Secondhand tobacco smoke (SHS) exposure increases nonsmokers’ risk of coronary heart disease and worsens outcomes after hospitalization for acute coronary syndrome, but it is rarely addressed in inpatient cardiac care. We developed and assessed a hospital-based intervention to increase nonsmokers’ awareness of SHS as a cardiovascular risk factor. Nonsmokers admitted to 2 cardiac units of a large Boston, Massachusetts, hospital were surveyed before (May 2010 to January 2011) and after (November 2011 to March 2012) a system-level nurse-delivered intervention was implemented in October 2011. It consisted of a revised admission form that prompted nurses to document SHS exposure at admission, provide a pamphlet about SHS risks, and advise nonsmokers to make their home and car smoke free. The primary outcome was patients’ short-term recall of advice to keep their home and car smoke free. The secondary outcome was patients’ awareness of the cardiovascular risk of SHS exposure. We enrolled 190 nonsmokers before and 142 nonsmokers after implementation. Adjusting for group differences, patients admitted after the system change were more likely to recall being asked if a household member smokes (24% vs 10%, adjusted odds ratio [AOR] 3.6, 95% confidence interval [CI] 1.8 to 7.1, p = 0.0002) and being advised to keep their home and car smoke free (28% vs 2%, AOR 27.3, 95% CI 7.8 to 95.7, p <0.0001). After the intervention, more patients believed that SHS exposure increased cardiovascular risk for nonsmokers (42% vs 21%, AOR 2.6, 95% CI 1.6 to 4.4) and for themselves (39% vs 22%, AOR 2.2, 95% CI 1.3 to 3.8). In conclusion, a system-level intervention in cardiac units successfully increased hospitalized nonsmokers’ awareness of the cardiovascular risk of SHS exposure.
Highlights
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A revised admission template prompted nurses to address secondhand smoke (SHS).
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We tested it in a pre-post study in 2 cardiac units of a large hospital.
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After the change, more patients recalled advice to keep their home smoke free.
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After the change, more patients knew that SHS was a cardiovascular risk factor.
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A simple tool increased inpatients’ awareness of SHS as a cardiovascular risk factor.
Secondhand tobacco smoke (SHS) exposure increases nonsmokers’ coronary heart disease (CHD) risk by 25% to 30%. Among nonsmokers hospitalized with acute coronary syndrome, higher levels of SHS exposure at admission are associated with higher 30-day postdischarge morbidity, mortality, and hospital readmission rates. Health care professionals are well positioned to inform hospitalized nonsmokers about avoiding the risk of SHS exposure but rarely do so. We developed an intervention to inform adult nonsmokers hospitalized with CHD about the risk of SHS exposure and assessed its effect on patients’ awareness of and attitudes about the health effects of SHS. The intervention aimed to increase hospital nurses’ delivery of brief advice to patients to adopt a smoke-free policy for their home and car. We chose this message because US homes and cars are now the major sources of adult nonsmokers’ SHS exposure. Laws and regulations have reduced SHS exposure in many public places, workplaces, restaurants, and bars, but even if these were adopted nationwide, they will not be sufficient to reduce SHS exposure in homes and cars. Reducing SHS exposure will also require persuading individuals to voluntarily adopt smoke-free policies for their homes and cars.
Methods
The study was conducted at Massachusetts General Hospital, a 900-bed hospital in Boston, Massachusetts. A pre-post study design assessed the effectiveness of an intervention in 2 inpatient cardiac units with a total of 72 beds. Research staff interviewed nonsmokers admitted to the participating units before (May 26, 2010, to January 27, 2011) and after (November 8, 2011, to March 18, 2012) the intervention was implemented on October 19, 2011. The Institutional Review Board of Massachusetts General Hospital/Partners HealthCare approved the study.
The intervention was a system-level change in nurses’ workflow for admitting patients. Standard nursing practice at Massachusetts General Hospital requires completion of a nursing admission data set for every new patient within 24 hours of admission. The intervention added to this data set (1) a question assessing patients’ SHS exposure (“Does anyone ever smoke in your home or car?”), (2) a statement of advice to be read to all patients (“In order to keep your heart healthy, you need to keep your home and car smoke free”), and (3) a prompt reminding nurses to distribute a pamphlet about SHS exposure (“Give the patient the smoke-free home pamphlet.”). We created a pamphlet that described the risk of SHS exposure to patients with cardiac disease and advised patients to protect themselves by adopting smoke-free rules for home and car ( Figure 1 ). Before the start of the intervention, nursing leaders notified all staff about the program by e-mail, and research staff introduced it at an educational session in each unit. A monthly meeting with nurses on each unit provided feedback about the unit’s performance.
To assess the implementation of the intervention, research staff conducted bedside interviews with nonsmokers admitted to the participating units with a diagnosis of CHD. This occurred on average on days 2 to 3 of the hospital stay. Patients were ineligible if they were aged <18 years, did not speak English, had used tobacco or nicotine replacement in the past 30 days, had no chart-documented CHD diagnosis, or were deemed by their nurse to be medically or cognitively inappropriate for a bedside assessment. Study staff screened records of patients newly admitted to the participating units to identify potentially eligible patients. The patient’s nurse approached each potentially eligible patient to request permission for research staff to visit. Study staff confirmed eligibility, obtained oral informed consent, and conducted a 10-minute assessment at the patient’s bedside.
The primary outcome measure was a patient’s report of having received advice to adopt a smoke-free policy for the home or car (“Since your admission to the hospital has a doctor, nurse, or other health professional advised you to keep your home or car smoke-free?”). Secondary outcome measures included a patient’s report of being asked in the hospital about potential SHS exposure (“Since your admission to the hospital has a doctor, nurse or other health professional asked you if you are exposed to other people’s tobacco smoke? Asked if anyone in your household smokes?”). Patients were asked if they recalled receiving the smoke-free pamphlet (“Has anyone given you a handout about making your home smoke-free?”). If not, research staff showed the patients the pamphlet and asked if they recalled seeing it.
Patients’ awareness of the risk of SHS exposure was assessed with 3 questions that measured patients’ awareness of risk to (1) nonsmokers’ overall health (“Do you think that breathing smoke from other people’s cigarettes is harmful to a nonsmoker’s health?”), (2) nonsmokers’ cardiovascular health (“Do you think that breathing smoke from other people’s cigarettes increases a nonsmoker’s chance of having a heart attack?”), and (3) the individual’s own cardiovascular health (“Do you think that breathing smoke from other people’s cigarettes increases your own chance of having a heart attack?”). Patients were also asked if they were worried about their current SHS exposure. Responses were dichotomized as “very” or “a lot” versus all other categories combined in the analysis.
We assessed demographic factors, recent SHS exposure (presence of a smoker in the household, any exposure in the 7 and 30 days before hospital admission in the home, in a car, and at work), and the rules about smoking in the patient’s home and car, using items adapted from a previous survey. The question about smoking rules was asked as follows, “Please tell me which of the following statements best describes how tobacco smoking is handled in your home … in the car in which you travel most often.” Response categories were collapsed for analysis to “no one is allowed to smoke” versus all others.
Analyses were conducted using SAS, version 9.3 (SAS Institute Inc., Cary, North Carolina). We compared covariates and outcome measures between preimplementation and postimplementation groups using 2-sample t tests and Fisher’s exact tests. We used multiple logistic regression models to adjust for potential confounding in the relation between time and outcome measures. Because of the restriction of the sample size, the models for being asked if a household member smokes, being advised to keep home and car smoke free, and attitudes about SHS outcomes included only the 3 factors that were imbalanced between groups at baseline (smoker in household, SHS exposure in car in the past 30 days, and strict home smoking policy). The models for beliefs about SHS outcomes included additional 4 preselected covariates (age, gender, race, and education). We also explored the effect of nurses’ advice as a mediator of patients’ beliefs and attitudes about SHS in these models.
Results
We enrolled 190 participants before implementation and 142 participants after implementation ( Figure 2 ). In the preintervention period, 2,289 nonsmokers were admitted to study floors, of whom 1,522 (67%) met criteria for CHD diagnosis and 209 (9%) met all eligibility criteria; 190 (91%) of eligible patients enrolled in the study. Reasons for ineligibility are shown in Figure 2 . The main reason was that patients were discharged before study staff could recruit them. During the postimplementation period, 1,397 nonsmokers were admitted to the study floors and screened for eligibility. Of these, 1,106 (79%) met criteria for CHD diagnosis and 147 (11%) met all eligibility criteria; 142 (97%) of the eligible patients enrolled in the study. Preimplementation and postimplementation groups were similar in age, gender, race, and education ( Table 1 ). The only statistically significant difference in recent SHS exposure was past-month exposure in the car, which was more frequent before the intervention. Smoke-free home and car policies before hospital admission were more frequent after the intervention than before ( Table 1 ).
| Variable | Before Implementation (5/2010–1/2011) (N = 190) | After Implementation (11/2011–3/2012) (N = 142) | p Value |
|---|---|---|---|
| Age (mean, SD) | 68 (11) | 70 (11) | .18 |
| Male | 73% | 73% | 1.00 |
| Race/ethnicity | |||
| Nonhispanic white | 81% | 82% | 1.00 |
| Nonhispanic black | 1% | 0% | |
| Hispanic | 5% | 5% | |
| Other | 13% | 13% | |
| Education | |||
| High school graduate or less | 42% | 31% | .12 |
| Some college or vocational school | 12% | 14% | |
| 4-Year college graduate or more | 46% | 55% | |
| Live with a smoker | 15% | 8% | .06 |
| Exposed to secondhand smoke in past 30 d | |||
| Home | 14% | 7% | .07 |
| Car | 16% | 6% | .003 |
| Workplace † | 15% | 15% | 1.00 |
| Any of above | 22% | 14% | .07 |
| Home or car only | 18% | 11% | .12 |
| Exposed to secondhand smoke in past 7 d | |||
| Home | 9% | 6% | .30 |
| Car | 6% | 3% | .29 |
| Home or car | 11% | 7% | .25 |
| Smoke-free home policy (=no one allowed to smoke vs. all other) | 66% | 89% | <.0001 |
| Smoke-free car policy ‡ (=no one allowed vs. all other among those with car) | 72% | 92% | <.0001 |
∗ By eligibility criteria, no patient had smoked in the past 30 days.
† Limited to those who worked outside the home.
‡ Among those who have a car or travel in a car at least once per week.
Table 2 displays the univariate analysis of outcome measures. More patients in the postimplementation group recalled having been asked in the hospital if anyone in their household smoked (24% vs 10%, p = 0.0004) and being advised to keep their home or car smoke free (28% vs 2%, p <0.0001). One quarter of patients recalled having received the smoke-free pamphlet and another 28% recognized the pamphlet when study staff showed them a copy; therefore, a total of 53% of patients had some recollection of the pamphlet ( Table 2 ). We found a similar result in a subanalysis limited to the 39 patients who lived with a smoker and were expected to be at highest risk of SHS exposure after hospital discharge. After the intervention, compared with before, 46% versus 7% (p = 0.012) of these patients recalled having been asked if anyone in their household smoked and 64% versus 0% (p <0.0001) of them recalled being advised to keep their home or car smoke free. Almost 1/2 of the at-risk subgroup (46%) recalled having received the smoke-free home pamphlet, and 64% had some recall of receiving the educational pamphlet.
| Variable | Before Implementation (N = 190) | After Implementation (N = 142) | p Value |
|---|---|---|---|
| Since admission to the hospital, has a doctor, nurse, or health professional … | |||
| Asked if you are exposed to other people’s tobacco smoke | 17% | 16% | 1.00 |
| Asked if anyone in your household smokes | 10% | 24% | .0004 |
| Advised you to keep your home or car smoke-free | 2% | 28% | <.0001 |
| Given you a handout about making your home smoke-free ∗ | |||
| Yes | 25% | ||
| No, but recognizes it when shown a sample | 28% | ||
| No, does not recognize it when shown a sample | 47% | ||
| Patient recalls receiving pamphlet or recognizes it when shown a sample ∗ | 53% | ||
| Beliefs and concern about SHS exposure (%) | |||
| SHS is harmful to nonsmokers’ health (very harmful vs. all other) | 58% | 57% | .91 |
| SHS increases nonsmokers’ risk of a heart attack (a lot vs. all other) | 21% | 42% | <.0001 |
| SHS increases your own risk of a heart attack (a lot vs. all other) | 22% | 39% | .001 |
| Worry about current SHS exposure (very vs. all other) | 13% | 23% | .018 |
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