Emergency department intervention aids in long-term smoking cessation

BMJMar 26 2024

An opportunistic emergency department stop smoking prompt, comprising brief advice by a trained professional, an e-cigarette starter kit, and referral to local stop smoking services can help smokers quit, with a significant proportion of them still not smoking 6 months later, finds research published online in Emergency Medicine Journal.

Some 6.4 million people in the UK still haven't stubbed out for good, and of the large numbers of people attending emergency departments, a substantial proportion are more likely to be smokers and have poorer overall health, explain the researchers. 

While initiatives in emergency departments to help people stop smoking have shown promise, it's not clear how well they work over the long term and what elements of them are most effective.

In a bid to find out, the researchers compared usual care with the real-world effectiveness of a brief intervention based in an emergency department to help smokers quit over a 6 month period in the Cessation of Smoking Trial in the Emergency Department (COSTED).

Between January and August 2022, they recruited 972 (out of 1443 screened) adult daily smokers attending the emergency department for medical treatment or accompanying someone who needed it.

Half the participants (484) were randomly allocated to the intervention arm and given brief smoking cessation advice of up to 15 minutes and an e-cigarette starter kit plus advice on its use (up to 15 minutes), as well as a referral to local stop smoking service. 

The advice was delivered by a dedicated stop smoking advisor while the patient was waiting to be seen or after discharge. It was tailored to their presenting condition-;for example, discussing how not smoking improved wound healing for patients with cuts. 

The local stop smoking service routinely followed up with a phone call offering support and, if taken up, advice on how to quit, as well as free provision of nicotine replacement therapy (NRT).

The rest of the participants (488) were randomly allocated to the comparison arm of the trial and given written details of local NHS stop smoking services but weren't referred directly.

Those reporting that they had stopped smoking at the 6 month assessment were asked to take a carbon monoxide test to biochemically confirm this.

After 6 months, continuous abstinence was just over 7% (35/484) in the intervention group and just over 4% (20/488) in the comparison group, meaning that those given the prompt were 76% more likely to have stopped smoking than those merely signposted to smoking cessation services.

Self-reported 7-day abstinence at 6 months was just over 23% (113/484) in the intervention group and 13% (63/488) in the comparison group. 

Those in the intervention group were also more likely to make quit attempts than those in the comparison group: 2 (1–4) vs 1 (0–3). And of those who responded to this query, nearly 40% (125/317) were using an e-cigarette daily at this point.

No serious side effects associated with taking part in the trial were reported.

The researchers acknowledge that those in the comparison group were supported rather more than perhaps would have been the case normally, and managing to obtain a carbon monoxide test to confirm trial participants had stopped smoking proved "very challenging," they add.

But they point out: "These results strengthen previous findings that [emergency department]-based smoking cessation interventions are effective. To our knowledge, the 6-month self-reported quit rate is the highest reported by any [such] smoking cessation intervention trial to date."

They conclude: "We consider that this could be rolled out to reach a large proportion of current smokers, although dedicated staff are clearly needed to deliver the intervention so as not to burden clinical staff." 

And this approach is also likely to narrow health inequalities, they suggest: "Those attending [emergency departments] are generally from more deprived communities and more likely to smoke than the general population. Therefore, this intervention has the potential to address health inequalities that arise from disparities in smoking rates between different socioeconomic groups."

In a linked editorial, Drs Gina Kruse and Jon Samet of the University of Colorado and Dr Joaquin Barnoya of the Integra Cancer Institute, Guatemala City, add that "the high uptake of the trial interventions makes a compelling argument for the potential of a cessation package that includes e-cigarettes for [emergency department] patients."

But as nearly 40% of participants in the intervention arm were using e-cigarettes daily and over half at least weekly during the 6 month follow-up period, they sound a note of caution.

"We need more information on the long-term use of e-cigarettes after cessation of combustible cigarettes, owing to concerns that persistent use is likely to be seen as a favourable finding by the e-cigarette industry that would profit from continued nicotine dependence," they write.

And they conclude: "We need to measure the harms to adolescents hand in hand with the potential for benefits to combustible cigarette users if we are to generate informed policies and practices about these devices."