AJTCCM VOL. 30 NO. 2 2024 33
EDITORIAL
e panoply of detrimental health eects directly linked to tobacco
smoking cannot be overstated.[1] A staggering mortality toll, exceeding
5 million deaths annually, is directly attributed to tobacco smoking
– awholly preventable, or at least modiable, risk factor.[2] It is a
startling fact that new tobacco users, frequently adolescents, may
become dependent aer as few as four cigarettes.[3] Furthermore,
only ~4% of smokers will achieve sustained abstinence without
adequate support.[3] Despite the known risks of smoking, nicotine
withdrawal and the potential for severe symptoms, there is a glaring
absence of in-hospital smoking cessation programmes and access to
nicotine replacement therapy. ese interventions have been proven
to signicantly enhance cessation rates, highlighting the urgency of
addressing this gap in healthcare provision.
In this edition of AJTCCM, Soin etal.[4] shed light on the prevalence
and consequences of smoking among inpatients at a single tertiary
hospital in Cape Town, South Africa (SA). eir ndings underscore
the urgent need for comprehensive strategies to address tobacco use
in healthcare settings. ey explore the potential role for smoking
cessation measures to be instituted at this critical time point of
hospitalisation. eir reported prevalence of smoking may be an
under-representation as, like many other studies of hospital inpatients
and smoking prevalence, they excluded groups with historically
high levels of tobacco use, specically those admitted for mental
health disorders. Nonetheless, the study reveals a startlingly high
prevalence of active smokers among hospitalised patients, with nearly
a third (32%) of inpatients identied as smokers. is prevalence far
surpasses the general population estimates in SA (18%), as well as
inpatient hospital prevalences in other countries such as the UK (25%)
and Spain (20%), indicating a unique and concerning smoking trend
among individuals seeking medical care in our country.[5,6]
Furthermore, the research highlights disparities in smoking
documentation across hospital wards, with some departments
signicantly lacking in terms of accurately recording patients’ smoking
status, with a total of 86% of the patients’ smoking status being
conrmed. Accurate recording was highest at 100% in the maternity
unit and lowest in the surgical and critical care wards (70-79%). is
oversight not only hampers eorts to address tobacco use, but also
undermines patient care by neglecting a crucial aspect of their medical
history.
No signicant dierence in smoking prevalence was found across
various wards, although numerically the prevalence in the maternity
ward was almost half of that found in most other wards. is dramatic
difference alludes to the importance of the preventive medicine,
counselling and education that form the backbone of most antenatal
programmes, which take place at a time when signicant changes are
happening in the mothers’ lives. e article also found that males were
almost twice as likely to be smokers, with a prevalence of 43% compared
with 22% for females, with an odds ratio of 2.64 (95% condence interval
1.7 - 4.1). e median age of smokers was 47 years, while alarmingly
the mean age of initiation was 16.7 years in a country where the legal
minimum age to purchase tobacco products is 18 years.
Once all the smokers were identied, two-thirds of them gave consent
to further explore patterns of nicotine use, dependence, withdrawal
symptoms and willingness to quit. In this part of the article, the study
exposes the inadequacy of current support systems for smokers in
hospitals. As would be expected, many patients reported a pattern of
declining tobacco use during the 3 months leading up to admission,
which probably reects overall declining health during this time. In
fact, an overwhelming majority of 83 of the 105 smokers interviewed
(79%) reported that they had considered quitting during the
preceding year and had made more than one quit attempt. Over half
of the inpatient smokers expressed current motivation to quit, while
~20% had no interest in quitting. Signicant proportions of patients
experienced severe dependence, had symptoms of withdrawal and
experienced moderate to severe cravings to smoke while admitted,
most of which were most common in the surgical wards. Although the
risks associated with nicotine withdrawal and the possibility of severe
symptoms are recognised, in-hospital smoking cessation programmes
and availability of nicotine replacement therapy are conspicuously
lacking. ere is a dearth of evidence to illustrate the importance and
impact of both motivational counselling and pharmacotherapy, even
dual pharmacotherapy with nicotine replacement and varenicline,
in strengthening sustained abstinence from smoking.[7-9] is failure
to address the needs of hospitalised smokers is not only ethically
dubious but also represents a missed opportunity for intervention and
improved patient outcomes.
Soin etal.[4] highlight that this same vulnerable group of patients
at risk for nicotine withdrawal and complications has increased
chances of successful smoking cessation if in-hospital programmes
are supported by adequate counselling, nicotine withdrawal treatment
and follow-up.[7] There is much in the literature to support the
premise that a ‘shotgun’ approach to target smoking cessation at a
time of major health crisis or change may have increased impact and
likelihood of success. Adult smokers with a new diagnosis of stroke,
diabetes, cancer, or lung or heart disease were 3.2 times more likely
to quit smoking than patients without a new health problem, while
cessation was also more likely in patients undergoing surgery, both
emergency and elective.[7,10,11] All quit attempts are strengthened by
the provision of at least a month of further counselling and support,
as well as pharmacotherapy where applicable.[7] It goes without saying
that the subsequent benets of smoking cessation on future health
risks are unquestionable. Few things in modern medicine rival
smoking cessation in its eect on improving overall health status and
all-cause mortality. On an individual level, a saving of ZAR13500 per
year would be possible for a pack-a-day smoker, with the average pack
costing ZAR38.[12]
The study findings call for immediate action to prioritise the
identification and support of smokers, ensuring that all patients
receive appropriate counselling and assistance to quit smoking if they
so desire. is should include implementing routine screening for
smoking status in all wards, providing access to nicotine replacement
therapy for those who medically require it, and oering cessation
counselling and interventions based on patients’ preferences while they
are in contact with the health system. It is simply an opportunity that
cannot be squandered. Healthcare professionals must be adequately
trained to address smoking cessation effectively, recognising the
Smoking cessation for hospitalised inpatients: Butt where do we begin?
34 AJTCCM VOL. 30 NO. 2 2024
EDITORIAL
complex nature of tobacco addiction. A multidisciplinary approach
that integrates smoking cessation support into routine clinical care
and empowers patients to make informed decisions about their health
should be a unifying goal.
Ultimately, addressing smoking among hospitalised patients is
not just a matter of public health, but also a moral imperative. By
prioritising the well-being of individuals struggling with tobacco
addiction, we can make meaningful strides towards a healthier future
for all South Africans. e time has come for hospitals to step up and
take decisive action to support smokers in their journey towards better
health. e evidence is clear, the need is urgent, and the opportunity
for positive change is within reach. Let us seize this chance to make a
dierence, and blow away the plume of ill health shrouding the lives
of those who need our help so much!
Nevadna Singh, MB ChB, FCP (SA), Cert Pulmonology (SA)
Division of Pulmonology, Department of Medicine, Faculty of
Medicine and Health Sciences, Stellenbosch University and Tygerberg
Hospital, Cape Town, South Africa
nevadnasingh@sun.ac.za
Coenraad F N Koegelenberg, MB ChB, FCP (SA), FRCP, PhD
Division of Pulmonology, Department of Medicine, Faculty of
Medicine and Health Sciences, Stellenbosch University and Tygerberg
Hospital, Cape Town, South Africa
1. Van Zyl Smit RN, Pai M, Yew WW, etal. Global lung health: e colliding epidemics
of tuberculosis, tobacco smoking, HIV and COPD. Eur Respir J 2010;35(1):27-33.
https://doi.org/10.1183/09031936.00072909
2. World Health Organization. WHO report on the global tobacco epidemic, 2017:
Monitoring tobacco use and prevention policies. Geneva: WHO, 2017. https://www.
who.int/publications/i/item/9789241512824 (accessed 13 May 2024).
3. World Health Organization. WHO report on the global tobacco epidemic 2021:
Addressing new and emerging products. Geneva: WHO, 2021. https://www.who.int/
publications/i/item/9789240032095 (accessed 13 May 2024).
4. Soin G, Kok J, Allie A, etal. e need for smoking cessation counselling and nicotine
withdrawal therapy for hospitalised patients: A smoking point prevalence study at
Groote Schuur Hospital, Cape Town, South Africa. Afr J oracic Crit Care Med
2024;30(2):e1360. https://doi.org/10.7196/AJTCCM.2024.v30i2.1360
5. Martínez C, Fu M, Castellano Y, et al. Smoking among hospitalized patients:
Amulti-hospital cross-sectional study of a widely neglected problem. Tob Induc Dis
2018;16:34. https://doi.org/10.18332/tid/92927
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hospital admissions from a national observational study. Eur Respir J 2017;50(Suppl
61):PA1268. https://doi.org/10.1183/1393003.congress-2017.PA1268
7. Rigotti NA, Clair C, Munafo MR, Stead LF. Interventions for smoking cessation in
hospitalised patients. Cochrane Database Syst Rev 2012, Issue 5. Art. No.: CD001837.
https://doi.org/10.1002/14651858.CD001837.pub3
8. Van Zyl-Smit RN, Allwood B, Stickells D, etal. South African tobacco smoking
cessation clinical practice guideline. S Afr Med J 2013;103(11):869-876. https://doi.
org/10.7196/SAMJ.7484
9. Koegelenberg CFN, Noor F, Bateman ED, etal. Ecacy of varenicline combined
with nicotine replacement therapy vs varenicline alone for smoking cessation:
Arandomized clinical trial. JAMA 2014;312(2):155-161. https://doi.org/10.1001/
jama.2014.7195
10. Keenan PS. Smoking and weight change aer new health diagnoses in older adults. Arch
Intern Med 2009;169(3):237-242. https://doi.org/10.1001/archinternmed.2008.557
11. Shi Y, Warner DO. Surgery as a teachable moment for smoking cessation.
Anesthesiology 2010;112(1):102-107. https://doi.org/10.1097/ALN.0b013e3181c61cf9
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Trends Organ Crime 2020;23:242-262. https://doi.org/10.1007/s12117-019-09372-9
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