ED Smoking Cessation Intervention Pays Off

Susan London

May 04, 2015

Smokers visiting the emergency department (ED) are more than twice as likely to quit if they receive counseling, nicotine replacement therapy, and relevant referrals during their visit, according to a randomized controlled trial published online April 24 in the Annals of Emergency Medicine.

ED visits may be an ideal opportunity for smoking cessation interventions, according to Steven L. Bernstein, MD, from the Department of Emergency Medicine, Yale School of Medicine, and the Yale Cancer Center in New Haven, Connecticut, and colleagues.

"Smokers are disproportionately from low-income households and commonly receive care in hospital EDs either for medical consequences of smoking or for comorbid medical and psychiatric conditions. These patients often have limited access to primary care providers, who tend to undertreat tobacco use," they explain.

The researchers enrolled 778 adult smokers who made a visit to an urban teaching ED and either had Medicaid insurance or were self-pay, and randomly assigned them to intervention and control groups.

Smokers in the intervention group received a motivational interview by a trained research assistant, 6 weeks of nicotine patches and gum started in the ED, a faxed referral to the state smokers' quitline, a booster call, and a brochure that included quitline information. Those in the control group received only the brochure.

Three months after their visit, the rate of biochemically confirmed smoking abstinence was 12.2% in the intervention group compared with 4.9% in the control group. In multivariate analysis, participants in the intervention group were still 2.72 times more likely to be abstinent than those in the control group.

An exploratory analysis showed that the abstinence rate remained higher in the intervention group at 1 year, at 16.3% vs 11.7%, although the difference was no longer significant.

The intervention group was also more likely to have made a 24-hour quit attempt since their ED visit (68.4% vs 55.9%) and had a greater reduction in the mean number of cigarettes smoked daily (9.1 vs 5.9 fewer cigarettes).

"This intervention may offer a new approach for treating the difficult-to-reach population of low-income smokers," Dr Bernstein and colleagues propose. "With continued implementation of the Patient Protection and Affordable Care Act, which mandates Medicaid coverage of smoking cessation medications, and declining rates of uninsurance, initiation of tobacco dependence treatment in the ED and linkage to aftercare may be particularly timely.... Given that more than 20 million smokers are treated in US EDs annually, ED-based tobacco interventions represent an important opportunity to increase national rates of tobacco abstinence."

Study results also showed that quit rates were similar whether or not smokers self-identified a tobacco-related reason for their ED visit, had a tobacco-related diagnostic code for that visit, or screened positive for depression. "The findings imply that ED-initiated tobacco control need not be limited to these clinical subgroups but should be offered to all adult smokers who visit the ED," the researchers maintain.

"While a busy emergency department may not welcome the additional responsibility of tobacco-cessation counseling, sometimes we have to meet our patients where they are," Dr Bernstein commented in a news release. "Future research should focus on longer-term interventions, as well as mobile health technologies, such as texting."

The authors have disclosed no relevant financial relationships.

Ann Emerg Med. Published online April 24, 2015. Full text

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