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2000万人到医院急诊科就诊。急症患者，特别是吸烟者，不成比例地属于低收入人群，他们获得传统初级保健服务的机会有限。向急诊科提出与烟草有关的触发事件的患者，如哮喘发作，可能正在经历一个“教育时刻”。因此，急诊科可能是鉴别吸烟者和开始烟草依赖治疗的理想场所。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年烟草报告和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位点。本研究旨在测试ed发起的烟草干预的效果，包括咨询和药物治疗。干预-筛选，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和尼古丁替代疗法（NRT）的开始，并在急诊科就诊期间传真转介到国家吸烟者戒烟热线。一套为期6周的NRT入门工具包（贴片和/或口香糖，根据成瘾程度和患者偏好定制）将提供书面材料。NRT的初始剂量将在急诊科进行。一名训练有素的护士将在访问后3天通过电话进行加强干预。SBIRT+NRT组将在一项对照试验中与标准治疗（SC）进行比较，标准治疗仅由书面材料组成，该试验以1:1的方式随机纳入778名18岁或以上的吸烟者。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天戒烟量方面优于SC。次要假设包括：(1)在急诊科就诊时被诊断为与烟草有关的患者的戒烟率高于未被诊断为与烟草有关的患者；(2)认为自己的急诊科就诊与吸烟有关的患者的戒烟率高于其他人。我们将对这些干预措施进行成本效益分析。在第1、3和12个月的随访评估将结合自我报告和3个月时通过电话声称戒烟的吸烟者的唾液可替宁测试。与早期研究相比，拟议项目的扩展包括：1)在ED访问期间启动NRT；2)提供多种形式的NRT；3)主动转介到戒烟热线；4)一个可信的对照条件，最低限度的基线评估，以避免类似ED研究中出现的评估反应性；5)测试干预措施的经济分析。

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.