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General Hospital Psychiatry 32 (2010) 599–606

General hospital admission as an opportunity for smoking-cessationstrategies: a clinical trial in Brazil☆

Renata Cruz Soares de Azevedo, M.D., Ph.D.a,⁎, Marisa Lúcia Fabrício Mauro, M.Sc., Ph.D.b,Daniela Dantas Lima, M.Sc.b, Karla Cristina Gaspar, M.D., M.Sc.b,

Viviane Franco da Silva, M.D., M.Sc.b, Neury José Botega, M.D., Ph.D.baFCM UNICAMP, PO Box 6111, 13083-887 Campinas, SP, Brazil

bDepartment of Medical Psychology and Psychiatry, College of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil

Received 23 June 2010; accepted 22 September 2010

Abstract

Objective: To compare the results of 6-month follow-ups for hospitalized patients who were divided into two groups of low- and high-intensity treatments for smoking cessation and compared to the results of standard hospital treatment.Methods: A total of 2414 patients were screened. Two hundred thirty-seven current smokers were randomly assigned to high-intensityintervention (HII; 30-min motivational interview plus seven routine telephone calls after hospital discharge) or to low-intensity intervention(LII; 15-min counseling about the benefits of quitting) and 80 comprised the usual care (UC) group. Six months after hospital discharge, allparticipants were contacted by phone. The main outcome measure was smoking cessation.Results: The smoking-cessation rates were 44.9%, 41.7% and 26.3% for the HII, LII and UC groups, respectively (P = .03). Themultivariable analysis identified the following variables which are associated with the failure to stop smoking: the absence of a tobacco-related disease (TRD), younger age and a low motivation for cessation at the initial contact.Conclusions: There was a great difference between intervention and nonintervention. The LII had an impact similar to the HII. The variablesassociated with no smoking cessation demonstrate the need for more personalized interventions for smokers who present lower indexes ofmotivation, are younger and do not have smoking-related diseases.© 2010 Elsevier Inc. All rights reserved.

Keywords: Smoking; Smoking cessation; Intervention; Inpatient

1. Introduction

Approximately 15-25% of medical and surgical inpatientsare smokers [1,2]. Tobacco-related diseases (TRD) constituteone of the main reasons for all general hospital admissions[3]. During hospital stays, patients should be advised to stopsmoking because this decision has been related to reductionsin morbidity and mortality [4]. Nevertheless, the use ofpsychoactive substances has been frequently ignored in thispopulation, and general internists often discharge patients from

☆ Funding: This work was supported by the Research Foundation of theState of São Paulo (grant no. 06/61885-6).

⁎ Corresponding author. Tel.: +55 19 33531639; fax: +55 19 33531639.E-mail address: azevedo.renata@uol.com.br (R.C.S. de Azevedo).

0163-8343/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2010.09.013

tertiary care without sufficiently addressing opportunities forsmoking prevention [1,5].

A Spanish study indicates that, although 19% ofinpatients are currently smokers, less than a third remem-bered having been asked about smoking during their stay inhospital. The study therefore concludes that smokingcessation is still not a priority in hospitals [6].

Hospitalization, especially for a TRD, may boost apatient's receptivity to smoking-cessation interventions.Many hospitals restrict or prohibit patients from smokingto protect the other patients and staff from the effects ofpassive smoking. This smoke-free environment may alsoprovide an opportunity for hospitalized smokers to attempt toabstain from smoking. For this reason, providing (or at leastinitiating) tobacco dependence treatments in hospitals maybe an effective preventive health strategy [7,8].

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To our knowledge, no Brazilian studies to date haveinvestigated the effects of smoking-cessation interventions ina sample of patients admitted to a general hospital. Thisstudy compared the results of 6-month follow-ups forhospitalized patients who were divided into two groups oflow- and high-intensity treatments, respectively, for smokingcessation. These results were also compared to the results ofstandard hospital treatment.

2. Methods

2.1. Design and setting

This article presents a randomized clinical trial withsmoking inpatients which was conducted in a publicuniversity hospital. Smoker patients were randomly allocat-ed to two intervention groups: low-intensity intervention(LII) or high-intensity intervention (HII). Six months afterbeing discharged from hospital, all participants received afollow-up telephone call and were reassessed.

The 394-bed hospital, affiliated with the Campinas StateUniversity, is the most specialized medical center availableto approximately 5 million people living in the metropolitanarea of the city of Campinas, Brazil. In the year 2009,326,000 people were seen at the outpatient clinics, 13,600people were hospitalized and 13,300 surgeries wereperformed. The average length of stay was 8.4 days. Thehospital is a smoking-free environment [9].

2.2. Subjects

Between October 2007 and June 2008, the research teamapproached 2414 (85.1%) out of 2837 patients aged 18 yearsor older consecutively admitted to the hospital wards, withthe exception of the intensive care and psychiatric units. Inthe case when a patient was admitted multiple times in thisperiod, only their first hospital admission was considered.

The criterion for inclusion in this smoking-cessation trialwas a patient report of a smoking habit of at least one cigarettesmoked daily immediately prior to hospital admission.Twenty-four individuals (1%) declined to participate in thescreening, and 337 (13.9%) were excluded (reasons given inthe flowchart in Fig. 1). Among them, 55 smoker patients whopresented with alcohol use disorders (AUD)were assigned to atrial on treatment strategies for AUD which was beingconducted at the same time of the current study.

Of the 353 individuals who fulfilled the inclusion criteria,273 were randomly assigned to either the LII or the HIIgroup. Eighty patients who were identified as smokers couldnot be approached again because of early hospital discharge.As these patients were lost to randomization, they receivedassistance according to the norms that prevail in the hospital.(Typically, the study hospital does not provide routinemental health assessment or treatment.) The hospital staffwas responsible for the treatment decisions according tousual hospital practice. This means that this latter group,

called the “usual care” (UC) group, received no specialistcounseling for smoking cessation while hospitalized.

For a significance level of 95% (two-sided) and a powerof 90%— assuming 20% and 50% smoking cessation in theLII and HII groups, respectively — it would be necessary tofollow-up with a total of 228 subjects after 6 months.

2.3. Screening interview

The screening interview was conducted at the patient'sbedside within 72 h of admission. All participants answereda questionnaire comprising sociodemographic items andself-report instruments, described below, all of whichpreviously validated in general hospital settings in Brazil.

Smoking was assessed by a single question: “Have yousmoked daily during the previous month?” Individuals whosmoked at least one cigarette a day were considered smokersand asked to complete the Fagerström Test for NicotineDependence (FTND) [10]. This is a standard method forassessing the intensity of nicotine dependence on a scale oflow (score b4), moderate (4–6) and severe (≥7) [3].

The patient's wish to stop smoking was assessed with aself-report 10-point scale anchored by 0 (no wish) and 10(very strong) which asked: “How strong is your wish to stopsmoking?”

The Hospital Anxiety and Depression Scale (HADS)comprises 14 multiple-choice items on anxiety and depres-sion [11]. Whenever a patient's score was equal to 8, orabove, in each subscale, a “case” of anxiety, or depression,was determined. This cut-off point corresponds to the criteriapreviously adopted by a local validation study [12].

The Alcohol Use Disorder Identification Test (AUDIT)comprises 10 multiple-choice items that identify the risk ofhazardous and harmful alcohol use when its score is equal to8 or higher [13,14].

The Charlson Comorbidity Index (CCI) [15,16] wasoriginally designed to measure the risk of 1-year mortalitythat is attributable to comorbidity using a longitudinal studyof patients admitted to general hospitals. Its contents andweighting scheme are based on Cox proportional riskmodeling. Two senior researchers reviewed the patients'charts and independently coded the baseline CCI and thepresence of TRDs [17,18]. Any disagreements were solvedby consensus. Information about the reasons for hospitaladmission (coded according to ICD 10) and currenttreatment was also collected from patient charts.

Screening interviewers were available every workday ofthe recruitment period. Twenty medical students weretrained to administer the screening questionnaire. Thistraining consisted of three 2-h modules, which comprisedintroductions, role-playing interviews and two practiceinterviews with patients under the supervision of the mainresearch team. All items of the self-report assessments wereread aloud by the interviewer to every patient to control forpotential illiteracy or poor schooling. No inter-rate reliabilityassessment was performed.

Low Intensity Intervention

n=132

High Intensity Intervention

n=141

Usual Care n=80

108 analysed 107 analysed 76 analysed

FOLLOW-UP

353 current smokers fulfilled inclusion criteria

80 lost to randomization

24 refused to participate

337 excluded: Smokers presenting alcohol use disorders assigned to alcohol study: 55 Severe clinical condition: 156 Living out of catchment area: 59 Discharge due in few hours: 55

SCREENING n=2414

RANDOMISATION

Fig. 1. Flowchart of subjects in the randomized trial on smoking-cessation intervention.

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2.4. Randomization and intervention

Within 48 h of the initial screening, a smoking-cessationcounselor interviewed each smoker patient. In this interview,information on the patient's smoking habit was gathered.Following this step, each patient was randomly assigned toone of two treatment groups when the counselor opened theenvelope that contained the patient's allocation.

An allocation sequence based on a random-number tablewas used to randomly assign all enrolled subjects to eitherLII or HII. The allocation was maintained in a seriallynumbered, opaque envelope, which was opened at the Phase2 interview to prevent counselor bias. The subjects wereblind to their assignments to the specific treatment groups. Inthe consent form, subjects were asked to agree to a follow-upwithout specification of the number and time of follow-upcontacts. This information was given only after subjects hadbeen randomly assigned to their groups.

The LII consisted of a 15-min session of individualcounseling session in which a trained smoking-cessation

counselor advised patients to “stop smoking.” The counselorreviewed the dangers of smoking and the benefits of quitting;furthermore, the counselor suggested that, after beingdischarged from hospital, the patient should seek help tostop smoking.

The HII consisted of a 30-min session of individualcounseling by a trained smoking-cessation counselor, whoperformed a motivational interview [19,20] with the patient.This style of interview was tailored to the patient's specificgoals for quitting smoking. The counselor reviewed thedangers of smoking and the benefits of quitting, assessed theparticipant's knowledge and beliefs about smoking cessationand provided counter-arguments to potential barriers to cessa-tion. This intervention also included a discussion of behavioralself-management techniques to counter known relapse triggerssuch as stress, the presence of other smokers and anxiety.

In both LII and HII, patients were advised to seek help forsmoking cessation after they were discharged from hospital.They received no smoking-cessation pharmacotherapyduring hospitalization or on discharge to home.

Table 1Baseline characteristics of the smoker patients by treatment group

Characteristics n Usual care (%) Low-intensity intervention (%) High-intensity intervention (%) P

Total 353 80 (24.2) 132 (37.4) 141 (39.9)SexMale 231 57 (71.2) 84 (63.6) 90 (63.8) .4a

Female 122 23 (28.7) 48 (36.4) 51 (36.2)Mean age (years) 353 49.2 47.8 47.6 .7b

Years of formal education (mean) 353 6.0 6.4 5.8 .4b

Marital statusSingle 59 12 (15) 20 (15.3) 27 (19.5) .9a

Married 210 48 (60) 79 (60.3) 83 (58.8)Divorced 30 9 (11.2) 11 (8.4) 10 (7.1)Widow 53 11 (13.7) 21 (16.0) 21 (14.9)

Occupational statusHousewife 15 2 (2.5) 7 (5.4) 6 (4.3) .06a

Economically active 147 35 (44.3) 65 (50.4) 47 (34.1)Economically inactive 184 42 (53.1) 57 (44.2) 85 (61.6)

Reason for admissionSurgical 195 55 (68.7) 65 (49.6) 75 (53.6) .02a

Medical 156 25 (31.2) 66 (50.4) 65 (46.4)Tobacco-related diseaseYes 160 29 (36.2) 70 (53.4) 61 (43.6) .04a

No 191 51 (63.7) 61 (46.6) 79 (56.4)Charlson Comorbidity Index0–2 234 55 (69.6) 88 (66.7) 91 (64.5) .4a

≥3 118 24 (30.4) 44 (33.3) 50 (35.5)Prior use of psychotropic medicineYes 63 11 (15.7) 25 (20.3) 27 (21.3) .6a

No 257 59 (84.3) 98 (79.7) 100 (78.7)DepressionYes 70 13 (16.2) 23 (17.6) 34 (24.1) .2a

No 282 67 (83.7) 108 (82.4) 107 (75.9)AnxietyYes 157 29 (47.5) 67 (51.1) 61 (43.6) .4a

No 175 32 (52.5) 64 (48.8) 79 (56.4)a Chi-square test.b Kruskal–Wallis test.

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After discharge, the same counselor who had conducted themotivational interview contacted the HII group patients forseven follow-up telephone calls according to a specific timelineover 6months (at 1, 2 and 3weeks, and at 1, 2, 3 and 4months).Each call lasted approximately 10min. It was an opportunity toreinforce motivation for stopping smoking (or maintainingabstinence). The style of the interview was in line with themotivational interview performed during hospitalization.

Six months after hospital discharge, all participants (i.e.,from the LII, HII and UC groups) were contacted bytelephone and reassessed using a standardized form. Themain outcome measure was smoking cessation, as deter-mined by self-reported abstinence (7-day point prevalenceabstinence). The assessment was made by the same counselorwho had made the initial interview and follow-up contacts.

All of the smoking-cessation counselors who participatedin the study (four psychologists, two nurses and oneoccupational therapist) had specialist postgraduate trainingin motivational interview and smoking-cessation therapy.They had been practicing smoking-cessation therapy for atleast 2 years and were actively involved in the hospital'soutpatient clinic for the treatment of nicotine dependence.

Style interview in both LII and HII was the focus of a 4-htraining prior to the beginning of the study. Individualsessions with the patients were conducted according to awritten protocol, which all counselors adhered to. Counse-lors and main researchers met fortnightly along the studyperiod for clarification of any doubt that might have arisen.

2.5. Data analysis

LII and HII groups were compared using the chi-squareand Kruskal–Wallis tests for categorical and continuousvariables, respectively. Multivariate logistical regressionanalysis with stepwise selection was used to obtain adiscriminate profile of the patients who reported that theycontinued to smoke at the 6-month follow-up. Variables withP≤.20 in the univariate analysis were included using astepwise selection algorithm, combining the features offorward selection and backward elimination. After the firstvariable was entered, the value of the criterion wasreevaluated for all variables not in the model, and thevariable with the largest acceptable criterion was enterednext. At this point, the variable entered first was reevaluated

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to determine whether it met the removal criterion. If it did, itwas removed from the model. The odds ratios (OR) wereobtained and the respective 95% confidence intervals werecalculated (95% CI). The statistical program used was SAS(Statistical Analysis System) version 8.02.

For the purposes of statistical analyses, the variableoccupational status was grouped according to the followingcriteria: economically active (full-time, part-time andtemporary employees), economically inactive (unemployed,on leave of absence because of ill health or retired) andhousewives. Other variables were recoded in dichotomousformat, as shown by the results in the tables.

An institutional research ethics committee approved thisstudy. All individuals enrolled agreed to participate andsigned a consent form. No kind of financial assistance orincentive was offered to the participants.

3. Results

The baseline characteristics of the participant patients,organized by treatment group, are shown in Table 1. Ahigher proportion of surgical patients and a lower proportionof TRDs were both observed in the UC group. Smokingcharacteristics were similar in the three groups (Table 2).

Overall, 62 (17.6%) individuals could not be contactedfor follow-up (LII=24, HII=34, UC=4). This attrition wasmostly due to address change (n=32), death (n=28) and re-

Table 2Smoking characteristics at baseline

Characteristics (%) Usualcare (%)

Total 80Age at initial smoking (years) 14.4 (5.1)Years smoked≤24 18 (27.7)25–39 21 (32.3)≥40 26 (40)Mean (S.D.) 33.7 (16.3)Number of cigarettes/dayduring last month1–10 20 (30)11–20 36 (52.2)N20 13 (18.8)Mean (S.D.) 18.9 (12.1)Prior smoking-cessation attemptYes 55 (77.5)No 16 (22.5)Severity of nicotine dependenceLow 20 (41.7)Moderate 23 (47.9)Severe 5 (10.4)Current wish to stop smokingYes 72 (90)Noc 8 (10)

a Kruskal–Wallis test.b Chi-square test.c Scored 0 on the 10-point scale.

hospitalization (n=11). Ninety-seven percent of the tele-phone calls scheduled for the HII group were completed forthose patients who completed the study.

Table 3 shows the outcome at the time of the 6-monthfollow-up assessment. LII and HII produced similar propor-tions of smoking cessation (41.7% and 44.9%, respectively)as opposed to the 26.3% of patients who stopped smoking inthe UC group.

Among those who were continuing to smoke when theywere contacted for the 6-month follow-up assessment, thenumber of cigarettes smoked daily was lower in the HII. Theprofile of these individuals was obtained by means of amultivariate regression analysis, the results of which areshown in Table 4 (only results that were statisticallysignificant on the final multivariate model are shown).

4. Discussion

This study reports on the treatment of hospitalizedsmokers in a different context than has been seen in theliteratures to date which have drawn almost exclusively onhospitalized population in North America and Europe. Thisis the first Brazilian study to describe and evaluate differentapproaches to smoking cessation in smokers, focusing onboth the in-hospital and post-discharge time periods. Theresults validate the benefits of opportune interventionsduring a hospital admission.

Low-intensityintervention (%)

High-intensityintervention

P

132 14116.1 (6.3) 15.8 (5.9) .08a

46 (35.1) 50 (35.7) .5b

47 (35.9) 43 (30.7)38 (29) 47 (33.6)31.6 (15.8) 31.7 (15.3) .7a

42 (32.1) 56 (40.3) .5b

63 (48.1) 60 (43.2)26 (19.8) 23 (16.5)18.8 (12.2) 16.9 (11.7) .3a

107 (81.7) 108 (77.1) .6b

24 (18.3) 32 (22.8)

43 (32.8) 56 (40.3) .2b

57 (43.5) 61 (43.9)31 (23.7) 22 (15.8)

118 (89.4) 127 (90.1) .8b

14 (10.6) 14 (9.9)

Table 3Outcome at the 6-month follow-up

Characteristics n Usualcare (%)

Low-intensityintervention (%)

High-intensityintervention (%)

P

Total 291 76 (26.1) 108 (37.1) 107 (36.7)Stopped smokingYes 113 20 (26.3) 45 (41.7) 48 (44.9) .03a

No 178 56 (73.7) 63 (58.3) 59 (55.1)Number of cigarettes

smoked daily (median)291 10 5 2 .001b

Received smoking-cessationspecialist therapyc

Yes 16 9 (12) 5 (4.6) 2 (1.9) .01a

No 273 66 (88) 103 (95.4) 104 (98.1)a Chi-square test.b Kruskal-Wallis test.c Received public health care services during post-discharge period, as the patient's option.

able 4ultiple regression analysis of patient characteristics associated withontinuing smoking at the 6-month follow-up

haracteristics OR ORa 95% CI P

o tobacco-related disease 1.43 1.05–1.94 .02oung age (18-35 vs 51-62 years old) 1.53 1.01–2.33 .04o wish to stop smoking at baselineb 1.06 1.01–1.13 .04

a Odds ratio 95% confidence interval.b Scored 0 on the 10-point scale (see Methods).

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4.1. Smoking cessation in a “teachable moment”

The attrition rate of patients from the study at the 6-monthfollow-up was similar to other international studies [8,21]which showed rates from 12% to 18%. Curiously, there wasa greater attrition rate from the HII group, which, at leastpartially, could suggest a negative effect from the moreintensive intervention. This phenomenon deserves to beevaluated in future studies to establish the ideal frequency ofcontacts for subgroups of patients who are better or lesssuited to more intensive approaches.

After 6 months in the study, the smoking-cessation rate inthe UC group (26.3%) was higher than the rate reported inthe literature for spontaneous cessation (approximately 5%)[22]. It is possible that the cessation rate in our UC groupmay have been partly due to the recruitment process itself, asthe screening questionnaire conveyed to the staff concernsabout the patient's smoking habit. However, this rate wassimilar to the cessation rate found in other follow-up studiesafter the discharge of patients submitted to interventions,especially smoking patients who presented TRD [23], butwas significantly lower than the cessation rate obtained in theintervention groups (41.7% in LII and 44.9% in HII).

Other studies have already pointed out similar smoking-cessation rates that result from more or less intensiveinterventions for hospitalized patients because the interven-tions took place in the context of hospitalization. Thesestudies suggest that hospitalization can contribute to thesmoker's perception of his vulnerability, thus creating anideal “teachable moment” for a change in behavior [24,25].

Even though the smoking-cessation rates for both groupsof intervention (LII and HII) were very close, the HII grouppresented significantly superior reductions in the number ofcigarettes smoked daily after 6 months in comparison to theLII. Although there is no evidence to support the hypothesisof reducing smoking damage, it is nevertheless true that adecrease in the number of cigarettes smoked daily isconsidered a path toward cessation [26]. At the 6-monthfollow-up, patients in the HII group also presented

significantly lower rates of seeking smoking-cessationtreatment. In view of these results, we can ask whether themore intensive intervention replaced the patients' search fortreatment because the patients considered the frequent phonecontacts an intervention of care.

4.2. Failure to stop smoking

The multivariable analysis identified three variablesassociated with the failure to stop smoking (noncessation)at the 6-month follow-up: the absence of a TRD, ayounger patient age and a low motivation for cessation atthe initial contact.

Other studies [8,27] have already shown that TRDpresence and particularly the instructions given to patientson the relationship between smoking and their diseaseincrease potential cessation rates after discharge.

Another variable associated with noncessation was ayounger patient age; this result has also been reported inanother study [28]. This result points to an important factorin cessation, which is that older patients, who present greatersmoking-cessation rates after intervention, are less frequent-ly targeted for interventions for smoking cessation by healthprofessionals when compared with younger smokers [27].The result of this study points to the need for a culturalchange in the way smoking-cessation interventions areviewed; they should be seen as valid for patients of all ages.

The third variable related to noncessation was a lowmotivation for cessation at the initial contact. The impor-

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tance of this variable has been widely supported by otherstudies [22,27,28]. This variable demonstrates the need forthe adoption of intervention approaches to suit the patient'smotivation phase, for example, by stimulating the possibilityof a transition from the precontemplation phase to the actionphase [29]. Unfortunately, our study did not register thepatient's stage of change, although we used motivationalinterview in the HII group.

The comparative analysis of the three groups showed agreat difference between intervention and noninterventionand indicated that the LII had an impact similar to the HII.The LII should therefore be considered initially in view of itslow cost. However, for some patients HII was the best meansto attain other relevant health measures.

4.3. Main limitations

For methodological reasons, patients who presented withsmoking comorbidity together with alcohol abuse ordependence were excluded to avoid participation in twointerventions at the same time; such a scenario would limitthe possibility of obtaining accurate results. Randomizationhas only been done for the two intervention groups (LII andHII) and not for the UC group. Thus, bias and confoundingcould be relatively strong in the latter, which consisted ofindividuals detected as smokers by the screening but who didnot undergo randomization because of early hospitaldischarge. When the profiles of the intervention groupsand the UC group were compared, significant differenceswere not found for the majority of characteristics. Only twodifferences were identified in the groups. The UC patientspresented greater rates of current admission for surgery. Thisfactor may explain their earlier discharges because somepatients were probably admitted for elective surgeries, whichrequire a less average hospitalization time. There was also agreater prevalence of TRD in the LII group, and thisdifference might explain the elevated rate of smokingcessation in that group. It is known that the presence of aTRD increases the patient's motivation to stop smoking [30].The remaining similarities between the groups allowedresearchers to compare the interventions results (HII and LII)and the usual care results in a balanced way.

No inter-rater (counselor) check was conducted todetermine whether there were differing counseling styles.On the other hand, all counselors had had the same specialistpostgraduate training in smoking-cessation therapy in thestudy institution. Interview style in both LII and HII wastrained and conducted according to a written protocol andwas the same one adopted at the hospital outpatient clinicwhere the counselors had been previously trained.

A further limitation stems from the evaluation of smokingcessation. It was made by an assessor who was not blind tothe treatment group, and this circumstance might increase therisk of biased responses. It should be kept in mind that socialdesirability may have influenced the results, as someparticipants did not want to disappoint their counselor. We

used the patient's self-report over the phone, without theconfirmation by biological measures such as cotininedosage. The latter is partially justified if we consider thatmany of the patients lived in other cities and therefore foundit difficult to travel to the main hospital. This circumstanceis especially significant because the majority of themsuffered from serious bodily illnesses with consequentphysical limitations.

Pharmacotherapy was not included either in the LII or inthe HII group because of two reasons: intervention was notconceived as a treatment per se. Patients were encouraged toengage in a treatment for smoking cessation after hospitaldischarge. Additionally, Brazil has developed a strategy forsmoking cessation based upon intensive support —including pharmacotherapy — delivered in accreditedtreatment units. This can provide quality assurance but alsocreates a barrier to patients living far from such units, as wasthe case with several of our patients. Besides, central controland distribution of medications have also resulted in delaysand interruption of treatments [31].

The profile of the evaluated hospitalized smokers wassimilar to the profile found in other studies [32–35]. Subjectswere predominantly men who suffered from anxiety anddepression, and whose use of psycho-medicines exceededthe average use of nonsmoking adults. The data also indicatea concentration of people in their 50s experiencing seriousclinical pathologies, which justified admission to a univer-sity main hospital; this fact was corroborated by the high CCIat baseline and the high mortality rates in the follow-up. Thecharacteristics of the population studied indicate a potentialexception for the extrapolation of this study's results topopulations in other contexts.

The variables associated with smoking noncessationdemonstrate the need for more personalized interventionsfor smokers who are admitted to general hospitals,particularly those who present lower indexes of motivation,are younger and do not have smoking-related diseases. Theinterventions used in this trial (especially the low-intensityarm) are likely generalizable and could serve as a usefulmodel for other centers in Brazil and for further study.

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