Research Article: Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions

Date Published: January 24, 2014

Publisher: BioMed Central

Author(s): David A Katz, Monica W Paez, Heather S Reisinger, Meghan T Gillette, Mark W Vander Weg, Marita G Titler, Andrew S Nugent, Laurence J Baker, John E Holman, Sarah S Ono.


The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians’ (EPs) and nurses’ (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A’s framework (Ask-Advise-Assess-Assist-Arrange) in the ED.

We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts.

The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients’ receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A’s in the ED.

There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies. registration number NCT00756704

Partial Text

Given that approximately 25 million smokers present to the emergency department (ED) annually [1], greater involvement of ED staff in cessation counseling has the potential to augment cessation rates at the population level. The US Public Health Service (USPHS) guideline specifically recommends that physicians and nurses should strongly advise their patients who use tobacco to quit, and calls for systems and practice policies to facilitate the delivery of smoking cessation counseling and pharmacotherapy [2]. Based largely on evidence from primary care settings, a public health task force convened by the American College of Emergency Physicians strongly recommends implementation of smoking cessation counseling in the ED setting [3].

Table 3 shows the characteristics of the ED staff who completed the in-depth interview. ENs and EPs had worked in the ED for a median of 7 years. Of the nineteen nurse participants, seven were diploma-educated registered nurses (RNs) and seven had attained a bachelor’s of science in nursing (BSN); approximately half of the EPs (5 of 11) were board-certified in emergency medicine. Three of 19 ENs and none of the EPs were current smokers.

Smoking causes more deaths each year than alcohol, motor vehicle accidents, suicide, AIDS, homicide, illicit drugs, and fires combined [30]. Previous studies have demonstrated that it is feasible for ED staff to improve delivery of the 5 A’s [7] and that these improvements are accompanied by enhanced self-efficacy and role satisfaction in cessation counseling [14]. Indeed, opportunistic cessation counseling is strongly recommended by professional societies of emergency medicine [1]. The current study shows that ED staff acknowledge the potential public health benefit of brief cessation counseling in the ED, which serves a disproportionate number of smokers [31], but are ambivalent toward counseling patients themselves on account of time constraints, competing demands, and perceived resistance from patients.

5 A’s: Ask-Advise-Assess-Assist-Arrange (framework for brief smoking cessation counseling); ED: Emergency department; EN: Emergency nurse; EP: Emergency physician; DBQ: Decisional Balance Questionnaire.

The authors have no potential competing interests to disclose. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Study concept and design: DK, HR. Acquisition of the data: MG, JH. Analysis and interpretation of the data: SO, MP, DK. Drafting of the manuscript: DK, SO. Critical revision of the manuscript for important intellectual content: DK, SO, HR, MVW, MT. Statistical expertise: JH. Obtained funding: DK. Administrative, technical, or material support: JH, AN, LB. Study supervision: SO, DK. All authors read and approved the final manuscript.




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