Evaluating Smoking Cessation Service at an Emergency Department Clinical Observation Unit

ABSTRACT

Objectives: To evaluate the effectiveness of a pilot smoking cessation service in an emergency department (ED) clinical observation unit.

Study Design: A descriptive case series review was undertaken of smoking cessation service patients in the short-stay unit of an acute hospital in Singapore from July 1, 2018, to December 31, 2019.

Methods: Upon admission, ED nurses screen all patients regarding their current smoking status and implement the 5 A’s framework, which involves the steps of Ask-Advise-Assess-Assist-Arrange. Patients in the “contemplation” and “preparation” stages were offered the following components: (1) a bedside counseling session by a pharmacist and (2) a follow-up appointment at an outpatient smoking cessation clinic. Postdischarge follow-up telephone calls at 1, 6, and 12 months were carried out as part of the study data collection to obtain abstinence information.

Results: Forty-seven patients were included in the study; the majority were male (n = 41; 87.2%). The median numbers of cigarettes smoked per day at baseline, 1 month, 6 months, and 12 months were 14, 5, 3, and 5, respectively. The overall point-prevalence abstinence rates over the same follow-up time points were 26.5%, 38.7%, and 31.3%, respectively. The proportions of patients lost to follow-up at 1 month, 6 months, and 12 months were 27.7%, 34.0%, and 31.9%, respectively.

Conclusions: Given the small sample and high number of uncontactable patients, more research is needed to assess whether the trend toward increasing point-prevalence abstinence rate over time and the trend toward decreasing median number of cigarettes smoked are observed in a larger sample.

Am J Manag Care. 2022;28(10):e388-e391. https://doi.org/10.37765/ajmc.2022.89256

Takeaway Points

Smoking is a well-known modifiable risk factor for many diseases. Most of the published reports on smoking interventions in the health care setting are focused on outpatient settings. This study aimed to evaluate the impact of a smoking cessation service in a group of patients admitted to a short-stay unit in the emergency department (ED).

• Hospitalization creates an opportune moment for smokers to contemplate smoking cessation.
• The collaborative care of nurses and pharmacists plays a pivotal role in the success and sustainability of this initiative.
• The introduction of a smoking cessation service at an ED clinical observation unit appears to be effective against smoking.

Smoking is a risk factor for lung cancer, chronic obstructive pulmonary disease, and coronary artery disease.¹ The World Health Organization (WHO) reported that tobacco is killing approximately more than 8 million people each year, including around 1.2 million deaths from exposure to second-hand smoke.² In Singapore, smoking kills about 2500 smokers and 250 nonsmokers each year.³ Local data also confirm that there is a higher proportion of smokers among patients with cancer, heart attack, stroke, and kidney failure than in the general population.⁴

In the United States, a systematic review of 15 studies from 1980 to 2006 reported statistically significant differences in the effectiveness of smoking cessation services, when comparing control groups with those receiving pharmacist-based intervention.⁵ A 2008 meta-analysis reported that with the most optimal drugs and counseling, a 1-year abstinence rate of 25% could be expected in smoking cessation.⁶

Currently, published reports on smoking cessation interventions in the health care setting have largely focused on outpatient settings, usually at primary care practices. However, observational studies have shown that a hospital stay can trigger smoking cessation even in the absence of intervention, especially in patients with cardiovascular and pulmonary disease or in patients having surgery.⁷ Based on a prospective survey in the United States, the prevalence of smoking tends to be higher among patients treated in the emergency department (ED), with 48% being current smokers.⁸ This statistic might represent an ideal opportunity to advance this public health goal by encouraging these ED attenders to stop smoking.

According to a previous pilot study of the outpatient smoking cessation clinic (SCC) at Changi General Hospital in Singapore, the smoking abstinence rate among its attendees, from September 2008 to July 2010, was comparable with existing published data.⁹ However, at that time, the hospital’s ED did not have direct access to this clinic to tap into its success. We aim to assess the effectiveness of a newly initiated smoking cessation service at our ED short-stay unit (SSU).

METHODS

A descriptive case series review was undertaken of smoking cessation service patients in the SSU of Changi General Hospital from July 1, 2018, to December 31, 2019. This acute care hospital belongs to a regional health care cluster with an emergency medicine academic clinical program, which has an annual ED attendance of approximately 150,000.

Upon admission to the SSU, ED nurses screen all patients regarding their current smoking status. According to WHO’s Smoking and Tobacco Use Policy, a smoker is defined as someone who smokes any tobacco product, either daily or occasionally. Smokers who were unable to complete the questionnaire form that was used to assess the smoker’s nicotine dependence or who were already using any form of smoking cessation pharmacotherapy and/or had participated in any form of smoking cessation program within the past 3 months were excluded.

All smokers who were 18 years or older were given a brief 5- to 10-minute advice session on smoking cessation by an ED SSU nurse. The patients were provided reading materials and assessed for readiness to quit. Based on the transtheoretical model on smoking behavior, patients in the “contemplation” and “preparation” stages were eligible for the ED SSU smoking cessation service. The nurse practiced according to the 5 A’s framework, which involves Ask-Advise-Assess-Assist-Arrange steps, before integrating the smoking cessation service.

Eligible smokers were offered the ED SSU smoking cessation service, which included the following components: (1) a bedside counseling session by a pharmacist and (2) a follow-up appointment at the outpatient SCC. Postdischarge follow-up telephone calls at 1, 6, and 12 months were carried out as part of the study data collection to obtain abstinence information. Service recipients may reject the outpatient SCC appointment. The SSU bedside counseling component was charged at SGD$35 (approximately US$25), which may be paid by the patient’s public health care savings account.

Bedside Counseling Session by Pharmacist in SSU

This was made available from 9 AM to 5 PM on weekdays and 9 AM to 12 PM on Saturdays. Each session lasted up to 45 minutes and was conducted by trained pharmacists certified by the Singapore Health Promotion Board as smoking cessation counselors.

The patient’s medication history, smoking history, previous quit attempts, nicotine dependency pattern, and motivation determination were assessed. Based on the information gathered, an individualized quit plan was devised. The quit plan consisted of (1) education on the harmful effects of smoking, benefits of quitting, and ways to cope with withdrawal symptoms; (2) recommendation of behavioral modifications and nonpharmacological interventions; and (3) measurement of breath carbon monoxide (CO) levels (Smokerlyzer test). However, the test is not offered if the smoker is not well enough to hold their breath for 15 seconds and exhale into the Smokerlyzer.

Outpatient SCC Follow-up

This was made available thrice weekly with each follow-up session lasting up to 20 minutes. At each clinic session, the patient’s smoking status would be chemically verified using the Smokerlyzer test. When correlated with history, patients with an exhaled CO level of less than 3 ppm were considered abstinent.

Postdischarge Follow-up Telephone Calls

Following discharge from the ED SSU, all enrolled smokers received postdischarge telephone calls at 1, 6, and 12 months as part of the study data collection to obtain their self-reported smoking status. Patients who reported 0 cigarettes smoked in the past 7 days at the time of the call were considered as having “quit.” If the reported number of cigarettes smoked was less than at baseline, “reduced” status was assigned. Patients who reported the number of cigarettes smoked as being the same as or more than at baseline were considered “not reduced.” Patients who were uncontactable at 1, 6, and 12 months were considered lost to follow-up and not included in statistical analyses.

Outcome Measures and Ethical Consideration

The primary outcome was the point-prevalence smoking abstinence rate at 1, 6, and 12 months among the ED SSU smoking cessation service recipients. The secondary outcome was to determine if the service recipients had a reduction in the number of cigarettes smoked.

The Centralized Institutional Review Board of Singapore Health Services (SingHealth) exempted the study from ethical consideration as it was considered to be a service evaluation.

Statistical Analysis

Descriptive statistical analyses were carried out on the 1-, 6-, and 12-month abstinence rates and presented as percentages. Data collected were summarized using frequency and proportion for categorical variables, mean and SD for participant age, and median and IQR for number of cigarettes smoked at each specific time point. All the statistical analyses were performed using SPSS version 20.0 (IBM Corporation) and statistical significance was set at P < .05.

RESULTS

Study Participants and Baseline Characteristics

During the recruitment period, from July 2018 to December 2019, 961 ED SSU smokers out of 5313 total ED SSU patients were identified, of whom 914 either were not eligible or declined the service.

Forty-seven patients were thus included in the study, with the majority being male (n = 41; 87.2%). As shown in Table 1 and Table 2, the median numbers of cigarettes reported smoked per day at baseline, 1 month, 6 months, and 12 months were 14, 5, 3, and 5, respectively. Although 29 patients agreed to outpatient SCC follow-up, only 6 of them attended the clinic subsequently. Among them, 2 of the patients who stated they had quit had a CO level of less than 3 ppm.

The last patient was included on November 28, 2019, and received the 12-month follow-up telephone call on November 30, 2020. The proportions of patients lost to follow-up at 1 month, 6 months, and 12 months were 27.7%, 34.0%, and 31.9%, respectively.

Primary Outcome

The overall point-prevalence abstinence rates from 1-, 6-, and 12-month follow-up telephone calls were 26.5%, 38.7%, and 31.3%, respectively, as shown in Table 2.

DISCUSSION

There are many published studies evaluating the effectiveness of smoking cessation programs, ranging from 14% to 40% in their 12-month abstinence rate.^10-15 To the best of our knowledge, ours is the first local ED smoking cessation service that involves ED nurses and pharmacists. Our study demonstrated a point-prevalence abstinence rate of 31.3% at 12-month follow-up, which is similar to existing published data. This result also is similar to the 1-year abstinence rate of approximately 25% reported by Tønnesen.⁶

Most of the studies showed a decrease in abstinence rate over time,^13-17 and our pilot study has demonstrated a similar trend. The exact reasons for our early findings of this abstinence trend with this pilot model are not clear. We must exercise caution when comparing it with other studies.

In 2004, Zow and colleagues studied the effectiveness of a non-ED smoking cessation program in another hospital in Singapore and found a sustained abstinence rate of 36% at both 6 and 12 months after the final clinic session.¹⁰ Compared with their results, our abstinence rates were comparable at 6 months and lower at 12 months. Apart from service location and design, our ED SSU service did not include the commencement of smoking cessation pharmacotherapy, which may affect the cessation rates. The interventions employed by the counselors were advocating either cold turkey or gradual reduction. Findings from our ED SSU service suggest that intensive behavioral counseling can benefit smokers even in the acute care setting. It mirrors the impact of published studies on bedside counseling of hospital inpatients, which had positive results.

A meta-analysis by Fiore et al has suggested that the number of counseling sessions and treatment effectiveness are associated in a dose-response relationship.¹⁸ This is supported by other studies, which found a significant increase in abstinence rate among patients who attended more sessions.^10,19 Hence, going forward, we could focus on initiatives to improve the uptake rate of the outpatient SCC at the SSU.

Limitations

First, compared with the number of smokers identified in the SSU, very few of them received the service. Nevertheless, the ED nurses provided all smokers with smoking advice and reading materials. Moving forward, we plan to evaluate reasons that patients who were eligible declined the program (eg, financial reasons, time commitment) and address them where possible.

Second, as many as 16 (34.0%) patients were uncontactable during follow-up. This reduces the effective sample size and affects the validity of the point-prevalence abstinence rate and observation toward a certain trend in the median number of cigarettes reported at that specific time point. We plan to devise a strategy to address this by designing the study carefully, implementing data quality procedures, and developing better mechanisms to retain and contact patients.

Third, a single-group case series design is not optimal for evaluating effectiveness of whether a hospital stay might trigger smoking cessation. For a complete evaluation, a comparison group of individuals receiving ED services but not smoking cessation services is required.

Finally, self-reported abstinence through telephone call follow-up could not be validated via any biochemical test as only baseline CO level was obtained; thus, the result was vulnerable to patient overreporting.

CONCLUSIONS

Given the small sample and high number of uncontactable patients, more research is needed to assess whether the trend toward increasing point-prevalence abstinence rate over time and the trend toward decreasing median number of cigarettes smoked are observed in a larger sample.

Acknowledgments

The authors would like to acknowledge the team of outpatient pharmacists (Delicia Ngui, Vivien Wong, and Kalaivani Supramaniam) who provide smoking cessation services.

Author Affiliations: Changi General Hospital (CCCN, WLM, PTT, EYLL, PLG, RPM, HCL), Singapore; University of South Australia (SK), Adelaide, Australia.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CCCN, WLM, EYLL); acquisition of data (CCCN, WLM, EYLL); analysis and interpretation of data (CCCN, WLM, PTT, EYLL); drafting of the manuscript (CCCN, SK, WLM, EYLL, HCL); critical revision of the manuscript for important intellectual content (CCCN, SK, WLM, PTT, EYLL, PLG, RPM, HCL); statistical analysis (CCCN, PTT); provision of patients or study materials (CCCN, SK, WLM, EYLL, PLG, RPM); administrative, technical, or logistic support (CCCN, WLM, EYLL); and supervision (CCCN, SK, PLG, RPM, HCL).

Address Correspondence to: Celine Chang Chyi Ng, BPharm, Changi General Hospital, 2 Simei St 3, Singapore 529889. Email: sci01580@yahoo.com.sg.

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