Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-023965 on 19 December 2018. Downloaded from Smoking behaviours of Hong Kong Chinese hospitalised patients and predictors of smoking abstinence after discharge: a cross-sectional study Ka Yan Ho,1 William Ho Cheung Li,1 Katherine Ka Wai Lam,1 Man Ping Wang,1 Wei Xia,1 Lok Yin Ho,1 Kathryn Choon Beng Tan,2 Hubert Kit Man Sin,3 Elaine Cheung,4 Maisy Pik Hung Mok,4 Tai Hing Lam5 To cite: Ho KY, Li WHC, ABSTRACT Strengths and limitations of this study Lam KKW, et al. Smoking Objectives Patients admitted to hospitals represent an behaviours of Hong Kong excellent teachable moment for smoking cessation, as ► This is the first study to investigate the smoking Chinese hospitalised patients they are required to abstain from tobacco use during and predictors of smoking behaviours of hospitalised patients in a Chinese hospitalisation. Nevertheless, smoking behaviours of abstinence after discharge: a context. hospitalised patients, and factors that lead to smoking cross-sectional study. BMJ Open ► This is the first study to identify contributing factors abstinence thereafter, remain relatively underexplored, 2018;8:e023965. doi:10.1136/ that lead to smoking abstinence after patients are particularly in a Hong Kong Chinese context. This study bmjopen-2018-023965 discharged. aimed to examine the smoking behaviours of hospitalised ► Biochemical validation was not conducted to verify ► Prepublication history for patients and explore factors leading to their abstaining this paper is available online. self-reported abstinence; therefore, results could be from cigarette use after being hospitalised. To view these files, please visit biased by social desirability. Design A cross-sectional design was employed. the journal online (http:// dx. doi. ► Participants were asked to provide details on their Setting This study was conducted in three outpatient org/ 10. 1136/ bmjopen- 2018- smoking behaviour during their hospital stay and clinics in different regions in Hong Kong. 023965). after discharge, which may have resulted in recall Participants A total of 382 recruited Chinese patients. bias. Received 3 May 2018 Primary and secondary outcome measures The Revised 11 September 2018 patients were asked to complete a structured Accepted 19 October 2018 questionnaire that assessed their smoking behaviours http://bmjopen.bmj.com/ before, during and after hospitalisation. associated with numerous diseases, including Results The results indicated 23.6% of smokers smoked stroke, diabetes, cancer, coronary heart secretly during their hospital stay, and about 76.1% of disease and respiratory disease,2 all of which smokers resumed smoking after discharge. Multivariate contribute to substantial amounts of hospital- logistic regression analysis found that number of days © Author(s) (or their isation and healthcare expenditure, posing of hospitalisation admission in the preceding year (OR employer(s)) 2018. Re-use a serious challenge to medical systems.3 1.02; 95% CI 1.01 to 1.27; p=0.036), patients’ perceived permitted under CC BY-NC. No Although the prevalence of daily cigarette commercial re-use. See rights correlation between smoking and their illness (OR 1.08; and permissions. Published by 95% CI 1.01 to 1.17; p=0.032), withdrawal symptoms smoking in Hong Kong has decreased from on September 29, 2021 by guest. Protected copyright. BMJ. experienced during hospitalisation (OR 0.75; 95% CI 23.3% in 1982 to 10.5% in 2015, 641 300 4 1School of Nursing, The 0.58 to 0.97; p=0.027) and smoking cessation support everyday smokers remain, and 400 000 University of Hong Kong, Hong from healthcare professionals (OR 1.18; 95% CI 1.07 to hospitalisations per year are attributable to Kong, China 5 2 1.36; p=0.014) were significant predictors of smoking smoking. Such compelling numbers cannot Department of Medicine, The abstinence after discharge. University of Hong Kong, Hong be overlooked or neglected. Conclusions The results of this study will aid Kong, China Hospitalisation represents an excellent 6 3Department of Medicine and development of appropriate and innovative smoking teachable moment for smoking cessation. Geriatrics, Tuen Mun Hospital, cessation interventions that can help patients achieve This is because being hospitalised with a more successful smoking abstinence and less relapse. Hong Kong, China smoking-related disease may impel change in 4Department of Medicine and Trial registration number NCT02866760. Geriatrics, United Christian smokers’ perceptions of their personal vulner- Hospital, Hong Kong, China ability, which in turn can greatly enhance 7 5School of Public Health, The their motivation to quit. Furthermore, hospi- University of Hong Kong, Hong INTRODUCTIOn talised smokers may have more available time Kong, China Cigarette smoking, responsible for around to receive intensive smoking cessation inter- Correspondence to 7 million deaths annually worldwide, is the ventions, which can remarkably increase 1 Dr William Ho Cheung Li; single greatest preventable cause of death. It their chances of successful abstinence after william3@ hku. hk harms nearly every organ in the body and is discharge.8 Additionally, a smoke-free policy Ho KY, et al. BMJ Open 2018;8:e023965. doi:10.1136/bmjopen-2018-023965 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-023965 on 19 December 2018. Downloaded from has been implemented in all public hospitals in Hong smoking behaviours of hospitalised patients in hospitals Kong since 2007. Violating the policy results in a fixed with smoke-free policies. It also sought to identify factors fine of HK$1500 (~US$192).9 Implementation of such leading to smoking abstinence after discharge. a policy may promote smoking cessation, as it prompts smokers, on hospital admission, to undergo an abrupt stop from their habitual use of tobacco. It also creates a METHODS smoke-free environment that temporarily facilitates absti- Study design nence by separating hospitalised smokers from smoking A cross-sectional study was conducted in outpatient clinics 10 cues. of three acute hospitals in different regions in Hong Kong. Given that habitual smoking in patients who have All participating hospitals had been awarded full accred- diseases can reduce the efficacy of clinical and medical itation status by the Australian Council on Healthcare treatments, and increase the risk of treatment-related Standards.16 These three hospitals were chosen because 11 side effects, and that smoking abstinence is enforced they are the largest acute regional hospitals and patients during hospitalisation, it is of paramount importance were normally referred back for medical follow-up in the for healthcare professionals to seize this golden oppor- outpatient clinics after discharge. tunity to promote cessation and help patients quit. The clinical guidelines for treating tobacco use and nico- Participants tine dependence also emphasise the importance of Patients were eligible for this study, if they were (1) targeting smoking cessation interventions at hospitalised aged ≥18 years, (2) able to speak Cantonese, (3) current smokers.12 Nevertheless, cigarette smoking is addictive, smokers who resumed smoking or ex-smokers who had quitting is extremely difficult and the rate of relapse is quit smoking after hospitalisation, and (4) hospitalised 13 high, especially among patients with diseases. It is there- in either a medical or surgical unit for ≥48 hours in the fore crucial that healthcare professionals first understand previous 3 months. ‘Ex-smokers’ in this study referred to how hospitalised smokers perceive the risks of smoking, patients who reported not having smoked in the preceding and their behaviour towards smoking, before any effec- 7 days. We excluded patients with mental illnesses or tive, appropriate smoking cessation intervention can be cognitive and learning problems noted in their medical planned, developed and evaluated. records because previous studies suggest such people Numerous studies in the West have investigated smoking possess smoking characteristics different from those of behaviours of hospitalised patients.10 14 15 In a secondary smokers in general.17 Including them in the study might analysis of data from a randomised control trial on 650 therefore bias the results, impeding generalisability to all adult smokers admitted to an urban teaching hospital, hospitalised smokers. 4% self-reported violating policy by smoking indoors.10 The sample size was calculated based on the results of Another cross-sectional study of 229 hospitalised smokers previous literature that indicated 46%–56.8% of smokers http://bmjopen.bmj.com/ found 60%–70% complied with the smoke-free policy.14 were willing to quit during hospitalisation.2 18 We assumed A study of 79 hospitalised smokers revealed about 75% a similar proportion of our participants were willing and intended to quit after discharge.15 However, the majority adopted a 95% confidence level. The sample size could perceived their symptoms associated with nicotine crav- be obtained using the following formula: ings would be a primary barrier towards maintaining N = [Z2 ×p (1 – p)]/e2 abstinence.15 Indeed, a study revealed smokers with nico- where Z represents the number of SD from the mean, tine cravings were more likely to smoke while hospitalised which is 1.96; p refers to the expected proportion, which 10 than those who did not report cravings. Additionally, is 0.46 in this case; and e is the margin of error, which is on