Summary
Hospital surgical services are often reluctant to offer nicotine replacement therapy (NRT) to inpatients due to concerns that nicotine leads to vasoconstriction and impaired wound healing. However, multiple potential health benefits result from offering NRT to hospitalized surgical patients who use tobacco products. A 28-year-old female patient, hospitalized following a motor vehicle accident, experienced severe nicotine withdrawal symptoms and a strong desire to smoke. After a Tobacco Treatment Specialist (TTS) consultation, the Physical Medical and Rehabilitation service at the hospital began her on NRT with positive outcomes. The patient experienced decreased cravings and withdrawal symptoms, as well as an increased desire to remain tobacco free after discharge. More surgical patients may have an increased commitment to remain tobacco free after discharge, if their withdrawal symptoms are treated during hospitalization using NRT.
Background
The literature suggests that NRT is not associated with increased risk of vasospasm or impaired wound healing (Carandang, Barton, Rordorf, Ogilvy, & Sims, Reference Carandang, Barton, Rordorf, Ogilvy and Sims2011; Seder et al., Reference Seder, Schmidt, Badjatia, Fernandez, Rincon and Claassen2011; Sørensen, Reference Sørensen2012; Sorensen, Karlsmark, & Gottrup, Reference Sorensen, Karlsmark and Gottrup2003; Møller, Villebro, Pedersen, & Tønnesen, Reference Møller, Villebro, Pedersen and Tønnesen2002). In fact, combining NRT (when indicated) and tobacco treatment counselling is the most effective way to help patients quit (Fiore et al., Reference Fiore, Jaen, Baker, Bailey, Bennett, Benowitz and Dorfman2008). While hospitals in some countries, such as Canada, have NRT protocols for all inpatients, this is not a universal standard (Reid et al., Reference Reid, Mullen, D’Angelo, Aitken, Papadakis and Haley2010). This case study summarizes the current literature on the safety of using NRT in surgical patients and, using a patient story, highlights the need to disseminate this information to clinicians and others involved in treating hospitalized tobacco users.
Case Presentation
The patient is a 28-year-old Caucasian female hospitalized for 20 days after a motor vehicle accident. For the first eight days of her hospitalization, Ms. S was on a surgical service that was not comfortable prescribing NRT because of experimental studies describing an association between NRT and vasoconstriction and NRT and impaired wound healing (Black et al., Reference Black, Huang, Neligan, Levine, Lipa and Lintlop2001; Forrest, Xu, & Pang, Reference Forrest, Xu and Pang1994). She arrived at the hospital unconscious and was on a ventilator for five days. Immediately after being taken off the ventilator, when she was able to breathe on her own, she asked for a cigarette. Ms. S relayed to the nurses that she was experiencing moderate to severe nicotine withdrawal symptoms, such as agitation, irritability and intense craving for cigarettes (Hughes, Reference Hughes2007). When Ms. S was medically stable, she was transferred to a Physical Medical & Rehabilitation Service, whereupon a TTS inpatient consult was ordered. At the bedside, she explained to the consult specialist that her withdrawal symptoms were severe, despite the fact that she was unconscious and on a ventilator for five days.
Treatment
The TTS's treatment recommendations included a 21 mg nicotine patch and comprehensive tobacco use treatment counselling. Prior to this accident, Ms. S smoked 20 cigarettes per day, and her first cigarette was smoked between 30 minutes and 1 hour after waking in the morning. The patient told the TTS that she had never used NRT prior to this hospitalization, and she was surprised by how effectively it was curbing her cravings. She had thought about quitting before but had never tried to quit because she always assumed that withdrawal would be too difficult. She indicated that she wanted to continue using nicotine patches after discharge, that she would like to remain tobacco free, and that she planned to wean off the patches over time. Her biggest stated motivations were to protect her long-term health and to save money. The counselling session also included discussion of Ms. S's smoking triggers, relapse prevention strategies and health benefits following cessation. Ms. S was referred to the state Quitline for ongoing phone-based tobacco treatment counselling and a free NRT starter kit after discharge.
Discussion
Many surgical services have concerns about the use of NRT among hospitalized surgical patients addicted to tobacco products. In this case, the concerns were related to risk of vasospasm and potentially impaired wound healing. The literature, however, does not support these concerns. Carandang et al. (Reference Carandang, Barton, Rordorf, Ogilvy and Sims2011) conducted a retrospective analysis on patients admitted to a neurosurgical intensive care unit for subarachnoid hemorrhage (SAH) from 1994 to 2008, comparing rates of clinical and angiographic vasospasm between smokers who received NRT and those who did not. After matching for Fisher score (an indicator of SAH severity), they concluded that NRT was not associated with increased risk of vasospasm (Carandang et al., Reference Carandang, Barton, Rordorf, Ogilvy and Sims2011). Others have looked at the impact of NRT in patients with acute SAH who smoke and found that NRT was associated with lower risk of death at three months, with no increased risk of vasospasm or delayed cerebral ischemia (Seder et al., Reference Seder, Schmidt, Badjatia, Fernandez, Rincon and Claassen2011).
Regarding wound healing, one experimental study (Forrest et al., Reference Forrest, Xu and Pang1994) found an association between nicotine and impaired wound healing in animals; however, the dose of nicotine used in the study was far greater than that provided to humans by NRT. A 2003 systematic review of 177 articles concluded that NRT has a neutral impact on wound healing (Sørensen, Reference Sørensen2012). Two randomized controlled trials have found that NRT has no negative impact on wound healing (Møller et al., Reference Møller, Villebro, Pedersen and Tønnesen2002; Sorensen et al., Reference Sorensen, Karlsmark and Gottrup2003). Clearly, further efforts are needed to disseminate information about the safety of evidenced-based tobacco treatment protocols to clinicians treating surgical patients.
Furthermore, when hospitalized patients receive no treatment for their tobacco use, their likelihood of remaining tobacco free after discharge is significantly lower than if they receive counselling and NRT during their hospital stay (Molyneux et al., Reference Molyneux, Lewis, Leivers, Anderton, Antoniak and Brackenridge2003). This further supports the need for systematic delivery of evidence-based tobacco use treatment––pharmacotherapy such as NRT (when indicated) plus counselling––to all surgical patients who smoke or use tobacco.
Limitations
Ms. S's long-term tobacco free status is unknown. The TTS was not able to reach her on the phone after discharge. Additionally, while Ms. S noticed a significant reduction in withdrawal symptoms using the nicotine patch alone, it should be noted that cessation rates are higher when patients use a combination of the nicotine patch with one of the short-acting forms of NRT such as gum, lozenge, inhaler and/or nasal spray (Stead et al., Reference Stead, Perera, Bullen, Mant, Hartmann-Boyce, Cahill and Lancaster2012). In this case, the patient wanted to use only one form of NRT.
Conclusion
This case highlights two important benefits of using NRT during a patient's hospital stay. Not only can the medication help reduce immediate nicotine withdrawal symptoms, but it can also allow patients the opportunity to try nicotine replacement, possibly for the first time. When given this opportunity, some patients like Ms. S realize that NRT can make quitting smoking a lot easier. Something that seemed hard to imagine – quitting smoking – becomes feasible. Given this patient's significant withdrawal symptoms while not receiving the nicotine patch, it is likely that she would have returned to smoking immediately upon discharge from the hospital. However, once her withdrawal symptoms were treated and she saw that the medication was effective, she became committed to using it. Her likelihood of quitting smoking long-term increased substantially because she decided to use NRT and engaged in a comprehensive tobacco treatment counselling session prior to discharge (Fiore et al., Reference Fiore, Jaen, Baker, Bailey, Bennett, Benowitz and Dorfman2008; Rigotti, Munafo, & Stead, Reference Rigotti, Munafo and Stead2007).
Learning Points
• NRT among hospitalized patients who use tobacco can successfully relieve withdrawal symptoms and should be offered to almost all inpatients.
• Encouraging cessation among, and offering counselling to, hospitalized patients who use tobacco can lead to higher rates of long-term abstinence.
• NRT does not lead to vasospastic complications among hospitalized surgical patients.
• NRT does not lead to delayed wound healing among hospitalized surgical patients.
Acknowledgements
The authors would like to acknowledge the assistance of Jennifer Greyber in the preparation of the case report.
Financial Support
None.
Conflict of Interest
None of the authors has any conflict of interest to report.
Ethical Standards
Not applicable.
