The ER docs said ‘stop smoking,’ and they did!

An intervention in the emergency department designed to encourage tobacco cessation in smokers appears to be effective. Two and a half times more patients in the intervention group were tobacco-free three months after receiving interventions than those who did not receive the interventions, according to a study published online Friday in Annals of Emergency Medicine (“Successful Tobacco Dependence Treatment in Low-Income Emergency Department Patients: A Randomized Trial”).

“Because approximately 20 million smokers visit emergency departments annually, this intervention has the potential to greatly reduce tobacco use among our patients,” said lead study author Steven L. Bernstein, MD, of the Yale School of Medicine in New Haven, Conn. “Given that cigarette smoking is the leading cause of preventable death and illness in the United States, anything we can do to discourage smoking has value. The need is particularly acute in low-income populations like those we studied.”

Researchers enrolled 778 patients who identified as smokers. They provided motivational interviewing, nicotine replacement and quitline referral for 386 of the patients. After three months, 12.2 percent of those patients were tobacco-free. Of the control group, only 4.9 percent were tobacco-free. The three-month abstinence rate was biochemically verified. At one year, abstinence rates were statistically significant as well for the intervention group, at least according to self-reported rates.

“While a busy emergency department may not welcome the additional responsibility of tobacco-cessation counseling, sometimes we have to meet our patients where they are,” said Dr. Bernstein. “Future research should focus on longer-term interventions, as well as mobile health technologies, such as texting.”


Tobacco use is common among emergency department (ED) patients, many of whom have low income. Our objective is to study the efficacy of an intervention incorporating motivational interviewing, nicotine replacement, and quitline referral for adult smokers in an ED.

The ER docs said 'stop smoking,' and they did! Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

Smokers are disproportionately from low-income households and commonly receive care in hospital emergency departments (EDs) either for medical consequences of smoking or for comorbid medical and psychiatric conditions. These patients often have limited access to primary care providers, who tend to undertreat tobacco use. Therefore, the ED visit may represent an ideal opportunity for screening, intervention, and referral for treatment, particularly given the greater prevalence of smoking in ED patients than in the general population.

In 2010, 129.8 million individuals visited US EDs. Recent reports from the Institute of Medicine, the federal government, and the 2008 Public Health Service tobacco treatment guideline include EDs as effective loci for tobacco control. Screening followed by brief intervention and referral to treatment has had success in reducing high-risk behaviors such as problem drinking.

EDs have been the focus of tobacco control efforts for 15 years. A recent meta-analysis of 7 studies containing 1,986 subjects found enhanced abstinence at 1 month, with the odds for tobacco abstinence in the intervention arm of 1.47 (95% confidence interval [CI] 1.06 to 2.06) compared with controls. At subsequent points of 3, 6, and 12 months, however, the effect was nonsignificant. The interventions in these studies included combinations of printed materials, brief counseling, motivational interviewing, and postdischarge telephone calls. Medications were not offered. An additional study found that smokers presenting to the ED with a tobacco-related International Classification of Diseases, Ninth Revision (ICD-9) code, or who thought they had a tobacco-related reason for the ED visit, were more likely to quit at 3 months than others.

We hypothesized that a more potent intervention, including ED-initiated “facilitated” referral to a quitline and initiation of pharmacotherapy, might result in sustained abstinence.


Julie Lloyd
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  Annals of Emergency Medicine

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