Forty-six million US smokers account for 6-12 million hospitalizations each year. These admissions provide a teachable moment for tobacco control. Advances in health information technology (HIT), like electronic medical records (EMR), provide an opportunity to implement evidence-based, cost-effective, sustainable programs in tobacco treatment for hospitalized smokers. The overall goal of this proposal is to study the effectiveness of a novel Integrated Tobacco Order Set (ITOS), embedded within an EMR, in promoting sustained smoking abstinence in a cohort of adult inpatients. We propose a 2-arm trial, randomized by provider, of ITOS + Academic Detailing (AD) at Yale-New Haven Hospital (YNHH) compared to AD alone. Subjects admitted to physicians in the AD arm may receive a smoking cessation brochure and medications ordered electronically, our standard of care. Providers in the ITOS arm will access an electronic order set that includes: (1) medication orders for varenicline, bupropion and nicotine replacement therapy;(2) a fax automatically sent to the patient's primary care provider, informing him/her of the initiation of tobacco treatment (3 an electronic fax sent to the state smokers'quitline (QL) for post-discharge treatment (4) a prompt at discharge encouraging prescription of outpatient pharmacotherapy, and (5) a set of 5 or more QL-initiated counseling calls to subjects for 2 months post-discharge. Prior to study initiation, internal medicine and emergency medicine housestaff and hospitalists will be trained in tobacco treatment. ITOS will be activated, and will cover all inpatient units. Outcome measures include biochemically confirmed tobacco abstinence and an economic analysis. Follow-up will be done at 1, 6, and 12 months. The primary aim of this project is to determine whether ITOS+AD compared to AD improves 12-month smoking cessation in 960 smokers age >18 years admitted to YNHH. Secondary aims are to 1) evaluate ITOS's ability to encourage smokers to engage in treatment;2) assess ITOS's ability to enhance inpatient treatment of smoking;and 3) conduct an economic analysis of the intervention. Study findings and a toolkit will be disseminated through various professional societies and organizations. The study team consists of an outstanding group of investigators with rich experience in tobacco treatment, provider training, implementation science, and HIT.

Public Health Relevance

Millions of smokers are admitted each year to US hospitals. These admissions may be a good time to begin treating tobacco dependence. This study will evaluate whether an electronic order set can improve the treatment of hospitalized smokers, and reduce their prevalence of smoking.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (ZHL1-CSR-K (M1))
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Stoney, Catherine
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Yale University
Emergency Medicine
Schools of Medicine
New Haven
United States
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Bernstein, Steven L; Rosner, June; DeWitt, Michelle et al. (2017) Design and implementation of decision support for tobacco dependence treatment in an inpatient electronic medical record: a randomized trial. Transl Behav Med 7:185-195
Schindler-Ruwisch, Jennifer M; Abroms, Lorien C; Bernstein, Steven L et al. (2017) A content analysis of electronic health record (EHR) functionality to support tobacco treatment. Transl Behav Med 7:148-156