Original research
be conservative and has been examined in a sensitivity analysis in the online supplemental material. The challenges achieving biochemical verification and the differences in response rates between the groups are limitations which arise from this being a pragmatic trial which attempted to replicate real life. This is in keeping with other ED-based smoking cessation trials which attempted to biochemically verify smoking status with loss to follow-up rates of around 30% and biochemical verification of those reporting abstinence of around 50%. Policy implications This trial has demonstrated the effectiveness of a simple, oppor- tunistic and acceptable intervention in a real-world setting with no serious adverse effects. We consider that this could be rolled out to reach a large proportion of current smokers, although dedicated staff are clearly needed to deliver the intervention so as not to burden clinical staff. Those attending EDs are generally from more deprived communities and more likely to smoke than the general population. 5 6 Therefore, this intervention has the potential to address health inequalities that arise from disparities in smoking rates between different socioeconomic groups. 3 Given high accessibility to an at-risk population, future research might explore the use of EDs as a location to support people to change other behaviours such as excess alcohol use or low physical activity. CONCLUSION In this study of adults who smoke and who were attending the ED, an intervention comprising brief advice, provision of an e-cigarette starter kit and referral to stop smoking services resulted in significantly increased sustained smoking abstinence 6 months later compared with those signposted to stop smoking services. Providing smoking cessation support in the ED should be considered to reach groups of the population that may not routinely engage with stop smoking services but have the most to gain from stopping smoking. Author affiliations 1 Norwich Medical School, University of East Anglia Norwich Medical School, Norwich, UK 2 Department of Health Sciences, University of York, York, UK 3 Department of Cardiovascular Sciences, University of Leicester, Leicester, UK 4 Usher Institute, The University of Edinburgh, Edinburgh, UK 5 University of Exeter, Exeter, UK 6 Leicester Royal Infirmary, Leicester, UK 7 Emergency Department, Barts Health NHS Trust, London, UK 8 Emergency Department, Addenbrooke’s Hospital, Cambridge, UK 9 Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK 10 Emergency Department, Homerton University Hospital NHS Foundation Trust, London, UK 11 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK X Ian Pope @drianpope, Adrian A Boyle @dradrianboyle and Caitlin Notley @ AddictionUEA Acknowledgements We thank the study sponsor, Norfolk and Norwich University Hospital NHS Foundation Trust. The study was led by researchers at the University of East Anglia and managed by the Norwich Clinical Trials Unit (specifically Mei-See Man, Matthew Hammond, Tom Conway, Ollie Ellacott, Antony Colles, Erica Berardi and Zuzanna Halicka). Our thanks go to the research teams at the organisations involved in recruitment and in supporting delivery of the trial and the sites’ local stop smoking services. We would also like to thank PPI contributors who were critical in defining the choice of e-cigarette starter kit and shaping the intervention. We acknowledge the contribution of the smoking cessation advisors who underwent training to deliver the intervention. We thank SmokeFree Norfolk for supporting the study by training the advisors. Thanks also to our independent Trial Steering Committee and Data Monitoring Committee members (Professor Steve Goodacre,
Table 4 Adverse event by type
Intervention (n=484)
Control (n=488)
Serious adverse events (≥1)*, n (%) Adverse events (≥1), n (%) Throat/mouth irritation (extreme)
25 (5.2%)
25 (5.1%)
10 (3.2%)
8 (2.7%)
n=310
n=293
Dry cough (extreme)
13 (4.2%)
12 (4.1%)
n=310 n=292 *All serious adverse events resulting in hospitalisation over the study period.
are novel as this is the first trial to use them opportunistically to support abstinence in those who smoke and are accessing health- care services, but who are not actively seeking help to quit. Of people who smoke attending the ED, half were willing to take part in the trial, indicating that the ED represents an accept- able location for smoking cessation intervention and therefore offers a valuable opportunity to engage those who smoke who are not currently seeking to quit. Strengths and limitations The strengths of this study include: its large sample size; it was inclusive, being delivered across multiple UK centres recruiting a diverse population; it used an objective primary outcome measure; inclusion criteria were broad to ensure generalisability; it had a robust study design with appropriate randomisation and allocation concealment and the trial had a pragmatic design with an intervention that should be easy to replicate in day-to-day practice assuming it is appropriately resourced. A limitation of the study was that control participants did not simply receive a leaflet signposting them to stop smoking services, as in order to collect the data needed from the control group there was a discussion with researchers that may have affected smoking behaviour. They underwent CO breath testing, were asked extensive questions about their smoking, received written information on stop smoking services and were asked their smoking status three times over the follow-up period. This may have caused a higher quit rate in the control group compared with true usual care (which is likely to have no mention of quitting smoking) and therefore potentially underes- timates the impact of the intervention. Successfully encouraging our trial participants to submit a CO reading at 6 months proved to be very challenging. This may in part be due to the transient and sometimes chaotic nature of the lives of many ED attendees, the large geographical catchment area of participating EDs and transportation complexities. Thus, the biochemically confirmed cessation rates (while statistically significant) may underestimate the true effect size. Equally, it is possible that being part of the intervention group encouraged more of those to provide biochemical confirmation, although our biochemical confirmation findings mirrored our self-report findings and the percentage of CO verifications at 6 months was similar across the intervention and control groups. While the biochemically confirmed quit rates in the intervention and control groups were not as large as the power calculation had been based on, the self-reported continuous abstinence rate was much larger. The difference is likely a result of the difficulty with collecting CO readings. There was a difference in response rate between the intervention and control groups. As is conven- tion in smoking cessation trials, we assumed that those who did not respond were still smoking; 23 however, this assumption may
Pope I, et al . Emerg Med J 2024; 41 :276–282. doi:10.1136/emermed-2023-213824
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