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Tobacco Cessation in the Emergency Department


Tobacco use is the leading preventable cause of death in the United States. Smoking or chewing tobacco may increase a patient’s risk for chronic obstructive pulmonary disease (COPD), coronary artery disease, lung cancer and stroke. While smokers account for less than 14% of the U.S. population, up to 30 to 40% of patients seen in emergency departments are smokers.

With this important knowledge of how many emergency room patients smoke, Yale Medicine is at the forefront of a growing movement to initiate smoking cessation interventions there. These include several tobacco intervention-related research studies, says Steven L. Bernstein, MD, an emergency medicine physician and the principal investigator of the Yale Medicine emergency department’s tobacco-related studies.

Why provide tobacco intervention in an emergency department?

Dr. Bernstein says that the importance of tobacco cessation was driven home to him while he was in hematology and oncology training nearly 30 years ago.

“I saw a lot of tobacco-related illness and, at that time, we weren’t doing much for patients in terms of prevention other than just treating their cancer,” he says. “I felt we were missing an opportunity to prevent terrible diseases.”

Dr. Bernstein completed a residency in emergency medicine in New York City where he saw high instances of tobacco-related asthma, emphysema, pneumonia, heart disease, and stroke. 

“We were pretty good at treatment to stabilize the patients,” he says. “But we were not doing much about the underlying cause that had made them sick in the first place. I started looking into the incidence of tobacco-related emergency visits, which are about double that of the general population. So there was this population of smokers, many with limited access to health care due to a lack of insurance or under insurance. It struck me that if we were to intervene while they were in the emergency department, maybe we could have a positive impact on their health.”

What tobacco-related studies are being conducted at Yale Medicine?

When Dr. Bernstein first came to what is now Yale Medicine in 2009, he applied for and received a grant from the National Cancer Institute (NCI) to conduct a tobacco cessation-related clinical trial in the emergency department.

The study, conducted from 2010 to 2012 in the emergency department of Yale New Haven Hospital, provided one group of uninsured or Medicaid-covered smokers with a motivational interview by a trained research assistant, six weeks worth of nicotine patches and gum, a referral to the Connecticut Tobacco Quitline, an informational brochure and a follow-up call. Another uninsured or Medicaid-covered control group received only the brochure.

The study found that 12 percent of people who had received tobacco-cessation intervention had abstained from smoking for at least a week before their three-month checkup, during which they were asked to provide a breath sample to measure carbon monoxide. Only five percent of the control group participants had abstained. “It was the first trial to show positive results of tobacco intervention in an emergency department,” Dr. Bernstein says. (To read more about the Yale study, click here.)

Dr. Bernstein’s team recently began a smaller pilot intervention study using texting. They received NCI financing for a study involving more than 1,000 patients that will gauge each piece of the intervention package separately and in various combinations.

“That study, which will be ongoing over the next few years, will give us a better sense of what really connects with these patients,” Dr. Bernstein says.

Who is eligible for tobacco-cessation studies at Yale Medicine’s emergency department?

The ongoing clinical trials of tobacco cessation intervention at Yale Medicine’s emergency department are open to people with any kind of insurance (or none at all) who visit the emergency department whenever research staff are available.

“We try to have research staff available 12 to 16 hours a day, six days a week,” says Dr. Bernstein. “When a smoker comes in who has been injured, is sick or experiencing behavioral problems, we really try to use that moment to address the cause.”

Where can tobacco users go for help if they are not emergency department patients?

If you want more information on the Tobacco Treatment Service at Smilow Cancer Hospital and you are not an emergency department patient, click here for more information.

What makes Yale Medicine’s tobacco cessation studies unique?

Dr. Bernstein says that while a small number of other emergency departments are doing similar work, none are yet doing so with the depth or commitment of Yale Medicine’s research teams. “Since we published the results of that first study, we get calls from other academic medical centers asking how they can replicate it,” he says. “We have done interventions of all kinds of addictive disorders, including tobacco, alcohol and opioids, and we’ve developed a deeper understanding of how to do it and how to do it successfully."