Adherence to Smoking Cessation Guidelines in the Emergency Department

Katz DA, Vander Weg MW, Nugent A, Kim R, Graham M, Holman JE, Hillis SL, Titler M. Adherence to Smoking Cessation Guidelines in the Emergency Department. Paper presented at: Society of General Internal Medicine Annual Meeting; 2009 May 15; Miami, FL.

BACKGROUND: The Society for Academic Emergency Medicine (SAEM) recommends use of the Agency for Healthcare Research and Quality (AHRQ) Smoking Cessation Guideline by emergency clinicians. The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation services in the ED, however. The aims of this study are: 1) to evaluate current practices of smoking cessation assessment and counseling in the ED, and 2) to identify characteristics of ED smokers associated with receipt of guideline-recommended cessation services. METHODS: We conducted a baseline face-to-face interview of adult smokers ( > 18 years old) who presented to one University ED by private vehicle or on a walk-in basis and who smoked more than 5 cigarettes per day (cpd). The baseline interview included questions about demographics, comorbid conditions, smoking-related beliefs, and other items pertaining to smoking cessation. To assess performance of guidelinerecommended actions by ED staff, we conducted a telephone interview of study patients shortly after the ED visit (typically within 48-72 hours). We used logistic regression to explore the following potential predictors of being asked about smoking and receiving brief cessation advice: sociodemographic variables (age, gender, race, education), prior diagnosis of smoking-related illnesses, Fagerstr m Test for Nicotine Dependence score, readiness to quit smoking (Contemplation Ladder), and depressed mood (score > 10 on the Patient Health Questionnaire depression module, PHQ9). RESULTS: Of 247 ED smokers who agreed to participate, 200 (81%) completed the post-ED interview and comprised the analytic sample. Thirty-six percent of study patients believed that they had a smokingrelated medical problem, and 21% had concern that their acute symptoms might be related to smoking. On the Contemplation Ladder (range 0-10), 40% scored 8 or higher, where 8 corresponds to "starting to think about how to change my smoking patterns." The majority of study patients were asked about smoking status (67%), but only 27% received any advice to quit and only 20% were asked about willingness to quit. Only 14% of patients received any assistance in quitting (selfhelp material, help in setting quit date, discussion of pharmacotherapy) and only 4% received a referral for telephone counseling. In multivariable models, female gender (OR 0.5, 95% CI = 0.2-1.0) and depressed mood (OR 0.3, 95% CI = 0.1-0.6) were negatively associated with being asked about smoking. Older patients (OR 1.04, 95% CI = 1.01-1.07 per year), those with < 12 years of education (OR 3.7, 95% CI = 1.5-9.0), and those reporting concern that acute symptoms were smoking-related (OR 3.0, 95% CI = 1.3-7.0) were more likely to receive advice to quit. Older patients (OR 1.04, 95% CI = 1.01-1.08 per year) were also more likely to be asked about willingness to quit. CONCLUSION: Although many ED smokers experience a "teachable moment" and are motivated to quit smoking, the ED encounter remains an underutilized opportunity to encourage smoking cessation. Based on the strength of evidence from primary care settings, ED clinicians should receive training and systems support to initiate cessation counseling for all smokers once these patients' acute care needs have been addressed.