Smoking study in JAMA

Automated phone calls and free medication helped hospital patients quit smoking after they were discharged, according to a new study in JAMA. (Robert Gauthier / Los Angeles Times)

A free supply of nicotine replacement medication and a handful of automated phone calls made smokers who wanted to quit much more likely to succeed, according to results of a clinical trial published Tuesday in the Journal of the American Medical Assn.

The researchers who designed the trial said they were looking for a simple and inexpensive way to aid smokers who were already motivated to kick the habit. They estimated that once their 90-day program was set up, it could be maintained at a cost of less than $1,000 per quitter.

The study involved 397 smokers who were admitted to Massachusetts General Hospital in Boston between August 2010 and November 2012. Like all hospitals in the U.S., Massachusetts General is a smoke-free facility, and smokers treated there are offered nicotine replacement therapy to help them deal with their withdrawal symptoms. Patients who want to remain smoke-free after they are discharged can get help from counselors in the hospital’s Tobacco Treatment Service.

For the trial, 199 patients received the usual care – a recommendation for specific tobacco cessation medication that could be prescribed by a doctor upon discharge and the number for a toll-free quit line. An additional 198 patients got “sustained care,” which included a free, 30-day supply of medication that was chosen by the patient and his or her counselor. The medication could be refilled twice during the trial. Patients getting “sustained care” also got five automated phone calls that encouraged them to keep taking their medication, offered advice to help them stay smoke-free and identified those who needed to talk to the counselor one-on-one.

After six months, 27% of the patients who got the extra help told researchers that they had not smoked anything (including electronic cigarettes) in the previous week. The researchers didn’t just take their word for it – they used a saliva test to check for a chemical called cotinine (which the body produces as it metabolizes nicotine) and they tested for carbon monoxide in exhaled air. These biochemical tests confirmed that 26% of the former smokers had abstained for at least seven days.

By comparison, 16% of the patients who got the usual care said they had not smoked for the previous week, and 15% were deemed smoke-free by a biochemical test.

Overall, the patients who got “sustained care” were 70% to 71% more likely to be non-smokers after six months than the patients who got the usual care, the researchers found.

The patients who enrolled in the study were not just casual smokers – before they wound up in the hospital, they smoked 16.7 cigarettes a day, on average. The 45% of study participants who were hospitalized for a smoking-related disease were just as likely to benefit from the extra help as the 55% of patients who wound up in the hospital for other reasons.

However, the researchers found that the program was most beneficial for the African Americans, Latinos, Asian Americans and Native Americans in the study. Among these patients, 38% who got the extra help were still not smoking after six months, compared with only 6% who received the usual care.

The researchers said that the biggest difference between the two groups is that patients who got “sustained care” used nicotine replacement therapy longer than patients who didn’t. For instance, 48% of patients in the usual care group used some form of NRT (such as nicotine patches, gum or lozenges) for only two weeks or less. By comparison, 61% of patients who tried the “sustained care” stuck with the medication for eight weeks or longer, according to the study.

The researchers calculated that the added cost of the more intensive program was $4,910 per successful quitter in the first year and $2,670 per quitter in subsequent years, after the staff had been trained and the automated phone system had been built.

However, the program costs would have been lower if health insurance companies had paid for the anti-smoking medication, as required by the Affordable Care Act. The researchers said that once the program had been set up, hospitals could keep it going for as little as $997 per successful quitter.

Nearly 4 million Americans smokers are admitted to a hospital each year, according to the researchers. Among the 5,211 daily smokers who were treated at Massachusetts General during the course of the study, 1,757 (34%) told counselors they would like to quit.

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