Treating Low-Income Smokers in the Hospital Emergency Department

描述（由申请人提供）：在全国4500万成年吸烟者中，每年有近2000万人访问医院急诊室（ED）。艾德患者，特别是吸烟者，收入低得不成比例，获得传统初级保健环境的机会有限。到艾德就诊的患者有与烟草相关的触发事件，比如哮喘发作，可能正在经历一个“可教的时刻”。“因此，艾德可能是一个理想的位置，在其中确定吸烟者和开始治疗烟草依赖。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的简短干预的可行性。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ED列为烟草控制工作的适当场所。本研究旨在测试ED发起的烟草干预的有效性，包括咨询和药物治疗。干预-筛查，简短干预和转诊治疗（SBIRT）-使用一种被称为简短谈判访谈（BNI）的动机访谈形式。我们建议的干预措施结合了BNI与尼古丁替代疗法（NRT）的启动，并在艾德访视期间传真转介到州吸烟者戒烟热线。将提供为期6周的NRT入门套件（贴剂和/或口香糖，根据成瘾程度和患者偏好量身定制）以及书面材料。NRT的初始剂量将在ED给予。经过培训的护士将在访视后3天通过电话给予加强干预。在一项以1：1方式随机化的778名18岁或以上吸烟者的对照试验中，将SBIRT+NRT组与仅由书面材料组成的标准治疗（SC）进行比较。主要假设是，SBIRT+NRT在减少3个月时自我报告和生化验证的7天戒烟方面优于SC上级。次要假设包括：（1）在艾德就诊时诊断为烟草相关的患者将比没有烟草相关诊断的患者具有更高的戒烟率，以及（2）认为他们的艾德就诊与吸烟相关的患者将比其他患者具有更高的戒烟率。我们将对干预措施进行成本效益分析。对于通过电话宣称戒烟的吸烟者，在1、3和12个月时的随访评估将结合联合收割机自我报告和3个月时的唾液可替宁测试。与早期研究相比，拟议项目的扩展包括：1）在艾德访视期间启动NRT; 2）提供多种形式的NRT; 3）主动转诊至戒烟热线; 4）具有最低基线评估的可信对照条件，以避免类似艾德研究中观察到的评估反应;以及5）对测试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.