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Dartmouth Medical School Dartmouth-Hitchcock Medical Center

Vital Signs

Ashes, ashes . . . cessation counseling rises

By Geoffrey Holman

John Butterly, far left, and Steven Liu, fourth from the left, were among the DHMC staff members participating in this early meeting of the Tobacco Treatment Team.

A few years ago, DHMC wasn't making the grade when it came to helping patients stop smoking. In 2004 and 2005, for example, only 39% of patients who smoked and had been hospitalized for heart failure (a condition exacerbated by smoking) received counseling and support to help them quit.

The situation is very different today, thanks to an effort spearheaded by Dr. John Butterly, Dartmouth-Hitchcock's executive vice president of medical affairs. Smoking cessation counseling is now a routine part of care for all hospitalized patients—and 96% of smokers hospitalized for heart failure receive cessation counseling.

Cues: "A hospitalization represents a 'teachable moment,' " wrote Butterly, DHMC hospitalist Dr. Stephen Liu, and others in a September 2010 paper published in the Journal of Cancer Education. "Admission to a hospital removes smokers from daily cues associated with smoking" and provides easy access to counseling and medications that can help them quit.

The first steps in that direction began in late 2005, with the formation of a tobacco improvement group led by Butterly. Soon after, Liu led an effort to partner with the New Hampshire Department of Health and Human Services to train 150 clinicians from seven inpatient units in tobacco cessation counseling. But the group quickly realized that most doctors and nurses did not have time in their already hectic schedules to provide the intensive counseling that was necessary. So they recruited about 50 frontline caregivers who were eager to help, including physical therapists, social workers, and some nurses and doctors. That group underwent further training and became known as the Tobacco Treatment Team (TTT). The effect was immediate.

After the implementation of the TTT, the documentation in patients' medical records of tobacco use and of cessation counseling rose steadily—from 1% of patients in January 2006 to 85% in December 2009.

More importantly, the rates of tobacco cessation counseling improved for patients admitted with several conditions aggravated by smoking. Not only did the rate for heart-failure patients rise from 39% to 96%, but for patients admitted with pneumonia the rate improved from 52% to 82%. And although patients diagnosed with a heart attack had already been receiving counseling at a high rate of 93% in 2006, even that rate improved to 98% by 2009.

Better: In recent years, both the federal agency that administers Medicaid and Medicare and the national organization that accredits hospitals have been pressuring health-care providers to do a better job at combating tobacco use, explains nurse Ellen Prior, DH's tobacco treatment coordinator.

In addition to helping inpatients kick the habit, Butterly's group has also focused on employees and visitors. DHMC became a smoke-free/tobacco-free campus—outside as well as inside—in 2008 and since then has been helping other hospitals and businesses in the region do the same.

The counseling rate for heart-failure patients rose from 39% to 96%.

Now, visitors to DHMC who are 18 or over and not pregnant can obtain free nicotine lozenges from nurses to help them abstain from smoking while they're at the Medical Center. Dartmouth-Hitchcock also offers free, twice-a-week, one-on-one tobacco dependence counseling and treatment clinics in its Health Education Center. And for employees, DHMC provides free one-on-one counseling, a monthly support group for those who've quit, and full coverage for tobacco cessation medications.

The progress is encouraging, but the process hasn't been easy. Patients and visitors will often try to find places where they can smoke unnoticed, says Prior, and can be very resistant when reminded—even politely—about the no-tobacco policy.

Quit: Inpatients, too, sometimes respond negatively to being asking about tobacco. Some don't appreciate being "nagged" about quitting, says Butterly. When TTT team members encounter such reactions, they note the individual's wishes and move on so they don't waste precious resources on patients with no desire to quit.

Though DH has come a long way in encouraging patients, visitors, and staff to stop using tobacco, it's unclear how many have actually quit as a result. Prior and Butterly hope that sort of assessment can be done soon.

Smoking is an addiction and a chronic condition, says Prior, and "requires constant intervention." So she, Butterly, and others plan to keep working on tobacco cessation for years to come.

Attention: "As long as smoking is legal," concludes Butterly, "I don't think you can ever take your attention away from it."


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