This feasibility pilot trial of a smoking cessation intervention initiated through the ED provides important information regarding the success and failures of ED-based interventions. First, we observed that the QL intervention completion rate (50%) was considerably higher than previous ED studies where no subjects followed-up with outpatient appointments for tobacco use counseling [4, 5]. Given the small numbers in this study, however, more research is needed to evaluate true participation rates for proactive QL interventions initiated in the ED. In addition, despite screening over 200 smokers, only 40 (20%) were enrolled in the study. Once enrolled, half were unreachable or became disinterested in any smoking cessation interventions. Overall, a system such as this appears to be time consuming, yet promising from the perspective of compliance with the intervention. Clearly, feasibility of a larger randomized controlled trial will first require a more efficient screening tool. Perhaps the most important issue is identifying patients who truly wish to cease smoking and referring them. Considerations such as targeting specific presenting complaints including chest pain or respiratory complaints may help increase interest in smoking cessation. Further research is required to assess whether this approach would improve efficiency of enrollment and lead to better success with follow-up.
Convenience may be an important factor affecting compliance in the ED population and the completion rate for phone counseling intervention in this small population is encouraging given the evidence already available supporting the efficacy of proactive QL counseling. Proactive QL counseling (i.e., telephone counselors initiate patient contact) has been shown to increase abstinence rates compared to a reactive QL (i.e., tobacco user initiates contact) in other populations , and proactive telephone counseling is recommended by the United States Public Health Service (USPHS) and the US Centers for Disease Control and Prevention (CDC)  as a format for delivering behavioral interventions . All U.S. state residents have access to QLs funded through various mechanisms of which 76% (38/50) are described as providing proactive QL counseling .
Despite their proven efficacy and widespread availability, significant barriers to QL use clearly exist as most state QLs currently reach only 1% to 5% of their tobacco-using population . One of the potential barriers may be that all state proactive QL models, except Wisconsin  and New York , proactively initiate subsequent contact with tobacco users but require tobacco users to make the initial contact. In the current study, we incorporated a referral technique similar to the Fax-to-Quit program developed by the Wisconsin Center for Tobacco Research and Intervention . In this model, patient information is provided to the QL and the QL initiates the first contact. In 2004, 30% of the 12,000 callers to the Wisconsin Tobacco Quit Line were enrolled through the Fax-to-Quit program. Investigators in Oregon have reported that the Fax-to-Quit model in the primary care setting is feasible and cost-effective . In the Oregon study, the QL was able to successfully contact 59% of subjects which is similar to the completion rate observed in our study. Future research is also required to evaluate whether reactive quitline interventions offered in the ED would result in participation rates as high as we observed with a proactive intervention.
The Fax-to-Quit model, however, has not been formally evaluated through the ED. Despite the promising completion rate for the QL counseling intervention in this pilot, we were only able to reach 51% of study participants for any follow-up smoking assessment. Further investigation of the efficacy of the Fax-to-Quit model in the ED population is warranted particularly given it has been encouraged by the American College of Emergency Physicians . However, follow-up in this population is problematic, and further evaluation of techniques to improve outcome data collection is needed in order for a larger randomized controlled trial to be feasible.