1. Introduction
Worldwide, tobacco use is responsible for the most preventable deaths with more than 8 million deaths annually, of which many are avoidable [1]. Over 7 million of these tobacco-related deaths are associated with direct use while 1.2 million are associated with second-hand smoke exposure [1]. It has been noted that smoking and inactivity rank among the three most adaptable risk factors for chronic disease and premature death, and it is predicted that current smokers die approximately 10 years earlier than age-matched nonsmokers [Reference Kaczynski, Manske, Mannell and Grewal2]. Smoking is also accountable for hundreds of billions of dollars of financial damage annually, which may subsequently be avoided if smoking incidence and magnitude were reduced [3]. In 2003, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was developed in response to the global tobacco epidemic with the goal to improve public health [1].
Currently, most hospitals do not allow patients to smoke on facility grounds, and therefore, as Reid et al. [Reference Reid, Mullen and Slovinec D'Angelo4] have noted, hospitalisation provides an excellent opportunity for the health service to identify, actively involve and engage smokers, and initiate the provision of smoking cessation treatments, support, and follow-up. Furthermore, encouragement from a health professional in the inpatient setting is a significant external prompt for a smoker to attempt quitting. Health [5] indicated that one in every 33 approaches leads to success in smoking cessation.
An evaluation by Reid et al. [Reference Reid, Mullen and Slovinec D'Angelo4] found that combination of SCIs such as inpatient-initiated counselling and nicotine replacement therapy (NRT) with postdischarge follow-up has demonstrated significantly higher smoking cessation rates. Furthermore, the Cochrane systematic review (SR) on ISCIs by Rigotti et al. [Reference Rigotti, Clair, Munafò and Stead6] found them to be effective, regardless of the patient’s admitting diagnosis, or whether the admission was to an acute or rehabilitation facility. This supports the use of ISCIs as effective interventions for smoking cessation.
In the United States, The Joint Commission [7] developed evidence-based guidelines for all hospitalised inpatients which mandate that following identification of all tobacco smokers, they are offered and/or provided with evidence-based support (counselling and medication) during their admission and on discharge from hospital, and this smoking status reassessed following discharge. Smoking cessation not only increases life expectancy, decreases the risk of associated chronic diseases [Reference West, Raw and McNeill8], and reduces healthcare costs; thus, ongoing investment in evidence-based interventions to assist with smoking cessation is crucial to addressing these ongoing issues. Indeed, the relatively low cost of inpatient smoking cessation interventions (ISCIs) has been shown to be cost-effective compared to the healthcare costs associated with ongoing smoking [Reference Mullen, Manuel and Hawken9].
2. Background
Although a SR on SCIs by Rigotti et.al [Reference Rigotti, Clair, Munafò and Stead6] for hospitalised patients identified their effectiveness, the SR was limited to the inclusion of randomised controlled trials (RCTs) or quasi-RCTs. Moreover, the funding mechanism of the facility and ISCI was not explicit and did not include any qualitative data reflecting participants’ perspectives on the ISCIs, and the SR has yet to be updated. Ugalde et al. [Reference Ugalde, White and Rankin10] conducted a SR on ISCI implementation strategies and their success evaluating outcomes. The authors highlighted the need for qualitative data to provide depth and understanding of the clinical and patient experience. In addition, Sharpe et al. [Reference Sharpe, Alsahlanee, Ward and Doyle11] conducted their SR on barriers to the provision of ISCIs from clinicians’ perspectives and, however, did not include patient perspectives or a broader range of staff perspectives. Therefore, in order to complement and build on the work of Rigotti et al. [Reference Rigotti, Clair, Munafò and Stead6], Sharpe et al. [Reference Sharpe, Alsahlanee, Ward and Doyle11], and Ugalde et al. [Reference Ugalde, White and Rankin10], this qualitative integrative review (IR) of the literature focusing on staff and participants’ perspectives of ISCIs will provide the reader with a broader understanding of potential contributing factors to the success or failure of ISCIs and therefore further insight in to the processes that lead to the outcome of this kind of intervention.
3. The Review
3.1. Aim
The aim of this qualitative IR was to identify, integrate, and appraise the evidence on hospitalised smokers’ and staff perspectives of ISCIs and impact on smokers’ quality of life (QOL) and to explore stakeholder and participant views on inpatient smoking cessation programs.
3.2. Design
The IR design was selected to include qualitative data as the methods involved in SRs and meta-analyses place a greater emphasis on the quality of RCTs and levels of evidence. [Reference Whittemore and Knafl12] The IR methodology produces a greater understanding of the breadth and depth of the phenomenon through the inclusion of nonexperimental and experimental research [Reference Whittemore and Knafl12, Reference de Souza, da Silva and de Carvalho13]. It also consider questions that remain unanswered by building on previous work in the area [Reference Rodgers and Knafl14]. The previous SRs conducted on this topic [Reference Rigotti, Clair, Munafò and Stead6, Reference Ugalde, White and Rankin10, Reference Sharpe, Alsahlanee, Ward and Doyle11] focused on effectiveness outcomes, implementation strategies, and some limited staff perspectives on delivering ISCIs. Therefore, through the inclusion of a wider range of staff and patient perspectives and impact on QOL for patients, this qualitative IR will provide the reader with a broader understanding of potential contributing factors to the failure/success of ISCIs by providing further insight into the processes leading to the outcome of an intervention [Reference Bazeley15]. Furthermore, the insights into the feasibility of translating an ISCI to other settings such as the private sector and funding limitations/preferences are also identified.
The methodology used for this qualitative IR was based on those described by Whittemore and Knafl [Reference Whittemore and Knafl12] as the framework provided address issues such as data analysis that are specific to IRs.
3.3. Search Methods
A search of the following online databases was conducted from January 2011 to October 2021: Ovid Medline, Joanna Briggs Institute, APA PsycInfo, CINAHL, Cochrane, Google Scholar, and Scopus. Key search terms on the variables of interest included the following: “hospitalised/hospitalized”, “inpatient”, “patient admission”, “smokers”, “smoking”, “tobacco”, “nicotine”, “smoking cessation/prevention intervention”, “counselling/behaviour therapy”, “pharmacotherapy”, “nicotine replacement therapy”, “outcome”, and “quality of life”. A search of grey literature and manual searching of reference lists was also conducted to identify further studies not identified in the online database search. The search strategy was inclusive of peer-reviewed studies limited to the English language or translated to English. Studies that addressed inpatient-initiated smoking cessation programs and addressed the outcomes of interest were included but were not limited to education, counselling, and the use of pharmacotherapy.
3.4. Data Collection Method
3.4.1. Types of Studies
Relevant papers were limited to any study design that included qualitative findings (i.e., qualitative, mixed methods, and survey research), and therefore, any papers producing only quantitative data (i.e., RCTs, quasiexperimental RCTs, cohort, and case series) were excluded.
3.4.2. Participants
All study participants were adult patients who were current smokers at the time of their hospital admission and underwent smoking cessation support.
3.4.3. Inclusion
The IR included relevant papers of any design with qualitative data on inpatient smoking cessation interventions during inpatient admission to hospital for adults (> age 18).
3.4.4. Exclusion Criteria
Studies that included only quantitative data; studies undertaken in the psychiatric, adolescent, and paediatric settings; and papers not published in English were excluded.
3.4.5. Search Screening and Selection Process
The EndNote referencing system (version 20, 2021; Clarivate Analytics, PA, USA) was utilised to organise records and assist with the removal of duplicate studies.
3.5. Search Outcome
The search identified 106 citations. Following the removal of duplicates, 100 studies underwent title or abstract screening with the resulting exclusion of 84 studies resulting in 16 studies. Reasons for exclusion are outlined in Figure 1. Reference lists were screened for eligible studies not previously identified, and two additional studies were included. In total, 18 full-text articles were assessed for quality.
Figure 1: Flow diagram outlining search outcome.
3.6. Quality Appraisal
Eighteen studies were critically appraised independently by two researchers for methodological quality using standardised critical appraisal instruments. Qualitative studies were appraised using the Joanna Briggs Institute (JBI) checklist for qualitative research [16], mixed method studies were appraised using the mixed method assessment tool (MMAT) [Reference Hong, Fàbregues and Bartlett17], and descriptive quantitative studies were appraised using the survey appraisal tool from the Center for Evidence-Based Management [18]. Following the critical appraisal process, three studies [Reference Katz, Paez and Reisinger19–Reference Faseru, Turner and Casey21] were excluded as a result of sensitivity analyses [Reference Thomas and Harden22].
3.7. Data Abstraction and Synthesis
The 16 studies that met the inclusion criteria for the qualitative IR are summarised in Table 1 under the following subheadings: design and method, sample size and location, and key findings. Outcomes from the studies included in the qualitative IR were organised, analysed and data abstracted, and synthesised using the process described by Whittemore and Knafle [Reference Whittemore and Knafl12]. This process involved data reduction, data display, and data comparison facilitating the identification of “patterns, themes, variations, and relationships” [Reference Whittemore and Knafl12] from which verification and conclusions can be drawn from the data collectively.
Table 1: Studies that met inclusion criteria for the qualitative IR.
Abbreviations: DMs: decision-makers; HCPs: healthcare professionals; OMSC: Ottawa Model of Smoking Cessation; QOL: quality of life; SCCs: smoking cessation coordinators; VA: veterans’ affairs.
4. Results
The 16 studies included in the IR were conducted in Australia, Austria, Canada, China, Czech Republic, Greece, Switzerland, the United States of America (USA), and the United Kingdom (UK) and consisted of qualitative interviews (n = 5), mixed methods (n = 6), and quantitative descriptive using surveys or questionnaires (n = 5). Seven studies focused on patient-related outcomes, seven studies focused on staff-related outcomes, and two studies evaluated outcomes from both patients and staff involved in ISCIs. Data abstracted from the studies covered the following topics: evaluation of and attitudes towards ISCIs, frequency of provision of ISCIs, barriers to ISCIs, preferences for ISCIs, and QOL changes associated with participating in an ISCI.
The key findings from the IR included positive evaluations from patients and staff involved in ISCIs with both reporting that hospitalisation was an appropriate opportunity to address smoking cessation. A number of facilitators and barriers to ISCIs consisted of creating a supportive patient-centred environment and considering cost of NRT and time to deliver ISCIs. Recommendations/preferences for future ISCIs included the use of a program champion and ongoing education to demonstrate the effectiveness of the intervention, and despite the cost of NRT being identified as a potential barrier, it was identified as a preference for most patients. Although QOL was only evaluated in two studies, statistically significant improvements were identified in both.
4.1. Evaluation of and Attitudes towards ISCIs
Ten studies are reported on the evaluation of and attitudes towards ISCIs. [Reference Campbell, Pieters, Mullen, Reece and Reid23–Reference Bains, Britton, Marsh, Jayes and Murray32] Overall, the evaluations and attitudes towards ISCIs were positive, and no negative comments were reported.
Patients involved in ISCIs reported that hospitalisation was an appropriately timed opportunity [Reference Jones and Hamilton28, Reference Bains, Britton, Marsh, Jayes and Murray32] and a positive experience [Reference Dobrinas, Blanc and Rouiller24, Reference Schoberberger, Böhm and Schroeder29] and were satisfied with the service received [Reference Vick, Duffy, Ewing, RugEn and Zak30]. Finkelstein and Cha [Reference Finkelstein and Cha26] assessed the feasibility of using of a mobile app for their ISCI. In their study, over 92% of the participants said they would recommend the use of the app to other hospitalised smokers.
Staff participants also reported that hospitalisation was an appropriate and effective time to approach smoking cessation [Reference Campbell, Pieters, Mullen, Reece and Reid23]. Participants reported that they enjoyed providing counselling as part of the ISCI [Reference Duffy, Ewing, Louzon, Ronis, Jordan and Harrod25], and the staff found that the processes involved in ISCIs saved time [Reference Duffy, Ronis and Ewing31]. In addition, the staff found that they had increased confidence in their ability to deliver smoking cessation services [Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27, Reference Vick, Duffy, Ewing, RugEn and Zak30] and believed that the intervention provided an important service that was helpful for patients [Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27, Reference Vick, Duffy, Ewing, RugEn and Zak30].
4.2. Provision of ISCI Services
Four studies [Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27, Reference Vick, Duffy, Ewing, RugEn and Zak30, Reference Duffy, Ronis and Ewing31, Reference Sarna, Bialous and Kraliková36] evaluated the delivery rate of ISCI services following a training period to introduce ISCIs through the use of surveys. Despite all four studies only consisting of 1–1.5 hours of training for staff, provision of services increased by 10–29% following the training period, demonstrating that even a short period of training increased the chance of a patient receiving an ISCI.
4.3. Facilitators and Barriers to ISCPs
Facilitators to ISCIs were discussed by one study [Reference Li, Lee, Chen, Jeng and Chen34] from a nursing perspective. The authors suggested that to ensure effective ISCIs and a positive outcome, the following was essential: a patient-centred and supportive environment, encouragement of lifestyle modification, appropriately timed counselling, and onward referral as required. This involved building teams to support the patient, as per Li et al. [Reference Li, Lee, Chen, Jeng and Chen34] (p4788), who reported that when health professionals worked together to emphasise the advantages of smoking cessation, “they are more effective at promoting smoking cessation counselling and motivating patients to quit smoking.”
Barriers to ISCPs were discussed in five of the studies [Reference Duffy, Ewing, Louzon, Ronis, Jordan and Harrod25, Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27, Reference Bains, Britton, Marsh, Jayes and Murray32–Reference Li, Lee, Chen, Jeng and Chen34]. Patient-related barriers included the cost of pharmacotherapy had it not been provided as part of an ISCI [Reference Bains, Britton, Marsh, Jayes and Murray32], fear of becoming tense, experiencing mood swings, gaining weight, failing to stop smoking [Reference York, Kane, Beaton, Keown and McMahan38], and overall lack of interest or resistance from patients. [Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27, Reference Katz, Stewart and Paez33] Organisational barriers included lack of expertise among staff to deliver an ISCI [Reference Bains, Britton, Marsh, Jayes and Murray32, Reference Katz, Stewart and Paez33], shortage of coordinators who are willing to take charge of the program [Reference Duffy, Ewing, Louzon, Ronis, Jordan and Harrod25], insufficient time [Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27, Reference Bains, Britton, Marsh, Jayes and Murray32–Reference Li, Lee, Chen, Jeng and Chen34], lack of resources [Reference Katz, Stewart and Paez33, Reference Li, Lee, Chen, Jeng and Chen34], and the presence of smoking areas on site [Reference Katz, Stewart and Paez33].
4.4. Recommendations and Preferences for ISCIs
Recommendations for future ISCIs were proposed in four studies [Reference Campbell, Pieters, Mullen, Reece and Reid23, Reference Duffy, Ewing, Louzon, Ronis, Jordan and Harrod25, Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27, Reference Li, Lee, Chen, Jeng and Chen34]. Recommendations from patients included longer follow-up periods and improved access to smoking cessation medications [Reference Duffy, Ewing, Louzon, Ronis, Jordan and Harrod25].
Recommendations from staff perspectives consisted of the appointment of a program coordinator or champion [Reference Campbell, Pieters, Mullen, Reece and Reid23, Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27], ensuring resources are readily available, scheduling specific times for counselling sessions, having simple to use documentation templates for guiding the delivery of ISCIs [Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27], and ongoing promotion and training for staff including the demonstration of effectiveness of the program [Reference Campbell, Pieters, Mullen, Reece and Reid23].
Patient preferences for ISCIs were provided by three studies [Reference Dobrinas, Blanc and Rouiller24, Reference Thomas, Abramson and Bonevski37, Reference York, Kane, Beaton, Keown and McMahan38]. Dobrinas et al. [Reference Dobrinas, Blanc and Rouiller24] reported on initial assessment that only 15% of their program participants were interested in receiving NRT; however, no other preferences were assessed. Interestingly, following only one to two hospital visits, one month following discharge, 20% of participants were using NRT and readiness to quit improved in 53% of patients. Thomas et al. [Reference Thomas, Abramson and Bonevski37] reported medication (49.5%), followed by “cold turkey” (33.5%), and gradual reduction (13.3%) as preferred strategies for smoking cessation. Within the medication preferences, NRT patches were the most popular (54.2%), then tablets (45%), inhalers (40.8%), lozenges (34.7%), e-cigarettes (32.3%), gum (27%), and sublingual tablets (23%). This is further supported by York et al. [Reference York, Kane, Beaton, Keown and McMahan38] who identified that not only was the use of an NRT patch considered a preferred cessation aid but also most patients were willing to pay for NRT patches on discharge as an ongoing cessation aid.
4.5. QOL Changes
Impact on QOL was assessed in two mixed method studies using survey-based methods [Reference Schoberberger, Böhm and Schroeder29, Reference Politis, Ioannidis, Gourgoulianis, Daniil and Hatzoglou35]. Politis et al. [Reference Politis, Ioannidis, Gourgoulianis, Daniil and Hatzoglou35] found statistically significant improvements in SF-36 scores in both groups who participated in an ISCI. Schoberberger et al. [Reference Schoberberger, Böhm and Schroeder29] reported statistically significant improvements in lifestyle satisfaction using the standardised German Fragebogen zur Erfassung des Gesundheitsverhaltens (FEG) questionnaire for ex-smokers versus continuing smokers.
5. Discussion
The findings from this review complement the previous work in this area by Rigotti et al. [Reference Rigotti, Clair, Munafò and Stead6], Sharpe et al. [Reference Sharpe, Alsahlanee, Ward and Doyle11], and Ugalde et al. [Reference Ugalde, White and Rankin10], by qualitatively presenting participants’ perspectives on ISCIs including the impact on QOL for patients.
Although Rigotti et al. [Reference Rigotti, Clair, Munafò and Stead6] identified that ISCIs are effective, no qualitative data or participants’ perspectives were included within the review. This present qualitative IR identified that both patients’ and staff experiences of ISCIs were positive experiences and an important and useful starting point to smoking cessation and therefore support the findings by Rigotti et al. [Reference Rigotti, Clair, Munafò and Stead6].
The SR conducted by Sharpe et al. [Reference Sharpe, Alsahlanee, Ward and Doyle11] on barriers to the provision of ISCIs from clinicians’ perspectives was limited as they did not include patient perspectives or a broader range of staff perspectives. Although the barriers presented in this review were similar to those highlighted by Sharpe et al. [Reference Sharpe, Alsahlanee, Ward and Doyle11], additional perspectives from both patients and staff included clinician recommendations for future ISCIs and patient preferences for ISCIs and impact on QOL.
Ugalde et al. [Reference Ugalde, White and Rankin10], in their SR on ISCI implementation strategies and evaluation of their success, identified that brief intervention strategies alone are insufficient for long-term success with rates of delivery of ISCIs. This is reflected in the findings from this IR, which identified that staff recommended the appointment of a ISCI program coordinator or champion [Reference Campbell, Pieters, Mullen, Reece and Reid23, Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27] to provide ongoing support for staff. However, despite these recommendations, the findings from this qualitative IR identified that following 1-1.5 hours of staff training, delivery of ISCIs improved at two months [Reference Sarna, Bialous and Kraliková36] and up to 15 months [Reference Fore, Karvonen-Gutierrez, Talsma and Duffy27] posttraining. Therefore, despite the findings from Ugalde et al. [Reference Ugalde, White and Rankin10], this qualitative IR indicates that brief training is still effective for those organisations investing in the delivery of ISCIs.
A more recent study [Reference Russell, Whiffen and Chapman39] on hospital staff perspectives on the provision on inpatient smoking cessation services concurred with findings from this IR that time constraints and lack of knowledge and resources are barriers to the delivery of these services. Russell et al. [Reference Russell, Whiffen and Chapman39] also identified that staff believe that all members who are part of the hospital workforce should be involved in ISCIs in order to ensure the consistent delivery of the smoking cessation message. Additional barriers identified included patient groups (e.g., mental health) and context (e.g., emergency department not deemed an appropriate location to address smoking cessation).
There are a number of limitations to this qualitative IR. Firstly, the review was limited to publications from the last 10 years, English language only publications, and studies published in peer-reviewed journals. This may have reduced the number of eligible studies in this review. Timing and funding to expand the inclusion criteria may have produced more data. Another limitation of this IR involved the appraisal of literature by two reviewers and their sensitivity analyses which lead to the exclusion of three studies. However, the use of two reviewers who independently appraised each study strengthened this IR.
Overall, this qualitative IR has added a further depth of knowledge and understanding as to why ISCIs are effective by providing an insight to patient and staff perspectives on ISCIs. However, only two studies [Reference Schoberberger, Böhm and Schroeder29, Reference Politis, Ioannidis, Gourgoulianis, Daniil and Hatzoglou35] assessed the impact of QOL of ISCIs, and although both demonstrated statistically significant improvements, further research in this area using additional QOL outcome measures and interviews would be beneficial to add to the qualitative findings.
Potential solutions for the successful delivery of ISCIs may include ensuring all health professionals are well supported and educated to provide this service to patients by allocating sufficient time and funding for both training (initial and refresher sessions) and delivery of the service as discussed by Reid et al. [Reference Reid, Mullen and Slovinec D'Angelo4]. Most ISCIs are facilitated by nursing and medical staff. By focusing on a multidisciplinary approach and involving other health professionals, other than nursing and medical staff, this may reduce the staff burden and ensure the consistent delivery of the smoking cessation message. If clinicians are enthusiastic and knowledgeable and have the time to discuss the importance of smoking cessation and explore strategies to deal with cravings, this may lead to better acceptance by patients and staff.
6. Conclusion
This qualitative IR provides further insight into both clinician and patient participants’ perspectives on ISCIs. Overall, they are considered to have positive benefits, and staff training appears to be an effective means for service delivery. However, insufficient time and lack of resources or expertise appear to be consistent barriers to the delivery of these services, so they should be considered when planning the implementation of an ISCI.
Data Availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Additional Points
Key Point Summary. (i) Tobacco use is responsible for most preventable deaths worldwide, with more than 8 million deaths annually attributed to tobacco use; smoking kills half of its consumers, of which many are avoidable [1]. (ii) “Hospitalisation provides a unique opportunity to identify and engage smokers, initiate cessation treatments and facilitate appropriate follow-up and support” as most hospitals do not allow patients to smoke on their grounds [Reference Reid, Mullen and Slovinec D'Angelo4] (p11). (iii) Encouragement from a health professional is a significant external prompt for a smoker to attempt quitting [5]. (iv) Previous systematic reviews conducted on this topic [Reference Rigotti, Clair, Munafò and Stead6, Reference Ugalde, White and Rankin10, Reference Sharpe, Alsahlanee, Ward and Doyle11] have focused on effectiveness outcomes, implementation strategies and outcomes, and some staff perspectives on delivering inpatient smoking cessation interventions. (v) To date, a qualitative review that is inclusive of all participants’ perspectives on inpatient smoking cessation interventions has not been conducted. Therefore, the purpose of this integrative review is to synthesise and present qualitative research findings from the last 10 years regarding staff and patients’ perspectives on participating in an inpatient smoking cessation intervention, including the impact on quality of life for patients.
Conflicts of Interest
No conflicts of interest have been declared by the authors.
Authors’ Contributions
Leah Epton was the primary author overseeing study conception and design and the draft manuscript preparation. Shane Patman and Tracey Coventry contributed to the study conception and design and draft manuscript preparation and acted as second reviewers. Caroline Bulsara contributed to the draft manuscript preparation and provided guidance on the integrative review process. All authors reviewed and approved the final version of the manuscript.
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