Cessation of smoking in people attending UK emergency departments: the COSTED RCT with economic and process evaluation.

Abstract

BACKGROUND

The emergency department represents a potentially valuable opportunity to support smoking cessation. Evidence is lacking around the use of e-cigarettes in opportunistic settings like the emergency department.

OBJECTIVE

To undertake a randomised controlled trial in people who smoke attending United Kingdom emergency departments, testing a brief intervention which included provision of an e-cigarette versus signposting to smoking cessation services, assessing smoking abstinence.

DESIGN

A two-arm pragmatic, multicentre, parallel-group, individually randomised, controlled superiority trial with an internal pilot, economic evaluation and mixed-methods process evaluation.

SETTING

Six emergency departments across England and Scotland.

PARTICIPANTS

Adults who smoked daily, who were attending the emergency department for medical treatment or accompanying someone attending for medical treatment, were invited to participate. People were excluded if they had an expired carbon monoxide of < 8 parts per million, required immediate medical treatment, were in police custody, had a known allergy to nicotine, were daily e-cigarette users, were considered not to have capacity to consent or had already taken part in the trial.

INTERVENTION

Brief stop smoking advice, e-cigarette starter kit and referral to stop smoking services.

MAIN OUTCOME MEASURES

The primary outcome was biochemically validated sustained abstinence at 6 months. Those lost to follow-up, or not providing biochemical verification, were considered not to be abstinent. Secondary outcomes were: self-reported 7-day smoking abstinence, number of quit attempts, number of cigarettes per day, nicotine dependence and incidence of self-reported dry cough or mouth or throat irritation.

RESULTS

At 6 months, of 972 participants randomised, biochemically verified smoking abstinence was 7.2% in the intervention group and 4.1% in the control group (percentage difference = 3.3%) (95% confidence interval 0.3 to 6.3; p = 0.032) [relative risk 1.76 (95% confidence interval 1.03 to 3.01)]. Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (percentage difference = 10.6%) (95% confidence interval 5.86 to 15.41; p < 0.001) [relative risk 1.80 (95% confidence interval 1.36 to 2.38)]. Daily e-cigarette use was 39.4% in the intervention group and 17.5% in the control group at 6 months. No serious adverse events related to taking part in the trial were reported. The economic evaluation found the intervention was likely to be cost-effective, judged by the National Institute for Health and Care Excellence threshold. The process evaluation found the intervention to be acceptable to both staff delivering it and participants receiving it. The brief nature of the intervention was highly adaptable to context, and interviews demonstrated how the intervention supported different pathways towards cessation.

LIMITATIONS

The inability to blind participants or researchers, the relatively low level of biochemical verification due to the nature of the population recruited and the fact that those in the control group did not receive usual care.

CONCLUSIONS

An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events.

FUTURE WORK

Future work will include testing other behaviour change interventions in the emergency department and adapting the Cessation of Smoking Trial in the emergency department intervention for other settings.

FUNDING

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR129438.

Plain language summary

Smoking remains the main cause of death and illness in the United Kingdom. We wanted to find out if providing brief stop smoking support might help people quit smoking. People who smoke who were attending the emergency department were randomly assigned (as if by the toss of a coin) to one of the two groups: stop smoking advice, including the offer of an e-cigarette ‘starter pack’, and referral to local stop smoking services or given information about locally available stop smoking services. Six months later, if people in either group told us they had quit smoking, their smoking status was confirmed by checking the amount of carbon monoxide (a gas you inhale from cigarettes) they breathed out using a breath test monitor. We recruited 972 people from six emergency departments. We found that about twice as many people had quit smoking 6 months later when they received the Cessation of Smoking Trial in the Emergency Department intervention compared to those who did not. We worked out that it costs £48 to advise people to quit smoking in the emergency department, including the cost of the e-cigarette starter kit given out. This is very cheap compared to the cost of treating someone who develops a health condition caused by tobacco smoking. We talked to some people who took part in the study. People told us that they welcomed the distraction of talking to a stop smoking advisor while they were waiting, and that having the e-cigarette given to them by someone in this setting gave them confidence to give it a try. We also interviewed emergency department staff. They said that they had to be flexible in the way in which they spoke with people, and that it was critical that they had dedicated time to do this. We worked closely with people with ‘lived experience’ of smoking throughout the study.

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