1. Describe your topic

Tobacco treatment interventions are often referred to as the ‘gold standard’ of healthcare cost effectiveness because they achieve more life-years gained for fewer resources than other interventions. There are several effective, guideline-recommended tobacco cessation treatments, including in-person behavioral counseling, telephone quitlines, nicotine replacement therapy, and prescription pharmacotherapies. Yet, treatments have shown disappointing impact due to limited reach, variable treatment fidelity and other dissemination and implementation challenges. Thus, there is a clear need to optimize both interventions and delivery strategies that enhance the effectiveness and reach of tobacco treatment interventions.

Hospitalization offers an opportunity to engage smokers who may not spontaneously seek tobacco treatment. It serves as a “teachable moment” of cognitive focus and emotional arousal, when smokers may be acutely aware of the consequences of smoking and thus, more receptive to tobacco treatment interventions. Hospital-based interventions, particularly when pharmacotherapy is provided with counseling and post-discharge support, are highly effective in increasing motivation for quit attempts and rates of smoking cessation.

Recognizing this opportunity, in 2012, the Joint Commission recommended global (population) tobacco quality standards that would address all hospitalized smokers regardless of diagnosis and clinical condition. These recommendations are evidence-based and consistent with the 2008 United States Public Health Service Guideline, Treating Tobacco use and Dependence and have been pilot tested in a range of hospital settings [24 hospitals from 19 states; ranging in size from 15 to 900 beds; 8 were Veterans Administration (VA) Hospitals; 7 hospitals used electronic health records (EHR) and seven used paper medical records; the remainder used a combination of electronic and paper records].

The Joint Commission’s reporting measures for tobacco quality standards include:

• Tob-1: Tobacco Use Screening among Inpatients (retired measure 2019)
• Tob-2: Tobacco Use Treatment, Counseling & Medication during Hospitalization
• Tob-3: Tobacco Use Treatment Management at Discharge
• Tob-4: One-Month Follow-Up Assessing Treatment Use/Cessation (retired measure 2018) (from: https://www.jointcommission.org/assets/1/18/5_Joint_Commission_Measures_Effective_January_1_2019.pdf)

Most studies have reported an increase in long-term quit rates with hospital-based tobacco treatment services consistent with Joint Commission’s standards (Tob-2 and Tob-3). However, understanding how to effectively translate this evidence into real-world clinical practice represents a host of challenges. Difficulty exists in adopting inpatient tobacco treatment and post-discharge interventions given limited resources, time, and expertise in the majority of real-world settings. Few hospitals have fully implemented the Joint Commission quality standards.

Relevant References

1. U.S. Cancer Statistics Working Group, United States Cancer Statistics: 1999-2013 Incidence and Mortality Web-based Report. 2016, Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute: Atlanta (GA). http://www.cdc.gov/uscs.
2. Jamal, A., et al., Current Cigarette Smoking Among Adults - United States, 2005-2015. MMWR Morb Mortal Wkly Rep, 2016. 65(44): p. 1205-1211.
3. Vidrine, I.J., et al The role of tobacco in cancer health disparities. Curr Oncol Rep, 2009. 11(6): p. 475-81.
4. Danaei, G., et al., The promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States. PLoS Med, 2010. 7(3): p. e1000248.
5. Delva, J., et al., Cigarette smoking among low-income African Americans: a serious public health problem. Am J Prev Med, 2005. 29(3): p. 218-20.
6. Cokkinides, V.E., et al., Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey. Am J Prev Med, 2008. 34(5): p. 404-12.
7. 2008 PHS Guideline Update Panel, L.a., and Staff, Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care, 2008. 53 (9): p. 1217-22.
8. Anthenelli, R.M., et al., Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double- blind, randomised, placebo-controlled clinical trial. Lancet, 2016. 387(10037): p. 2507-20.
9. Rigotti, N.A., et al., Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev, 2012(5): p. CD001837.
10. The Joint Commission. Tobacco treatment measure set. 2012 http://www.jointcommission.org/tobacco_treatment/.
11. Fiore, M.C. and R. Adsit, Will Hospitals Finally "Do the Right Thing"? Providing Evidence- Based Tobacco Dependence Treatments to Hospitalized Patients Who Smoke. Jt Comm J Qual Patient Saf, 2016. 42(5): p. 207-8.
12. Leone, F.T., et al., An Official American Thoracic Society Research Statement: Current Understanding and Future Research Needs in Tobacco Control and Treatment. Am J Respir Crit Care Med, 2015. 192(3): p. e22-41.
13. Fiore, M.C., E. Goplerud, and S.A. Schroeder, The Joint Commission's new tobacco-cessation measures--will hospitals do the right thing? N Engl J Med, 2012. 366(13): p. 1172-4.

Please provide the following information about your topic suggestion:

Question 1:

• What is the issue or question? 
  • Among hospitalized patients receiving inpatient treatment for tobacco dependence, is extending treatment for 1-month post-discharge more effective at promoting abstinence than inpatient treatment alone?                        
• Identify the population of interest, including details such as age range, gender, coexisting diagnoses, and reasons for therapy.
  • Hospitalized patients who are current users of tobacco (stratify by severity of tobacco dependence if data allows)
• Identify the interventions (treatments, tests, or strategies) that you want to know more about, and what are the appropriate comparisons.
  • Intervention: Inpatient tobacco treatment + 1 month post-discharge treatment
  • Comparator: inpatient tobacco treatment alone
• Identify the important outcomes (health related benefits and harms) in which you are interested, such as improvements in symptoms or problems with diagnosis.
  • Smoking abstinence, and tobacco use relapse rates following treatment.

Question 2:

• What is the issue or question? 
  • For hospitalized patients who smoke cigarettes, is varenicline more effective at promoting abstinence than nicotine replacement therapy?
• Identify the population of interest, including details such as age range, gender, coexisting diagnoses, and reasons for therapy.
  • Hospitalized patients who are current users of tobacco.
• Identify the interventions (treatments, tests, or strategies) that you want to know more about, and what are the appropriate comparisons.
  • Intervention: Varenicline
  • Comparator: nicotine replacement therapy
• Identify the important outcomes (health related benefits and harms) in which you are interested, such as improvements in symptoms or problems with diagnosis.
  • Smoking abstinence, nicotine withdrawal symptoms, and tobacco use relapse rates following treatment, adverse events

Question 3:

• What is the issue or question? 
  • For vulnerable patient populations [serious mental illness (SMI), low SES, and/or substance use disorders (SUD)] with co-morbid tobacco dependence, are enhanced strategies more effective at (1) facilitating uptake of evidence-based tobacco treatment during hospitalization inpatient and at discharge and (2) promoting abstinence compared to minimal standard inpatient tobacco treatment alone?
• Identify the population of interest, including details such as age range, gender, coexisting diagnoses, and reasons for therapy.
  • SMI/low SES/SUD patients with co-morbid tobacco dependence.
• Identify the interventions (treatments, tests, or strategies) that you want to know more about, and what are the appropriate comparisons.
  • Intervention: Minimal standard inpatient tobacco treatment* + enhanced strategies**
  • Comparator: Minimal standard inpatient tobacco treatment alone
  • *Minimal standard inpatient tobacco treatment: (1) NRT (nicotine replacement therapy) patch for management of acute nicotine withdrawal while hospitalized and advice to quit and (2) offering NRT and referral to state quitline at hospital discharge
  • **Enhanced strategies: (1) Minimal standard inpatient tobacco treatment + (2) inpatient tobacco treatment counseling OR (3) interactive voice recognition at discharge OR other modality
• Identify the important outcomes (health related benefits and harms) in which you are interested, such as improvements in symptoms or problems with diagnosis.
  • Treatment engagement following hospital discharge, smoking abstinence, and tobacco use relapse rates following treatment, increase or decrease in other substance use, change in tobacco use

Question 4:

• What is the issue or question? 
• How effective are performance-based payment strategies (e.g. pay-for-performance, accountable care organizations, and bundled payment) in meeting hospital-based tobacco treatment quality standards?
• Identify the population of interest, including details such as age range, gender, coexisting diagnoses, and reasons for therapy.
• Hospitalized patients who are current users of tobacco and/or hospital programs.
• Identify the interventions (treatments, tests, or strategies) that you want to know more about, and what are the appropriate comparisons.
• Intervention: Payment strategies
• Comparator: no payment strategies
• Identify the important outcomes (health related benefits and harms) in which you are interested, such as improvements in symptoms or problems with diagnosis.
• Delivery of tobacco treatment, meeting Joint Commission tobacco quality standards for hospitals, cost savings, effect on disparity
• Importance of Suggested Topic

2. Describe why this topic is important

Cigarette smoking is the leading cause of preventable death in the US, yet nearly 36.5 million Americans continue to smoke cigarettes. Smoking prevalence is inversely correlated with socioeconomic status (SES), and is more than twice the national average among the lowest income individuals. There are extraordinarily high smoking rates among certain populations admitted to the hospital, such as those with HIV, psychiatric and/or substance use disorders.

3. Tell us why you are suggesting this topic

The Department of Health and Human Services (DHHS) 2008 update on Clinical Practice Guidelines for Treating Tobacco Use and Dependence recommends that clinicians use hospitalization as an opportunity to promote tobacco treatment and to prescribe medications to alleviate withdrawal symptoms. Joint Commission, which sets quality standards for hospitals in the United States, recommended global (population) tobacco performance measures that would address all hospitalized smokers regardless of diagnosis and clinical condition. Despite evidence generally supporting the benefits of providing tobacco treatment services to hospitalized patients, few hospitals have fully implemented the Joint Commission quality standards.

With the Affordable Care Act (ACA) placing greater focus on prevention in healthcare, Medicaid coverage mandates, and other legislative and regulatory requirements (Meaningful Use requirements and Joint Commission Hospital Tobacco Cessation measures), there is a great opportunity to engage healthcare providers and systems in tobacco control efforts in the hospital setting.

The policy changes represented by the ACA and the Joint Commission Tobacco Cessation Measure Set, in combination with the increase in experience in treating smokers who are hospitalized, makes this is an opportune time to provide guidance on how to implement the most efficient and effective ways to treat hospitalized patients who smoke.

While studies have shown that tobacco treatment services can be effectively integrated into hospital workflows, adoption is low. There is considerable variability and controversies that could be resolved by development of an evidence report as detailed below:

Despite evidence supporting the benefits of providing tobacco treatment services to hospitalized patients, few hospitals have fully implemented the Joint Commission quality standards.

Most hospitals lack a common, feasible, cost-effective and sustainable approach to delivering tobacco treatment interventions.

Evidence-based tobacco treatment is not consistently provided to patients who are hospitalized.

There is the low proportion of smokers who complete all components of the originally recommended Joint Commission Tobacco Cessation Performance Measure Set.

Given limited resources, there is controversy on whether to focus tobacco treatment services to all smokers versus focusing on selected patient populations (e.g., motivated patients; patients willing to set a quit).

The goal of this evidence review and subsequent clinical practice guideline is to provide guidance to healthcare systems on implementing tobacco treatment strategies to hospitalized smokers that meet both national guideline recommendations and quality standards, support clinicians in these efforts, and most importantly improve patient care.

Target date

Month 

Day 

Year  

Tell us if you have a target date for answering your question and whether you are under a specific timeline.

Impact of a New Evidence Report

4. Describe what you are doing currently and what you are hoping will change because of a new evidence report.

As described above, there is still considerable variability in providing tobacco treatment services that could be resolved by the development of an evidence report, and subsequent clinical practice guideline:

Despite evidence supporting the benefits of providing tobacco treatment services to hospitalized patients, few hospitals have fully implemented the Joint Commission quality standards.

Most hospitals lack a common, feasible, cost-effective and sustainable approach to delivering tobacco treatment interventions.

Evidence-based tobacco treatment is not consistently provided to patients who are hospitalized.

There is the low proportion of smokers who complete all components of the originally recommended Joint Commission Tobacco Cessation Performance Measure Set.

Given limited resources, there is controversy on whether to focus tobacco treatment services to all smokers versus focusing on selected patient populations (e.g., motivated patients; patients willing to set a quit).

5. How will you or your group use the information from a new evidence report?

Systematic evidence reviews form the basis of all CHEST clinical practice guidelines.  If this topic is selected for an AHRQ review, the results of the review will directly inform a guideline that establishes the minimum standard of support for tobacco users across hospitals. This guideline will provide guidance on how to place the necessary systems and policies in place to encourage and enable consistent and effective support to hospitalized tobacco users.

6. How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?

The findings of the report will be disseminated in various ways: 1) Communication to CHEST membership (over 19,000 members) via electronic (i.e, eNews alerts), print (i.e., CHEST Physician Newsletter) and social media.  There will be several opportunities to inform providers about the report through our eLearning and Live Learning platforms, including the CHEST Annual Meeting.  We also intend to present results at other scientific forums high visibility to clinicians and stakeholders. We will present, as relevant, to the American Thoracic Society (ATS), the Society for Research on Nicotine and Tobacco (SRNT), Free to Breathe, a patient advocacy organization for lung cancer, American College Physicians (ACP), American Cancer Society (ACS), and the American Association for Cancer Research (AACR).  We also plan to aggressively market the resulting guideline and resources in both academic forums and to the larger audience of hospitalized smokers and their clinicians.

Other Stakeholders Who Could Use a New Evidence Report

The EHC Program appreciates opportunities to collaborate with other organizations that can use or implement evidence report findings, whether through practice guidelines, decision support, education, policies, or new research.

Example types of organizations include: patient advocacy organizations, clinical professional societies, health care organizations, and Federal, State, or local agencies.

7. Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?

CHEST serves at the primary organization that will directly use this evidence report to develop a clinical practice guideline on this topic.  However, we intend to collaborate with organizations that could also benefit from the use of this evidence report, including: the American Thoracic Society, Free to Breathe, The American College of Physicians, the American Cancer Society, the Association for the Treatment of Tobacco Use and Dependence, Society for Research on Nicotine and Tobacco, and the American Association for Cancer Research

8. Would you be willing to partner with another organization to develop policy, program, guidelines, or dissemination and implementation materials? This information is for internal discussion only and will not be displayed on the EHC Program Web site.

Yes, CHEST has a strong history of collaboration in the development of guidelines, educational programming, and dissemination & implementation tools.

Information About You

To help us understand the context of your topic suggestion, it would be helpful to know more about you. The answers you give will not influence the progress of your suggestion.

Provide a description of your role or perspective

e.g., patient/consumer, physician, professional society, administrator

The American College of Chest Physicians (CHEST) is a professional society, and is the global leader in advancing best patient outcomes through innovative chest medicine education, clinical research, and team-based care. With more than 19,000 members representing 100+ countries around the world, our mission is to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research. This includes connecting health-care professionals to the latest clinical research and a wide array of evidence- based guidelines through the CHEST Journal, while also serving as a total education resource for clinicians through year-round meetings, books, mobile apps, and live courses in pulmonary, critical care, and sleep medicine.

If you are you making a suggestion on behalf of an organization, please state the name of the organization

The American College of Chest Physicians (CHEST)

Please tell us how you heard about the Effective Health Care Program

CHEST has collaborated with AHRQ in the past on evidence reviews, most recently the Venous Thromboembolism Prophylaxis in Orthopedic Surgery Update.