Treatment of Smoking Among Older Hospitalized Patients

Background:Quitting smoking at any age lowers morbidity and mortality, and is especially important for older adults. Older smokers may receive less cessation treatment for many reasons, including treatment refusal, yet little is known about treatment of older smokers in health care settings. We hypothesized that older hospitalized smokers would be less likely to 1) be counseled for smoking and 2) be recommended and 3) prescribed smoking cessation medication by healthcare providers.

Methods: We abstracted data from the electronic health record (EHR) and linked tobacco QI database for hospitalized smokers who were admitted to a large US tertiary care facility that had an inpatient tobacco treatment service (TTS). The TTS attempted to counsel identified smokers and for those counseled 5+ minutes, made medication recommendations to the primary hospital team or documented reasons for non-recommendation (patient refusal, medical contraindication). Primary teams could prescribe medications pre or post-TTS consult. We used chi-squared analysis to determine baseline differences by age group (18-49, 50-64, 65+) on demographic, health-related, and smoking-related variables. Multivariable logistic regression assessed the relationship between: 1) receipt of counseling and 2) medication recommendation by TTS providers (Y/N); and medication prescription by primary medical team 3) pre and 4) post-TTS consult (Y/N) after adjustment for significant baseline variables. The UPMC Quality Improvement IRB approved the study.

Results: 3102 hospitalized patients were offered a TTS consult between 1/10/13-4/4/14 (2856 counseled, 2149 of these for >5 minutes). 49% of smokers were 18-49, 38% 50-64, and 13% 65+. Older smokers were more likely to be male (54%,58%,58%, respectively), insured (88%,92%,99%), have ever tried to quit (78%,84%,84%), have a smoking-related primary diagnosis (9%,22%,34%), and be referred by their provider for TTS consult (5%,10%,14%); all p values <0.05. There were no age-related differences in importance, confidence, plan to quit smoking, time-to-first-cigarette, cigarettes per day, or daily smoking. Among 571 smokers who were not recommended medication by the TTS, patient refusal was the most common reason, and older (vs. younger) smokers were more likely to refuse (25%,26%,33%, p=0.02). Medication contraindications were rare and there were no age-related differences. After adjustment (sex, insurance, past quit attempt, smoking-related diagnosis, TTS consult referral), smokers 65+ were equally likely to be counseled and be recommended medications by the TTS, but less likely to be prescribed medication by the primary team both pre-TTS consult (65+ vs. 18-49: OR=0.63, 95% CI 0.46—0.86; 65+ vs. 50-64: OR=0.69, 95% CI 0.5-0.95), and post-TTS consult (65+ vs. 18-49: OR=0.63, 95% CI 0.47-0.83, 65+ vs. 50-64: OR=0.68, 95% CI 0.51-0.91). These results held among the 2022 older smokers who did not refuse medication during the hospital stay.  

Conclusion: Among smokers hospitalized at a large US tertiary care facility, older smokers were as likely as younger smokers to receive counseling and medication recommendations from trained tobacco counselors, but less likely to be prescribed medication by their hospital medical providers. Future analyses should address explanatory reasons at the patient and provider level, as quitting smoking remains a critical goal for smokers at any age.