Tobacco Cessation in the Emergency Department

Medical students represent a potentially underutilized resource for discussing tobacco cessation counseling with ED patients. Students in the emergency department often have more time to spend with patients than any other member of the clinical team. In addition, nicotine addiction is a frequently encountered co-morbidity in the ED.2-3 This is especially true in the context of clinical learning environments where attending and resident physicians rarely have time to provide nicotine addiction counseling or are hesitant to do so in the ED setting.4-6 Additionally, physicians can bill for their time spent counseling patients on tobacco cessation.7

By routinely incorporating a clinical tool for smoking cessation into patient encounters, medical students can play a pivotal role in helping busy clinical teams achieve an often-unmet key clinical objective defined by the EM community.8-10

All it takes is starting the conversation, one patient at a time. While you may stumble initially, practice precedes confidence, and you may be surprised how receptive your patients are.12

THE 5 A's
The following “5 A's” represent a validated approach to tobacco cessation in a busy clinical environment. 11 Furthermore, this smoking cessation tool can easily be employed during a clinical encounter to prompt the student and help initiate a brief discussion about nicotine addiction.

  • ASSESS. Attempt to quantify both the number of total pack-years and current nicotine consumption. Don’t forget to ask about all tobacco products (chewing tobacco, etc.)
  • ADVISE. Every patient should be counseled to reduce and eventually quit all tobacco consumption. Studies have shown that telling patients to stop makes a difference. If relevant, advise the patient of any relationship between tobacco consumption and their presenting chief complaint.
  • AGREE. Collaborate with the patient to understand personal barriers to kicking his/her nicotine habit, understand his/her motivation to quit, and formulate a mutually agreeable goal (simple reduction, tapering, cold-turkey, etc.).
  • ASSIST. Many patients may not be aware of available resources. Whether encouraging the patient to follow-up with a PCP for outpatient medication, printing state quit-line literature, or educating the patient on over-the-counter nicotine replacement products, try to formulate a plan educate and equip your patient for success.
  • ARRANGE. Provide appropriate contact information for PCP follow-up and/or offer to assist with scheduling an appointment specifically dedicated to the patient’s nicotine addiction.

References
1. “Curriculum Inventory and Reports (CIR) - Initiatives - AAMC.” Percentage of Medical Schools with Seperate Required Clerkships by Discipline: Emergency Medicine, Association of American Medical Colleges, 2016. aamc.org/initiatives/cir/406450/05a.html.
2. Lowenstein S, Koziol-McLain J, Thompson M, et al. Behavioral risk factors in emergency department patients: a multisite survey. Acad Emerg Med. 1998;5:781–787.
3. McCaig L. Advance data from vital and health statistics, no. 313. National Center for Health Statistics; Hyattsville, MD: 2000. National Hospital Ambulatory Medical Care Survey: 1998 emergency department summary.
4. Vokes NI, Bailey JM, Rhodes KV. “Should I give you my smoking lecture now or later?” Characterizing emergency physician smoking discussions and cessation counseling. Ann Emerg Med. 2006;48(4):406–14.
5. Prochaska JO, Koziol-McLain J, Tomlinson D, Lowenstein S. Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs. Acad Emerg Med. 1995;2:211–6.
6. Jaen CR, Crabtree BF, Zyzanski SJ, Goodwin MA, Stange KC. Making time for tobacco cessation counseling. J Fam Pract. 1998;46(5):425–8.
7. Billing, Coding Tips for Smoke Cessation Counseling in the Emergency Department. ACEP Now. http://www.acepnow.com/article/billing-codint-tips-smoke-cessation-counesling-emergency-department/.
8. Bernstein S, Boudreaux ED, Cydulka RK, et al. Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations. Ann Emerg Med. 2006;48:e417–25.
9. Fiore M, Bailey W, Cohen S, et al. Clinical Practice Guideline. US Department of Health and Human Services, US Public Health Service; Rockville, MD: 2008. Treating tobacco use and dependence.
10. Kruger J, et al. Receipt of Evidence-Based Brief Cessation Interventions by Health Professionals and Use of Cessation Assisted Treatments among Current Adult Cigarette-Only Smokers: National Adult Tobacco Survey, 2009–2010. BMC Public Health, BioMed Central, 11 Feb. 2016.
11. Whitlock E, Orleans CT, Pender N, Allan J. Evaluating Primary Care Behavioral Counseling Interventions An Evidence-Based Approach. Am J Prev Med. vol. 22, no. 4, 2002, pp. 267–284.
12. uspreventiveservicestaskforce.org/Page/Name/behavioral-counseling-interventions-an-evidence-based-approach#the-five-a39s-organizational-construct-for-clinical-counseling.
13. Rodrigues R, Kreider W, Baraff L. Need and desire for preventive care measures in emergency department patients. Ann Emerg Med. 1995;26(5):615–20.

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