AJTCCM VOL. 30 NO. 2 2024 39
ORIGINAL RESEARCH: ARTICLES
Background. South Africa has high tobacco-attributable mortality and a smoking prevalence of 32.5% in males and 25.6% in females. ere
are limited data on smoking prevalence and desire to quit in hospitalised patients, who have limited access to smoking cessation services.
Objectives. To determine smoking prevalence and the extent of nicotine withdrawal symptoms, using a hospital-wide inpatient survey.
Methods. A 1-day point prevalence survey was conducted at Groote Schuur Hospital, Cape Town. All wards except the haematology isolation,
active labour and psychiatry lock-up wards were evaluated. Smoking status, withdrawal symptoms and desire to quit were established.
Results. Smoking status was conrmed in 85.8% of inpatients (n=501/584), of whom 31.9% (n=160) were current smokers; 43.5%
(n=101/232) of male and 21.9% (n=59/269) of female inpatients were smokers. Documentation and conrmation of smoking status was
highest in the maternity wards (100%) and lowest in the surgical wards (79.6%) and intensive care units (70.0%). Smoking prevalence
ranged from 47.6% in male surgical patients to 15.2% in maternity patients. Of the smokers, 54.5% reported being motivated to quit, with
a median (interquartile range) Fagerström test for nicotine dependence score of 4 (2 - 6), and 31.4% reported moderate to severe cravings
to smoke, highest in the surgical wards.
Conclusion. Smoking prevalence was higher in hospitalised patients than in the local general population. Many inpatients were not
interested in quitting; however, a third had signicant nicotine withdrawal symptoms. All inpatients who are active smokers should be
identied and given universal brief smoking cessation advice. Patients with severe withdrawal symptoms should be allowed to smoke outside,
and nicotine withdrawal pharmacotherapy should be provided to those who are bedbound or express a desire to stop smoking during the
current admission.
Keywords. In-hospital smoking cessation, hospitalised, nicotine withdrawal.
Afr J Thoracic Crit Care Med 2024;30(2):e1360. https://doi.org/10.7196/AJTCCM.2024.v30i2.1360
Tobacco use is associated with very high tobacco-attributable
mortality in South Africa (SA), specically in the mixed ancestry
and black African populations.[1] The harms of tobacco smoking
are well established, and of particular concern in Africa are the
colliding epidemics of tobacco smoking, HIV, tuberculosis and
chronic obstructive pulmonary disease.[2] Smokers who are admitted
e need for smoking cessation counselling and nicotine with-
drawal therapy for hospitalised patients: A smoking point preva-
lence study at Groote Schuur Hospital, Cape Town, South Africa
G Soin,1 MB ChB, FCP (SA); J Kok,2 medical student; A Allie,2 medical student; Q Bhawoodien,2 medical student; K Dheda,2 medical
student; A Geragotellis,2 medical student; K Mulisa,2 medical student; A Sibi,2 medical student; T Tarwa,2,3 medical student; F Leone,4 MD;
R N van Zyl-Smit,1 MB ChB, FRCP, MMed (Med), Dip HIV Man (SA), FCP (SA), Cert Pulmonology (SA), PhD, ATSF
1 Division of Pulmonology and UCT Lung Institute, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote
Schuur Hospital, Cape Town, South Africa
2 Faculty of Health Sciences, University of Cape Town, South Africa
3 Molecular Mycobacteriology Research Unit, Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University
of Cape Town, South Africa
4 Division of Pulmonology, University of Pennsylvania, USA
Corresponding author: R N van Zyl-Smit (richard.vanzyl-smit@uct.ac.za)
Study synopsis
What the study adds. A single data point prevalence study of active smokers at Groote Schuur Hospital, Cape Town, was conducted. e
prevalence of smoking was higher in the hospitalised patients than in the general community, but not all smokers were identied by the
clinicians. Although symptoms of nicotine withdrawal were severe in some patients, motivation to quit smoking was not related to the
degree of withdrawal being experienced. Many patients were not motivated to quit smoking.
Implications of the ndings. Better identication of inpatient smokers is required, and all should be given smoking cessation advice.
Withdrawal symptoms can be severe in some patients, and those who are not interested in stopping smoking should allowed to smoke
outside or be provided with nicotine withdrawal pharmacotherapy while in hospital. ose who are willing to quit should be supported
as well as possible, including provision of nicotine replacement therapy or varenicline, and followed up aer discharge as best practice.
40 AJTCCM VOL. 30 NO. 2 2024
ORIGINAL RESEARCH: ARTICLES
to hospital are subjected to enforced tobacco abstinence owing to
government restrictions on smoking indoors, and are required to
smoke outside with permission from nursing sta. Fires in hospital
wards have been caused by patients smoking under their bed sheets.
International best practice identies hospitalised smokers as a group
as at high risk for nicotine withdrawal and complications, but also
highly likely to succeed in quitting if in-hospital cessation programmes
are supported by adequate counselling, nicotine withdrawal treatment
and follow-up.[3] e subsequent benets of smoking cessation in
terms of reducing future health risks are unquestionable. However,
there are no in-hospital smoking cessation programmes in SA, and
there is no access to nicotine replacement therapy for patients with
nicotine withdrawal symptoms.
The estimated smoking prevalence in SA adults is 17.6% (95%
condence interval (CI) 16.3 - 18.9), but it varies between populations
and provinces. Western Cape Province has the highest overall prevalence
of smoking: 32.5% for men (95% CI 32.5 - 43.7) and 25.6% for women
(95% CI 20.6 - 31.4).[4] Published data from the Groote Schuur Hospital
(GSH) outpatient smoking cessation clinic have shown that ~50% of
current smokers have high addiction levels and >25% have very high
dependence levels (Fagerström test for nicotine dependence (FTND)
score >8).[5] ere are no data from SA on the prevalence of smoking in
hospitalised patients, or on which patient group (e.g. pregnant women,
coronary care unit patients, vascular surgery patients or medical
inpatients) has the highest smoking prevalence.
An accurate estimate of the prevalence and distribution of
smoking among inpatients is therefore required to inform the need
for and extent of intervention strategies. As provision of nicotine
replacement therapy for all smokers has been denied on a cost basis,
hospital policy should facilitate smoking outside the building to curb
severe withdrawal symptoms. It is unethical not to manage nicotine
withdrawal in bed-bound smokers, and all smokers should at least be
provided with brief smoking cessation advice and support to quit if
they wish to do so.
We hypothesised that smoking rates are higher in hospitalised
patients than in the background community, and that a limited
number of patients would have severe nicotine withdrawal symptoms
along with a variable desire to quit smoking. We therefore set out
to complete a single-day point prevalence study of all hospitalised
patients in a multidisciplinary tertiary hospital (GSH) in Cape Town,
to determine the prevalence and distribution of smokers across the
hospital and the extent and severity of nicotine withdrawal symptoms
to inform future hospital policies.
Methods
A single-day point prevalence study of all patients admitted to GSH was
conducted. A team of trained medical student researchers identied
every patient currently admitted in the hospital on 9 September 2022.
For every patient, an attempt was made to document their smoking
status. Patient folders were scrutinised for documentation of smoking
status. Patients without documentation were then informed about the
study, and if they consented, questions about their smoking status and
patterns were asked. For active smokers, the presence of any symptoms
suggestive of nicotine withdrawal was then enquired about. Patients
who had stopped smoking immediately prior to admission were
included as active smokers, given the risk for nicotine withdrawal.
Motivation to quit was evaluated using a simple 10-point Likert
scale (motivated dened as scoring ≥7), nicotine dependence was
evaluated using the FTND, and symptoms of nicotine withdrawal
were evaluated using a modied four-axis Minnesota withdrawal
scale to simplify patient interaction. Patients were asked about:
(i) their desire or craving to smoke; and being (ii) angry/irritable/
frustrated; (iii) anxious/nervous; and (iv) sad/depressed in mood.
ese subjective entities were rated with scores of 0 (none), 1 (slight),
2 (mild), 3 (moderate) and 4 (severe).
If patients could not answer questions (owing to being intubated,
confused, or having a low level of consciousness), the hospital notes
were the only source of information to identify whether the patient
was an active smoker. Patients in haematology isolation wards,
acute psychiatry lock-up wards and active labour wards were not
included in the survey. e survey was undertaken when there were
no COVID-19 restrictions in place and active cases of COVID-19 in
the hospital did not require any changes to the hospital workow, i.e.
admissions, surgery, isolation, etc.
Permission to engage with patients and conduct the study was
provided by the GSH administration and the University of Cape
Town Faculty of Health Sciences Human Research Ethics Committee
(ref. no. HREC214/2017), and informed consent was provided by
all smokers prior to further in-depth questioning. All smokers were
provided with an ‘in-hospital’ focused smoking cessation pamphlet,
and those identied with symptoms suggestive of severe nicotine
withdrawal were brought to the attention of the attending medical
sta.
All available patients were surveyed on a ward-by-ward basis to
capture the entire hospital population. Data were presented using
descriptive statistics, and appropriate parametric and non-parametric
analyses were used to determine dierences between groups.
Results
A total of 584 patients were documented in the hospital on 9
September 2022. All wards except the haematology isolation, active
labour and acute psychiatric lock-up wards were surveyed, and 503
patients (86.1%) had their smoking status conrmed by either in-
person conversation or medical le review. Smoking status could not
be conrmed in 81 patients owing to a low level of consciousness/
confusion/intubation, etc. and lack of smoking status/history
documentation in the patient’s folder. A further two patients had
incomplete data entry, leaving 501 inpatients for full data analysis.
A total of 160 hospitalised patients (31.9%) were identified as
active smokers. Overall, 43.5% (n=101/232) of male inpatients and
21.9% (n=59/269) of female inpatients were smokers. Of these, 34.4%
(n=55/160) did not provide consent for further interaction with the
researchers or to receive smoking cessation counselling. A nal total
of 105 smokers were recruited for additional engagement to complete
the smoking survey and were provided with brief counselling.
Documentation of smoking status varied signicantly across the
various hospital inpatient wards. e maternity wards had the most
comprehensive documentation of smoking status (100%) and the
intensive care/high-care units the lowest (70.0%). e surgical wards
were significantly poorer in terms of documentation of smoking
status (79.6%) compared with the medical wards (91.4%) (p<0.001).
e median (range) age of the smokers was 47 (14 - 77) years, which
AJTCCM VOL. 30 NO. 2 2024 41
ORIGINAL RESEARCH: ARTICLES
was comparable to the 47 (21 - 96) years for
non-smokers. e mean (standard deviation
(SD)) age of patients in the surgical wards
was signicantly lower at 46.9 (17.3) years
than that in the medical wards (51.1 (17.9)
years) (p=0.02).
e prevalence of smoking was numerically
higher in the surgical compared with the
medical wards, including both genders, but
this did not reach statistical significance
(Table 1). e maternity wards had the lowest
prevalence of smoking at 15.2%. Only male
gender (odds ratio (OR) 2.64; 95% CI 1.7 -
4.1) was associated with smoking status, not
age or ward type.
Of the 160 inpatient smokers, 105 (65.6%)
provided informed consent to further
engagement around willingness to quit and
potential nicotine withdrawal symptoms. e
mean (SD) age of initiating smoking was 16.7
(5.9) years. e median (interquartile range
(IQR)) number of cigarettes smoked per day
during the 3 months prior to admission was 6
(4 - 15), with a median (IQR) of 15.5 (6 - 30.5)
pack-years of consumption. e current (past
3 months) cigarette consumption reported
by the patients (median (IQR) 6 (4 - 15) per
day) was lower than that during their years
of smoking overall (10 (5 - 20) per day)
(p=0.0002). is held true for both medical
(10 v. 14/day; p=0.006) and surgical (5.5 v. 10/
day; p=0.008) patients.
A total of 83 of the patients who were
interviewed about their smoking (79.0%)
reported having thought about quitting, with
a median (range) of 2 (0 - 10) attempts to quit
during the past year. e median (IQR) FTND
score was 4 (2 - 6) (Fig. 1). Severe nicotine
dependence (score 37) was documented in
20.6% of inpatient smokers, and 54.5% of
smokers were currently motivated to quit
(Likert scale score 37), with 18.8% ‘not at all
interested’. ere was no correlation between
desire to quit and nicotine dependence.
On assessment of symptoms of nicotine
withdrawal using a modified Minnesota
withdrawal scale, the overall median (IQR)
score was 2 (0 - 5), indicating mild symptoms.
e ‘desire or craving to smoke’ was moderate
to severe in 31.4% of smokers (n=33),
57.6% of whom were in surgical wards. e
distributions of the individual scores are
depicted in Fig. 2.
To evaluate the potential identifiers of
patients with nicotine withdrawal-related
symptoms, we correlated the severity of
cravings with the FTND score, the number of
cigarettes smoked daily, and the motivation to
quit. ere was a strong positive correlation
between the FTND score and presence/
intensity of cravings to smoke (Pearson
r=0.41; p<0.001). ere was no correlation
between the number of cigarettes smoked
daily and the cravings reported, and there
was also no correlation between the presence
of cravings and the motivation to quit. No
gender dierences were associated with the
presence of cravings, motivation to quit, or
the FTND score. e odds of having cravings
to smoke were higher in the surgical wards
than in the medical wards (OR 1.38; 95% CI
1.06 - 1.83), with a mean ‘cravings’ score of 2
in the surgical wards compared with 1 in the
medical wards (p=0.017).
Discussion
e prevalence of smoking in hospitalised
patients in the present study was high,
although inadequately documented in
many wards. The presence of withdrawal
symptoms was not ubiquitous, although it
was signicantly higher in surgical compared
with medical wards. Only half of the inpatient
smokers expressed a current motivation to
quit, with ~20% reporting no interest at all
in quitting. One-third of the smokers had
signicant nicotine withdrawal symptoms,
but could not be provided with nicotine
withdrawal pharmacotherapy. Support of
hospitalised smokers is an ethical imperative
20
15
10
5
0
0 1 2 3 4 5 6 7 8 9 10
Relative frequency, %
Fagerström score
Fig. 1. Distribution of nicotine dependence scores as dened by the Fagerström test for nicotine
dependence in hospitalised smokers. (Interpretation of the score: 0 - 1 = low, 2 - 3 = average, 4 - 5
= above average, 6 - 7 = high, 8 - 10 = extreme nicotine dependence.)
Table 1 Comparison of hospital ward types and smoking status by gender
Ward type Gender, % female Overall smokers, % Male smokers, % Female smokers, %
Medical (n=266 patients) 50.6 31.7 43.3 20.3
Surgical (n=201) 47.5 36.9 47.6 25.0
ICU/HCU (n=50) 45.7 37.1 31.6 43.8
Maternity (n=46) 100 15.2 n/a 15.2
Ophthalmology (n=17) 47.1 23.5 33.3 12.5
ICU/HCU = intensive care unit/high-care unit; n/a = not applicable.
42 AJTCCM VOL. 30 NO. 2 2024
ORIGINAL RESEARCH: ARTICLES
and should be tailored to the wards and the
unique requirements of hospitalised smokers,
but for this to happen, smoking status must
be established routinely.
The present study suggests that the
prevalence of smoking in hospitalised patients
is higher than the background estimates for
the local Cape Town population. Although
prevalence data on hospitalised smokers are
lacking from Africa in general and from other
low- to middle-income countries, there are
supporting ndings from a recent national
observational study in the UK that found the
prevalence of smoking to be higher than in
the background population.[6] In contrast,
a multi-hospital study in Spain found that
smoking rates were similar in hospitalised
individuals compared with the general
population.[7] Two small studies in Brazil
showed that smoking rates in hospitalised
patients varied, with a 13.2% smoking
prevalence in cardiovascular disease wards[8]
and a 17% prevalence in a general tertiary
hospital.[9] Smoking prevalence is clearly
dependent on the hospitalised population
being evaluated. At GSH in the present study,
lower rates (~15%) were seen in the generally
younger obstetrics group, in comparison with
the nearly 50% smoking prevalence in the
male surgical wards.
Unfortunately for many patients,
documentation in the clinical records was
insucient to determine the patient’s smoking
status. For example, it was noted that in the
obstetric wards, there was a pre-printed clerking
book with tick boxes and checklists including
smoking status. In the general surgical
wards, the clerking notes were very ‘problem
orientated’, oen not documenting smoking
status. Uniform clerking sheets (provided they
are lled out) would improve comprehensive
documentation of issues pertinent to the
patient. In patients with reduced level of
consciousness/confusion/intoxication or
intubated and sedated, for example, the ability
to document smoking status is dependent
on obtaining collateral history. Establishing
smoking status is important in patients with
reduced levels of consciousness, as nicotine
withdrawal is associated with delirium and
oen unrecognised.[10,11] As it is not possible to
obtain this information from the patient, the
attending clinician has to establish this history
from the patient’s family members.
For many patients, hospitalisation is
an opportunity for smoking cessation.
The phrase ‘teachable moment’[12] is often
used, which is pejorative but also belies the
complexity of smoking cessation in hospital
and in the context of low-income settings.
e success of in-hospital smoking cessation
is limited, and a multidisciplinary approach
with provision of pharmacological support
and follow-up after discharge is required.
[3] Our local clinic data also indicate that
smoking is often a coping mechanism
for life stressors, and ‘teaching’ is not an
appropriate response.[5] For ~20% of patients
in the present study there was no expressed
interest in stopping smoking, so initiation of
a programme would be likely to have limited
success.
It could further be argued that provision
of nicotine replacement therapy to prevent
withdrawal is futile, and allowing the patient
to exit the building to smoke would be the
most cost-eective option to reduce cravings.
is would obviously be done in conjunction
with simple brief smoking cessation advice.
For patients with significant nicotine
withdrawal symptoms who are unable to exit
the building to smoke, nicotine replacement
therapy or other pharmacotherapy must be
provided to alleviate withdrawal symptoms,
without the intention of this being a smoking
cessation intervention upon discharge. For
those patients with a desire to stop smoking
during the current admission, counselling
and the provision of nicotine withdrawal
pharmacotherapy to manage cravings would
be with the express goal of sustained smoking
cessation upon discharge.
In the present study, the proportion of
smokers in the hospital was higher than in the
background population at ~32%, with nearly
half of the male patients in surgical wards
being current smokers. It was noticeable
that reported cigarette consumption was on
average lower during the 3 months prior to
admission. is decrease was seen in both
surgical and medical ward patients, and
is likely to be driven by patients admitted
with relapsing or chronic illness rather
than, for example, acute trauma. Further
studies are required to better understand
the phenomenon and its implications. It
is important that all sta in every ward be
adequately trained to provide brief smoking
cessation counselling, cognisant that the goals
of the advice are dependent on the individual
patient’s situation. Similarly, recognising that
withdrawal symptoms may result in disruptive
Anxious, nervous feelings
Score
Score
Score
Score
Relative frequency, %
Relative frequency, %
Relative frequency, %
Relative frequency, %
80
70
60
50
40
30
20
10
0
85
80
70
60
50
40
30
20
10
0
85 80
70
60
50
40
30
20
10
0
85
80
70
60
50
40
30
20
10
0
85
0 1 2 3 4
0 1 2 3 4 0 1 2 3 4
0 1 2 3 4
Desire/craving to smoke feelings Angry, irritable, frustrated feelings
Depressed mood feelings
Fig. 2. Presence and severity of symptoms potentially related to nicotine withdrawal reported by
hospitalised smokers. (Scoring system: 0 = none, 1 = slight, 2 = mild, 3 = moderate, 4 = severe.)
AJTCCM VOL. 30 NO. 2 2024 43
ORIGINAL RESEARCH: ARTICLES
behaviour and not allowing the patient to exit the building to smoke
is counterproductive. Appreciation and understanding of withdrawal
symptoms should be non-judgemental and actively managed, as one
would do for a patient with alcohol or cocaine/heroin withdrawal.
Study limitations
is study has several limitations. e survey was done on a single
day, so the balance of preoperative/postoperative patients may
be biased given that the survey took place on a Friday. ere are
inherent limitations to the scoring instruments used, especially in ill
hospitalised patients. Symptoms of nicotine withdrawal could overlap
with alcohol/drug withdrawal symptoms and are confounded by
acute medical/surgical conditions, so it is not possible to be 100%
certain that all the symptoms reported would be relieved by nicotine
replacement therapy or being allowed to smoke. It was not possible
to identify the primary diagnosis of each patient to ensure that every
smoker in a surgical ward in fact had a surgical problem. Furthermore,
patients’ ability to exit the building and the attending sta ’s willingness
to facilitate smoking outside the building were not evaluable. Patients
who were not in their hospital bed, having gone for a ‘smoke break’ to
combat withdrawal symptoms, may not have been captured, resulting
in an underestimation of withdrawal symptoms. In future, a detailed
survey of wards with a high smoking prevalence should be undertaken
to identify barriers to smoking outside the building, unless nicotine
withdrawal interventions are provided to smokers.
Conclusions
ere was found to be a higher prevalence of inpatient smokers in a
multidisciplinary tertiary SA hospital than in the general population.
Severe nicotine dependence was documented in a h of inpatient
smokers, and a third had experienced withdrawal symptoms with
moderate or severe cravings to smoke. A comprehensive approach
to inpatient smoking is required to address withdrawal symptoms
and engage in formal smoking cessation in those who are interested,
founded on complete documentation of smoking status and provision
of brief counselling to all smokers.
Declaration. RNvZS is a member of the editorial board.
Acknowledgements. e authors t hank the GSH administration and
ward sta who permitted the survey to be conducted.
Author contributions. Study design: RNvZS, FL, GS. Data collection: GS,
JK, AA, QB, KD, AG, KM, AS, TT. Data analysis: RNvZS. All authors
contributed to manuscript preparation and review.
Funding.None.
Conicts of interest.None.
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Received 4 August 2023. Accepted 25 March 2024. Published 4 July 2024.
