Of the nation's 45 million adult smokers, nearly 20 million visit hospital emergency departments (EDs) each year. ED patients, particularly smokers, are disproportionately low-income, with limited access to traditional primary care settings. Patients presenting to the ED with a tobacco-related trigger event, like an asthma attack, may be experiencing a """"""""teachable moment."""""""" Thus, the ED may be an ideal location in which to identify smokers and initiate treatment for tobacco dependence. Initial pilot research by our group has demonstrated the feasibility of ED-based brief interventions for smokers. Based on our feasibility studies, the Institute of Medicine 2006 report on tobacco and the 2008 US Public Health Service guidelines now list EDs as appropriate loci for tobacco control efforts. This study aims to test the efficacy of an ED-initiated tobacco intervention which includes counseling and medication. The intervention-Screening, Brief Intervention, and Referral to Treatment (SBIRT)-uses a form of motivational interviewing known as the Brief Negotiation Interview (BNI). Our proposed intervention combines a BNI with initiation of nicotine replacement therapy (NRT) and a fax referral to the state Smokers'Quitline during the ED visit. A 6-week starter kit of NRT (patch and/or gum, tailored to level of addiction and patient preference) will be provided with written materials. The initial dose of NRT will be given in the ED. A trained nurse will administer the booster intervention via telephone 3 days post-visit. The SBIRT+NRT arm will be compared to standard care (SC), which consists of written materials only, in a controlled trial of 778 smokers age 18 years or older randomized in a 1:1 fashion. The primary hypothesis is that SBIRT+NRT will be superior to SC in reducing self-reported and biochemically verified 7-day tobacco abstinence at 3 months. Secondary hypotheses include: (1) Patients with a tobacco- related diagnosis for the ED visit will have a higher cessation rate than patients without a tobacco-related diagnosis, and (2) Patients who believe their ED visit is smoking-related will have a higher quit rate than others. We will conduct a cost benefit analysis of the interventions. Follow-up assessments at 1, 3 and 12 months will combine self-report with in-person salivary cotinine testing at 3 months for smokers who assert abstinence via phone. Expansions of the proposed project as compared to earlier studies include: 1) initiation of NRT during the ED visit;2) provision of multiple forms of NRT;3) a proactive referral made to the Quitline;4) a credible control condition with minimal baseline assessment, to avoid the assessment reactivity seen in similar ED studies;and 5) an economic analysis of the tested interventions.

Public Health Relevance

Tobacco dependence is the leading cause of preventable death and illness in the United States. In 2006, approximately 45.3 million US adults were current smokers, and 435,000 Americans died of tobacco-related illness. The economic costs of tobacco dependence, estimated at greater than $193 billion/year, have far reaching implications for the individual, workplace, society and the healthcare system. Treatment is associated with substantial individual and societal benefits;and the Emergency Department visit, often the smoker's only contact with the medical system, is a unique opportunity for screening, intervention and referral to treatment.

Agency
National Institute of Health (NIH)
Institute
National Cancer Institute (NCI)
Type
Research Project (R01)
Project #
5R01CA141479-02
Application #
8063671
Study Section
Special Emphasis Panel (ZCA1-SRRB-Y (M1))
Program Officer
Augustson, Erik
Project Start
2010-04-16
Project End
2015-01-31
Budget Start
2011-02-01
Budget End
2012-01-31
Support Year
2
Fiscal Year
2011
Total Cost
$638,694
Indirect Cost
Name
Yale University
Department
Emergency Medicine
Type
Schools of Medicine
DUNS #
043207562
City
New Haven
State
CT
Country
United States
Zip Code
06520
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Bernstein, Steven L; Rosner, June-Marie; Toll, Benjamin (2016) Cell Phone Ownership and Service Plans Among Low-Income Smokers: The Hidden Cost of Quitlines. Nicotine Tob Res 18:1791-3
Bernstein, Steven L; Weiss, June-Marie; Toll, Benjamin et al. (2016) Association Between Utilization of Quitline Services and Probability of Tobacco Abstinence in Low-Income Smokers. J Subst Abuse Treat 71:58-62
Bernstein, Steven L; Rosner, June; Toll, Benjamin (2016) A Multicomponent Intervention Including Texting to Promote Tobacco Abstinence in Emergency Department Smokers: A Pilot Study. Acad Emerg Med 23:803-8
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Bernstein, Steven L; D'Onofrio, Gail; Rosner, June et al. (2015) Successful Tobacco Dependence Treatment in Low-Income Emergency Department Patients: A Randomized Trial. Ann Emerg Med 66:140-7
Li, Jian; Yu, Chao; Sun, Yang et al. (2015) Serum ubiquitin C-terminal hydrolase L1 as a biomarker for traumatic brain injury: a systematic review and meta-analysis. Am J Emerg Med 33:1191-6
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