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Promoting smoking cessation in the hospital

Michael Kunze
Professor and Director
Institute of Social Medicine
University of Vienna

Treating tobacco dependence is the most ­important strategy to control smoking-related disease, and nicotine replacement therapy (NRT) is the best evaluated treatment option with an excellent safety profile. A variety of products are available. The future will see a much wider use of these compounds to promote tobacco abstinence, reduction/ controlled smoking and to aid temporary withdrawal/craving management.(2)

Primary prevention is the most desirable goal to control tobacco-related diseases. However, to date this has not been very effective; moreover, it would take 30–40 years for primary prevention to translate into major health benefits. Therefore the focus must be directed towards diagnosis and treatment of tobacco dependence.(1)

NRT has been shown to double successful smoking cessation rates, and evidence-based guidelines for the treatment of tobacco addiction have recommended routine use of NRT, particularly in heavily dependent smokers. Success rates of up to 40% can be achieved in specialist clinics.(2)

Despite early concerns regarding the safety of NRT in smokers with heart disease, it is now clear that the health risks far outweigh any treatment-related risks.(2) There is a bulk of scientific literature on the clinical use of NRT and its public health aspects.(3)

There are several  issues that need to be discussed regarding the use of NRT in the hospital setting. Diagnosis and treatment of tobacco dependence are a top priority in the hospital environment.

There are at least five aims in the diagnosis and treatment of tobacco dependence:

  • Smoking cessation as causal treatment of tobacco- related diseases.
  • As support treatment – for example, to improve the results of chemotherapy and ­radiation therapy.
  • To promote a healthy lifestyle.
  • To achieve temporary abstinence among hospital patients.
  • Inpatient treatment for heavy dependent smokers – in this instance the hospital stay is mainly devoted to achieving tobacco abstinence or harm reduction.

In a recent overview on the existing scientific evidence it was stated that: “Efficacious inpatient smoking programs have been developed and validated. The challenge now is to translate these interventions more widely into practice, given changing hospitalization patterns.”(4) Given the ban on smoking in hospitals, hospitalisation imposes a forced abstinence from smoking.

Target groups for diagnostic and treatment services are not just patients, but also the hospital staff members.

When it comes to pharmaceutical intervention, NRT is the best documented approach. NRT doubles successful smoking cessation rates and evidence-based guidelines for the treatment of tobacco addiction recommended routine use of NRT, particularly in ­heavily dependent smokers.(3)

The use of NRT in hospital-based smoking cessation studies mirrors the general evolution of ­pharmacotherapy for smoking cessation. When nicotine gum first became available, it was prescribed for less than 15% of the intervention group. As pharmacotherapy for smoking cessation became more common, it was included as another tool to be offered to subjects during hospitalisation, like printed materials or relaxation tapes. The use of NRT among intervention subjects during this period ranged from 44% to 65%.(4) Two placebo-controlled trials evaluated the use of NRT as a hospital intervention, looking at the efficacy of nicotine gum(5) and the patch.(6)

Five nicotine replacement preparations are currently available: gum, patch, nasal spray, oral inhaler and sub-lingual tablet. As far as safety issues are concerned, scientific evidence shows that the use of NRT involves almost no risk for consumers and patients, especially when compared with the consumption of tobacco products. New concepts developed by our group are the following:

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  • Definition of possible endpoints of smoking ­control measures.
  • Reduced smoking and nicotine dependence.
  • Preventive oncology, chemoprevention of lung cancer by NRT.
  • The public health impact of the availability of over-the-counter NRT and the “let them choose approach” of NRT, focusing on the specific ­preferences and needs of the individual client.

One may also speculate whether NRT will, at some stage, replace cigarettes as the major source of nicotine for people who need this psychoactive drug.(3)

Reduced smoking (which leads to a reduced intake of toxic substances) may be indicated in individuals who:

  • Are failing in cessation attempts.
  • Want to quit but are unable to do so.
  • Do not want to quit but want to reduce smoking.

Studies have shown that nicotine replacement medications may be an untapped source in efforts to reduce smoking.(1)

The diagnostic procedures that are necessary to improve treatment outcomes are established. The ­minimum requirement consists of measuring carbon monoxide in the exhaled air and performing the Fagerström Test for Nicotine Dependence.(7)

Diagnosis and treatment of tobacco dependence needs to be integrated into the medical services in general and in the hospital in particular.

The treatment follows the principles of lifestyle ­medicine, combining pharmaceutical intervention with behaviour modification.

The best evaluated and documented drugs are those of the nicotine replacement category. They are safe and available in several different forms, which differ with regard to pharmacokinetics. Products can be selected according to patient preference, which plays a major role in the abstinence developing process.

The future of NRT will see new developments, including long-term treatment, high-dose treatment, and combination therapy with drugs such as bupropion.

The endpoints of NRT use are complete abstinence, controlled smoking (harm reduction) and temporary abstinence.


  1. Jimenez-Ruiz C, Kunze M, Fagerström KO. Nicotine replacement: a new approach to reducing tobacco-related harm. Eur Respir J 1998;11:473-9.
  2. Balfour D, Benowitz N, Fagerström KO, Kunze M, Keil U. Diagnosis and treatment of nicotine dependence with emphasis on nicotine replacement ­therapy. Eur Heart J 2000;21:438-45.
  3. Kunze U, Schoberberger R, Schmeiser-Rieder A, Groman E, Kunze M. Alternative nicotine delivery systems (ANDS) — public health aspects. Wien Klin Wochenschr 1998;110(23):811-16.
  4. France EK, Glasgow RE, Marcus AC. Smoking cessation interventions among hospitalized patients: what have we learned? Prev Med 2001;32:376-88.
  5. Campbell LA, Prescott RJ, Tjeder-Burton SM. Smoking cessation in hospital patients given repeated advice plus nicotine or placebo chewing gum. Respir Med 1991;85(2):155-7.
  6. Lewis SF, Piasecki TM, Fiore MC, Anderson JE, Baker TB. Transdermal nicotine replacement for hospitalized patients: a randomized clinical trial. Prev Med 1998;27(2):296-303. Schoberberger R, Kunze U, Schmeiser-Rieder A, Groman E, Kunze M. Wiener Standard zur Diagnostik der Nikotinabhängigkeit. Wien Med Wochenschr1998; 148(3):52-64.
  7. Groman E, Bayer P. A combination of exhaled carbon monoxide (CO) measurement and the Fagerström Test for Nicotine Dependence (FTND) is recommended to complete information on smoking rates in population-based surveys. Soz Präventivmed 2000;45:226-8.

European Network on Young People And Tobacco (ENYPAT)
Nicotine Institute
World Health Organization

Further reading
Bolliger CT, Fagerström KO. Tobacco epidemic. Basel: Karger; 1997
Schoberberger R, Kunze M. Nikotinabhängigkeit. Diagnostik und therapie. Heidelberg: Springer; 1999

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