Staying Free Smoking Cessation Program

Evidence Rating: Top Tier

Highlights

Program: A low-cost smoking cessation program for hospitalized smokers who are willing to make a quit attempt.
Evaluation Methods: Four well-conducted randomized controlled trials (RCTs).
Key Findings: 30% increase in likelihood of confirmed abstinence from smoking approximately one year after patients’ discharge from the hospital.

Staying Free is a smoking cessation program for hospitalized smokers who (i) are willing to make a quit attempt during hospitalization; and (ii) do not have a medical history of substance abuse or psychiatric disorders, and are not pregnant, medically unstable, or cognitively disabled.

Participants first receive a one-minute scripted smoking cessation message from their physician, followed by:

An intensive counseling session provided at bedside by a nurse case-manager specially trained in smoking cessation (approximately 30-60 minutes); and
Four to seven telephone counseling sessions – each 5-10 minutes long – provided by the nurse at periodic intervals between 2 and 90 days after discharge.

The bedside session includes (i) education on hazards of smoking personalized to the patient’s condition, benefits of quitting, the withdrawal process, and importance of social support; (ii) take-home materials (video, workbook, relaxation tape); and (iii) counseling. The counseling focuses on relapse-prevention – specifically, identifying high-risk situations for smoking relapse and working with the nurse to develop behavioral, cognitive, and social support strategies to remain smoke-free in such situations. The post-discharge phone sessions also focus on relapse prevention. Pharmacotherapy (e.g., nicotine replacement therapy) is provided on an as-needed basis.

The program’s cost is $118-$236 per patient (2019 dollars). The program implementation manual is available here; a summary of effective strategies for program dissemination is available here.

References

Study 1 – (Large Urban Canadian Hospital):

Smith, Patricia M. and Ellen Burgess. “Smoking Cessation Initiated During Hospital Stay for Patients with Coronary Artery Disease: A Randomized Controlled Trial.” Canadian Medical Association Journal, June 23, 2009, vol. 180, no. 13, pp. 1297-1303.

Study 2 – (San Francisco Area Hospitals, All-Female Sample):

Sivarajan Froelicher, Erika S., Nancy Houston Miller, Dianne J. Christopherson, Kirsten Martin, Kathleen M. Parker, Marcy Amonetti, Zhen Lin, Min Sohn, Neal Benowitz, C.B. Taylor, and Peter Bacchetti. “High Rates of Sustained Smoking Cessation in Women Hospitalized with Cardiovascular Disease: The Women’s Initiative for Nonsmoking (WINS).” Circulation, February 10, 2004, vol., 109, pp. 587-593.

Study 3 – (Kaiser Permanente Medical Centers in the San Francisco Bay Area):

Houston Miller, Nancy, Patricia M. Smith, Robert F. DeBusk, David S. Sobel, and C. Barr Taylor. “Smoking Cessation in Hospitalized Patients: Results of a Randomized Trial,” Archives of Internal Medicine, February 24, 1997, vol. 157, pp. 409-415.

Taylor, C. Barr, Nancy Houston Miller, Steven Herman, Patricia M. Smith, David Sobel, Lynda Fisher, and Robert F. DeBusk. “A Nurse-Managed Smoking Cessation Program for Hospitalized Smokers,” American Journal of Public Health, November 1996, vol. 86, no. 11, pp. 1557-1560.

Study 4 – (Community Hospitals in Ontario):

Smith, Patricia M., Linda Corso, K. Stephen Brown, and Roy Cameron. “Nurse Case-Managed Tobacco Cessation Interventions for General Hospital Patients: Results of a Randomized Clinical Trial.” Canadian Journal of Nursing Research, 2011, vol. 43, no. 1, pp. 98 – 117.

Other Studies:

Feeney, Gerald F. X., A. McPherson, J. P. Connor, A. McAlister, R. M.Young, and P. Garrahy. “Randomized Controlled Trial of Two Cigarette Quit Programmes in Coronary Care Patients after Acute Myocardial Infarction.” Internal Medicine Journal, 2001, vol. 31, pp.470 – 475.

DeBusk, Robert F., Nancy Houston Miller, H. Robert Superko, Charles A. Dennis, Randal J. Thomas, Henry T. Lew, Walter E. Berger III, Robert S. Heller, Jonathan Rompf, David Gee, Helena C. Kraemer, Albert Bandura, Ghassan Ghandour, Mia Clark, Raksha V. Shah, Lynda Fisher, and C. Barr Taylor. “Annals of Internal Medicine: A Case-Management System for Coronary Risk Factor Modification after Acute Myocardial Infarction.” Annals of Internal Medicine, May 1, 1994, vol. 120, no. 9, pp. 721-729.

Taylor, C. Barr, Nancy Houston-Miller, Joel D. Killen, and Robert F. DeBusk. “Smoking Cessation after Acute Myocardial Infarction: Effects of a Nurse-Managed Intervention.” Annals of Internal Medicine, 1990, vol. 113, pp. 118-123.

The LJAF Evidence-Based Policy Team is grateful to David Henry, Ph.D., Professor, Department of Psychiatry, University of Illinois at Chicago, for conducting the meta-analysis of the Staying Free program described in this summary.

To see our full evidence summary:

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Top Tier

Programs shown in well-conducted RCTs, carried out in typical community settings, to produce sizable, sustained effects on important outcomes. Top Tier evidence includes a requirement for replication – specifically, the demonstration of such effects in two or more RCTs conducted in different implementation sites, or, alternatively, in one large multi-site RCT. Such evidence provides confidence that the program would produce important effects if implemented faithfully in settings and populations similar to those in the original studies.
Near Top Tier

Programs shown to meet almost all elements of the Top Tier standard, and which only need one additional step to qualify. This category primarily includes programs that meet all elements of the Top Tier standard in a single study site, but need a replication RCT to confirm the initial findings and establish that they generalize to other sites. This is best viewed as tentative evidence that the program would produce important effects if implemented faithfully in settings and populations similar to those in the original study.
Suggestive Tier

Programs that have been evaluated in one or more well-conducted RCTs (or studies that closely approximate random assignment) and found to produce sizable positive effects, but whose evidence is limited by only short-term follow-up, effects that fall short of statistical significance, or other factors. Such evidence suggests the program may be an especially strong candidate for further research, but does not yet provide confidence that the program would produce important effects if implemented in new settings.

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