title: Cigarette smoking as a risk factor for delirium in hospitalized and intensive care unit patients. A systematic review.
abstract: BACKGROUND
  Active smokers are prevalent in hospitalized and critically ill patients. Cigarette smoking and nicotine withdrawal may increase delirium in these populations. This systematic review aims to determine whether active cigarette smoking increases the risk for delirium in hospitalized and intensive care unit (ICU) patients.
  
  
  METHODS
  A systematic search of English-, Spanish-, and French-language articles published from 1966 to April 2013 was performed. Studies were included if they measured cigarette smoking as a risk factor and delirium as an outcome in adult hospitalized or ICU patients. Methodologic quality of studies was assessed using both the validated Newcastle Ottawa Scale and an additional evidence-based quality rating scale.
  
  
  RESULTS
  A total of 14 cohort studies of surgical and ICU populations were included in the review. No studies in non-ICU inpatients were identified. The incidence of delirium ranged from 9 to 52%, and the prevalence of active smokers ranged from 9 to 44%. The quality of assessment for active smoking varied widely. None of the studies used biochemical measures to determine cigarette smoke exposure. Of the six studies restricting the smoking group to active smokers only, active smoking was independently associated with delirium in one study, trended toward an association in one study, and showed a dose response in one study. Quantitative summary measures were not calculated due to study heterogeneity and missing data.
  
  
  CONCLUSIONS
  There is currently insufficient evidence to determine if cigarette smoking is a risk factor for delirium. Future studies should consider using biochemical measures of cigarette smoke exposure to objectively quantify smoking behavior.
authors.affiliation: 1 Albert Einstein College of Medicine, Bronx, New York; and.
authors.forename: S Jean
authors.initials: SJ
authors.lastname: Hsieh
authors.forename: Mili
authors.initials: M
authors.lastname: Shum
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Lee
authors.forename: Fairouz
authors.initials: F
authors.lastname: Hasselmark
authors.forename: Michelle N
authors.initials: MN
authors.lastname: Gong
mesh_terms: D016638:Critical Illness; D003693:Delirium / Q000453:epidemiology*; D006760:Hospitalization; D006801:Humans; D007297:Inpatients / Q000523:psychology / Q000706:statistics & numerical data*; D007362:Intensive Care Units; D012307:Risk Factors; D012907:Smoking / Q000453:epidemiology*