the elements of a comprehensive approach for addressing the problem (first column). The focus of the review is described in the second column. Key findings from the review that relate to the element are listed in the third column, while the fourth column records the last year the literature was searched as part of the review. The fifth column presents a rating of the overal quality of the review. The quality of each review has been assessed using AMSTAR (A MeaSurement Tool to Assess Reviews), which rates overall quality on a scale of 0 to 11, where 11/11 represents a review of the highest quality. It is important to note that the AMSTAR tool was developed to assess reviews focused on clinical interventions, so not all criteria apply to systematic reviews pertaining to delivery, financial or governance arrangements within health systems. Where the denominator is not 11, an aspect of the tool was considered not relevant by the raters. In comparing ratings, it is therefore important to keep both parts of the score (i.e., the numerator and denominator) in mind. For example, a review that scores 8/8 is generally of comparable quality to a review scoring 11/11; both ratings are considered "high scores." A high score signals that readers of the review can have a high level of confidence in its findings. A low score, on the other hand, does not mean that the review should be discarded, merely that less confidence can be placed in its findings and that the review needs to be examined closely to identify its limitations. (Source: Lewin S, Oxman AD, Lavis JN, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP): 8. Deciding how much confidence to place in a systematic review. Health Research Policy and Systems 2009; 7 (Suppl1):S8. The last three columns convey information about the utility of the review in terms of local applicability, applicability concerning prioritized groups, and issue applicability. The third-from-last column notes the proportion of studies that were conducted in Canada, while the second-from-last column comments on the proportion of studies included in the review that deal explicitly with one of the prioritized groups. The last column indicates the review's issue applicability in terms of the proportion of studies focused on hospital-based tobacco-use cessation supports. Al of the information provided in the appendix tables was taken into account by the issues brief's authors in compiling Tables 2-4 in the main text of the Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Appendix 1: Systematic reviews relevant to Element 1 – Establishing and institutionalizing a common approach to identifying tobacco users
upon admission to hospital
Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients
Selecting options for the Effectiveness of service Service organization interventions process (e.g., who does what organization interventions, for ischemic heart disease patients and in what order) identifying which types and (IHD) that included regular elements of service change are planned appointments, patient associated with most improvement education and structured in clinician and patient adherence monitoring of medication and risk to secondary prevention factors, had no significant effects recommendations relating to risk on smoking cessation factor levels and monitoring (blood pressure, cholesterol and lifestyle factors such as diet, exercise, smoking and obesity), and appropriate prophylactic Effectiveness of innovations in There is little evidence to date on management of chronic disease the effectiveness of nurse-led involving nurses for patients with interventions for COPD patients chronic obstructive pulmonary on smoking cessation disease (COPD)* (50) * Note that this review is not specifical y focused on tobacco-use cessation supports, however, lessons can be drawn from nurse- led interventions with COPD patients Providing additional Effectiveness of training healthcare Training health professionals to training, certification and/or professionals to deliver smoking provide smoking cessation oversight of those providing cessation interventions to their interventions had a measurable the function at admission to patients, and to assess the effect on professional additional effects of prompts and performance. There was no strong reminders to the health evidence that it changed smoking professional to intervene (45) Engaging all staff in No reviews were found tobacco-use cessation Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients
Developing or adapting No reviews were found policies, procedures and care pathways (e.g., hospital formularies to include required medication, medical directives to support all professional staff to administer nicotine- replacement therapy) Establishing indicators for No reviews were found successful tobacco-user identifications, streamlined data collection and feedback mechanism for hospital staff Implementing reminder Effectiveness of interventions in Of the 25 identified studies, 18 system for hospital staff increasing smoking cessation care were in inpatient settings. Of the provision in hospitals (46) 10 controlled trials, four addressed Description states: cardiac patients, five measured one smoking cessation care practice, and nine implemented multistrategic interventions (e.g., combining educational meetings with reminders and written resources). Meta-analysis of control ed trials demonstrated a significant intervention effect for provision of assistance and counsel ing to quit, but not for assessment of smoking status, advice to quit, or the provision or discussion of nicotine-replacement Effects of computerized clinical The computerized clinical decision 2004 decision support systems on support systems improved practitioner performance and practitioner performance in patient outcomes (47) diagnostic systems, reminder Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients
systems, disease management systems, and drug-dosing or prescribing systems Effectiveness of clinic systems for A review reported in a clinical assessment and documentation of practice guideline found clinic tobacco-use status(35) systems designed to increase the assessment and documentation of tobacco-use status increased the rate at which clinicians intervened with their patients who smoke. However, while such systems may increase rates of intervention, this does not necessarily produce significantly higher rates of smoking cessation Providing targeted funding Effect of changes in the method Three cluster-RCTs included in the 2009 and/or financial incentives and level of payment on the quality review investigated how financial of care provided by primary care incentives influenced physicians' physicians (PCPs) and to identify: propensity to deliver advice to their the different types of financial patients on smoking cessation, to incentives that have improved refer patients to smoking cessation quality; the characteristics of help lines, or patients' adherence to patient populations for whom evidence-based smoking cessation quality of care has been improved practice guidelines by financial incentives; and the characteristics of PCPs who have In the three studies examining responded to financial incentives smoking cessation, there were statistically significant effects of financial incentives on PCP behaviours (referral rates and recording of smoking status), but not on measures of patients' smoking cessation Establishing accountability Effects of computerized clinical The computerized clinical decision 2004 within hospitals for this decision support systems on support systems improved function (which could practitioner performance and practitioner performance in include public reporting) patient outcomes (47) diagnostic systems, reminder Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients
systems, disease management systems, and drug-dosing or prescribing systems Effectiveness of public reporting Reporting to the public is effective 2007 No rating tool Not reported on healthcare quality (52) if the public has the information, understands the information, and uses the information in a manner that accomplished the objectives of the reporting program. There are a number of factors to take into consideration to develop an effective public reporting program: objective(s), audience, content, products, distribution and impacts (intended and unintended) Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Appendix 2: Systematic reviews relevant to Element 2 – Providing tobacco users with assistance in quitting and continuing support for nicotine
withdrawal while in hospital
Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
Selecting the types of Evaluate the benefits and harms of Bupropion increases smoking assistance provided (e.g., different treatments for nicotine abstinence rates in smokers with balance of counselling and dependence in schizophrenia (53) schizophrenia, without jeopardizing pharmacotherapy) and the their mental state. Bupropion may schizophrenia cessation; four ‘dose' of assistance (e.g., also reduce the amount these trials of smoking intensity of counselling) have been in a trial for relapse prevention; five Effect of nicotine-replacement Nicotine-replacement therapy therapy by the dosage, form and appears to be largely independent of timing of use; the intensity of the intensity of additional support additional advice and support provided to the individual. Provision offered to the smoker; or the of more intense levels of support, clinical setting in which the smoker although beneficial in facilitating the is recruited and treated (54) likelihood of quitting, is not essential to the success of nicotine- replacement therapy Effectiveness of interventions for Results indicated that high intensity smoking cessation in hospitalized behavioural interventions that include at least one month of fol ow- up contact are effective in promoting smoking cessation in hospitalized Effects of four behavioural Intensive behavioural interventions interventions, including minimal result in substantial increases in clinical intervention (brief advice smoking abstinence compared with from a healthcare worker), and control. There was insufficient Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
intensive interventions, including evidence regarding the efficacy of individual, group, and telephone minimal clinical interventions counselling (55) corresponding to various age, sex, status, or ethnic Effect of interventions in the Results suggest that smoking- preoperative clinic for long-term cessation interventions initiated at detail: the included 2) 4/4 smoking cessation (56) the preoperative clinic can increase trials originated the odds of abstinence by up to 60% within a three-to-six month fol ow- the United States, Further trials needed to evaluate possibility of longer abstinence. Effectiveness of cel phones and Findings indicate that the users of text messaging interventions in telehealthcare (e.g., people treated by applica improving health outcomes for telephones, video cameras and the Description states: individuals suffering from chronic internet to al ow people to stay at Canada (1); Spain obstructive pulmonary disease (57) home and communicate with a nurse (1); Belgium (1); or doctor when they have a period of increased breathlessness) manage to stay out of hospital longer than people treated by conventional systems of care. There are also some data showing that although these systems are expensive to start off with, if they are successful at keeping people out of hospital, then the cost Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
saving from this means that they are cheaper in the long run. Effectiveness of smoking cessation Al the studies reviewed revealed that 2006 interventions prior to surgery and the smoking-cessation interventions examining smoking-cessation rates offered prior to surgery were at six months fol ow-up (60) effective with a mean success rate of 55%. The findings revealed that short-term quit rates (or a reduction by more than half of normal daily rate) ranged from 18% to 93% in patients receiving a smoking intervention (mean 55%), compared with a range of 2%-65% of controls (mean 27.7%). Two studies examined smoking status at six months, but these revealed no significant difference in abstinence rates between patients who had received an intervention and those who had not. Studies that incorporated counselling in addition to nicotine- replacement therapy appeared to show greater benefits Cost-effectiveness of smoking- Cost-effectiveness of smoking- cessation interventions (64) cessation interventions (e.g., brief advice, counsel ing, nicotine- replacement therapy, and bupropion) found that telephone counselling appeared to be the most cost- effective intervention, bupropion appeared to be more cost effective than nicotine-replacement therapy, and combined bupropion and nicotine-replacement therapy did not appear to be cost effective Efficacy of biomedical risk In one study, smokers who had their 2009 assessment provided in addition to lung function tested and the results Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
various levels of counselling, as a explained in terms of their lung age contributing aid to smoking compared to a non-smoker of the cessation. Biomedical risk same age were more likely to quit assessment is the process of giving than people given the same test but smokers feedback on the physical without the explanation. Due to the effects of smoking by physiological scarcity of evidence of sufficient measurements (e.g., exhaled carbon quality, we can make no definitive monoxide measurement or lung statements about the effectiveness of function tests) (65) biomedical risk assessment as an aid for smoking cessation. Current evidence of lower quality does not however support the hypothesis that biomedical risk assessment increases smoking cessation in comparison with standard treatment Effectiveness of service There is weak evidence that regular organization interventions, planned recal of patients for identifying which types and appointments, structured monitoring elements of service change are of risk factors and prescribing, and associated with most improvement education for patients can be in clinician and patient adherence effective in increasing the to secondary prevention proportions of patients within target recommendations relating to risk levels for cholesterol control and factor levels and monitoring (blood blood pressure pressure, cholesterol and lifestyle factors such as diet, exercise, smoking and obesity), and appropriate prophylactic Effectiveness of internet-based Some internet-based interventions interventions for smoking can assist smoking cessation, detail (Multiple especial y if the information is appropriately tailored to the users, and frequent automated contacts with the users are ensured, however trials did not show consistent Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
Effectiveness of pharmacy-based Four randomized control ed trials interventions to improve the risk (RCTs) were identified, two in of coronary health disease (68) smoking cessation and two in lipid Description states: management. The two RCT studies Canada (1); Spain on smoking cessation found that (1); Belgium (1); community pharmacy advice in smoking cessation was effective in the prevention of heart disease. Although the role of the community pharmacy in disease detection has been widely discussed, only a smal number of studies was found and warrants further research. Effectiveness of advice by physical Self-help materials, fol ow-up, and therapists and its components to interventions based on psychological report optimize smoking cessation or motivational frameworks were instituted in the context of physical particularly effective components of therapy practice (59) intermediate and intensive advice interventions. Incorporating smoking cessation as a physical therapy goal is consistent with the contemporary definition of the profession and the mandates of physical therapy professional associations to promote health and wellness, including smoking cessation for both primary health benefit and to minimize secondary effects (e.g., delayed healing and recovery, and medical and surgical complications) Effectiveness of cel phones and Findings indicate that enhancing text messaging interventions in standard care with reminders, disease detail: 4 studies improving health outcomes and monitoring and management, and processes of care (58) education through cellphone voice and short message service can help improve health outcomes, and care setting is unclear processes have implications for both Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
patients and providers Effects of peer support telephone This review provides some evidence cal s in terms of physical, that peer support telephone cal s can psychological, and behavioural be effective for certain health-related health outcomes and other concerns. However, the generalizability of findings is limited due to methodological limitations. Selecting the options for the Effectiveness of service Service organization interventions process (i.e., who does what organization interventions, for ischemic heart disease patients and in what order?) identifying which types and (IHD) that included regular planned elements of service change are appointments, patient education and associated with most improvement structured monitoring of medication in clinician and patient adherence and risk factors, had no significant to secondary prevention effects on smoking cessation recommendations relating to risk factor levels and monitoring (blood pressure, cholesterol and lifestyle factors such as diet, exercise, smoking and obesity), and appropriate prophylactic Effectiveness of delivery of Physicians and other clinicians are tobacco cessation counselling by similarly effective in delivering type of provider (35) tobacco cessation counselling. The review also found that treatments delivered by two or more types of clinicians increased abstinence rates as compared to those not delivered through a clinician. The review also notes that the number of contacts may be equal y or more important than that the number of clinicians providing treatment Effectiveness of interventions for High intensity behavioural smoking cessation in hospitalized interventions that include at least one month of fol ow-up contact are Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
effective in promoting smoking cessation in hospitalized patients Effectiveness of advice by physical Self-help materials, fol ow-up, and therapists and its components to interventions based on psychological report optimize smoking cessation or motivational frameworks were instituted in the context of physical particularly effective components of therapy practice (59) intermediate and intensive advice interventions. Incorporating smoking cessation as a physical therapy goal is consistent with the contemporary definition of the profession and the mandates of physical therapy professional associations to promote health and wellness, including smoking cessation for both primary health benefit and to minimize secondary effects (e.g., delayed healing and recovery, and medical and surgical complications) Effectiveness of nursing-delivered Nurse-led smoking cessation smoking cessation interventions interventions significantly increased detail: 7 studies the likelihood of quitting. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Five studies of nurse counselling on smoking cessation during a screening health check, or as part of secondary prevention in general practice, found nursing intervention to have less effect under these conditions Effects of individual counsel ing The review looked at trials of counselling by a trained therapist Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
providing one or more face-to-face sessions, separate from medical care. All the trials involved sessions of more than 10 minutes, with most also including further telephone contact for support. Individual counsel ing is more effective than minimal behaviour interventions. There was no evidence of greater effect of intensive counsel ing compared to brief counselling Effects of motivational Results suggest that motivational interviewing in promoting smoking interviewing may assist smokers to quit. However, the results should be interpreted with caution due to variations in study quality, treatment fidelity and the possibility of publication or selective reporting Effectiveness of smoking-cessation These findings suggest that interventions by type of provider psychologists, physicians, and nurses will be more likely to successfully assist patients in smoking cessation than other healthcare providers or self-help materials. Effectiveness of innovations in There is little evidence to date to management of chronic disease support the widespread involving nurses for patients with implementation of nurse-led chronic obstructive pulmonary management interventions for disease (COPD)* (50) COPD, but the data are too sparse to exclude any clinical y relevant benefit * Note that this review is not specifical y or harm arising from such focused on tobacco-use cessation supports, however, lessons can be drawn from nurse- led interventions with COPD patients Providing additional Effectiveness of training healthcare Training health professionals to training, certification and/or professionals to deliver smoking- provide smoking-cessation Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
oversight of those providing cessation interventions to their interventions had a measurable effect ed the function in hospital patients, and to assess the on professional performance. There additional effects of prompts and was no strong evidence that it reminders to the health changed smoking behaviour. professional to intervene Developing or adapting Effectiveness of specific There is insufficient evidence to policies, procedures and care interventions for relapse support the use of any specific pathways (e.g., hospital prevention reduce the proportion behavioural intervention for helping formularies to include of recent quitters who return to smokers who have successful y quit required medication, medical smoking (69) for a short time to avoid relapse. The directives to support all verdict is strongest for interventions professional staff to focusing on identifying and resolving administer nicotine- tempting situations, as most studies replacement therapy) were concerned with these. Establishing indicators for No reviews were found successful tobacco-use- cessation, streamlined data col ection and feedback mechanism for hospital staff Implementing reminder Effects of computerized clinical The computerized clinical decision systems for hospital staff decision support systems on support systems improved practitioner performance and practitioner performance in patient outcomes (47) diagnostic systems, reminder systems, disease management systems, and drug-dosing or prescribing systems Effectiveness of clinic systems for Clinic systems designed to increase the assessment and documentation the assessment and documentation of tobacco-use status (35) of tobacco-use status increased the rate at which clinicians intervened with their patients who smoke. However, while such systems may increase rates of intervention, this does not necessarily produce significantly higher rates of smoking Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
Effectiveness of interventions in Of the 25 identified studies, 18 were increasing smoking cessation care in inpatient settings. Of the 10 provision in hospitals (46) control ed trials, four addressed Description states: cardiac patients, five measured one smoking cessation care practice, and nine implemented multistrategic interventions (e.g., combining educational meetings with reminders and written resources). Meta-analysis of control ed trials demonstrated a significant intervention effect for provision of assistance and counsel ing to quit, but not for assessment of smoking status, advice to quit, or the provision or discussion of nicotine-replacement Providing targeted funding Effect of changes in the method Three cluster-RCTs included in the and/or financial incentives and level of payment on the quality review investigated how financial of care provided by primary care incentives influenced physicians' physicians (PCPs) and to identify: propensity to deliver advice to their the different types of financial patients on smoking cessation, to incentives that have improved refer patients to smoking cessation quality; the characteristics of help lines, or patients' adherence to patient populations for whom evidence-based smoking cessation quality of care has been improved practice guidelines by financial incentives; and the characteristics of PCPs who have In the three studies examining responded to financial incentives smoking cessation, there were statistical y significant effects of financial incentives on PCP behaviours (referral rates and recording of smoking status) but not on measures of patients' smoking Establishing accountability Effects of publicly reported Evidence suggests that publicly within hospitals for this performance data on quality of releasing performance data stimulates Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
function (which could quality improvement activity at the include public reporting) hospital level. A synthesis of data from eight health plan-level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, al hospital- level, suggests stimulation of quality improvement activity Effectiveness of the public release One study found a smal positive of performance data in changing effect of the publishing of data on the behaviour of healthcare patient volumes for coronary bypass consumers, professionals and surgery and low-complication organizations (51) outliers for lumbar discectomy, but these effects did not persist longer than two months after each public release. One cluster-randomized control ed trial, conducted in Canada, studied improvement changes in care after the public release of performance data for patients with acute myocardial infarction and congestive heart failure. No effects for the composite process-of-care indicators for either condition were found, but there were some improvements in the individual process-of-care indicators Effectiveness of public reporting Reporting to the public is effective if 2007 on healthcare quality (52) the public has the information, understands the information, and uses the information in a manner that accomplished the objectives of the reporting program. There are a number of factors to take into consideration to develop an effective public reporting program: Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic review
Key findings
Proportion of
Proportion of
Proportion of
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
objective(s), audience, content, products, distribution and impacts (intended and unintended) Effects of computerized clinical The computerized clinical decision decision support systems on support systems improved practitioner performance and practitioner performance in patient outcomes (47) diagnostic systems, reminder systems, disease management systems, and drug-dosing or prescribing systems Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Appendix 3: Systematic reviews relevant to Element 3 – Ensuring follow-up counsel ing once tobacco users leave hospital to assist them in
remaining tobacco-free
Option element
Focus of systematic
Key findings
Proportion of
Proportion of
Proportion of
review/cost-effectiveness study
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
Providing documentation of Effectiveness of cellphones and Findings indicate that enhancing 2/9 (AMSTAR 0/25 and enhancing production text messaging interventions in standard care with reminders, detail: 4 studies and dissemination of improving health outcomes and disease monitoring and community-based resources processes of care (58) management, and education through cellphone voice and short message service can help improve setting is unclear health outcomes, and care processes have implications for both patients and providers Effectiveness of interventions for High intensity behavioral smoking cessation in hospitalized interventions that begin during a hospital stay and include at least one month of supportive contact after discharge promote smoking cessation among hospitalized patients. These interventions are effective regardless of the patient's admitting diagnosis. Interventions of lower intensity or shorter duration have not been shown to be effective in this setting. There is insufficient direct evidence to conclude that adding nicotine- replacement therapy or bupropion to intensive counsel ing increases cessation rates over what is achieved by counselling alone Effects of four behavioural Intensive behavioural interventions 2007 interventions, including minimal result in substantial increases in clinical intervention (brief advice smoking abstinence compared with from a healthcare worker), and intensive interventions, including individual, group, and telephone counselling (55) Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic
Key findings
Proportion of
Proportion of
Proportion of
review/cost-effectiveness study
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
such as pregnant diabetic patients, corresponding to various age, sex, status or ethnic Selecting options for the Effectiveness of advice by a health Evidence-based strategy to effect process (i.e., who does what professional and its components to smoking cessation that can be and in what order?) optimize smoking cessation exploited in physical therapy instituted in the context of physical practice. Further research to refine therapy practice (59) how best to assess smokers and, in turn, individualize brief smoking cessation advice could augment positive smoking cessation Effects of proactive telephone Proactive telephone counsel ing counselling for smoking cessation had a statistically significantly greater effect on point prevalence abstinence (non-smoking at fol ow- up or abstinent for at least 24 hours, seven days before follow- up) at six-to-nine months, but not at 12-to-15 months after Effects of peer support telephone This review provides some cal s in terms of physical, evidence that peer support psychological, and behavioural telephone cal s can be effective for health outcomes and other certain health-related concerns. However, the generalizability of findings is limited due to methodological limitations. Effectiveness of interventions by Trained community pharmacists, Evidence >> Insight >> Action Expanding the Uptake of Hospital-based Tobacco-use Cessation Supports Across Ontario Option element
Focus of systematic
Key findings
Proportion of
Proportion of
Proportion of
review/cost-effectiveness study
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
community pharmacy personnel to providing a counselling and record assist clients to stop smoking (71) keeping support program for their customers, may have a positive effect on smoking cessation rates. Effectiveness of community In the best designed trials, light to interventions for reducing the moderate smokers did slightly prevalence of smoking (73) better than heavy smokers (the US COMMIT study), and men did a little better than women (the Australian CART study), but overall smoking rates remained similar between intervention and control communities. Providing additional No reviews were found training, certification and/or oversight of those providing the function in community Establishing indicators for No reviews were found successful tobacco-use- cessation, data collection and feedback mechanisms for community-based organizations and physicians Implementing reminder Effects of computerized clinical The computerized clinical decision 2004 systems for community- decision support systems on support systems improved based organizations and practitioner performance and practitioner performance in patient outcomes (47) diagnostic systems, reminder systems, disease management systems, and drug-dosing or prescribing systems Providing targeted funding Effect of changes in the method The use of financial incentives to (e.g., nicotine-replacement and level of payment on the quality reward PCPs for improving the therapy, counselling fees) of care provided by primary care quality of primary healthcare and/or financial incentives physicians (PCPs) and to identify: services is growing. However, there the different types of financial is insufficient evidence to support Evidence >> Insight >> Action McMaster Health Forum Option element
Focus of systematic
Key findings
Proportion of
Proportion of
Proportion of
review/cost-effectiveness study
(quality)
studies that were
studies that
studies that
conducted in
deal explicitly
focused on
with one of the
prioritized
tobacco-use
groups of: 1)
cessation
hospitals; and
supports
2) patients.
incentives that have improved or not support the use of financial quality; the characteristics of incentives to improve the quality of patient populations for whom primary health care. quality of care has been improved Implementation should proceed by financial incentives; and the with caution and incentive schemes characteristics of PCPs who have should be more careful y designed responded to financial incentives before implementation. Effect of financial interventions on Financial interventions directed at patients and healthcare providers smokers found a statistically favourable effect of financial interventions on continuous abstinence compared with no interventions, and a significant effect of financial interventions when compared with no interventions on the number of participants making a quit attempt. Financial interventions included a cost comparison of ful , partial and no financial support and found costs per additional quitter ranging from $260 to $1453. There was a significant effect of financial interventions directed at healthcare providers in increasing the utilization of behavioural interventions for smoking Establishing accountability No reviews were found within community-based organizations and among community-based physicians for this function Evidence >> Insight >> Action

Source: http://mcmasterhealthforum.ca/docs/default-source/Product-Documents/evidence-briefs/tobacco-use-cessation-in-hospitals-in-ontario-eb.pdf?sfvrsn=2

Jn142000 1.7

The Journal of Nutrition. First published ahead of print December 21, 2011 as doi: 10.3945/jn.111.142000. The Journal of Nutrition Ingestive Behavior and Neurosciences Mild Dehydration Affects Mood in HealthyYoung Women1,2 Lawrence E. Armstrong,3 Matthew S. Ganio,3,4 Douglas J. Casa,3 Elaine C. Lee,3 Brendon P. McDermott,3,7Jennifer F. Klau,3 Liliana Jimenez,5 Laurent Le Bellego,5 Emmanuel Chevillotte,5and Harris R. Lieberman6*

lesteragency.free.fr

Rights List SPRING 2016 TABLE OF CONTENTS Mariages de saison A travers ciel Jean-Philippe Blondel . 5 Jean-Luc Cattacin .13 Le dernier colonel Colombe Boncenne . 6 Jean Lods .14 L'Ombre de nos nuits Deux jours de vertige