Nurse-led post-discharge cessation support for smoking patients using mobile-based intervention : a randomized clinical trial

Abstract

Background Hospitalization provides a teachable moment for smokers to achieve temporary abstinence, but many smokers continue to smoke after discharge. While mobile health is increasingly popular in delivering personalized smoking cessation interventions, its application in hospitalized patients remains understudied. This thesis examined the effectiveness of interactive mobile-based intervention and active referral to smoking cessation services on smoking cessation in hospitalized patients after discharge. Methods Before the main trial, two population-based surveys in 2021-2022 were conducted to assess the associations of smoking and quitting behaviours with cardiopulmonary health status among current smokers. A secondary analysis was conducted to identify the quitting trajectories of Chinese adult smokers in a community-based smoking cessation program during 2014-2021. In a two-arm, parallel-group, pragmatic, multicenter randomized controlled trial (ClinicalTrials.gov NCT05430789), smoking patients who were hospitalized were proactively recruited from 3 public hospitals in Hong Kong and equally randomized into intervention or control group. Participants in both groups received brief advice and a self-help e-booklet at baseline. Intervention group further received 3-month chat-based personalized behavioural support on smoking cessation and offers of referral to smoking cessation services. Control group received a similar frequency of text messages on general health and follow-up reminders for attention control. Participants, outcome assessors, and data analysts were blinded to group allocation. The primary outcome was biochemically validated abstinence at 6 months, analyzed by intention-to-treat. Results In two population-based surveys, smokers with cardiopulmonary diseases (41.8%, 1426/3420) had greater nicotine dependence, more quit attempts and smoking cessation service use, but showed no difference in intention to quit within 30 days than those without such diseases. The secondary analysis identified four quitting trajectories of 8300 Chinese adult smokers, including quitters (4.6%), returners (6.8%), reducers (54.8%), and persistent smokers (33.8%). Nicotine dependence, previous quit attempts, intention to quit, and perceived importance of and confidence in quitting were significant predictors of trajectories. In the main trial, 770 hospitalized smoking patients were recruited and randomized into the intervention (n=385) and control (n=385) group. 50.1% had no intention to quit at baseline, and 53.2% were primarily diagnosed with circulatory or respiratory diseases. The intervention group than control group had a higher biochemically validated abstinence at 6 months (20.0% vs 10.4%; RR 1.93; 95%CI 1.35 to 2.75) and self-reported 7-day PPA at 3 months (29.9% vs 18.2%; RR 1.64; 95%CI 1.26 to 2.13). No significant difference was found in 6-month self-reported 7-day PPA (27.3% vs 23.6%; RR 1.15; 95%CI 0.91 to 1.47). Biochemically validated abstinence rates did not differ significantly in subgroups. Engagement rate in using only chat-based intervention was 57.4% and was associated with higher validated abstinence (adjusted RR 1.64; 95%CI 1.05 to 2.56; P 0.028).

Conclusion This study first shows the effectiveness of interactive mobile-based support integrated with active referral to community smoking cessation services among a cohort of hospitalized smoking patients. Effective engagement in the chat-based intervention highlighted its feasibility. Future studies are warranted to explore the application of mobile-based interventions in other populations or for other modifiable behaviours among hospitalized patients.