Cessation of Smoking Trial in the Emergency Department (CoSTED)

Research question: In people attending the Emergency Department who smoke does a brief intervention (including the provision of an e-cigarette and referral to stop smoking services) increase smoking cessation in comparison with usual care and is it cost effective?

Background: Tobacco smoking is the leading cause of years of life lost in the UK, and negatively impacts significantly on physical health conditions and recovery outcomes from injury or surgery. Currently, smoking prevalence is recorded at approximately 15% of the population, but this masks substantial variation between different population groups. PPI development work demonstrates that prevalence of smoking for people attending the emergency department is approximately 24%.

Most current smokers will, if asked, state that they want to quit, but need support. The NHS long term plan and the Tobacco control plan for England recommend smokers are supported to quit at every contact with the health service by 2023/4. To date there have been no RCTs of smoking cessation support in the ED setting in the UK, which potentially provides a highly motivating opportunistic route to intervention.

Aims and objectives: To undertake a randomised controlled trial (RCT), with internal pilot, comparing a brief intervention (including provision of an e-cigarette and referral to smoking cessation services), assessing long term smoking abstinence, in people attending Emergency Departments. 1. To run an internal pilot study, with clear stop/go criteria, primarily to test recruitment systems.

2. To definitively test real-world effectiveness of an ED based smoking cessation intervention in comparison with usual care, by comparing smoking abstinence at 6 month follow-up between trial groups.

3. To undertake a cost effectiveness analysis of the intervention in comparison with usual care, from an NHS and personal social services (PSS) perspective.

4.To undertake an embedded mixed-methods process evaluation to assess delivery, implementation, fidelity and contamination.

Methods: RCT of people who smoke attending an Emergency Department, with an internal pilot, health economic evaluation and process evaluation. The primary outcome is smoking cessation, self-reported as continuous smoking abstinence, biochemically confirmed at 6 months. The sample size is 972 (with a power of 90% and a difference in quit rates between the groups of 6%).

Start date 01/04/2021. Total duration 30 months: 31/09/2023 Trial set up- 01/04/2021 – 30/09/2021 (6 months) Recruitment- 01/10/2021 – 30/09/2022 (12 months) Follow up- 01/11/2021 – 31/03/2023 (6 months from last month of recruitment) Analysis- 01/04/2023 – 31/07/2023 (4 months) Dissemination- 01/08/2023 – 30/09/2023 (2 months)

Anticipated impact and dissemination: We will definitively test an ED based smoking cessation intervention and make recommendations for future implementation if effective. The intervention has the potential to reduce smoking prevalence by at least 6% based on existing evidence, impacting on improved long term health outcomes for approximately 334,000 members of the UK population if adopted across the NHS.

Results will be disseminated at international conferences and published in leading journals to reach academic experts, through NHS networks and the Royal College of Emergency Medicine to reach commissioners, managers and members of the public.