Optimizing Tobacco Dependence Treatment in the Emergency Department

Conditions:Smoking Cessation, Hospital, Tobacco Consumers
Therapuetic Areas:Pulmonary / Respiratory Diseases, Other
Age Range:18 - Any
Start Date:February 13, 2017
End Date:June 2020
Contact:June-Marie Weiss, MA, MEd

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The investigators propose an innovative full-factorial design in a cohort of 1056 adult
smokers in an urban emergency department (ED), to test the efficacy of four key intervention
components: motivational interviewing, medication, quitline referral, and texting. At the
trial's completion, a mixed-methods approach will be used to identify the components that
were efficacious within the proposed cost constraint, along with feasibility and
acceptability to providers and subjects. The investigators will then assemble an intervention
that maximizes efficacy, given a cost-effectiveness constraint and findings from a
qualitative analysis.

The investigators propose to optimize the identification and treatment of adult smokers seen
in a hospital ED. To do this the Multiple Optimization Strategy (MOST) will be employed to
develop a multicomponent intervention that will consist of some combination of the following:
(1) a Brief Negotiation Interview (BNI, a variant of a motivational interview), delivered by
a trained research assistant; (2) provision of 6 weeks of nicotine patches and gum to the
research participant, with application of the first patch in the ED; (3) active referral to
the Connecticut Smokers' Quitline; and (4) enrollment in the SmokefreeTXT short-messaging
service (SMS) texting program for mobile phones. Using MOST principles, the first phase of
the study will use a 2x2x2x2 full-factorial design to identify the components most likely to
be efficacious in combination. Although the factorial design requires the allocation of
participants to 16 different combinations of the 4 components (Table 1), evaluation of each
individual component is performed comparing all of those receiving a component to all of
those not receiving a component, making this an efficient design. For instance, evaluation of
the BNI component will compare those randomized to arms 1 through 8 to those in arms 9 to
16.The second phase will consist of designing and proposing a 2-arm randomized clinical trial
comparing the efficacy of the multicomponent intervention package to usual care; this will be
conducted in a future application.

The specific aims of this proposed study are:

Aim 1. To conduct a fully powered factorial randomized trial of 1056 adult smokers to test
the efficacy of 4 key components of ED-initiated tobacco treatment: BNI, NRT, QL referral,
and SMS texting.

Aim 2. To identify the most efficacious components of our intervention, within fixed
constraints of cost effectiveness and feasibility/acceptability to providers and subjects.

Aim 3. To lay the groundwork for a future randomized trial testing the previously identified
components, delivered as a package, against a control arm in a new cohort of adult ED

Our associated hypotheses are:

1. At 3 months, at least 1 intervention component will yield a biochemically verified
tobacco abstinence rate at least 5% greater than in the control condition. Carbon
monoxide breath test will be used for biochemical verification.

2. At 3 months, at least 1 intervention will be cost-effective, using a societal

3. At 3 months, at least 1 intervention will be acceptable and feasible to providers and

Inclusion Criteria:

- 18 years or older

- have smoked >= 100 cigarettes lifetime

- describe themselves as every or some day smokers

- smoke at least 5 cigarettes/day

- own a cellphone with texting capability

- are able to give written informed consent

Exclusion Criteria:

- Inability to read or understand English

- currently receiving formal tobacco dependence treatment

- life-threatening or unstable medical, surgical, or psychobehavioral condition

- unable to provide at least one collateral contact

- live out-of-state

- leaving the ED against medical advice

- pregnant (self-report or urine testing), nursing, or trying to conceive.
We found this trial at
New Haven, Connecticut 06520
Phone: 203-737-3582
New Haven, CT
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