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Singapore Med J 2004 Vol 45(9) : 430
Smoking cessation programme:
the Singapore General Hospital experience
H C Zow, A A L Hsu, P C T Eng
Conclusion: We strongly recommend that all
inpatients who are smokers to be routinely referred
Introduction: The National Health Survey in
Singapore repor ted that the prevalence of
smoking had decreased from 20 percent in 1984
Keywords: bupropion, counselling, nicotine
to 15 percent in 1998. This may be due to the
dependence, pharmacotherapy, smoking cessation
efforts of smoking cessation education established
Singapore Med J 2004 Vol 45(9):430-434 island-wide. In this study, we review the efficacy of
the Singapore General Hospital smoking cessation
programme and examine the efficacy of different
Tobacco smoking is the single most preventable treatment modalities.
and predictable cause of morbidity and mortality.
Methods: We studied the immediate quit rate
Worldwide, smoking is responsible for at least 3 and point prevalence abstinence rates at six and
million deaths a year(1). In Singapore, smoking- 12 months in our telephone survey. Subjects were
related diseases are responsible for >2,600 deaths patients who attended our programme from June
a year, or seven deaths a day(2). Since the 1970s, 1999 to December 2002. Pharmacotherapeutic aids
the government has been involved in tobacco utilised with counselling sessions were individualised.
control campaigns and activities in Singapore. From 1984, anti-smoking education has been advocated Results: The study populations for outpatient and
inpatient arms were 394 patients and 425 patients,
through smoking control programmes established respectively. In the outpatient programme, mean
at community centres, hospitals, schools and age was 46 years (range of 12 to 80 years), and the
workplaces. A National Health Survey in 1998 showed that the smoking prevalence had decreased ratio between males and females was 8.6. The
from 20% in 1984 to 15% in 1998(3). Although outpatient immediate quit rate was 33 percent,
and the six and 12 month quit rates were both
several studies have been published in major 36 percent. However, in the inpatient programme,
journals on the efficacy of smoking cessation programmes, there is currently no published local mean age was 65 years (range of 15 to 93 years),
or regional data. This study was conducted to review and the ratio between males and females was 4.9.
the effectiveness of the Singapore General Hospital Department of
The six and 12 month quit rates of the inpatient
arms were 30 percent and 32 percent, respectively.
examine the efficacy of different treatment arms in Medicine
Although there is no statistically significant
difference in the different treatment modalities,
the immediate quit rates for bupropion only and
counselling only were relatively higher (36 percent
The SGH smoking cessation programme was officially and 41 percent, respectively). These were sustained
launched in June 1999. This included an outpatient at more than 35 percent at six and 12 months
treatment programme and a one-time counselling follow-up. We achieved comparable efficacy
compared to published data. Counselling, as a
for inpatients. Group therapy was also available which consists of one 30-minute individual evaluation sole therapy, can be effective in a select patient
group. One-time inpatient counselling achieved
session and four 45- minute group counselling Correspondence to:
sessions. Appropriate clinical recommendations a quit rate (32 percent at 12 months) far superior
were given, based on the first clinic visit with the to previously- reported self-quit rate (3 percent
smoking cessation clinic medical officer. The and 8 percent at 12 months).
patients would be routinely given an appointment Singapore Med J 2004 Vol 45(9) : 431
with the smoking cessation counsellor, who was Table I: Characteristics of outpatients and inpatients.
Pharmacotherapy recommended was individualised, which included sustained-release bupropion, 16 hour nicotine patch, and nicotine inhaler. Patients who were more than 18 years old and without medical contraindication for pharmaceutical aid Mean age (range)
were matched with one or more of these aids targeted at their smoking and behavioral pattern.
The regime for various pharmaceutical aids used in the programme were: (1) sustained-release bupropion: 150mg per day was given for the first six days, followed by 150mg twice daily for eight weeks; (2) 16 hour nicotine patch- starting with 15mg Profession
nicotine patch for eight weeks, followed by 10mg for two weeks and 5mg for two weeks, one patch daily; (3) nicotine inhaler- initially six to 12 cartridges per day for eight weeks, thereafter three to six cartridges per day for two weeks, followed by one to three cartridges per day for two weeks.
Patients who were under 18 years old or with medical contraindication for pharmaceutical aids received counselling only. Inpatient counselling involved 15 minutes face-to-face counselling. Patients Source of referral
would be referred to the outpatient programme if they needed further assistance on smoking cessation.
Patients who attended at least one counselling session in the smoking cessation programme between June 1999 and December 2002 were included in the outpatient treatment programme. The study population for inpatient counselling was smokers admitted to SGH and who were referred for smoking cessation counselling. After the last counselling session, the patients were followed-up at six and 12 months through a telephone survey.
treatment arms. Chi-square test was used to evaluate The main outcomes analysed were: outpatient the association between quit rates and number of immediate quit rate, outpatient and inpatient point- sessions attended, and the association between quit prevalence abstinence rates followed-up at six rates and different treatment arms. Stepwise logistic and 12 months, and quit rates of outpatients in regression analysis was applied to identify predictors different treatment arms. Immediate success of for each quit rate. The factors included in the model quitting was defined as a statement that smoking were the number of sessions attended and the had stopped totally before or at the last counselling session. The individual self-reported smoking status was assessed in each session by exhaled carbon monoxide level using mini smokerlyzer as a smoking The characteristics of the outpatients and inpatients biochemical marker. A measurement of carbon are presented in Table I. Intra-departmental referrals monoxide level in expired air of <6ppm was within SGH constituted the major source of outpatient considered a valid reported abstinence(4). The six and referrals. Forty-two patients were discharged from 12 month point prevalence abstinence rates were the programme after the first session because they defined as self-reported smoking status at the time of were more interested in acupuncture or hypnotherapy, or they could not afford the costs of treatment.
Descriptive statistical analyses were performed A total of 436 outpatients attended at least one to assess the overall immediate quit rates, six and session between June 1999 and December 2002.
12 month quit rates, and the efficacy of different The group therapy had enrolled 11 patients in Singapore Med J 2004 Vol 45(9) : 432
Table II: Abstinence rates of outpatients who attended different
the programme, with only four patients completing number of sessions and inpatients who received one-time
all five sessions. There were 446 inpatients referred brief counselling.
for smoking cessation counselling during the same period. Of these, 21 were enrolled into the outpatient programme for further counselling and pharmacotherapy. These patients were grouped under the outpatient programme in the analysis of outcomes. Therefore, the study populations for outpatient and inpatient arms were 394 patients and The overall outpatient immediate quit rate, and six and 12 month quit rates of outpatients and inpatients, and quit rates of outpatients who attended different number of sessions are presented in Table II. For the outpatient programme, subjects who attended more counselling sessions were more likely to quit at the last counselling sessions (p<0.005) and at 6 months follow-up (p=0.004).
Based on self-reported smoking cessation and exhaled carbon monoxide However, this were not apparent at 12 months level at the last counselling session.
follow-up (p=0.132). The quit rates of outpatients ** Point-prevalence abstinence rates based on self-reported smoking in the different treatment arms are shown in Table cessation at the telephone follow-up survey.
III. There is no statistical difference at immediate, n+ total number of patients evaluated.
six and 12 month quit rates between the treatment arms. Using stepwise logistic regression, only the number of sessions was significant at immediate and six month quit rates (p<0.0005 and p=0.019, respectively). For the quit rate at 12 months, neither Table III: Abstinence rates of outpatients in different treatment arms.
the number of sessions nor the treatment arms were significant. However, except for bupropion only and no pharmacotherapy arms, the numbers of patients in the remaining treatment arms were small. The immediate quit rates for bupropion only and no pharmacotherapy arms were relatively higher (36% and 41%, respectively) and these were sustained at >35% at 6 and 12 months DISCUSSION
Previous published data on smoking cessation programme in hospital or outpatient settings reported quit rates of between 19% and 35.5% at 12 months follow-up(5-10). The programme in SGH has achieved comparable efficacy compared to these data, which included different pharmaceutical aids(5-10). Unlike the reported decay in abstinence rate over time(8), our overall abstinence rates appeared to be more Based on self-reported smoking cessation and exhaled carbon monoxide sustained. In our programme, we aimed to provide at level at the last counselling session.
least four individual counselling sessions of ** Point-prevalence abstinence rates based on self-reported smoking 30-minute duration as recommended by the United cessation at the telephone follow-up survey.
States Agency for Healthcare Research and Quality(11).
n+ total number of patients evaluated.
We found that more counselling sessions have an Excluded from analysis because of the very small numbers.
impact on immediate and six month quit rates; however, this was not apparent on 12 month quit rate. The optimal number of sessions for individual Singapore Med J 2004 Vol 45(9) : 433
counselling to achieve long-term quit rate needs to be There are several limitations in this study. First, it is a retrospective study. Therefore, the outpatients were not randomly assigned to different treatment showed similar findings in the efficacy of different arms and the numbers in some treatment arms pharmaceutical aids, as illustrated in previous were small. In addition, unaccounted sources of published trials(8-10). However, it is difficult to bias, such as the patient’s preference for specific compare the various pharmacotherapies due to the pharmacotherapy, may have skewed the efficacy of heterogeneity in the published trials. In our study, different treatment arms. Secondly, self-reported the efficacy of the different treatment arms was abstinence, in the absence of other confirmatory similar. However, except for bupropion recipients sources such as biochemical and third party and patients who received only counselling, verification, may overestimate the cessation rate.
the numbers in each treatment arm were small Finally, the impact of one-time inpatient counselling and all patients were not randomly assigned to may not be significant as these patients are more likely the different treatment arms. Bupropion recipients to quit due to the episode of acute illness. We are had a higher long-term abstinence rate and currently analysing the matched data of smokers patients who were not suitable for pharmaceutical admitted during the same period and those who did therapy also has a high immediate quit rate, which was maintained at >35% during follow-up at On conclusion, despite its limitations, the quit 12 months. In practice, pharmacotherapy should rates of the smoking cessation programme in SGH be individualised rather than randomly assigned.
are comparable, if not superior, to previous studies This was probably one of the reasons for the on such programmes in hospitals or outpatient relatively high and sustained quit rates in our settings involving different pharmaceutical aids.
programme. More research is needed before The good results achieved in this study may be partly evidence-based pharmacotherapy algorithms can due to the use of multiple pharmacological aids during the counselling sessions. Patients who received We could not analyse the results of group only counselling because of contraindication for therapy due to the small sample size. Few patients pharmacotherapy achieved good quit rates in the were interested in the group sessions. The main programme. Counselling, as a sole therapy, can be reason given by our patients was that the group effective in a select patient group. The good results programme was time-consuming. The group therapy of brief inpatient counselling may indicate that consists of a single 30 minute individual evaluation hospitalisation is a critical period to motivate patients session and four group sessions lasting 45 minutes to quit smoking. We strongly recommend all smokers each. During group counselling, it usually takes to be routinely referred for counselling during a longer time to provide mutual support and share resources among group members who face common problems. It is possible that group therapy ACKNOWLEDGEMENTS
is less popular and efficacious in heterogeneous The authors thank Ms Stephanie Fook-Chong, Biostatistician, Department of Clinical Research, For one-time inpatient counselling, which Singapore General Hospital, for providing statistical involved 15 minutes of face-to-face counselling, a quit rate of 32% at 12 months follow-up were achieved.
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