Motivational smoking cessation counselling with proactive referral to community-based follow-up after hospitalisation for vascular disease: a pragmatic, randomised trial

Abstract Introduction One-third of European patients with atherosclerotic cardiovascular-, cerebrovascular-, and peripheral artery disease are daily smokers prior to hospitalisation (1). Motivational interviewing for cessation counselling is recommended but evidence of its effectiveness on long-term cessation rates is limited (2). Purpose To evaluate the effect of an intervention consisting of one session of in-hospital motivational interviewing smoking cessation counselling combined with proactive referral to follow-up in a community-based cessation program on continuous smoking abstinence rates at six and twelve months. Methods We conducted a multi-centre pragmatic, randomised, open, blinded endpoint (PROBE) intervention trial at three secondary care hospitals. We included patients with established atherosclerotic vascular disease smoking ≥ 1 cigarette daily prior to unplanned or elective hospitalisation. Participants were randomised 1:1 to (i) brief advice, a leaflet with contact information for a community-based cessation program, and discharge information to their general practitioner (control), or (ii) identical interventions as (i), plus a single in-hospital motivational counselling session that included referral to the cessation program, and a proactive telephone invitation from the community-based centre staff within two weeks post-discharge (intervention). Results Among 332 screened patients, 110 were excluded, and 221 (67%) were randomised. The mean age was 65 years (SD 10, range of 37 to 85 years), with 40% being women. In intention-to-treat analyses (excluding 7 deaths and one consent withdrawal), 50% (53/107) in the intervention group and 25% (26/106) in the control group reported smoking abstinence at six months (adjusted odds ratio [OR] 3.1, 95% confidence interval [CI] 1.7-5.6, p<0.001), biochemically confirmed in 89% (70/79) with carbon monoxide measurements. The number needed to treat to achieve abstinence in one additional patient who smoke was 4 (95% CI 3 to 8). The intervention increased participation in the cessation programme (41% vs. 11%) and increased the number of participants that obtained coupons for free cessation medications (36% vs. 11%). At 12 months, abstinence was reported by 46% of the intervention group and 28% of the control group (Figure 1). After a median follow-up of 18 months (range 12–24), recurrent vascular events occurred in 26% (28/109) of the intervention group and 34% (38/111) of the control group. Conclusions One session of in-hospital motivational counselling combined with proactive referral to follow-up in a community-based cessation program nearly doubled long-term smoking abstinence rates in patients with atherosclerotic vascular disease. Moreover, early data suggests that the intervention might translate into a numeric reduction in recurrent cardiovascular events and death during a follow-up period of 1-2 years.Figure 1.