Cigarette smoking is a leading cause of preventable death and illness in the United States. Recent data show that more than 18% of all American adults smoke cigarettes and more than 20 million smokers are treated in U.S. EDs each year. While smoking cessation has been linked to significant health benefits, studies show that smokers are disproportionately from low-income households. These patients commonly receive care in hospital EDs for medical consequences resulting from smoking and/or for comorbid conditions.
“Patients from low-income households frequently have limited access to healthcare providers and often don’t receive smoking cessation,” says Steven L. Bernstein, MD. “It’s possible that ED visits can serve as an opportunity to screen, intervene, and refer these patients for treatment.” This may be especially true considering that there is a greater prevalence of smoking among ED patients than the general population.
EDs have been the focus of tobacco control efforts for many years, but results from studies of these interventions have been mixed. Previous research has shown that ED-initiated smoking cessation can yield short-term improvements in tobacco abstinence, but the positive effects typically last only about 1 month in duration.
Testing an Intervention
For a study published in Annals of Emergency Medicine, Dr. Bernstein and colleagues tested a comprehensive intervention in which the ED facilitated referrals to a smoking quitline and provided pharmacotherapy. The research was conducted over 2 years at an urban ED that averages about 90,000 visits per year. Patients were eligible for participation if they were 18 or older, smoked, and paid for insurance on their own or had Medicaid.
The intervention involved using a brief motivational interview by a trained research assistant that took about a short time to administer. In addition, patients received a 6-week supply of nicotine patches and gum that was initiated in the ED. “We actually made patients chew their first piece of gum and try the patch during their ED visit so that we could show them how to use it correctly,” adds Dr. Bernstein. Furthermore, participants received a faxed referral to the state smokers’ quitline, a booster call 3 days after ED discharge, and an educational brochure. The control group received only the brochure, which provided quitline information.
The primary endpoint in the study was biochemically-confirmed tobacco abstinence when patients were assessed at 3 months. According to the results, the prevalence of abstinence was 12.2% for patients who received the intervention and 4.9% for the control group, amounting to a difference in quit rates of 7.3%. Because the 95% confidence intervals for the odds ratios for age, sex, and race/ethnicity spanned 1, they were not deemed statistically significant. The only statistically significant determinant of smoking cessation in the analysis was assignment to the intervention group (Table).
Several factors likely played a role in achieving smoking abstinence at 3 months. These included:
- Providing evidence-based treatments to participants.
- Using a combination of medication and counseling.
- Offering two forms of nicotine replacement therapy.
- Initiating medication management during ED encounters.
- Delivering motivational interviews in only about 15 minutes.
“Our results are encouraging because many interventions that have been tested for smoking cessation in the ED setting have had challenges with implementation,” says Dr. Bernstein. “EDs are often busy and many practitioners may feel that they have little or no time to intervene for smoking. Our data show that this isn’t necessarily the case.” He notes that clinicians involved in the study bought into the concepts utilized in the intervention and were amenable to using them.
The intervention tested in the study nearly showed efficacy out to 1 year, suggesting that sustained smoking cessation efforts initiated by EDs may be possible. However, this was a secondary endpoint of the study, and more research is needed to better detect differences at 1 year and beyond.
Seize the Opportunity
Dr. Bernstein says that ED visits may be an opportune time to intervene for patients with an adverse consequence of a risky health behavior like smoking. “ED-initiated tobacco control should be routinely offered to all adult smokers who visit the ED,” he says. “When patients come to the ED for care, this is an important opportunity to increase the likelihood of tobacco abstinence.” He adds the intervention may give healthcare providers a new approach for treating low-income smokers, a group that is often difficult to reach. He also says that future research should explore the use of technologies, such as mobile device interventions, to further assist efforts to get ED smokers to quit.
Bernstein SL, D’Onofrio G, Rosner J, et al. Successful tobacco dependence treatment in low-income emergency department patients: a randomized trial. Ann Emerg Med. 2015 Apr 18 [Epub ahead of print]. Available at: http://www.annemergmed.com/article/S0196-0644(15)00284-X/abstract.
Lowenstein S, Tomlinson D, Koziol-McLain J, et al. Smoking habits of emergency department patients: an opportunity for disease prevention. Acad Emerg Med. 1995;2:165-171.
Rabe GL, Wellmann J, Bagos P, et al. Efficacy of emergency department–initiated tobacco control—systematic review and metaanalysis of randomized controlled trials. Nicotine Tob Res. 2013;15:643-655.
Bernstein SL, Bijur P, Cooperman N, et al. A randomized trial of a multicomponent cessation strategy for emergency department smokers. Acad Emerg Med. 2011;18:575-583.