Original Contribution
A systematic review of smoking cessation interventions in the emergency setting,☆☆,,★★

https://doi.org/10.1016/j.ajem.2014.03.042Get rights and content

Abstract

Study objective

Cigarette smoking remains the leading cause of preventable death in the United States, and tobacco use rates are known to be higher among emergency department (ED) patients than in the general population. Despite recommendations from the Society for Academic Emergency Medicine and the American College of Emergency Physicians, many emergency clinicians remain uncertain about the benefits of providing ED-based smoking cessation interventions. To address this gap in knowledge, we performed a systematic review of cessation interventions initiated in the adult or pediatric ED setting.

Methods

We conducted an electronic search of the MEDLINE and CINAHL databases through February 2014 and hand searched references from potentially relevant articles. We identified eligible studies, evaluated bias and validity, and extracted data and synthesized findings.

Results

Seventeen studies underwent critical appraisal, with 13 included in qualitative synthesis. The majority (11/13, 85%) of investigations did not report significant differences in tobacco abstinence between cessation intervention groups. The 2 studies reporting significant differences in cessation both used motivational interviewing-based interventions. Two studies evaluated patient satisfaction with ED-based tobacco cessation interventions, and both reported greater than 90% satisfaction.

Conclusions

Findings indicate that ED visits in combination with ED-initiated tobacco cessation interventions are correlated with higher cessation rates than those reported in the National Health Interview Survey. Clear data supporting the superiority of one intervention type were not identified. Lack of a standardized control group prevented quantitative evaluation of pooled data, and future research is indicated to definitively evaluate intervention efficacy.

Introduction

Cigarette smoking is responsible for 1 in 5 deaths and is the leading cause of preventable death in the United States (US) [1], [2]. The health care costs attributed to smoking exceed $167 billion annually [1], [2]. These high costs and significant mortality have provided the impetus for public health campaigns focused on smoking reduction. Such cessation interventions are generally considered to be cost-effective and are associated with decreased mortality for all [3], [4], [5], [6]. A 2010 National Health Interview Survey (NHIS) of adult smokers demonstrated that even those who have not quit are influenced by these efforts, with 68.8% of smokers reporting that they wanted to quit completely, 52.4% stating they had stopped smoking for at least 1 day because they were trying to quit, and 6.2% reporting recent smoking cessation [7]. Efforts to drive smokers from the contemplation and planning Stages of Change to the action stage are ongoing; the US Department of Health and Human Services (DHHS) has set an ambitious Healthy People 2020 goal of reducing cigarette smoking rates to 12% of US adults [2], [8], [9], [10].

The US DHHS 2008 clinical practice guideline endorsed screening all patients for tobacco use and treatment of every tobacco user via the “5 A’s” approach: asking patients if they smoke, advising patients to quit smoking, assessing patients’ willingness to quit smoking, assisting patients’ quit attempts with medication and counseling, and arranging follow-up contact [11]. With this in mind, it is notable that cigarette smoking rates have been demonstrated to be higher among emergency department (ED) patients than in the general population. Surveys of ED patients have demonstrated the prevalence of cigarette smoking to be between 21% and 48%, with higher estimates reported in urban EDs [12], [13], [14], [15]. The Society for Academic Emergency Medicine Public Health and Education Task Force and an American College of Emergency Physicians task force recommend smoking cessation counseling for all smokers receiving treatment in the ED setting [16], [17], [18]. Despite these recommendations, a recent survey revealed that although 88.7% of emergency physicians believed that smoking cessation interventions were an “important professional responsibility,” 57.2% of them thought that such treatments were “not appropriate service” for their practice environment [19]. Another survey reported that only 60% of ED staff agreed that they were comfortable advising patients to quit smoking and only 51% agreed that the ED should assist patients to stop using tobacco [11]. Survey data also indicated that beliefs regarding the importance, appropriateness, and efficacy of various interventions were correlated with physician compliance with the corresponding recommendations of the US DHHS clinical practice guidelines [19]. Physicians have previously cited time constraints, perceived lack of patient interest, and belief that ED-based counseling is ineffective as barriers to providing smoking cessation counseling [20].

Uncertainty regarding the efficacy and appropriateness of ED-based smoking cessation interventions is reasonable, given that a systematic review published in 2002 included only 1 article and 1 abstract that addressed smoking cessation interventions in an emergency care setting and many of the conclusions were extrapolated from other settings such as primary care [21]. Review authors endorsed screening for tobacco use and the provision of care according to the “5 A’s” recommendations but concluded that additional study in emergency settings was needed. Additionally, they were unable to make recommendations regarding referral to outside smoking cessation programs. A recent systematic review and meta-analysis of 5 ED-based tobacco intervention studies using motivational interviewing and follow-up phone calls found a trend towards increased episodically measured abstinence from tobacco use (odds ratio, 1.33; P = .10) [22]. These authors classified the included studies as being of weak to moderate quality and cautioned that the ability to draw conclusions from their review is limited. A plethora of ED-based studies have been published since the original 2002 review; therefore, the objectives of this investigation were to identify, summarize, and analyze the scientific literature available through February 2014 to answer the following question: are any smoking cessation interventions for patients in the adult or pediatric emergency care setting effective, feasible, and appropriate as assessed by their impact on smoking cessation, all-cause mortality, patient satisfaction, practitioner time spent, nonpractitioner time spent, and cost per quit?

Section snippets

Study design

Our study protocol was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the reporting of systematic reviews and guidelines provided by the Cochrane Collaboration, with consideration given to the methods previously reported by Bernstein and Becker [21], [23], [24], [25]. Our review was registered with the PROSPERO international prospective registry of systematic reviews, registration # CRD42012002517, prior to the conduct of the work.

Search strategy and study inclusion

Study

Characteristics of studies included

Of the 17 studies subjected to systematic appraisal, 4 were excluded from synthesis, in each case because of an inability to verify the relationship between the studied intervention and outcome or to generalize the results of the study (Figure) [11], [28], [29], [30]. The remaining 13 studies were determined to have noncritical threats to validity and were included in qualitative review and synthesis (Figure). Of these 13 studies, only 4 provided information regarding trial registration with a

Discussion

Emergency department–based smoking cessation interventions have been much more extensively studied in the years since their first systematic review, published by Bernstein and Becker in 2002 [22]. However, these new studies have largely searched for differences in effectiveness between interventions and have predominately presented nonsignificant results. Despite recommendations by multiple clinical societies, differing opinions regarding the appropriateness of smoking cessation interventions

Conclusions and implications for practice

This review addresses previously identified ED physicians’ concerns regarding the efficacy, appropriateness, and feasibility of ED-based smoking cessation interventions. Our review supports that ED-based cessation interventions may be effective, but the available data are somewhat limited and heterogeneous. Most studies reviewed demonstrated that pamphlet administration, brief advice, and motivational interviewing had nonsignificant differences in raising observed smoking cessation rates;

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  • Cited by (0)

    Funding: This study did not receive external funding.

    ☆☆

    Conflict disclosure: The authors report no conflicts of interest.

    Presentations: An abstract summarizing the results of this study was presented at the Society for Academic Emergency Medicine Annual Meeting in Atlanta, GA, May 2013.

    ★★

    Author contributions: MRB and TDS conceived the trial. JHP, TDS, and MRB designed the trial. JHP and TDS collected and extracted the study data. JHP and TDS performed data analyses, provided statistical expertise, and interpreted the study findings. JHP and TDS drafted the manuscript. JHP, TDS, and MRB revised the manuscript for important intellectual content. MRB supervised the conduct of the study. All authors take responsibility for the manuscript as a whole.

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