Stepped Care Approach to Smoking Cessation in Patients Hospitalized for Coronary Artery Disease

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Abstract
Smoking cessation is an important goal for smokers with coronary artery disease (CAD) because it reduces cardiac morbidity and mortality. Effective interventions for cigarette smokers with CAD exist, but they often are considered to be intensive and expensive. Steppedcare interventions have been proposed as a promising way to allocate smoking cessation treatments in a cost-effective manner. Stepped care refers to the practice of initiating treatment with low-intensity intervention and then exposing treatment failures to successively more intense interventions. To address the efficacy of this approach, 254 cigarette smokers hospitalized with CAD were provided a brief cessation intervention. The participants then were assigned randomly to either a more intensive stepped-care treatment (counseling and nicotine patch therapy) or no additional treatment. Outcomes were point-prevalent abstinence measured 3 months and 1 year after hospital discharge. Stepped-care treatment increased smoking cessation rates from 42% to 53% during a 3-month follow-up period (P = .05), but showed little effect at the 1-year follow-up assessment, as evidenced by a cessation rate for the minimal intervention group of 36% versus 39% for the stepped-care group (P = .36). A stepped-care approach to smoking cessation increased short- but not long-term point-prevalent abstinence in patients with CAD. For improvement of long-term effectiveness, refinement of the timing and content of stepped-care interventions needs to occur.