Emergency departments prove fertile ground for smoking cessation success

By Hugo Francisco de SouzaReviewed by Benedette Cuffari, M.Sc.Mar 28 2024

In a recent study published in the Emergency Medicine Journal, researchers discuss the outcomes of the Cessation of Smoking Trial in the Emergency Department (COSTED) study, which aimed to understand the optimal intervention and long-term outcomes of emergency department (ED)-based smoking cessation interventions.

Study: Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre, randomized controlled trial. Image Credit: rangizzz / Shutterstock.com

The dangers of smoking and the untapped potential of the ED

Tobacco consumption, which is generally in the form of smoking, is responsible for about eight million deaths each year and, as a result, is the leading cause of human mortality worldwide. Research in the United Kingdom has revealed that 22% of its 6.4 million smoking citizens belong to the ‘routine and manual’ occupations segment, whereas 8.3% belong to the ‘managerial and professional’ occupational cohort.

Reducing the global dependency on tobacco and tobacco products is one of the highlights of modern medicine, with addiction treatment presenting a potent intervention against premature death, oversaturation of the healthcare system, and health inequalities. EDs present a viable and untapped setting for implementing anti-tobacco interventions, as these departments see large numbers of individuals, many of whom smoke and experience complex health inequalities.

Previously, smoking cessation interventions have been tested in ED settings with generally favorable outcomes. However, current challenges to the widespread implementation of these methodologies are due to these trials having only evaluated behavioral support or a combination of behavioral support and nicotine replacement therapy (NRT), particularly in populations already motivated to quit smoking.

Recent research and anecdotal evidence suggest that e-cigarettes are more potent anti-tobacco addiction tools than NRTs; however, their effectiveness has never been formally tested. Thus, understanding the real-world and long-term effectiveness of smoking cessation interventions carried out in ED settings and involving e-cigarette use may help millions of people worldwide reduce the prevalence of tobacco smoking in the future.

About the study

The present study aims to evaluate the long-term effectiveness of an ED-based smoking cessation intervention as compared to usual care. The effectiveness of e-cigarette starter kits in reducing smoking as compared to their absence was also investigated.

The COSTED study is a multicenter, parallel-group, and computer-randomized controlled trial involving six UK National Health Service (NHS) EDs. The study included adults 18 years and older who were either admitted to an NHS ED or accompanying someone who was.

Study participants were identified during routine ED screening and included those who reported daily tobacco use and excluded individuals who exhaled less than eight parts per million (ppm) of carbon monoxide (CO) or were currently using both traditional cigarettes and e-cigarettes daily. Identified individuals who provided informed consent were then enrolled in the study and computer-randomized into either the intervention or control cohort.

The intervention cohort was provided a 15-minute long smoking cessation session with a dedicated smoking cessation advisor, an e-cigarette starter kit along with detailed instructions on its use, and an electronic referral to a local smoking cessation center. Comparatively, individuals in the control group were provided with written cessation advice but no further intervention.

Study outcomes, which included self-reported and biochemically measured smoking abstinence, were measured during routine questionnaires and ED-based follow-ups conducted one, three, and six months following participant randomization. Risk estimates and differences in outcomes between cohorts were calculated using binary regression models, including fixed effects and Gaussian models with robust variances.

Study findings

Individuals in the intervention cohort were significantly more likely to quit smoking and remain tobacco-free longer than those in the control group. Although the biochemically verified smoking quit rate was not as high as expected, self-reported abstinence, which was defined as six or fewer relapses over the course of the six-month-long study, was higher than expected. These results suggest that biochemical results, both from this and previous studies, are likely underestimates of the true potential contribution of EDs in smoking cessation efforts.

The ED represents an acceptable location for smoking cessation intervention and therefore offers a valuable opportunity to engage those who smoke who are not currently seeking to quit.”

Policy implications and conclusions

The study findings demonstrate the effectiveness of simple and opportunistic smoking cessation interventions provided in real-world ED settings. Self-reported daily tobacco users showed significant reductions in smoking dependency and use following a brief 15-minute-long counseling session with a dedicated smoking cessation advisor, an e-cigarette starter kit, and digital referral to a local stop-smoking service, particularly when compared to controls who only received text-based cessation advice and stop-smoking services referral.

Those attending EDs 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.”