Tobacco Control Interventions in the Emergency Department: A Joint Statement of Emergency Medicine Organizations

HEALTH POLICY AND CLINICAL PRACTICE/CONCEPTS

Tobacco Control Interventions in the Emergency Department:A Joint Statement of Emergency Medicine Organizations

Steven L. Bernstein, MDEdwin D. Boudreaux, PhDRita K. Cydulka, MD, MSKarin V. Rhodes, MD, MSNadine A. Lettman, MDSherri-Lynne Almeida,

DrPH, MSNLynne B. McCullough, MDSelma Mizouni, MDArthur L. Kellermann,

MD, MPHFor the American College of

Emergency Physicians TaskForce on Smoking Cessation

From the Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY(Bernstein, Lettman); the Department of Emergency Medicine, Montefiore Medical Center, Bronx, NY(Bernstein); the Department of Emergency Medicine, University of Medicine and Dentistry of NewJersey/Cooper Medical Center, Camden, NJ (Boudreaux); the Department of Emergency Medicine,MetroHealth Medical Center, Cleveland, OH (Cydulka); the Department of Emergency Medicine,University of Chicago, Chicago, IL (Rhodes); TeamHealth, Houston, TX (Almeida); the Department ofEmergency Medicine, University of California, Los Angeles Medical Center, Los Angeles, CA(McCullough); the Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, VA(Mizouni); and the Department of Emergency Medicine, Emory University, Atlanta, GA (Kellermann).

Smoking is the leading cause of preventable death and illness in the United States. National practiceguidelines call for all health care providers to “ask” all patients about tobacco use, and to “advise,assess, assist, arrange” when smokers want to quit smoking (the “5 As”). Emergency departments(EDs) have not been an important locus of tobacco control efforts, although ED patients typically smokeat rates exceeding that of the general population, are interested in quitting, and often have limitedaccess to primary care. To address the role of emergency medicine in tobacco control, the AmericanCollege of Emergency Physicians convened a task force of representatives of major emergency medicineprofessional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and2005. This article represents a summary of the task force’s recommendations for tobacco controlpractice, training, and research. We call on emergency care providers to routinely assess patients’smoking status, offer brief advice to quit, and refer patients to the national smokers’ Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task forceconsiders it essential for emergency physicians to conduct research into the efficacy of ED-basedinterventions and to place tobacco control into the training curriculum for emergency medicineresidencies. Tobacco control fits within the traditions of other ED-based public health practices, such asinjury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010mandate to reduce the prevalence of smoking among US citizens. [Ann Emerg Med. 2006;48:e417-e425.]

0196-0644/$-see front matterCopyright © 2006 by the American College of Emergency Physicians.Published simultaneously with the Journal of Emergency Nursing.doi:10.1016/j.annemergmed.2006.02.018

INTRODUCTIONForty years after publication of the epochal surgeon general’s

report linking smoking and lung cancer,1 smoking remains theleading cause of death in the United States. Tobacco use kills430,000 Americans yearly, approximately 20% of all deaths.More Americans are killed by smoking than by alcohol, illicit
drugs, violence, and HIV combined (Figure 1).2 The list of
Volume 48, . : October

diseases caused by smoking is extensive and continues to grow(Figure 2). The persistence of smoking reflects several factors,including the addictive power of nicotine, the pervasiveness ofcigarette advertising, and the reluctance of health care providersand payers to fully embrace tobacco control. Sparked by the$206 billion Master Settlement Agreement3 and a widely
disseminated practice guideline,4 the tobacco control movement
Annals of Emergency Medicine e417

Smoking Cessation Bernstein et al

entered the new millennium with the promise of driving USrates of cigarette consumption to record low levels. In the 5years since these landmark events, the prevalence of currentcigarette smoking among US adults has decreased slightly, to22.1%.5 The decrease in smoking prevalence, althoughwelcome, is too slow to allow the nation to achieve the HealthyPeople 2010 objective of a less than or equal to 12% prevalencerate of cigarette smoking.

The 2000 Public Health Service clinical practice guidelinerecommends that “clinicians and health care systems . . .institutionalize the consistent identification, documentation,and treatment of every tobacco user seen in a health caresetting.”4 However, one health care setting, overlooked in theguideline, has the potential to reach millions of people whomight not otherwise engage in tobacco interventions with a

Figure 1. Comparative causes of annual deaths, United StaPrevention.

Coronary heart disease, 410-414Other heart disease, 390-398, 401-405, 415-417, 420-429Cerebrovascular lesions, 430-438Other circulatory disease, 440-448Chronic obstructive pulmonary disease, 490-492, 496Other respiratory disease, 010-012, 480-489, 493Cancer, lip, oral cavity, pharynx, 140-149Cancer, esophagus, 150Cancer, pancreas, 157Cancer, larynx, 161Cancer, lung, 162Cancer, kidney, 189Cancer, bladder and other urinary organs, 188Cancer, cervix, 180Peptic ulcer disease, 531-535Burns, 940-949

Figure 2. Smoking-related International Classification ofDiseases, Ninth Revision diagnostic codes. (Adapted from1989 surgeon general’s report.)82

health care provider: the hospital emergency department (ED).

e418 Annals of Emergency Medicine

US EDs treat more than 115 million patients yearly, ofwhom 85 million are aged 15 years or older.6 Because access toprimary care is erratic or nonexistent for many of these patients,the ED is increasingly viewed as the “safety net of the safetynet,” providing care for millions of individuals who havemultiple unmet health care needs.7-11 Furthermore, there isevidence that ED patients smoke at rates far in excess of thenational average, as high as 48%.12

This article will explore the feasibility of ED-based tobaccocontrol, review the evidence, and propose a research andeducational agenda for emergency health care providers tofacilitate tobacco control efforts. The task force hopes that thisreport will inspire ED personnel to adopt simple, effectivemeasures to help smokers quit and encourage funders to supportED-based tobacco control.

BackgroundEmergency medicine encompasses the delivery of care for

unscheduled patients with acute illness and injury. Thespecialty’s role in delivering preventive services remainscontroversial. Screening and intervention remain difficult to doin the ED because of barriers of time, resources, andreimbursement.13,14 Moreover, EDs that treat the mostvulnerable patients often have the fewest resources.

Nonetheless, there is now great focus on the public healthimplications of being a “safety net” provider for more than 40million uninsured Americans. The last decade has witnessedgrowing recognition of the role of EDs in injury surveillanceand population-based public health strategies.13,15

In 1998, the Society for Academic Emergency Medicine’sboard of directors directed its public health task force to developrecommendations for prevention, screening, and counselingactivities to be conducted in EDs.14,16 Following the lead of the

2000. Source: Centers for Disease Control and
tes,
US Preventive Services Task Force, the public health task force


Bernstein et al Smoking Cessation

developed a list of candidate prevention services that appearedto be inexpensive, feasible, and potentially effective in the ED.Using an evidence-based approach, the public health task forceidentified 5 preventive services with sufficient evidence ofeffectiveness to support a recommendation for implementationin the ED setting: alcohol screening and intervention, HIVscreening and referral, hypertension screening and referral,pneumococcal vaccinations (for those older than 65 years), andsmoking cessation counseling.14,17,18

Tobacco control offers an opportunity to strengthen the linkbetween patient-centered acute medical care and thepopulation-based interventions of public health practice.Important precedents include ascertainment of tetanus statusand administration of toxoid19-22 and detection and treatmentof alcohol-related problems.23-26 Many ED patients areinterested in obtaining information about preventive healthmeasures; in one study, 26% of patients indicated that thehealth care–related subject in which they were most interestedwas smoking cessation.27

The growing interest in smoking cessation interventionstargeting ED patients led to the convening of this task force.Funded by a grant to the American College of EmergencyPhysicians from the Smoking Cessation Leadership Center, anational program office of the Robert Wood JohnsonFoundation, the task force’s mission was to convene a summitof emergency medicine organizations to develop a jointstatement on the role of emergency medicine in encouragingsmoking cessation and identifying barriers to these efforts.Representatives of all major emergency medicine professionalorganizations were invited to serve on the task force. Memberswere specifically sought who demonstrated interest in tobaccocontrol or public health issues in emergency medicine, asevidenced by published research or national presentations inthese areas. The task force met 3 times, in October 2004,February 2005, and May 2005, to review the relevant publishedliterature and current research and consider variousrecommendations. A draft of this article, withrecommendations, was written by the chair of the task force andcirculated among its members for review and comment.Individual task force members wrote specific sections as well.The final document was approved by all task force members andhas been submitted to their respective organizations. This reportis intended to become source material for future studies and ablueprint for action. The task force hopes it will stimulateefforts among health care leadership groups to improve theability of emergency health care providers to help smokingpatients quit.

Individuals representing the following organizations servedon the task force:American College of Emergency PhysiciansCouncil of Emergency Medicine Residency DirectorsEmergency Medicine Residents Association
Emergency Nurses Association

Three other emergency medicine organizations were asked toparticipate but declined or did not respond.

Health Effects of Smoking and NicotineCigarettes and cigarette smoke contain a complex mixture of

roughly 4000 gaseous and particulate compounds. The 3 maintoxic constituents are nicotine, carbon monoxide, and tar.28

Their adverse health effects are as follows:Nicotine is a colorless, volatile liquid that occurs naturally in the

leaves and stems of Nicotiana tabacum and N rustica.29

Nicotine binds to acetylcholine receptors located in thenucleus accumbens and prefrontal cortex, stimulating releaseof dopamine and other neurotransmitters.29 These regionsmediate pleasure and reward seeking, accounting fornicotine’s addictive properties.

Carbon monoxide preferentially binds to hemoglobin, reducingthe oxygen-carrying capacity of the blood.28 Blood levels ofcarboxyhemoglobin are 3 to 10 times higher in smokers thannonsmokers. Along with nicotine, carboxyhemoglobin isthought to contribute to the increased risk of heart disease insmokers.30

Tar is a black, sticky amalgam of compounds that lodge in theupper airway and lungs. Tar contains more than 40carcinogens, including hydrocarbons known to contribute tooncogenic mutations in the p53 gene. Tar also causesparalysis of pulmonary cilia, contributing to the developmentof respiratory tract infections.28,30 Macrophage activationwithin the airway lumen contributes to the development ofemphysema.30

In addition, cigarette smoke contains solvents such asbenzene and toluene; heavy metals such as cadmium, arsenic,and mercury; ammonia; and dioxins.31

Health Benefits of QuittingAbout 70% of all smokers want to quit. Every year, 30% to

50% try; 5% of smokers who try quitting without assistance aresuccessful.28 Most smokers average 8 quit attempts before asuccessful, final quit.32 Thus, smoking is best conceptualized asa chronic disease, with relapses and remissions.33

The health benefits of quitting occur quickly. Twentyminutes after smoking ceases, blood pressure and pulse drop tonormal. Temperature of hands and feet increases to normal.Eight hours after smoking ceases, carbon monoxide level inblood drops to normal and oxygen saturation normalizes. Forty-eight hours after smoking ceases, nerve regrowth begins and theability to smell and taste begins to improve. Two weeks to 3months after smoking ceases, circulation improves, claudicationdiminishes, and pulmonary function improves up to 30%. Oneto 9 months after smoking ceases, coughing, congestion, fatigue,and dyspnea decrease. Ciliary regrowth occurs in lungs. Oneyear after smoking ceases, risk of coronary artery disease halves.Five years after smoking ceases, lung cancer death rate declinesby half, risk of stroke becomes the same as that of a nonsmoker,and risk of cancer of the mouth, throat, esophagus, bladder,
kidney, and pancreas decreases.34


Review of ED-Based LiteratureStudies of tobacco use among ED patients find prevalence

rates exceeding that of the general population. In a 3-city study,the prevalence rate was 48%12; in a suburban ED serving anaffluent community, it was 21%, approximately the same as thegeneral population.35 A study of 1,847 adult asthmatic patientsin 64 EDs found a prevalence rate of 35%.36 According to anattributable risk methodology at a single ED, 4.9% of all EDadult visits were found to be attributable to smoking, 6.8% ofall admissions, and 10.0% of all charges.37 These data led to thepublication in 2002 of a clinical practice guideline calling foruniversal screening of ED patients for tobacco use,17 with anevidence grade of B (�), based largely on the strength ofevidence in the primary care literature. One meta-analysis,conducted for the 2000 Public Health Service clinical practiceguideline, shows that brief advice from a physician to quit canincrease abstinence rates from 7.9% to 10.2% (odds ratio 1.3;95% confidence interval [CI] 1.1 to 1.6).4

ED patients appear willing to engage in a brief intervention.In a survey of 139 smokers in 4 Boston EDs, 34% wereinterested in an outpatient referral for cessation.38 Surveys ofsmokers in New Jersey and Minnesota found 61% to 79% ineither the contemplation or preparation stages of change.39,40

Smokers presenting to the ED with an acute tobacco-relatedcondition have similar levels of motivation to quit as smokerswith a non–tobacco-related condition but a slightly higher levelof nicotine addiction and slightly higher daily cigaretteconsumption.41

Two recent studies support the potential utility of the ED asa locus of smoking cessation efforts for patients with tobacco-related conditions.42,43 A survey of 63 adult smokers with acuterespiratory illness from an inner city ED found that 60% werewilling to discuss smoking cessation with study personnelduring the ED stay.43 Another study from the same institutionof 159 adult ED patients admitted to the chest pain observationunit (38% of whom smoked) yielded similar results concerningphysician interventions.42

Emergency physicians are likely to ask about smoking statusbut unlikely to assess the patient’s desire to quit or dispenseadvise about quitting.4,42-44 Reasons for this inaction mayinclude time pressures, a perception that patients are notinterested in tobacco cessation interventions, lack of belief in theeffectiveness of counseling, and the belief the that the ED is notthe appropriate venue for such interventions.44

Most cessation research has been conducted in primary caresettings. Those conducted in the ED have yielded equivocalresults.45,46 Although these studies confirm the feasibility ofED-based interventions, they have not reported success inreducing smoking rates and related outcomes like nicotinedependence and motivation to quit. Reasons for this failure mayinclude the limited intensity and frequency of the intervention,the failure to screen smokers about their interest in quitting, thelack of training in tobacco dependence counseling, the lack of
follow-up, and failure to provide nicotine replacement.

One study randomized 152 adult smokers either to receive apamphlet from the American Heart Association or a briefscripted counseling session and the pamphlet from theemergency physician.45 The latter group was also referred to thehospital’s cessation clinic. At 3 months, patients in both groupsreported quit rates of 10%, and no patient in the interventiongroup (95% CI 0% to 3%) had contacted or attended thecessation clinic.

There were significant methodologic weaknesses in thisstudy, including small sample size and failure to assess treatmentfidelity.

Barriers to ED-Based Tobacco ControlEmergency physicians are likely to ask about smoking status

but unlikely to assess the patient’s desire to quit or dispenseadvise about quitting.4,42-44 There are several reasons for thesebarriers, including insufficient time with the patient, perceivedlack of interest on the part of patients, the belief that the ED isan inappropriate setting for preventive health activities,perceived ineffectiveness of counseling, lack of training intobacco cessation techniques, difficulties with follow-up, andlack of reimbursement for brief screening and referral.44

Incorporating tobacco counseling into clinical practice musttake these barriers into account. Some system interventionsexplored in the primary care arena may be readily translated intothe ED. Simple interventions such as computerized promptsembedded in an electronic medical record, printed medicalrecord reminders, and “vital sign” stamps on medical recordscan improve documentation, referral, and completion of avariety of preventive health services, including tobaccocounseling.47-50 Technologic advances, such as computerizedassessment, interactive video, and tailored feedback reports, mayreduce the barriers that impede delivery of brief tobaccointerventions in health care settings.51-57

Emergency physicians have been inundated with numerous“fifth vital signs” in recent years, including measurement ofoxygen saturation,58 pain score,59 and intimate partnerviolence.60 Viewed in this context, screening for tobacco usemay be perceived as an administrative burden, particularly ifsmoking is not perceived to be the proximate cause of the EDvisit. However, smoking and ED use are often intimatelyconnected. Moreover, because tobacco remains the leadingcause of death in the United States, it has achieved prioritystatus in many public health initiatives, including HealthyPeople 2010.

Impact, Reach, Efficacy, and Cost-EffectivenessTraditionally, the efficacy of cessation interventions has been

assessed by measuring the point prevalence of abstinence andcomparing intervention and control groups. Intensive programscan achieve cessation rates of 20% to 30% but requireattendance at weekly meetings for 6 to 8 weeks. Clinicians oftenfind these modest success rates discouraging and may be
inclined to view these strategies as ineffective.


A newer approach to outcome assessment involves theconcept of impact, which is the product of reach (number ofpeople who would use the intervention) and efficacy (percentageof people who use the intervention who benefit from it).61

Interventions that maximize impact are frequently populationbased and may include strategies such as telephone quit lines,public service announcements, and nicotine replacementproduct giveaways.

Similarly, ED-based tobacco control may also constitute ahigh-impact, high-reach, low-efficacy intervention. For example,85 million Americans aged 15 years and older visit US EDsyearly.62 If 30% of them smoke, then 25.5 million smokers visitEDs yearly (rounded down to 20 million patients to account forrepeat visits). If an additional 1% of these smokers can bepersuaded to quit, this equals 200,000 new ex-smokers becauseof ED-initiated programs. Thus, even a low-efficacyintervention can have a sizeable reach and impact if it isdelivered to a large number of people.

Further, the task force does not advocate adoption of ED-based screening as a stand-alone intervention. A better termmight be ED-initiated tobacco control, thus placing ED effortsfirmly within a continuum of interventions that covers thespectrum of patient-provider encounters in ambulatory andinpatient settings.

Last, smoking cessation remains perhaps the most cost-effective medical intervention among all commonly usedtreatments. Several cost-effectiveness analyses have shown thattobacco control interventions compare favorably withtreatments such as use of statins in hypercholesterolemia,mammographic screening, and coronary artery bypass graftingin terms of quality-adjusted life-years saved.63,64

INTERVENTIONS WITH ADULTSPersonnel

Screening and intervention can be carried out by clinical staff(triage nurse, treatment nurse, physician) or nonclinical staff,such as social workers or health educators. Providers may screenand counsel during the medical history, physical examination,or discharge phases of the encounter, using the model of“opportunistic delivery of preventive services.”65,66 Anotherapproach, at Boston Medical Center, uses trained lay peercounselors to conduct brief substance abuse counseling in theED.26 The type of training required to prepare health careworkers for this task remains unclear. National trainingstandards and licensure for tobacco interventionists do notcurrently exist, although draft guidelines are available.67

FormatSmoking cessation screening and counseling can be

conducted in various ways, ranging from computerized self-report and video interventions to traditional verbal assessmentand counseling. Screenings may be verbal, with no written cuesfor the provider, cued by a checkbox on a paper chart, or cuedelectronically from a computerized health record. In general,
structured, prompted cues are more efficient and effective than

unstructured questions, especially if the prompt must beanswered in a “forced” fashion.68 Screening may also beconducted by means of a computer kiosk in the waiting area,with results given to the provider by the patient.69,70

Counseling may be provided in the form of a brochure;verbally by a provider, ED-based peer educator, or dischargenurse; or through a video played in the waiting area. Freebrochures in various languages are available; the Agency forHealthcare Research and Quality offers several (available onlineat http://www.ahrq.gov). Posters placed in waiting areas ortreatment rooms provide another means of patient education.

All counseling should include the telephone number of thenational quit line (800-QUIT-NOW) or the appropriate statequit line. A quit line is a toll-free number that smokers may callto receive free advice, information, and counseling aboutcessation. In some states, such as New York, nicotinereplacement products may also be obtained at no cost from thequit line. Many quit lines allow providers to refer patients fortreatment and provide follow-up in the form of a faxed report.Quit lines are an efficacious, cost-effective means of promptingcessation and involve minimal effort by the provider.71,72

Provision of a wallet card, similar in size to a credit card, printedwith the quit line number is another option. A sample card is

Figure 3. A sample wallet card containing the telephonenumber of the North American Quitline. (Provided by theSmoking Cessation Leadership Center. Reprinted with thepermission of the Smoking Cessation Leadership Center.)

shown in Figure 3.


http://www.ahrq.gov


Last, providers may consider initiating nicotine replacementtherapy from the ED, particularly for heavily addicted smokersadmitted to the hospital. Hospitals with a tobacco treatmentconsultation service may be best equipped to continue theseservices to inpatients.

INTERVENTIONS FOR CHILDREN ANDCAREGIVERS

In pediatric emergency medicine, there are 2 targetpopulations of smokers to consider: young adolescents andcaregivers. The former provide opportunities to discourageinitiation of tobacco use among nonsmoking teens andpromotion of cessation for those already smoking. Effortsdirected at caretakers can help reduce children’s exposure toenvironmental tobacco smoke and prevent diseases associatedwith secondhand smoke.

Nearly 1,200 adolescents initiate smoking daily, replacingadults who succumb to tobacco-related disease. Most smokingcessation interventions targeted to adolescents have been basedon adult models rather than tailored to their needs and haveshown mixed results.73 Few studies have examined the efficacyof cessation treatment for adolescents. Recent interventions haveattempted to target teens by using approaches such as textmessaging and the Internet.74,75

The prevalence of smoking among caregivers of children whovisit the ED appears higher than that of the general population.In one single-site study, the prevalence of smoking was 41%among 249 caregivers of children in the ED for asthma orbronchiolitis.76

Parental concerns about exposing their children tosecondhand smoke can be a powerful motivator for cessation.77

Winickoff et al78 suggested that counseling parent smokerswhile their child is hospitalized with a respiratory illness mayrepresent a unique opportunity to enroll parents in a smokingcessation program.

REGULATORY MANDATES MAY ENHANCEEMERGENCY MEDICINE TOBACCO CONTROLEFFORTS

Documentation of smoking status and advice to quit are nowquality measures cited by national accrediting bodies, includingthe Joint Commission on the Accreditation of HealthcareOrganizations, the Centers for Medicare & Medicaid Servicesand state peer-review organizations.79,80 These measuresessentially compel hospitals and health care systems to offertobacco screening and counseling to patients with definedhealth conditions. For example, provision of smoking cessationcounseling is part of the core measures set for the treatment ofpatients hospitalized with acute myocardial infarction,congestive heart failure, and community-acquired pneumonia.Because most of these patients enter the hospital through theED, initiation (and documentation) of tobacco screening andcounseling in the ED may facilitate compliance, which maymotivate institutional and ED leadership about the value of
offering tobacco screening and interventions in the ED.

DEFINING A RESEARCH AGENDAThere is good evidence for the high prevalence of tobacco use

among ED patients, patient motivation to quit, and acceptanceof intervention in the ED.26,38-40 Although current literatureshows minimal efficacy in ED-based cessation interventions,future research must look at ways of increasing the impact ofsuch efforts.

To develop the evidence base on the efficacy of ED-basedscreening and intervention, well-designed, methodologicallyrigorous, multicenter, randomized, clinical trials with validatedoutcome measures are needed to demonstrate whether briefinterventions initiated in the ED lead to abstinence, reducedcigarette consumption, or enhanced motivation to quit. Severalsuch trials are in progress.

There are several challenges to this research agenda,including the large sample size needed to show a decrease inmorbidity. However, one can also examine intermediateoutcomes such as harm reduction (eg, cutting down dailyconsumption, not smoking around children) or processmeasures (eg, readiness to change, following up with referral).

Other less expensive research strategies include addingquestions to national survey instruments to obtain population-based data and performing secondary analysis of previouslycollected administrative data.

FUNDINGFunding for tobacco counseling remains piecemeal.

Reimbursement for cessation counseling varies by payer. Inseveral states, Medicaid pays for tobacco counseling.81 Medicaidgenerally covers pharmacotherapy. The March 2005 decision bythe Center for Medicare & Medicaid Services to reimburseproviders for counseling given to Medicare patients withsmoking-related diseases82 offers hospitals a financial incentiveto expand these services. Because many Medicare patients withtobacco-related diseases are admitted through the ED, thislandmark decision may provide EDs an opportunity to bereimbursed for initiating tobacco screening and counseling. Thenew Part D medication benefit will likely coverpharmacotherapy too, although the extent of coverage isunclear.

Among private third-party payers, funding varies widely.Typically, prescription pharmacotherapy is covered but notcounseling. The International Classification of Diseases, NinthRevision code for nicotine dependence, 305.1, may be usedwhen submitting claims.

For ED researchers, there are numerous opportunities tosecure funding for trials of brief interventions, includingcomponents of National Institutes of Health, Agency forHealthcare Research and Quality, the Robert Wood JohnsonFoundation, the American Legacy Foundation, and others. Todate, the National Institute on Drug Abuse has funded bothcareer development awards and research series grants in ED-based tobacco control.

Funding success may be enhanced by collaborating with
basic scientists researching the neurobiologic effects of nicotine,


and with other clinical researchers with an interest in tobaccocontrol, consistent with the National Institutes of Health’sRoadmap Initiatives.83

DEVELOPING A CURRICULUM IN TOBACCOCONTROL FOR EMERGENCY MEDICINERESIDENTS

Tobacco is not part of the core curriculum for emergencymedicine residents.84 The discordance between tobacco’sburden of disease in ED patients and its absence from the corecurriculum is striking.

There is growing interest in introducing clinical preventionand population health interventions into the curriculum for allhealth professionals.85 Other specialties, such as pediatrics andsurgery, have developed curricula to strengthen residents’knowledge, attitudes, and skills in tobacco control.86,87

A curriculum for emergency medicine residents would placeemergency medicine in the forefront of medical specialtiesaddressing smoking and smoking-induced illnesses. Such acurriculum could include lectures on the epidemiology oftobacco-related disease, treatment options, and role-playing andinstruction in motivational interviewing. Curricular materialscould be made available to program directors through the“sharepoint” site of the Council of Emergency MedicineResidency Directors Web site (available online athttp://www.cordem.org).

RECOMMENDATIONSHelping smokers quit should be included as a part of every

ED visit. Screening, advising, and referring smokers totreatment is simple and fast. It can be performed during anyphase of the ED visit. Simple interventions can be provided inless than 30 seconds. A wealth of evidence from primary careand other settings documents the efficacy and effectiveness ofbrief interventions for smoking. Although the evidence

Table. Recommendations for ED-based tobacco control practice

Personnel

Clinicians Ask all adults and adolescents who viAdvise all smokers to quit, in a clearRefer smokers who want to quit to the

treatment center.Consider prescribing nicotine replacem

ED administrators Create a field in the electronic medicaDeliver intense interventions targeting

asthma.Install a cessation guideline on providFacilitate referral to local cessation prUse health educators to perform tobaRun public service videos in the ED w

Educators and researchers Perform clinical trials testing the efficaincrease the rates of tobacco scree

Pursue extramural funding for these trCreate and disseminate a curriculum

continues to accrue in the ED setting, the task force suggests


that at present the evidence supports the followingrecommendations:1. educate all faculty and emergency medicine residents about

the burden of smoking and the potential for ED cessationprograms;

2. identify the most effective ED-based strategies for urban,suburban, and rural EDs and assist institutions in adoptingthem;

3. conduct research on novel approaches to ED-based smokingcessation; and

4. identify funds to encourage ED-based research anddemonstration projects on smoking cessation.

Specific recommendations for clinicians, administrators,educators and researchers are provided in the Table.

CONCLUSIONSAs long as smoking remains America’s leading cause of death,

tobacco control will maintain a central, essential role in clinicalmedicine. The prevalence of tobacco use and tobacco-relatedillness in ED patients, their willingness to quit, and evidence ofefficacy of brief interventions from other ambulatory settings allsuggest the ED can be a fruitful site for tobacco control. As EDresearchers continue to study the efficacy of specificinterventions, the task force believes the moment is ripe to maketobacco control an integral component of emergency care.Given the magnitude of the public health problem posed bytobacco, it would be an abrogation of our responsibility asphysicians not to do so.

We wish to thank Steven A. Schroeder, MD, for his guidanceand vision throughout this project and Marilyn Bromley for herable administrative support.

Supervising editors: Kathy J. Rinnert, MD, MPH: Michael L.

ucation, and research.

Recommendation

e ED about tobacco use.onconfrontational manner.onal Quitline (800-QUIT-NOW), a local, state-based quit line, or a local

therapy.ord to capture tobacco use.kers with tobacco-related illness such as acute coronary syndrome or

personal digital assistants.s.

creening.area.

f various ED-based administrative and educational interventions toand treatment referral.

acco control for emergency medicine residents.

, ed

sit thand n

nati

entl recsmo

ers’ogramcco saitingcy oningials.in tob

Callaham, MD


http://www.cordem.org


Funding and support: Supported by a grant from the SmokingCessation Leadership Center, Robert Wood JohnsonFoundation.

Publication dates: Received for publication November 21,2005. Revision received February 8, 2006. Accepted forpublication February 14, 2006. Available online June 8, 2006.

Reprints not available from the authors.

Address for correspondence: Steven L. Bernstein, MD,Department of Emergency Medicine, Montefiore MedicalCenter, 111 East 210th St, Bronx, NY 10467; 718-920-2068,fax 718-798-0730; E-mail [email protected].

REFERENCES1. US Public Health Service. Smoking and Health: Report of the

Advisory Committee to the Surgeon General of the Public HealthService. Rockville, MD: US Department of Health, Education, andWelfare, Public Health Service, Center for Disease Control; 1964.PHS Publication No. 1103.

2. Centers for Disease Control and Prevention. Comparative causes ofannual deaths in the United States. Available at: http://www.cdc.gov/tobacco/research_data/health_consequences/andths.htm.Accessed May 27, 2005.

3. Schroeder SA. Tobacco control in the wake of the 1998 MasterSettlement Agreement. N Engl J Med. 2004;350:293-301.

4. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use andDependence: Clinical Practice Guideline. Rockville, MD: USDepartment of Health and Human Services, Public Health Service;2000.

5. Centers for Disease Control and Prevention. State-specificprevalence of current cigarette smoking among adults: UnitedStates, 2003. MMWR Morb Mortal Wkly Rep. 2004;53:1035-1037.

6. McCaig LF, Ly N. National Hospital Ambulatory Medical CareSurvey: 2000 Emergency Department Summary: Advance Datafrom Vital and Health Statistics: No. 326. Hyattsville, MD:National Center for Health Statistics; 2002.

7. Glauser J. Rationing and the role of the emergency department associety’s safety net. Acad Emerg Med. 2001;8:1101-1106.

8. Taylor TB. Threats to the health care safety net. Acad Emerg Med.2001;8:1080-1087.

9. Asplin BR. Tying a knot in the unraveling health care safety net.Acad Emerg Med. 2001;8:1075-1079.

10. Richardson LD, Hwang U. America’s health care safety net: intactor unraveling? Acad Emerg Med. 2001;8:1056-1063.

11. Gordon JA, Chudnofsky CR, Hayward RA. Where health andwelfare meet: social deprivation among patients in the emergencydepartment. J Urban Health. 2001;78:104-111.

12. Lowenstein SR, Koziol-McLain J, Thompson M, et al. Behavioralrisk factors in emergency department patients: a multisite study.Acad Emerg Med. 1998;5:781-787.

13. Pollock DA, Lowery DW, O’Brien PM. Emergency medicine andpublic health: new steps in old directions. Ann Emerg Med. 2001;38:675-683.

14. Irvin CB, Wyer PC, Gerson LW. Preventive care in the emergencydepartment, part II: clinical preventive services: an emergencymedicine evidence-based review. Acad Emerg Med. 2000;7:1042-1054.

15. Bernstein E, Goldfrank LR, Kellermann AL, et al. A public healthapproach to emergency medicine: preparing for the twenty-firstcentury. Acad Emerg Med. 1994;1:277-286.

16. Rhodes KV, Gordon JA, Lowe RA. Preventive care in the
emergency department: report of the Society for Academic

Emergency Medicine Public Health and Education Task Force, partI: clinical preventive services: are they relevant to emergencymedicine? Acad Emerg Med. 2000;7:1036-1041.

17. Bernstein SL, Becker BM. Diagnosis and management of smokingand smoking-related illness in the emergency department: asystematic review. Acad Emerg Med. 2002;9:720-729.

18. D’Onofrio G, Degutis LC. Preventive care in the emergencydepartment: screening and brief intervention for alcohol problemsin the emergency department: a systematic review. Acad EmergMed. 2002;9:627-638.

19. Roper MH. Tetanus prophylaxis in the emergency department.Ann Emerg Med. 2004;43:315-317.

20. Talan DA, Abrahamian FM, Moran GJ, et al. Tetanus immunity andphysician compliance with tetanus prophylaxis practices amongemergency department patients presenting with wounds. AnnEmerg Med. 2004;43:305-314.

21. Hollander JE, Singer AJ. Laceration management. Ann EmergMed. 1999;34:356-367.

22. Provance L, Alvis D, Silfen E. Quality improvement and publichealth: tetanus immunization in the emergency department. Am JMed Qual. 1994;9:165-171.

23. Spirito A, Monti PM, Barnett NP, et al. A randomized clinical trialof a brief motivational intervention for alcohol-positiveadolescents treated in an emergency department. J Pediatr.2004;145:396-402.

24. Helmkamp JC, Hungerford DW, Williams JM, et al. Screening andbrief intervention for alcohol problems among college studentstreated in a university hospital emergency department. J Am CollHealth. 2003;52:7-16.

25. Gregor MA, Shope JT, Blow FC, et al. Feasibility of using aninteractive laptop program in the emergency department toprevent alcohol misuse among adolescents. Ann Emerg Med.2003;42:276-284.

26. Bernstein E, Bernstein J, Levenson S. Project ASSERT: an ED-based intervention to increase access to primary care, preventiveservices, and the substance abuse treatment system. Ann EmergMed. 1997;30:181-189.

27. Llovera I, Ward MF, Ryan JG, et al. A survey of the emergencydepartment population and their interest in preventive healtheducation. Acad Emerg Med. 2003;10:155-160.

28. Foulds J, Burke M, Steinberg M, et al. Advances inpharmacotherapy for nicotine dependence. Expert Opin EmergDrugs. 2004;9:39-53.

29. Metz CN, Gregersen PK, Malhotra AK. Metabolism andbiochemical effects of nicotine for primary care providers. MedClin North Am. 2004;88:1399-1413.

30. Kamholz SL. Pulmonary and cardiovascular consequences ofsmoking. Med Clin North Am. 2004;88:1415-1430.

31. Association AL. Tobacco facts. Available at:http://www.nhlung.org/tobacco_facts.cfm. Accessed July 13,2005.

32. US Department of Health and Human Services. Women andSmoking: A Report of the Surgeon General. Rockville, MD: USDepartment of Health and Human Services, Public Health Service,Centers for Disease Control and Prevention, Center for ChronicDisease Prevention and Health Promotion, Office of Smoking andHealth; 2001.

33. Slade JD. A disease model of cigarette use. N Y State J Med.1985;85:294-297.

34. Center SCL. Physical benefits of quitting. Available at:http://smokingcessationleadership.ucsf.edu. Accessed July 13,2005.

35. Richman PB, Dinowitz S, Nashed A, et al. Prevalence of smokersand nicotine-addicted patients in a suburban emergency
department. Acad Emerg Med. 1999;6:807-810.


36. Silverman RA, Boudreaux ED, Woodruff PG, et al. Cigarettesmoking among asthmatic adults presenting to 64 emergencydepartments. Chest. 2003;123:1472-1479.

37. Bernstein SL. The impact of smoking-related illness in theemergency department: an attributable risk model. Am J EmergMed. 2002;20:161-164.

38. Boudreaux ED, Kim S, Hohrmann JL, et al. Interest in smokingcessation among emergency department patients. HealthPsychol. 2005;24:220-224.

39. Boudreaux ED, Baumann BM, Friedman K, et al. Smoking stageof change and interest in an emergency department-basedintervention. Acad Emerg Med. 2005;12:211-218.

40. Klinkhammer MD, Patten CA, Sadosty AT, et al. Motivation forstopping tobacco use among emergency department patients.Acad Emerg Med. 2005;12:568-571.

41. Bernstein SL, Cannata M. Nicotine dependence, motivation toquit, and diagnosis in emergency department patients whosmoke. Addict Behav. 2006;31:288-297.

42. Bock BC, Becker B, Niaura R, et al. Smoking among emergencychest pain patients: motivation to quit, risk perception andphysician intervention. Nicotine Tobacco Res. 2000;2:93-96.

43. Bock BC, Becker B, Monteiro R, et al. Physician intervention andpatient risk perception among smokers with acute respiratoryillness in the emergency department. Prev Med. 2001;32:175-181.

44. Prochazka A, Koziol-McLain J, Tomlinson D, et al. Smokingcessation counseling by emergency physicians: opinions,knowledge, and training needs. Acad Emerg Med. 1995;2:211-216.

45. Richman PB, Dinowitz S, Nashed A, et al. The emergencydepartment as a potential site for smoking cessationintervention: a randomized, controlled trial. Acad Emerg Med.2000;7:348-353.

46. Antonacci MA, Eyck RT. Utilization and effectiveness of anemergency department initiated smoking cessation program[abstract]. Acad Emerg Med. 2000;7:1166.

47. Chang HC, Zimmerman LH, Beck JM. Impact of chart reminderson smoking cessation practices of pulmonary physicians. Am JRespir Crit Care Med. 1995;152:984-987.

48. Fiore MC, Jorenby DE, Schensky AE, et al. Smoking status as thenew vital sign: effect on assessment and intervention in patientswho smoke. Mayo Clin Proc. 1995;70:209-213.

49. Tierney WM, Hui SL, McDonal CJ. Delayed feedback of physicianperformance versus immediate reminders to perform preventivecare: effects on physician compliance. Med Care. 1986;24:659-666.

50. Turner BJ, Day SC, Borenstein B. A controlled trial to improvedelivery of preventive care: physician or patient reminders? J GenIntern Med. 1989;4:403-409.

51. Etter JF, Perneger TV. Effectiveness of a computer-tailoredsmoking cessation program: a randomized trial. Arch Intern Med.2001;161:2596-2601.

52. Krishna S, Balas EA, Spencer DC, et al. Clinical trials ofinteractive computerized patient education: implications for familypractice. J Fam Pract. 1997;45:25-33.

53. Prochaska JO, Velicer WF, Fava JL, et al. Evaluating a population-based recruitment approach and a stage-based expert systemintervention for smoking cessation. Addict Behav. 2001;26:583-602.

54. Prochaska JO, Velicer WF, Fava JL, et al. Counselor and stimuluscontrol enhancements of a stage-matched expert systemintervention for smokers in a managed care setting. Prev Med.
2001;32:23-32.

55. Revere D, Dunbar PJ. Review of computer-generated outpatienthealth behavior interventions: clinical encounters “in absentia.”J Am Med Inform Assoc. 2001;8:62-79.

56. Velicer WF, Prochaska JO, Bellis JM, et al. An expert systemintervention for smoking cessation. Addict Behav. 1993;18:269-290.

57. Velicer WF, Prochaska JO, Fava JL, et al. Interactive versusnoninteractive interventions and dose-response relationships forstage-matched smoking cessation programs in a managed caresetting. Health Psychol. 1999;18:21-28.

58. Mower WR, Myers G, Nicklin EL, et al. Pulse oximetry as a fifthvital sign in emergency geriatric assessment. Acad Emerg Med.1998;5:858-865.

59. Joint Commission on the Accreditation of HealthcareOrganizations. Improving the quality of pain management throughmeasurement and action. Available at: http://www.jcaho.org/news�room/health�care�issues/pain_mono_jc.pdf. AccessedJuly 15, 2005.

60. Anglin D, Sachs C. Preventive care in the emergency department:screening for domestic violence in the emergency department.Acad Emerg Med. 2003;10:1118-1127.

61. Burke M, Eberman K, Ewy B, et al. Increasing the populationimpact of quitlines. Available at: http://dccps.nci.nih.gov/TCRB/quitlines_conf/Thursday/4-Impact-McAfee/impact.html. AccessedMay 16, 2005.

62. McCaig LF, Burt CW. National Hospital Ambulatory Medical CareSurvey: 2003 Emergency Department Summary: Advance Datafrom Vital and Health Statistics: No. 358. Hyattsville, MD:National Center for Health Statistics; 2005.

63. Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness ofthe clinical practice recommendations in the AHCPR guideline forsmoking cessation: Agency for Health Care Policy and Research.JAMA. 1997;278:1759-1766.

64. Meenan RT, Stevens VJ, Hornbrook MC, et al. Cost-effectivenessof a hospital-based smoking cessation intervention. Med Care.1998;36:670-678.

65. Flocke SA, Stange KC, Goodwin MA. Patient and visitcharacteristics associated with opportunistic preventive servicesdelivery. J Fam Pract. 1998;47:202-208.

66. Stange KC, Flocke SA, Goodwin MA. Opportunistic preventiveservices delivery: are time limitations and patient satisfactionbarriers? J Fam Pract. 1998;46:419-424.

67. Burke M, Eberman K, Ewy B, et al. Core competencies forevidence-based treatment of tobacco dependence [Association forthe Treatment of Tobacco Use and Dependence Web site].Available at: http://www.attud.org/docs/Standards.pdf. AccessedOctober 25, 2005.

68. Bates DW, Gawande AA. Improving safety with informationtechnology. N Engl J Med. 2003;348:2526-2534.

69. Porter SC, Cai Z, Gribbons W, et al. The asthma kiosk: a patient-centered technology for collaborative decision support in theemergency department. J Am Med Inform Assoc. 2004;11:458-467.

70. Rhodes KV, Lauderdale DS, Stocking CB, et al. Better healthwhile you wait: a controlled trial of a computer-based interventionfor screening and health promotion in the emergency department.Ann Emerg Med. 2001;37:284-291.

71. Zhu SH, Anderson CM, Tedeschi GJ, et al. Evidence of real-worldeffectiveness of a telephone quitline for smokers. N Engl J Med.2002;347:1087-1093.

72. Ossip-Klein DJ, McIntosh S. Quitlines in North America: evidencebase and applications. Am J Med Sci. 2003;326:201-205.

73. Sussman S, Lichtman K, Ritt A, et al. Effects of thirty-fouradolescent tobacco use and prevention trials on regular users of
tobacco products. Subst Use Misuse. 1999;34:1469-1503.


74. Obermayer JL, Riley WT, Asif O, et al. College smoking-cessationusing cell phone text messaging. J Am Coll Health. 2004;53:71-78.

75. Borzekowski DL, Vaughn IR. Adolescent cybersurfing for healthinformation: a new resource that crosses barriers. Arch PediatrAdolesc Med. 2001;155:813-817.

76. Mahabee-Gittens M. Smoking in parents of children with asthmaand bronchiolitis in a pediatric emergency department. PediatrEmerg Care. 2002;18:4-7.

77. Jarvis MJ. The association between having children, familysize and smoking cessation in adults. Addiction. 1996;91:427-434.

78. Winickoff JP, Hibberd PL, Case B, et al. Child hospitalization: anopportunity for parental smoking intervention. Am J Prev Med.2001;21:218-220.

79. Agency for Healthcare Research and Quality. National HealthcareQuality Report. Rockville, MD: US Department of Health andHuman Services; 2003.

80. Joint Commission on the Accreditation of HealthcareOrganizations. Core measure list by core measure set: JointCommission on the Accreditation of Healthcare Organizations.Available at: http://www.jcaho.org. Accessed December 20,
2004.

81. Schauffler HH, Barker DC, Orleans CT. Medicaid coverage fortobacco-dependence treatments. Health Aff (Millwood). 2001;20:298-303.

82. Center for Medicaid and Medicare Services. Smoking andcessation. Available at: http://cms.hhs.gov/SmokingCessation.Accessed March 8, 2006.

83. National Institutes of Health. NIH roadmap. Available at: http://nihroadmap.nih.gov. Accessed June 5, 2005.

84. Task Force on the Core Content for Emergency Medicine Revision.Core content for emergency medicine. Acad Emerg Med. 1997;4:628-642.

85. Allan J, Barwick TA, Cashman S, et al. Clinical prevention andpopulation health: curriculum framework for health professions.Am J Prev Med. 2004;27:471-476.

86. Hymowitz N, Schwab J, Eckholdt H. Pediatric residency training ontobacco. Pediatrics. 2001;108:E8.

87. Steinmann S, Roytman T, Chang J, et al. Impact of education onsmoking cessation counseling by surgical residents. Am J Surg.2005;189:44-46.

88. US Department of Health and Human Services. Reducing theHealth Consequences of Smoking: 25 Years of Progress: AReport of the Surgeon General. Rockville, MD: Public HealthService, Office on Smoking and Health; 1989. Publication no. 89-
8411.

Documents

Tobacco Control Interventions in the Emergency Department: A Joint Statement of Emergency Medicine Organizations