Smoking cessation in the emergency department (The COSTED trial)

If I am honest, on most of my shifts, other substances seem to be far more destructive than nicotine. I spend a lot of time talking to patients about suboxone, or dealing with the consequences of alcohol. I definitely talk to people about smoking, but aside from brief counseling and occasionally prescribing nicotine replacement for patients being held in the ED, I usually leave the long term management of nicotine addiction to primary care. With the current state of primary care, it is possible that is a huge mistake. So, let’s have a look at the COSTED trial, a multicenter RCT looking at smoking cessation in the emergency department. 

The paper

The COSTED trial: Pope I, Clark LV, Clark A, Ward E, Belderson P, Stirling S, Parrott S, Li J, Coats T, Bauld L, Holland R, Gentry S, Agrawal S, Bloom BM, Boyle AA, Gray AJ, Morris MG, Livingstone-Banks J, Notley C. Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial. Emerg Med J. 2024 Apr 22;41(5):276-282. doi: 10.1136/emermed-2023-213824. PMID: 38531658 NCT04854616

The Methods

COSTED is a pragmatic, multicenter RCT from 6 emergency departments in the United Kingdom.

Patients

Adult patients in the ED (either as patients or visitors) who smoked cigarettes daily (and had a confirmed expired carbon monoxide level above 8 parts per million) and did not currently use an e-cigarette.

Intervention

The intervention group received an opportunistic smoking cessation intervention undertaken face-to-face in the ED, comprising three elements: (1) brief smoking cessation advice (up to 15 min), (2) the provision of an e-cigarette starter kit plus advice on its use (up to 15 min) and (3) referral to local stop smoking services.

Comparison

Participants allocated to the control group were given details of local NHS stop smoking services via written material but were not referred directly.

Outcome

The primary outcome was self-reported smoking abstinence at 6 months, confirmed by carbon monoxide testing. 

The Results

They enrolled 972 patients. Mean age was 40, and about 40% of the cohort was female. Individuals were smoking a median of 15 cigarettes a day. They were able to collect the primary outcome data on about 70% of patients. 

For their primary outcome of biochemically verified abstinence at 6 months, the intervention resulted in significant improvement (4.1% vs 7.2%; ARR 3.3%, 95% CI 0.3% to 6.3%).

There was also an increase in the number of patients who were abstinent for at least 7 days at some point during the trial (23.3% vs 12.9%; ARR 10.6%, 95% CI 5.8-15.4%).  

There was no difference in adverse events. (I am always skeptical of trials that claim no differences in harms, but given that this is a trial of harm reduction, this claim is probably believable.)

My thoughts

I think this is an important study because, despite some limitations, it draws attention to an intervention that is relatively easy for us to perform and can be very beneficial for our patients. That being said, the success of a smoking cessation program probably lies in resources outside the emergency department. There are likely limits to what any individual physician can do, and even ignoring amount of time spent counseling patients here, it sounds like these patients were provided with resources that I don’t have at my disposal. 

Considering the difficulty of tracking patients in a study like this, they had relatively impressive follow up (73% in the intervention group and 65% in the control group). That being said, they still lost far more patients than the small absolute difference reported, which is problematic. If only a small percentage of the lost patients had divergent outcomes from those reported, the conclusion of this study could easily be reversed. 

This control group may not perfectly represent the patients you are seeing. In addition to being handed a pamphlet, which was the planned control intervention, they did have a rather in depth conversation about their smoking habits to get enrolled, and they knew that they were going to have follow-up assessments of their smoking. This is a rare case where the Hawthorne effect might have had a bigger effect on the control group, biasing that trial towards the null hypothesis. 

For many community emergency providers, a 15 minute face to face counseling session about nicotine might be too much, especially with another 15 minutes allocated to discussing the use of the e-cigarette. In the trial, the smoking cessation advice was given by a trained counselor, which I don’t have access to. I think this trial would have been much stronger if the smoking cessation intervention had been left entirely in the hands of the emergency staff (physicians and nurses), with or without additional training. As it stands, generalizability is questionable.

The addition of carbon monoxide testing over simple self-report made the trial much much more difficult to complete, but makes the results far more reliable. We always complain about self report as an outcome, so I think this is a good addition. That being said, I don’t know about the clinically validity of the carbon monoxide measure they were using, and if I was planning on making big changes based on this paper, I might want into that more to ensure the outcome measure makes clinical sense. 

Kudos to the authors for having a manuscript that actually matches their clinicaltrials.gov registry. 

There is a bigger question that overlies every additional public health / primary care task like this that we take on in the emergency department: what is the opportunity cost? I am not sure that it will really take me 15 minutes to counsel about smoking, but maybe it takes that much time to be effective. If that is the case, the department will be 1 or 2 patients further behind. What is the cost of making all the patients in the waiting room wait another 15 minutes? What if that elderly patient sitting out there with back pain actually has an aortic dissection? One instance is obviously trivial, but multiplied across all the patients we see, and all the primary care interventions we are being asked to perform, the impact on emergency departments could be substantial. (Realistically, though, smoking cessation may have a bigger impact than tetanus vaccination. We need to think about and triage the primary care interventions we think can realistically be accomplished in an emergency setting.)

That being said, I think a 3% absolute decrease in confirmed smoking at 6 months is an important outcome, and all emergency departments should probably think carefully about whether they are doing enough to help patients addicted to cigarettes.

Bottom line

This is a strong trial that demonstrates that emergency departments can play a role in increasing smoking cessation for patients. It is not clear that this specific intervention is the best, nor if it is feasible in all settings. We should also be concerned about opportunity cost if this work is downloaded onto already overly busy emergency nurses and physicians.

Other FOAMed

St Emlyn’s: Cessation of Smoking Trial in the Emergency Department (COSTED): A Critical Appraisal

Evidence based medicine is easy

The EBM bibliography

Evidence based medicine resources

EBM deep dives

References

Pope I, Clark LV, Clark A, Ward E, Belderson P, Stirling S, Parrott S, Li J, Coats T, Bauld L, Holland R, Gentry S, Agrawal S, Bloom BM, Boyle AA, Gray AJ, Morris MG, Livingstone-Banks J, Notley C. Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial. Emerg Med J. 2024 Apr 22;41(5):276-282. doi: 10.1136/emermed-2023-213824. PMID: 38531658