The prevalence of smoking among patients in emergency departments (ED) is reported to be higher than in the general population, so encouraging smoking cessation in these settings has been recommended. However, 57% of ED staff believe that smoking cessation treatments are inappropriate for the ED setting, citing time constraints, lack of patient interest and treatment ineffectiveness as the main causes of these beliefs (Tong et al., 2010).

A systematic review published in the American Journal of Emergency Medicine (Pelletier et al., 2014), has recently analysed the most up to date research on the effectiveness, feasibility and appropriateness of smoking cessation interventions in ED settings.

The primary outcome measure was:

• Self-reported and/or biomarker-assessed smoking cessation.

Secondary outcomes were:

• All-cause mortality;
• Cost per quit;
• Patient satisfaction;
• Practitioner time spent and non-practitioner time spent (these last two were considered together).

Methods

The authors included all original studies of smoking cessation interventions performed in either adult or paediatric ED settings that assessed at least one of the outcome measures outlined above.

One investigator conducted the literature search (on the Medline and CINAHL databases), identifying 17 articles which were then examined for sources of bias (such as lack of randomisation, non-blinding of participants or study personnel and incomplete outcome data reporting). Four studies were excluded due to a high or unclear risk of bias, leaving 13 studies to undergo full systematic review.

Although a meta-analysis of these studies was planned, their heterogeneity precluded this and therefore only a systematic review was conducted. All studies were also rated on a three point scale for quality, using 19 quality criteria questions.

Results

Of the 13 studies, 11 were conducted in the USA, one in Germany and one in Turkey. Six studies used a single time-point follow-up for assessing smoking cessation, three had two follow-ups, three studies had three follow-ups and one had four follow-ups.

The smoking cessation interventions varied between studies and fell into six broad categories:

1. Administration of self-help materials;
2. Faxed referrals to other programmes;
3. Brief advice;
4. Counselling;
5. Nicotine replacement therapy (NRT);
6. Motivational interviewing-based interventions.

Eleven studies included at least two of these interventions and there was no consistent control group across the studies.

The main findings of the systematic review were as follows:

• The overall quality of the studies was relatively poor:
  • Quality ratings ranged from 31 to 81% (where 100% refers to a study scoring top marks on all 19 quality criteria)
  • The average quality rating was 57% (SD = 15.1%).
  • Studies generally scored poorly on the documentation of participant retention and follow-up, justification of sample size and appropriate follow-up.
  • Data on all-cause mortality and cost per quit were absent or inadequate in the majority of studies and therefore these two secondary outcome measures were dropped from further consideration.
• The majority of studies found no difference between intervention and control groups in terms of cessation rates (the primary outcome measure):
  • Twelve studies reported cessation rates and 10 of these reported no beneficial effect of the intervention.
  • Two studies reported a beneficial effect of smoking cessation intervention (Bock et al, 2008; Bernstein et al, 2013), however, this was only observed at three months in the first study and only one and three months, but not six months in the second study.
  • The authors of the systematic review note that these two studies used motivational interviewing-based techniques, and suggest that these techniques may be particularly effective. However, it is important to note that four other studies also used motivational interviewing, but did not find any beneficial effect.
  • Although the majority of these studies did not observe a beneficial effect of smoking cessation interventions, the authors note that many did find that overall smoking cessation rates (in both intervention and control arms) was higher than that reported among the general population in the USA (according to the 2010 National Health Interview Survey [NHIS]). This is a crude comparison however, as the 13 studies included in this review were conducted between 2000 and 2014, and were conducted in Turkey and Germany as well as the USA, whereas the NHIS survey was conducted in 2010 only in the USA.
• Patient satisfaction was high, but was not often reported:
  • In the two studies reporting patient satisfaction, this was found to be 90% or above.
  • Both of these studies used motivational interviewing-based interventions and both considered paediatric patients or their parents, rather than adult patients receiving treatment for themselves.
• Intervention time varied, but was not often reported:
  • A faxed referral was reported to take an average of 3 minutes, brief advice 5 minutes and motivational interviewing-based interventions 37 minutes.

Conclusions and implications for practice

The authors of this systematic review conclude that:

ED-based cessation interventions may be effective, but the available data are somewhat limited and heterogeneous.

Only two of the 13 studies included in the review found any benefit of smoking cessation intervention in the ED settings, with both using motivational interviewing. This led the authors of this review to further conclude that:

Motivational interviewing may prove to be a promising strategy where feasible.

However, it is important to note that four of the six studies which used motivational interviewing did not find any beneficial effect of this intervention.

The authors recommend that:

ED providers ask about smoking status, provide brief motivational interviewing or brief advice to quit as time allows, and provide a pamphlet with information about the benefits of smoking cessation and information about the benefits of smoking cessation and information for verified smoking cessation programs to all patients.

The evidence supporting emergency based interventions for smoking cessation is limited and heterogeneous. Further research is required to determine whether smoking cessation interventions are more effective in encouraging cessation than simply visiting the ED alone, and if so, which interventions are most effective.

Limitations

• The reviewers only searched two databases (Medline and CINAHL) so are likely to have missed studies published in journals not indexed on those databases.
• The general quality of the studies included in the systematic review was weak to moderate, even after studies with high risk of bias were excluded. Future research should use rigorous designs with large sample sizes.
• No studies investigated time-effectiveness, all-cause mortality, or cost per quit as outcomes and these factors should be considered in future research.
• Only four studies pre-registered study information, meaning that the degree to which the remaining studies fully reported all study outcomes cannot be guaranteed.
• Smoking cessation was assessed by the majority of studies using self-report, rather than through biometrically confirmed abstinence, potentially artificially increasing cessation success.
• The lack of a standardised control group meant that study findings could not be pooled into a meta-analysis.
• None of the studies included in this systematic review were conducted in the UK, with the focus on EDs in the USA.

Links

Pelletier JH, Strout TD, Baumann MR. A systematic review of smoking cessation interventions in the emergency setting. Am J Emerg Med. 2014 Jul;32(7):713-24. doi: 10.1016/j.ajem.2014.03.042. Epub 2014 Apr 2. [PubMed abstract]

Bernstein SL Bijur P, Cooperman N et al. Efficacy of an ED-cased multi-component intervention for smokers with substance use disorders. Journal of Substance Abuse Treatment, 2013; 44(1): 139-42.

Bock BC, Becker BM, Niaura RS et al. Smoking cessation among patients in an emergency chest pain observation unit; outcomes of the Chest Pain Smoking Study (CPSS). Nicotine and Tobacco Research, 2008; 10(10):1523-31. [PubMed abstract]

Quitting Smoking Among Adults – United States, 2001-2010. Centers for Disease Control and Prevention; 2011 [11/11/2011]