MARC-33: A Multicenter Cohort Study of Tobacco Users Treated in the Emergency Department

Investigators:
Edwin D. Boudreaux, PhD, Cooper Hospital, Camden, NJ
Carlos A. Camargo, MD, DrPH, Massachusetts General Hospital, Boston, MA

Funding Source: National Institutes of Health (R21DA020772)

Objectives/Purpose of the Research: The Specific Aims are to (1) determine the prevalence of smoking among adult emergency department (ED) patients, interest in quitting, and patient preferences pertaining to the format of ED-initiated tobacco interventions; (2) Determine the prevalence and predictors of cessation after the visit under treatment-as-usual conditions; and (3) determine ED healthcare providers’ recommendations regarding the structure, processes, barriers, and logistics of ED-initiated tobacco interventions.

Rationale: Although brief counseling for tobacco cessation is known to be effective, ED healthcare providers rarely carry out such counseling, even when the patient is presenting with respiratory symptoms or smoking-related medical problems. Increasingly, however, the ED has been heralded as both appropriate and vital for preventive health initiatives. One important reason for this paradigm shift is the recognition that 25-50% of patients being treated in EDs use them as their source of routine or non-urgent healthcare. Minorities, the economically disadvantaged, and the uninsured are more than twice as likely to use the ED for routine medical care. These segments of the US population are the very segments that are least likely to quitting smoking once they start. If smoking is not addressed with these disadvantaged patients in the settings where they are most likely to receive healthcare, like the ED and other acute care settings, it is unlikely to be addressed at all. Before ED staff can fully integrate tobacco interventions into routine clinical practice, they will need empirically-validated treatments studied within the ED setting and that have been designed with their early input. In order to plan these intervention trials, however, the characteristics of this patient population, their “untreated” cessation and relapse patterns, and both psychological and behavioral characteristics that will inform development of stepped or tailored interventions need to be better understood. Since multicenter longitudinal research on tobacco use within the ED setting is unprecedented, a study as the one described herein is vital before progressing to multicenter intervention studies.

Study Procedures: The Cohort Study will include ten sites representing diverse geographic regions and demographic groups. A combined total of 362 current smokers will undergo an initial 15-20 minute Baseline Assessment in the ED to collect data on smoking and predictors of cessation. These variables are viewed as relevant to the design of stepped-care and tailored treatment programs, as well as logistical planning for clinical trial execution. They include several novel predictors which are central to understanding how tobacco use is affected by an acute health event, including smoking-related causal attribution and event-related fear, as well as traditional predictors, including nicotine dependence, intention to quit, self-efficacy, depression, and substance abuse. The assessment will conclude by measuring participants’ interest in a variety of hypothetical ED-initiated tobacco interventions and counseling styles. Follow-up Assessments taking approximately 10 minutes each will occur 14-days, 3-months, and 6-months after the ED visit via telephone interview. Primary outcomes will consist of sustained abstinence, 7-day point prevalence abstinence, and any quit attempt lasting >=24 hours. Secondary outcomes will consist of nicotine dependence, readiness to change, relapse curves for those attempting to quit, and tobacco treatment initiation. The Healthcare Provider Survey will enroll approximately 500 ED healthcare providers (physicians, physician extenders, nurses) from the ten sites participating in the Cohort Study. The providers will report their willingness to incorporate the same hypothetical ED-initiated tobacco interventions and counseling styles presented to the patients in the Cohort Study.