Deliver an Evidence-based Smoking Cessation Intervention for Smokers Attending A&E Departments in Hong Kong

Smoking exerts harmful effects on nearly every organ of the body and is considered responsible for 7 million deaths worldwide every year.1 Despite a decrease in the prevalence of daily cigarette smoking from 23.3% in 1982 to 10.0% in 2017, 615,000 daily smokers2 remain in Hong Kong, where 400,000 hospitalisations per year are attributable to smoking.3 These statistics cannot be overlooked or undervalued.

The provision of medical attention to smokers in physical discomfort who visit accident and emergency departments (AEDs) could be an excellent teachable model, as it provides an invaluable opportunity to encourage smoking cessation. Smokers who consult physicians in an emergency setting are more likely to adopt better health-related behaviours. According to the Hospital Authority,4 approximately 2 million people visit AEDs in Hong Kong each year; of them, 68% are triaged as semi-urgent (level 4) or non-urgent (level 5). The average waiting time for a medical consultation varies among AEDs but generally exceeds 30 min for triage level 4 and 1-2 h for level 5. These wait times represent a golden opportunity in which healthcare professionals could advise smokers to quit and provide information about available smoking cessation programmes.4 However, cigarette smoking is addictive, and cessation is a difficult process associated with a high rate of relapse, particularly among smokers with a high level of nicotine dependency.5 According to the latest Hong Kong Thematic Household Survey, 31.2% of participating cigarette smokers had tried but failed to quit smoking.2 Therefore, an innovative intervention is needed and should be evaluated with the intent to enhance its effectiveness and potential for implementation in clinical settings. Based on the health needs of the community, we propose that such a smoking cessation strategy should combine different components, such as the administration of brief advice by healthcare professionals and the provision of referrals and follow-up boosters by community smoking cessation services, to achieve a larger intervention effect.

Most existing cessation programmes, including stage-matched interventions6 and motivational interviews,7 generally require implementation periods exceeding 30 minutes. Previous reviews have indicated that a comprehensive intervention might more effectively promote smoking cessation, compared to brief advice.8-10 However, the provision of a comprehensive smoking cessation intervention is not feasible in the busy clinical settings of Hong Kong. Indeed, healthcare professionals most commonly cite a lack of time as the reason for their inability to help patients with smoking cessation; specifically, these professionals are very busy and cannot spare even a few extra minutes.11 Other barriers to assistance include a lack of training and experience, lack of confidence in the effectiveness of the interventions and deficiencies in or a lack of incentives, support or requirements from hospital management regarding the implementation of these programmes. Moreover, our previous smoking cessation projects in an outpatient clinical setting revealed that many patients were too impatient to participate in a long intervention, while others expressed a reluctance to participate because of concerns that they might miss or experience delays in their medical consultations or other medical procedures.11-13 Nevertheless, although a brief intervention is more feasible in a clinical setting, it may be too brief and inadequate to have a significant effect on smokers.12,13 Moreover, the effectiveness of some brief interventions for smokers which focus mainly on providing self-help materials is undermined by a failure to offer or arrange any follow-up.9 Evidence indicates that smoking cessation services, including telephone quitlines, are an effective means of supporting smoking cessation efforts.14 However, these services are generally poorly utilised, with a usage rate of 23.2% among smokers in Hong Kong.2 Therefore, the combination of brief cessation advice plus referrals for smokers to utilise existing smoking cessation services in Hong Kong may comprise an alternative strategy that could enhance the effects of intervention, particularly for patients requiring additional counselling.

Interventions will include:

• Use of brief smoking cessation interventions by healthcare professionals
• Self-determination intervention for smoking cessation (i.e., immediate or progressive cessation with the ultimate goal of completion over an acceptable period)
• Active referral

Service targets

Phase I: To promote our project to the emergency departments of hospitals under the Hospital Authority.

Phrase II: To recruit healthcare professionals from participating emergency departments to attend a half-day training workshop.

Phrase III: To provide brief smoking cessation advices by healthcare professionals to smokers who attend emergency departments and actively refer them to existing smoking cessation services

• Healthcare professionals employed in the emergency departments of various hospitals under the Hospital Authority
• Smokers attending emergency departments who are triaged as semi-urgent (level 4) or non-urgent (level 5)