Journal of General Internal Medicine

, Volume 28, Issue 11, pp 1420–1429 | Cite as

Implementing Smoking Cessation Guidelines for Hospitalized Veterans: Effects on Nurse Attitudes and Performance

  • David A. Katz
  • John Holman
  • Skyler Johnson
  • Stephen L. Hillis
  • Sarah Ono
  • Kenda Stewart
  • Monica Paez
  • Steven Fu
  • Kathleen Grant
  • Lynne Buchanan
  • Allan Prochazka
  • Catherine Battaglia
  • Marita Titler
  • Mark W. Vander Weg
Original Research



A minority of hospitalized smokers actually receives assistance in quitting during hospitalization or cessation counseling following discharge. This study aims to determine the impact of a guideline-based intervention on 1) nurses’ delivery of the 5A’s (Ask-Advise-Assess-Assist-Arrange follow-up) in hospitalized smokers, and 2) nurses’ attitudes toward the intervention.


We conducted a pre-post guideline implementation trial involving 205 hospitalized smokers on the inpatient medicine units at one US Department of Veterans Affairs (VA) medical center. The intervention included: 1) academic detailing of nurses on delivery of brief cessation counseling, 2) modification of the admission form to facilitate 5A’s documentation, and 3) referral of motivated inpatients to receive proactive telephone counseling. Based on subject interviews, we calculated a nursing 5A’s composite score for each patient (ranging from 0 to 9). We used linear regression with generalized estimating equations to compare the 5A’s composite score (and logistic regression to compare individual A’s) across periods. We compared 29 nurses’ ratings of their self-efficacy and decisional balance (“pros” and “cons”) with regard to cessation counseling before and after guideline implementation. Following implementation, we also interviewed a purposeful sample of nurses to assess their attitudes toward the intervention.


Of 193 smokers who completed the pre-discharge interview, the mean nursing 5A’s composite score was higher after guideline implementation (3.9 vs. 3.1, adjusted difference 1.0, 95 % CI 0.5–1.6). More patients were advised to quit (62 vs. 48 %, adjusted OR = 2.1, 95 % CI = 1.2–3.5) and were assisted in quitting (70 vs. 45 %, adjusted OR = 2.9, 95 % CI = 1.6–5.3) by a nurse during the post-implementation period. Nurses’ attitudes toward cessation counseling improved following guideline implementation (35.3 vs. 32.7 on “pros” subscale, p = 0.01), without significant change on the “cons” subscale.


A multifaceted intervention including academic detailing and adaptation of the nursing admission template is an effective strategy for improving nurses’ delivery of brief cessation counseling in medical inpatients.


smoking cessation Veterans counseling guideline-based intervention 


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Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • David A. Katz
    • 1
    • 2
    • 3
  • John Holman
    • 1
  • Skyler Johnson
    • 1
  • Stephen L. Hillis
    • 1
    • 4
    • 5
  • Sarah Ono
    • 1
  • Kenda Stewart
    • 1
  • Monica Paez
    • 1
  • Steven Fu
    • 7
  • Kathleen Grant
    • 8
  • Lynne Buchanan
    • 10
  • Allan Prochazka
    • 9
  • Catherine Battaglia
    • 9
  • Marita Titler
    • 11
  • Mark W. Vander Weg
    • 1
    • 2
    • 6
  1. 1.Comprehensive Access & Delivery Research and Evaluation (CADRE) CenterVA Iowa City Health Care System (152)Iowa CityUSA
  2. 2.Department of MedicineUniversity of IowaIowa CityUSA
  3. 3.Department of EpidemiologyUniversity of IowaIowa CityUSA
  4. 4.Department of BiostatisticsUniversity of IowaIowa CityUSA
  5. 5.Department of RadiologyUniversity of IowaIowa CityUSA
  6. 6.Department of PsychologyUniversity of IowaIowa CityUSA
  7. 7.Center for Chronic Disease and Outcomes ResearchMinneapolis VA Medical CenterMinneapolisUSA
  8. 8.Mental Health and Behavioral Sciences DepartmentVA Nebraska-Western Iowa Health Care SystemOmahaUSA
  9. 9.Department of MedicineVA Eastern Colorado Health Care SystemDenverUSA
  10. 10.The College of NursingUniversity of NebraskaOmahaUSA
  11. 11.University of Michigan School of NursingAnn ArborUSA

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