Treating Low-Income Smokers in the Hospital Emergency Department

描述(申请人提供)：在全国4500万成年吸烟者中，每年有近2000万人去医院急诊科就诊。ED患者，特别是吸烟者，收入低得不成比例，获得传统初级保健服务的机会有限。出现与烟草相关的触发事件的患者，如哮喘发作，可能正在经历一个“可教的时刻”。因此，ED可能是识别吸烟者和开始烟草依赖治疗的理想地点。我们小组的初步试点研究已经证明了对吸烟者进行基于ED的短期干预的可行性。根据我们的可行性研究，医学研究所2006年关于烟草的报告和2008年美国公共卫生服务指南现在将电子烟列为适当的控烟地点。这项研究旨在测试ED发起的烟草干预的有效性，其中包括咨询和药物治疗。干预-筛查、简短干预和转诊治疗(SBIRT)-使用一种称为简短谈判访谈(BNI)的激励性访谈形式。我们建议的干预措施结合了BNI和开始尼古丁替代疗法(NRT)，并在ED访问期间传真转诊到州吸烟者专线。将提供为期6周的NRT(贴片和/或口香糖，根据成瘾程度和患者偏好量身定制)入门套件，并提供书面材料。初始剂量的NRT将在急诊室进行。一名训练有素的护士将在就诊后3天通过电话实施加强干预。SBIRT NRT ARM将与标准护理(SC)进行比较，后者只包括书面材料，在778名18岁或18岁以上的吸烟者中以1：1的方式随机进行对照试验。主要的假设是，SBIRT NRT在3个月后减少自我报告和生化验证的7天烟草戒断方面将优于SC。第二个假设包括：(1)有烟草相关诊断的ED患者比没有烟草相关诊断的患者有更高的戒烟率，以及(2)认为他们的ED就诊与吸烟有关的患者比其他人有更高的戒烟率。我们将对干预措施进行成本效益分析。对于通过电话坚持戒烟的吸烟者，在1、3和12个月的跟踪评估将结合自我报告和3个月的亲身唾液可替宁测试。与以前的研究相比，拟议项目的扩展包括：1)在ED访问期间启动NRT；2)提供多种形式的NRT；3)主动转诊到Quitline；4)具有最低基线评估的可信控制条件，以避免类似ED研究中的评估反应性；以及5)对测试的干预措施进行经济分析。

DESCRIPTION (provided by applicant): Of the nation's 45 million adult smokers, nearly 20 million visit hospital emergency departments (EDs) each year. ED patients, particularly smokers, are disproportionately low-income, with limited access to traditional primary care settings. Patients presenting to the ED with a tobacco-related trigger event, like an asthma attack, may be experiencing a "teachable moment." Thus, the ED may be an ideal location in which to identify smokers and initiate treatment for tobacco dependence. Initial pilot research by our group has demonstrated the feasibility of ED-based brief interventions for smokers. Based on our feasibility studies, the Institute of Medicine 2006 report on tobacco and the 2008 US Public Health Service guidelines now list EDs as appropriate loci for tobacco control efforts. This study aims to test the efficacy of an ED-initiated tobacco intervention which includes counseling and medication. The intervention-Screening, Brief Intervention, and Referral to Treatment (SBIRT)-uses a form of motivational interviewing known as the Brief Negotiation Interview (BNI). Our proposed intervention combines a BNI with initiation of nicotine replacement therapy (NRT) and a fax referral to the state Smokers' Quitline during the ED visit. A 6-week starter kit of NRT (patch and/or gum, tailored to level of addiction and patient preference) will be provided with written materials. The initial dose of NRT will be given in the ED. A trained nurse will administer the booster intervention via telephone 3 days post-visit. The SBIRT+NRT arm will be compared to standard care (SC), which consists of written materials only, in a controlled trial of 778 smokers age 18 years or older randomized in a 1:1 fashion. The primary hypothesis is that SBIRT+NRT will be superior to SC in reducing self-reported and biochemically verified 7-day tobacco abstinence at 3 months. Secondary hypotheses include: (1) Patients with a tobacco- related diagnosis for the ED visit will have a higher cessation rate than patients without a tobacco-related diagnosis, and (2) Patients who believe their ED visit is smoking-related will have a higher quit rate than others. We will conduct a cost benefit analysis of the interventions. Follow-up assessments at 1, 3 and 12 months will combine self-report with in-person salivary cotinine testing at 3 months for smokers who assert abstinence via phone. Expansions of the proposed project as compared to earlier studies include: 1) initiation of NRT during the ED visit; 2) provision of multiple forms of NRT; 3) a proactive referral made to the Quitline; 4) a credible control condition with minimal baseline assessment, to avoid the assessment reactivity seen in similar ED studies; and 5) an economic analysis of the tested interventions.