Hospitalised Smokers’ and Staff Perspectives of Inpatient Smoking Cessation Interventions and Impact on Smokers’ Quality of Life: An Integrative Review of the Qualitative Literature

Table 1

Studies that met inclusion criteria for the qualitative IR.

Author	Design and method	Sample size and site	Key findings
Bains et al. [32]	Qualitative: semistructured interviews for patients and a different interview for HCPs (nursing and medical staff), on the smoking cessation service, they were offered/offer	Random sample of patients (, 22 service users and 8 nonservice users) and purposive sample of HCPs ( to represent all specialty areas) from one hospital in the UK	Most patients felt that the service was appropriately timed and a good opportunity to attempt smoking cessation. If patients had not been approached, many patients reported that they would have attempted to quit alone, although some stated pharmacotherapy costs would have been a barrier.; Service delivery by a specialist advisor was favoured by patients and HCPs, largely because HCPs lacked time and expertise to intervene.
Campbell et al. [23]	Qualitative: semistructured interviews for 12 key informants from 6 hospitals that differed on OMSC program activities (identify and document smokers, advise quitting, provide medication, and offer follow-up)	Key informants (SCCs and DMs) (, 2 each from 6 hospitals using the OMSC) were intentionally selected in Canada	Key informants viewed the OMSC as an effective smoking cessation intervention for the hospital setting that can reduce the prevalence of smoking in the population.; Using program champions; incorporating relevant performance feedback; conducting ongoing education, training, and promotion; designating a hospital-based coordinator role; and demonstrating program effectiveness emerged as important factors for sustainability and success of the OMSC.
Jones and Hamilton [28]	Qualitative: structured interviews with patients who had participated in a new stop smoking service	Patients from 4 different wards () at one hospital in the UK	All participants interviewed welcomed the opportunity to access the hospital smoking cessation service. The hospital was seen as an appropriate venue, where it was easier to make a quit attempt, and there was ready access to nicotine replacement therapy (NRT) and a supportive environment.; Nine of the 19 users followed up stated that they had maintained to quit, 2 successfully went “cold turkey,” 4 said they had cut down, 2 were not clear what had happened, and 2 continued to smoke as they had prior to admission.
Katz et al. [33]	Qualitative: nurses’ survey and semistructured interviews conducted in a purposeful sample to collate different attitudes toward cessation counselling	Nurses who worked on internal medicine units at four academic VA hospitals in the USA completed surveys () and were interviewed ()	Knowledge-related and attitudinal barriers included perceived lack of skills in cessation counselling and scepticism about the effectiveness of cessation guidelines in hospitalised veterans. Nurses also reported multiple behavioural and organisational barriers to guideline adherence: resistance from patients, insufficient time and resources, the presence of smoking areas on VA premises, and lack of coordination with primary care.
Li et al. [34]	Qualitative: interviews were conducted with nurses who were qualified smoking cessation counsellors to explore their perspectives of facilitators and barriers in the implementation of effective smoking cessation counselling services for inpatients	Nurse counsellors () from eleven health promotion hospitals that were smoke-free and located in China	An effective smoking cessation program should be patient-centred and provide a supportive environment. Effective smoking cessation counselling also involves encouraging patients to modify their lifestyles. Time constraints and inadequate resources are barriers that inhibit the effectiveness of smoking cessation counselling programs in acute care hospitals.
Dobrinas et al. [24]	Mixed methods: questionnaire with open- and close-ended questions to evaluate the impact of a smoking cessation intervention for hospitalised patients by a clinical pharmacist previously trained for smoking cessation counselling using change in motivational stage, abstinence at follow-up, change of readiness to quit score between hospital visit and follow-up, and patients’ evaluation of the program and pharmacotherapy interventions	Hospitalised smokers () who received smoking cessation intervention at a hospital in Switzerland	At least 1 month after discharge, the readiness to quit of 53% of patients improved and 33% of patients declared themselves abstinent. Even though 35% of patients declared having mild to moderate withdrawal symptoms in hospital, only 15% were interested in receiving nicotine replacement therapy. Study participants evaluated the intervention positively.
Duffy et al. [25]	Mixed methods: qualitative interviews and evaluation of volunteer telephone smoking cessation counselling follow-up program implemented as part of the inpatient Tobacco Tactics intervention using reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. Program evaluation included number of telephone smoking cessation counselling calls, abstinence rates, intervention costs, and program feedback from volunteers and veterans	Data was collected, and interviews are conducted with inpatient Tobacco Tactics intervention participants () and volunteers () at a VA hospital in the USA	19% of the sample was reached 0–1 times while 81% were reached 2–4 times. Those reached more often were more likely to quit smoking.; Sixty-day 24-hour point-prevalence quit rates (abstracted from volunteer documentation) were 33% for those reached 2–4 times compared to 4% of those reached 0–1 times () (74% follow-up rate with 34 assumed to be smokers).; Themes from patient interviews revealed that veterans were enthusiastic about the program and liked and appreciated the support from the volunteers. Suggestions for improvement included more phone calls over a longer period of time and better patient access to smoking cessation medications.; Volunteer counsellors expressed that they felt properly prepared for being a telephone cessation counsellor and that they enjoyed counselling veterans. In terms of maintenance, the greatest organisational barriers to implementing the program were lack of space, a coordinator who can “own” the program, and restrictions on volunteers being able to document in the EMR.; The reach, effectiveness, adoption, and implementation of the program were high, and while the intervention was not maintained long term, it was maintained short term.
Duffy et al. [31]	Mixed methods: survey and interviews provided an evaluation of the nurse-administered Tobacco Tactics intervention versus usual care measuring rates of receipt/delivery of services and nurses’ evaluation of the intervention	Convenience sample of patients () and nursing staff () from six Michigan Trinity Health community hospitals in the USA (matched on size and number of minority patients), of which three were to receive the nurse-administered Tobacco Tactics intervention and three were to receive usual care	In the intervention sites, more patients (39.9%) in the postintervention period reported receiving handout materials compared to the preintervention period (28.4%) (), whereas there was a decrease in receipt of handout materials in the control group pre- to postintervention (30.2% pre- versus 20.5% postintervention; ).; Qualitative comments were very positive (“user friendly,” “streamlined,” or “saves time”), although problems with showing patients the DVD and charting in the electronic medical record were noted.
Finkelstein and Cha [26]	Mixed methods: survey and semistructured interviews were used before and after evaluations of mobile app for the hazards of smoking education delivered via touch screen tablets to hospitalised smokers using change in hazards of smoking knowledge score (KS), smoking attitudes, and stage of change. Attitudinal surveys are used to evaluate patients’ acceptance of app, and their perceptions of usability, content clarity, and usefulness of the system and interviews are used to explore participants’ views on app content and interface	Active smokers () consecutively admitted to two medicine units at two large urban academic teaching hospitals (location not stated)	After the mobile app use, mean KS increased from 27 (3) to 31 (3) (). Attitudinal surveys and qualitative interviews identified high acceptance of the mobile app by hospitalised smokers. Over 92% of the study participants recommended the app for use by other hospitalised smokers, and 98% of the patients were willing to use such an app in the future.
Politis et al. [35]	Mixed methods: 52-week trial of open-label, preference-based, parallel group comparing standard regimen of varenicline combined with postdischarge advanced behavioural support (group A) or one private consultation session during hospitalisation (group B) measuring abstinence rates and change in SF36 score	Hospitalised smokers self-selected at the First Pulmonology Clinic of Kavala General Hospital, Greece, to group A () or group B ()	At week 52, 52.3% in group A and 14% in group B were still smoking abstinent.; Smoking cessation improved QoL in both groups. The comparison of mean scores between baseline and week 52 showed statistically significant changes for all SF36 domains.
Schoberberger et al. [29]	Mixed methods: abstinence rates and use of standardised questionnaire by participants who completed an inpatient smoking cessation program and explore benefit participating in the program	Patients () who completed the inpatient smoking cessation program in a hospital in Austria	In 12-month postprogram completion, more than 90% of ex-smokers believe that an inpatient smoking cessation therapy has a positive effect on one’s health, i.e., an encouraging, supportive environment appears to assist the cessation process.; 42.6% of participants (loss to F/U 23%) were identified by carbon monoxide verifications as ex-smokers.; Significant changes in lifestyle satisfaction were reported by ex-smokers compared to still smokers.
Fore et al. [27]	Quantitative descriptive: two cross-sectional surveys of nurses and other staff after participating in the Tobacco Tactics training program to determine (1) factors associated with nurses’ perceived confidence in and importance of delivering cessation interventions to patients and (2) whether self-reported delivery of smoking cessation services increased after training program was implemented	Survey data collected from nurses two months after participating in the one-hour Tobacco Tactics (USA) training () and again 15-month posttraining ()	At 15-month posttraining, the vast majority (over 85%) of staff felt at least moderately, very, or extremely confident in providing smoking cessation services and felt that providing these services was important or very important. The vast majority (nearly 90%) were somewhat or extremely satisfied with the training and agreed or strongly agreed that they had a good understanding of the elements of the intervention.; The most commonly cited barriers included patients not being interested and lack of time. Common suggestions for improvement included designating key personnel to perform or coordinate smoking cessation interventions, having resources readily available, planning scheduled sessions for counselling, and improving the documentation template to improve usability.; Following the training, the proportion of nurses self-reporting the provision of cessation services significantly increased from preintervention to postintervention, suggesting that the Tobacco Tactics training increased nurses’ likelihood of providing smoking cessation services.
Sarna et al. [36]	Quantitative descriptive: use of surveys to evaluate self-reported frequency of nursing interventions to support patients’ quit efforts in their nursing practice pre/posttraining and the impact of nurses’ smoking status on program outcomes	Convenience sample of nurses () from the Czech Republic who attended 1 of 10 educational programs about brief smoking cessation interventions for hospitalised smokers	At 3 months, compared to baseline, significantly (), more nurses assessed patients’ interest in quitting, assisted with quit attempts, and recommended the use of the quitline for cessation. Also at 3 months, nurses who smoked were less likely to ask about smoking status (odds ratio and 95% confidence interval (CI; 1.71, 10.53)), advise smokers to quit (, 95% CI (1.24, 7.45)), and refer patients to a quitline (, 95% CI (0.99, 8.63)) compared to nonsmokers.
Thomas et al. [37]	Quantitative descriptive: face-to-face interview using a structured questionnaire to identify quit experiences and preferences for a future quit attempt among smokers	Hospitalised smokers () enrolled in a smoking cessation trial from inpatient wards of three Australian hospitals	Previous quit attempts: motivation to quit smoking was high, and almost two-thirds (64.3%) of participants had tried quitting at least once during the previous 12 months. Of the participants who tried quitting in the previous 12 months, 80.6% reported experiencing at least one difficulty or withdrawal symptom during their quit attempts.; Of those who tried quitting in the previous 12 months, 69.9% had used at least one method (either pharmacological or nonpharmacological support) to assist their quit attempts.; Motives and preferences for future quit attempt: more than half the participants (58.5%) believed that medication would assist them to quit. The most widely selected strategy to give up smoking was “quit with the help of medicines” (49.5%), followed by “cold turkey” (33.5%) and “reduce gradually” (13.3%). Nicotine patches (54.2%) were the preferred form to assist quitting, followed by tablets (45.0%), inhalers (40.8%), lozenges, (34.7%), electronic “cigarettes” (e-cigarette) (32.3%), chewing gum (27.0%), and sublingual tablets (23.0%).; There is a clear need for patient education regarding evidence-based treatments, and the implications of using unproven treatments should also be explained while also considering patient preferences.
Vick et al. [30]	Quantitative descriptive: before/after survey on receipt, satisfaction and use of services for patients (reach), and staff perceptions and delivery of service (adoption/implementation)	Survey data collected from patients () and staff () at Jesse Brown VA Medical Centre, USA	Postintervention patients reported receipt of services 10% more, and service satisfaction was 10% higher than preintervention patients.; In both before and after intervention implementation, staff felt that the VA should be doing more to assist smokers to quit and felt that providing cessation services was important. Staff confidence in their ability to provide smoking cessation services improved greatly posttraining () as did self-reported delivery of smoking cessation services (). At two-month postintervention, staff survey revealed that the vast majority of staff were extremely/somewhat satisfied with the training sessions.
York et al. [38]	Quantitative descriptive: cross-sectional survey of hospitalised medical-surgical patients who smoke determine their perceived barriers to quitting and participating in a free smoking cessation support program	Current smokers () in acute care medical-surgical units at a community-based hospital in the USA	Subjects’ greatest fears about quitting included becoming tense/nervous, mood swings, fear of failure, and weight gain.; 59.5% of subjects stated that they would be willing to call the free statewide quitline, while 29.1% stated that they were willing to participate in a web-based cessation program.; The majority of subjects preferred the nicotine patch as a cessation aid and were willing to pay for the nicotine patch as a cessation aid after discharge.

Abbreviations: DMs: decision-makers; HCPs: healthcare professionals; OMSC: Ottawa Model of Smoking Cessation; QOL: quality of life; SCCs: smoking cessation coordinators; VA: veterans’ affairs.