Background Tobacco use is common among ED patients, many of whom are low-income. Our objective was to study the efficacy of an intervention incorporating motivational interviewing, nicotine replacement, and quitline referral for adult smokers in an ED. Methods A two-arm randomized clinical trial conducted from October 2010–December 2012, at a 90,000 visit/year urban ED in the northeastern U.S. Eligible subjects were age 18 years or older who smoked and were self-pay or had Medicaid insurance. Intervention subjects received a motivational interview by a trained research assistant, 6 weeks of nicotine patches and gum initiated in the ED, a faxed referral to the state smokers’ quitline, a booster call, and a brochure. Control subjects received the brochure, which provided quitline information. The primary outcome was biochemically confirmed tobacco abstinence at three months. Secondary endpoints included quitline utilization. Results Of 778 enrolled subjects, 774 (99.5%) were alive at three months. The prevalence of biochemically confirmed abstinence was 12.2% (47/386) in the intervention arm vs. 4.9% (19/388) in the control arm, for a difference in quit rates of 7.3% (95% CI 3.2%, 11.5%). In multivariable logistic modeling controlling for age, sex, and race/ethnicity, study subjects remained more likely to be abstinent than controls (OR 2.72, 95% CI 1.55, 4.75). Conclusions An intensive intervention improved tobacco abstinence rates in low-income ED smokers. Because approximately 20 million smokers, many of whom are low-income, visit US EDs annually, these results suggest ED-initiated treatment may be an effective technique to treat this group of smokers.

www.ClinicalTrials.gov (NCT01691105).

Background Emergency department (ED) patients commonly smoke. Current treatment approaches use motivational interviewing, which is effective, but resource-intensive. Mobile health approaches may be more feasible and generalizable. Objective To assess the feasibility of an ED-initiated program of tobacco dependence treatment that employs text messaging. Methods Smokers age 18 or older were randomized to intervention or control arms. Control subjects received a brochure describing the state smokers’ quitline. Intervention subjects received the brochure, four weeks of nicotine patches and gum, with the initial dose administered in the ED, a referral to the quitline, and enrollment in SmokeFreeTxt, a free SMS-messaging service. SmokeFreeTxt delivered 28 days of messages, 2–5 messages/day. Some messages ask subjects to provide data on mood or craving. Follow-up was conducted by phone call. Results 60 subjects were enrolled in May 2014. Of all subjects, 33 (55%) were nonwhite; 78% were insured by Medicaid. All intervention subjects used the texting program, with 24/30 (80%) using the program for all 28 days. At one month, 14/30 subjects (47%) in the intervention arm reported abstinence, vs. 3/30 (10%) in the control arm (P=0.003). At three months, the abstinence rates in the intervention and control arms were, respectively, 9/30 (30%) and 4/30 (13%) (P=0.21). Subjects responding to more assessments of mood or craving were more likely to report abstinence at one month. Conclusion A texting program, combined with pharmacotherapy and a quitline referral, is feasible and may promote tobacco abstinence in ED smokers. A larger trial is planned to assess these results.

Background Smoking cessation clinical trials assess tobacco abstinence using self-report and biomarkers. Optimum methods for each are unclear; a common question assesses smoking in the prior 7 days. In contrast, timeline follow-back (TLFB) is another technique often used to assess use of alcohol in treatment trials; it is used less frequently in studies of smoking cessation. The goal of this study was to assess concordance between the 7-day smoking question and a 7-day TLFB. Methods Secondary analysis of data from a randomized clinical trial of smoking cessation conducted at a busy, urban hospital emergency department (ED) from October 2010-December 2012. At 1, 3, and 12 months, subjects were contacted by phone to assess smoking status. Those reporting abstinence at 3 months were asked to return for an in-person measurement of exhaled carbon monoxide. For this analysis, we compared smoking status at 1 month for subjects in response to 2 questions asked concurrently, addressing 7-day point prevalence tobacco use, and a 7-day TLFB. Results Of 780 subjects, 666 (85.4%) were available for 1-month follow-up. Of these, 99 (14.9%) reported no smoking in response to the 7-day question, and 96 (14.4%) reported no smoking in response to the 7-day TLFB. The overall proportionate agreement between the 2 methods was 98.6%, with a kappa of 0.95 (95% CI 0.91-0.98). Conclusions A single question that assesses smoking at 7 days provides excellent concordance with the more detailed TLFB. The single question appears adequate to assess self-reported tobacco use in clinical trials of smoking cessation.

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