Health risks associated with tobacco consumption are well documented. At the beginning of the 21st century, tobacco consumption continues to be the single most important cause of preventable morbidity and mortality in Spain.1 Health professionals should be an example in tobacco control initiatives, playing an active role in curbing the epidemic. However, health professionals’ smoking is itself often a barrier for their participation in tobacco control.2,3 It is well known that health professionals who smoke are less likely to intervene and encourage their patients to quit smoking.4,5 Thus, health professionals are among the first targets for tobacco control.6
The World Health Organization emphasizes the value of a nonsmoking hospital staff and a smoke-free hospital environment and recommends conducting programs to help health workers quit to increase their participation in tobacco control.7 Smoking bans in hospitals encourage smoking cessation and should be considered in the list of strategies to reduce and prevent smoking among health professionals.8 Progressive implementations of tobacco control policies help to increase the readiness to quit, yet by hospitals workers, but have actually a small impact in decreasing their tobacco consumption.9–11 Workplace tobacco cessation programs (TCPs) have been associated with several advantages such as helping to reach a great number of smokers, providing peer group support for those remaining in tobacco abstinence, and assisting young healthy adults.12–14 However, few studies report comprehensive tobacco cessation strategies to help hospital workers to quit smoking.15,16 Furthermore, to our knowledge, there are no previous studies about TCPs at hospital level coordinated at a regional or national level.
This article describes the design, implementation, and effectiveness of a regional TCP addressed to hospitals workers, coordinated by the Catalan Network of Smoke-free Hospitals in Catalonia, Spain.
Materials and Methods
The Catalan Network of Smoke-free Hospitals is a public initiative that promotes the implementation of tobacco control policies by applying the European Network of Smoke-free Hospitals’ (ENSH’s) guidelines in the hospitals serving the National Health System in Catalonia, Spain. The Catalan Network promotes a “smoke-free hospital” based on organizational and cultural changes.11,17 This project requires the commitment of the organization to adopting the European Code and Standards of the ENSH project (www.ensh.eu). In each hospital, a smoke-free policy-working group composed of managerial and key professionals within the institution is created. This working group is responsible for the design, scaling down, communication, monitoring, streamlining, and evaluation of the hospital’s tobacco control policy. The working group communicates the new policies to the rest of the staff members, patients, and community. The network helps working groups provide common tools for implementation and evaluation and promotes sharing of experiences.17
In the process of becoming a smoke-free hospital, the network guides each institution by providing expert counseling and support. Once the hospital achieves the basic standards—commitment, communication, and tobacco control11—it should go further and offer TCPs. In this regard, the Network Coordinator Center provides a set of strategies to implement policies in hospitals such as (1) education and training in tobacco cessation18 and (2) a common smoking cessation program that targets health professionals in a first phase and patients in a second phase. These active policies and the evaluation activities are funded by the Catalan government since the year 2005.
Since its beginnings in 1999, a total of 50 of the 61 public hospitals had decided to join the Network up to December 2007. Thirty-three hospitals offered the TCPs for workers, and 15, for hospitalized patients.
The Tobacco Cessation Program
Tobacco cessation program is a comprehensive program to promote, monitor, and evaluate tobacco cessation interventions in the smoke-free hospitals. The Catalan Network provides hospitals with the resources needed to implement TCPs, such as education, tobacco therapy, and a Web-based software. The Web-based software is managed through the Internet and aimed to register, monitor, and control the inventions of the program in each hospital, facilitating the centralized collection and management of data.
Hospitals interested in implementing the TCP are asked a detailed proposal with the implementation process, available resources, flow paths, and available personnel. The feasibility of the program according to these resources is studied beforehand by the coordination of the network.
Once the program is approved, health professionals of each center are trained on both tobacco cessation interventions and in the managing of the software. Afterwards, the educational material such as motivational cessation leaflets and free pharmacological treatments, which includes nicotine replacement therapy (NRT) and bupropion, is distributed.
The project coordinator in each hospital is responsible to inform hospital workers about the intervention using flyers, e-mail, and other available local resources (ie, hospital’s intranet), which included information such as the contact number and hours of the therapies in each hospital. The intervention is run by specialists of each center, specially trained on cessation, with individual or group approach with a minimum of 6 months of follow-up. Each hospital is responsible for ensuring the confidentiality of their patients and issuing a follow-up appointment.
Because the TCP was incorporated as usual practice in each hospital and it involved the use of common nonexperimental treatments, no ethical approval by the Research and Ethics Committee was needed.
Participants and Assessment
The employees who wanted to quit smoking and agreed to participate in the program were registered on the TCP database. Verbal and written information about the characteristics of the electronic data record was provided to all the participants. The inclusion criteria for the participants were the following: daily or occasional smoker, hospital worker of any of the hospitals that offered the cessation intervention, and agree with having 6 months of follow-up after the quitting day. Among the exclusion criteria, we included participants who did not want to be followed during this period and refused to be included in the study. The initial assessment included questions on demographics such as date of birth, gender, profession, ward or working area, detailed history of smoking including current and past consumption, age at initiation, number of cigarettes smoked, nicotine dependence,19,20 and expired-air carbon monoxide (CO) concentrations as an optional information. Additional information included the desire and confidence in quitting, personal and social resources, and a list of personal advantages and disadvantages about smoking. Once the diagnostic was done, the cessation plan was arranged with the hospital worker with a minimum follow-up of 6 months. The follow-up consisted of a minimum assessment of abstinence after the first, third, and the sixth months after the day of quitting. The follow-up data included the number of abstinence days and the registration of relapse or lapse episodes. Moreover, other data such as the withdrawal symptoms and clinical observations were included. Finally, we registered the kind and quantity of treatment dispensed by visit, which may include nicotine replacement in the form of patch, lozenge and/or gum, and bupropion. The treatment dispensed to each smoker enrolled in the program was free of charge.
Main Outcome and Independent Variables
The main outcome variable was duration of sustained abstinence. We considered quitting smoking as continued abstinence during a 6-month period. Thus, participants were considered to have relapsed if they smoked on 1 or more days.21 The time of relapse was calculated as the number of days from the quit date to the date of the relapse. Those patients who relapsed immediately after the intervention (n = 259) were included in the analysis and were assigned a 1-day time to relapse.
The main independent variables were gender, age, years of consumption, profession, dependence measured by the Fagerström Test Nicotine Dependence (FTND), and pharmacological treatment. The age variable was transformed in 3 categories according to approximate tertiles (<35, 35–44, and ≥45 years). Profession was classified as physicians, nurses, and other hospital workers (ie, technicians, administrative staff, support staff). Age of initiation was categorized as younger than 16, 16 to 18, and 19 years or older. Years of consumption were categorized as below 15, 15 to 24, and 25 years or more. We also aggregated the number of cigarettes consumed daily as less than 10, 10 to 20, and more than 20. The FTND scores were classified as low (0–3), moderate (4–6), and high addiction (7–10). Finally, pharmacological treatment was registered into 4 categories: no treatment, NRT (including nicotine gums, lozenges, and/or paths), bupropion, and combined (NRT and bupropion).
We used the Kaplan-Meier method to estimate cumulative abstinence (probability of continued abstinence) and 95% confidence intervals (CI) at 6 months of follow-up by all the independent variables. In addition, we performed separate analysis by gender and age. Afterwards, we adjusted Cox regression models to estimate the relative risk (estimated as hazard rate [HR] ratios with 95% CI) for relapse at the end of follow-up to assess the independent contribution of each variable. We first assessed the crude HR of relapse, and afterwards, we fitted adjusted models for gender, age, and the rest of variables to investigate potential confounding. We finally chose the model adjusted for all variables. We checked the proportionality of the hazards during the follow-up. We used SPSS version 14 (SPSS Inc, Chicago, Illinois) for all the analyses.
Description of the Participants Enrolled in the TCP
A total of 1087 hospital workers who smoked were included in the TCP among the 33 hospitals. We considered the subjects recruited from July 2005 to December 2007 with at least 6 months of follow-up in the program. From these, 157 (14.4%) were excluded because the quit day was missing. Therefore, 930 subjects were finally analyzed.
Table 1 shows the characteristics of the participants by demographic characteristics, tobacco consumption profile, and pharmacological treatment received. The workers were mainly women (71.3%) and were equally distributed among the 3 age groups. By profession, 28.1% were nurses, 10.2% were physicians, 15.4% were administrative employees, and 46.3% were other professionals (ie, statisticians, technical assistants, physics, informatics, and others).
Most workers enrolled in our program were heavy and long-time smokers: 64.0% of them smoked 20 cigarettes or more per day, 46.2% smoked for 25 years or longer (see Table 1), and 26.9% reported having a high dependence to tobacco according to the FTND. Close to 58% of the smokers had made 1 or 2 previous quit attempts, and 21.7% of them made 3 or more attempts. Most of the smokers (83.4%) expressed being ready to make a plan to quit (preparation stage). From the different tobacco cessation treatments, NRT was the most used (51.9%). Bupropion therapy was used for 10.0% of the subjects, and 6.2% used both (NTR and bupropion). About 31.9% of the smokers did not use any kind of drug to quit (Table 1).
Smoking Abstinence and Predictors
The overall median of abstinence was 46.1 days. At the end of the 6-month follow-up, 62 men (of 267) and 138 women (of 663) were abstinent. Table 2 shows continuous smoking abstinence at 6 months and its predictors. Overall abstinence probability was 0.504 (95% CI = 0.431–0.570) at 6 months. The abstinence rate was slightly higher in men (0.526, 95% CI = 0.398–0.651) than in women (0.495, 95% CI = 0.410–0.581) although it was not statistically significant (P = 0.198). Less nicotine-dependent participants (FTND ≤ 6) were more likely to remain abstinent (0.529, 95% CI = 0.458–0.599; P = .022). In addition, workers treated with combined treatment (NRT and bupropion) obtained a higher abstinence probability (0.761, 95% CI = 0.588–0.933) than did workers following other treatments (no drug, NRT, or bupropion). The Figure shows the Kaplan-Meier curves with the probability of abstinence by gender, profession, nicotine dependence, and treatment.
To assess gender differences, we separately computed the probabilities of abstinence by gender (Table 3). Among physicians, no differences in the probability of abstinence were found. Male nurses (0.662, 95% CI = 0.467–0.856) had a higher nonsignificant probability of remaining abstinent than female nurses (0.425, 95% CI = 0.299–0.550). In addition, according to the overall FNTD score, men obtained a similar probability of abstinence regardless of their nicotine dependence, whereas women with lower FTND had a higher probability of abstinence than those with higher nicotine dependence (Table 3).
We examined the abstinence probabilities by age (Table 4). We found a similar probability of abstinence in the 3 age groups considered, except when profession was taken into account. Physicians between 35 and 44 years had the highest probability of abstinence (0.808, 95% CI = 0.568–1.041), which was 2-fold that of nurses in the same age group (0.404, 95% CI = 0.174–0.633).
Finally, we investigated the risk of relapsing adjusting for all the independent variables (Table 5). Consistent with the previous analysis, we found that women had significantly higher risk of relapse than men (HR = 1.44, 95% CI = 1.02–2.04). In addition, as compared to physicians, the other professional group had a nonsignificant increased risk of relapsing (HR = 1.55; 95% CI, 0.86–2.80). Furthermore, risk of relapsing increased for participants who consumed more cigarettes per day and had a higher level of dependence according (Table 5). As compared to participants not using pharmaceutical treatment, smokers treated with both drugs had a significant lower risk of relapsing (HR = 0.37, 95% CI = 0.16–0.87).
The present study found that smoker hospital workers treated in the framework of a TCP presented a high probability of remaining abstinent after 6 months of follow-up. Workers with a lower physical dependence were more likely to remain abstinent and those treated with combined (NRT and bupropion) obtained the highest abstinence probability at 6 months of follow-up.
There are 2 main reasons that might explain the observed differences in tobacco cessation in our study. On the one hand, nicotine dependence is a strong determinant of success in quitting.22,23 On the other hand, the efficacy differences among the pharmacological aids could determine the success. According to the last 3 meta-analyses about drug therapy for smoking cessation, varenicline, bupropion, and NRT were more helpful than placebo.24–26 In addition, all forms of NRT increased the chances of quitting smoking by 50% to 70% after at least 6 months of follow-up (patch: odds ratio [OR] = 1.81, 95% CI = 1.63–2.02; gum: 1.66, 95% CI = 1.52–1.81).26 Furthermore, evidence on the effect of combined treatment has been recently proved.27,28 Nevertheless, there are few studies evaluating the effectiveness of pharmacological treatments in large populations outside the clinical trial context. Among those, data from the California Tobacco Survey showed that NRT, bupropion, or both, in association with smoke-free home polices, increased the abstinence in smokers of 15 or more cigarettes per day.29 Unfortunately, we did not collect contextual data on smoking by others (relatives, friends) at the participants’ homes.
By gender, we observed a statistically significant difference in the risk of relapsing among women compared with men. By professional group, although the tendency of relapsing is higher for nurses and other professionals in comparison to physicians, we did not obtain statistically significant results. However, previous studies backed up the existence of marked differences among both characteristics after conducting TCPs.16,30–33
In the present study, the hospital workers treated in this TCP obtained higher probability of remaining abstinent than in other programs. Healthcare cessation programs generally report quit rates of 13% to 30% at 6 to 12 months,34,35 indicating an important variability of success depending on the treatment and approach applied. We presume that the high levels of abstinence in our study can be explained by the own characteristics of the program. First is by the array of advantages of workplace programs, such as (1) provision of access to a large number of healthy people, (2) boost in participation, (3) encouragement of sustained peer group support, and (4) proximity of the treatment.12 Second is the free cost of the pharmacology for all the workers during the follow-up period. And third, the exclusion of the lost participants might select the most motivated participants, and in consequence, boosting the smoking abstinence levels up.
As suggested by World Health Organization, health professionals should be leaders in promoting tobacco control activities.7 To decrease the harms of tobacco in our society, improved interventions headed by healthcare professionals are needed.36 Our data show that a coordinated TCP maintained by a regional network of smoke-free hospitals is feasible and effective in decreasing tobacco cessation in health organizations. Many studies have reported on tobacco prevalence rates, attitudes, and behaviors among health professionals in Spain.10,37–40 However, to our knowledge, no previous coordinated national or regional TCPs addressed to health workers have been implemented and evaluated. There are some experiences in other countries. For example, in Japan, a coordinated national TCP has proved that low-intense interventions to health workers are effective.41 Moreover, Denmark has demonstrated in a national TCP that common database helps to report the efficiency and cost-effectiveness of these interventions.42 The regional strategy adopted in Catalonia helps to motivate hospital managers and project coordinators not only to implement cessation programs but also to be active in implementing common tobacco control strategies. For instance, since starting the TCP for hospital staff, 15 of the 33 hospital participants have also offered a similar cessation program for patients during their hospital stay.
Some limitations of the present study deserve attention. First, we evaluated the effectiveness of a multicenter coordinated program in 33 hospitals, which share a standard protocol, some educational materials, and the same software. However, small differences in the way of scaling down the protocol interventions are possible because of heterogeneity across hospitals. The purpose of this project was to foster hospitals to set up TCPs to help their workers to quit smoking and to evaluate the usefulness of this experience. They counted with some external aid to help them fit the program to the particular characteristics of each hospital. Second, the follow-up was restricted to a 6-month period. As stated by some tobacco cessation guidelines, 1-year follow-up and the use of expired-air CO levels are fundamental to evaluate the effectiveness of such programs.43 However, as mentioned, our program limited by design the follow-up period to 6 months, and we did not collect CO levels because not all the hospitals had coximeters. Third, 259 individuals dropped out after the first visit, so we do not have data for them, and we assumed that they relapsed immediately after the first visit. This is a very conservative scenario, and hence, it is likely that the actual cessation rates would be higher than that computed.
It is, however, worth mentioning some of the strengths of this program. Nearly 1000 hospital workers have benefited from this free resource to quit smoking in their workplace. The common protocol and software used, which facilitated the follow-up, have helped to jointly evaluate the cessation program.
In conclusion, this TCP is effective in helping hospital workers to quit, highlighting 3 useful considerations for future programs: first, the increased difficulty in quitting among smokers who present high nicotine dependence or have a long history of consumption; second, differences in abstinence rates by gender and profession, pointing out the susceptible vulnerability of some groups such as female nurses; and last, the high abstinence rates obtained by use of combined therapies.
The authors would like to thank the 33 Project Coordinators of the Tobacco Cessation Program (TCP) and their teammates for implementing and tracking the program. We also want to express our gratitude to Dena Bushman for her careful revision of the article.
The TCP project coordinators are Anna Riccobene, ICO-Duran i Reynals (L’Hospitalet del Llobregat); Sebastiana Quesada, Hospital Clínic (Barcelona); Francesc Fibla and Olga Nieto, Hospital San Joan de De`u (Espluges de Llobregat); Ruth Ripoll, Hospital de L’Hospitalet (L’Hospitalet del Llobregat); Ricard Badosa, Coorporació Maresme i la Selva (Calella); Esther Barbe`, Hospital Arnau de Vilanova (Lleida); Teresa Catalán, Hospital Verge de la Cinta (Tortosa); Susana Sabaté, Pius Hospital (Valls); Jordi Bugés, Hospital de L’Esperit Sant (Santa Coloma de Gramanet); Jaume Ravantós, IMAS-Hospital del Mar (Barcelona); Antónia Raich, Fundació Althaia Xarxa Sanitària (Manresa); Irma Casas, Hospital Germans Trias i Pujol (Badalona); Joana Guerrero, Hospital General de Granollers (Granollers); Pilar Roig, Tre Borràs and Lourdes Rofes, Hospital Sant Joan (Reus);Teresa Mestre, Hospital Joan XXIII (Tarragona); Rosa Serrano, Hospital Parc Taulí (Sabadell); Gemma Tàpies, Consorci Maresme (Mataró); J. Manuel Baucells, Soledad Cascajosa and Jesús Ribas, Hospital Residència Sant Camil (Sant Pere de Ribes); Josep Maria Sánchez, Hospital Universitari Vall d’Hebron (Barcelona); Assumpció Vilarasau, Hospital Santa María (Lleida); Genís Cervantes, Hospital Alt Penedés (Vilafranca del Penedès); Carme Cunillera, Hospital Sant Jaume (Olot); Justo López, Hospital Sant Rafael (Barcelona); Sílvia Fernández, Hospital Municipal de Badalona (Badalona); Beatriu Castells, Hospital de L’Anoia (Igualada); Antònia Llunell, Hospital de Terrassa (Terrassa); Mònica González, Hospital de Mollet (Mollet del Vallès); Rosa Montoliu, Hospital Dos de Maig (Barcelona); Sergio Morchón, Hospital Universitari de Bellvitge (L’Hospitalet de Llobregat); Marc Bonin, Hospital de Figueres (Figueres); Dolores Benito, Hospital de Palamós (Palamós); Alvaro Viejo, Hospital Josep Trueta (Girona); Cristina Pinet, Hospital de Sant Pau (Barcelona).
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Keywords:© 2012 Lippincott Williams & Wilkins, Inc.
Database; Evaluation; Hospitals; Program; Smoking cessation