Health Articles
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.
Product registration numbers
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.
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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;
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• 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
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(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
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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)
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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
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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
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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
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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
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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
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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
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*
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