The Cessation of Smoking Trial in the Emergency Department (COSTED): A New Opportunity for Tobacco Intervention
Tobacco use remains one of the leading preventable causes of illness and death worldwide. Yet many people who smoke rarely engage with traditional cessation services. Accident and Emergency departments are increasingly recognized as strategic settings to identify high-risk individuals and connect them with evidence-based support.
The Cessation of Smoking Trial in the Emergency Department (COSTED) was designed to examine whether offering smoking-cessation interventions during an A&E visit could meaningfully improve quit rates among people who smoke.
Study Rationale
A&E departments in the UK treat millions of patients annually. These include high numbers of individuals with chronic disease, acute exacerbations linked to smoking, socioeconomic vulnerabilities, or limited access to primary care.
An A&E department is, therefore, a unique setting with the potential to offer intervention as patients there may be more receptive to advice about health-related behaviour. COSTED sought to test whether leveraging opportunities to support smoking cessation could:
- Increase quit attempts
- Improve long-term abstinence rates
- Provide equitable cessation access for underserved populations
- Integrate brief interventions into routine emergency clinical workflows
Study Design and Methods
While specific details vary by implementation site, the COSTED study generally followed a pragmatic randomized controlled trial model. Key components typically included:
1. Participant Recruitment
Adults presenting to the ED who self-reported daily or regular smoking were offered participation. Recruitment captured a broad range of demographics, including individuals who might not engage with outpatient cessation services.
2. Randomization
Participants were randomized into two groups:
Intervention Group: Received brief behavioural counselling, immediate nicotine replacement therapy (NRT) initiation, and/or structured referral to follow-up cessation services.
Control Group: Received usual care, typically limited to standard medical advice without structured cessation support.
3. ED-Based Intervention
The intervention emphasized feasibility in a busy emergency department:
- A brief (5–15 minute) motivational conversation
- Assessment of nicotine dependence and readiness to quit
- Immediate offer of an e-cigarette starter pack (a pod device and a week's supply of e-liquid)
- Quit-plan development
- Referral to community or telephone-based cessation services
4. Follow-Up
Participants were followed for several months to evaluate:
- Self-reported smoking status
- Biochemically verified abstinence (when possible)
- Quit attempts, reduction in cigarette consumption
- Engagement with ongoing cessation services
- Health and socioeconomic outcomes
Key Findings
While results varied by study phase or publication, the overarching conclusions of the COSTED project include:
1. ED-Based Cessation Is Feasible and Acceptable
Many patients welcomed the offer of support, even during emergency visits. Clinicians found that brief counselling could be integrated without significantly slowing A&E flow.
2. Immediate NRT Improves Engagement
The provision of e-cigarettes increased patient willingness to attempt quitting and boosted uptake of follow-up services.
3. Higher Quit Rates Compared to Standard Care
Participants receiving the COSTED intervention had significantly higher rates of quit attempts and short-term abstinence relative to those receiving usual care. Longer-term abstinence signals were positive, though dependent on follow-up adherence.
4. Reaching Underserved Populations
The A&E setting allowed cessation teams to connect with people who smoke but who seldom seek preventive care, including individuals facing socioeconomic disadvantage, unstable housing, or limited access to primary healthcare.
5. Potential for Health-System Impact
Even modest improvements in cessation at the population level could translate into meaningful reductions in tobacco-related A&E visits and hospitalizations.
Implications for Clinical Practice
The COSTED trial highlights an important paradigm shift: smoking cessation support should not be confined to primary care offices or specialty clinics. Emergency departments can, with minimal additional resources, become powerful intervention points.
Broader Public Health Significance
Tobacco control depends on reaching people who would benefit. A&E-based cessation interventions can:
- Expand reach to high-risk populations
- Reduce health disparities
- Deliver immediate, evidence-based pharmacotherapy
- Align emergency care with preventive health priorities
If scaled, the COSTED model could meaningfully contribute to national smoking-reduction goals.
Conclusion
The Cessation of Smoking Trial in the Emergency Department (COSTED) demonstrates that emergency departments are not only places for urgent care but also critical environments for initiating meaningful health behaviour change. By meeting people who smoke at a moment of vulnerability interventions can increase the likelihood of quitting and help close gaps in access to cessation support. COSTED offers a promising blueprint for integrating tobacco-treatment services into acute care settings across the healthcare system.
