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Open Access Veröffentlicht von De Gruyter 1. August 2008
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EMERGENCY DEPARTMENT TOBACCO CESSATION PROGRAM: STAFF PARTICIPATION AND
INTERVENTION SUCCESS AMONG PATIENTS

 * Marna Rayl Greenberg
   Marna Rayl Greenberg
   
   Diesen Autor / diese Autorin suchen:
   De Gruyter | Google Scholar
   , Michael Weinstock
   Michael Weinstock
   
   Diesen Autor / diese Autorin suchen:
   De Gruyter | Google Scholar
   , Deborah Gaston Fenimore
   Deborah Gaston Fenimore
   
   Diesen Autor / diese Autorin suchen:
   De Gruyter | Google Scholar
   und Gina M. Sierzega
   Gina M. Sierzega
   
   Diesen Autor / diese Autorin suchen:
   De Gruyter | Google Scholar

Aus der Zeitschrift Journal of Osteopathic Medicine
https://doi.org/10.7556/jaoa.2008.108.8.391
Artikel downloaden (PDF)
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10




ABSTRACT

Context: The emergency department (ED) is often the primary source of healthcare
for uninsured and underinsured patients.

Objectives: To evaluate ED staff attitudes toward and participation in referring
patients to a tobacco cessation program, and to assess the program's
effectiveness.

Methods: A nonvalidated survey on smoking cessation and preventative services
for ED patients was mailed to ED staff at a suburban hospital. After survey
completion, ED staff was encouraged to refer smokers with diagnoses
substantially worsened by tobacco use to a brief intervention delivered in the
ED. An incentive was provided to staff beginning in the second month of the
3-month period. Referred patients were briefly counseled by a hospital social
worker or an ED physician or nurse. Follow-up telephone interviews with patients
occurred 1 to 3 months postintervention.

Results: Of the 70 ED staff contacted, 63 (90%) responded to the survey. Most
staff members (81%) agreed that they should facilitate clinical prevention.
Fewer staff (60%) were comfortable advising patients to quit tobacco use
(P<.03), and fewer still (51%) agreed that ED staff should assist patients in
tobacco cessation (P<.001). Tobacco users were more likely to favor implementing
patient education in the ED (P=.01) and were less comfortable advising patients
to quit (P=.06). Staff referrals increased with program incentives (P=.008),
with a total of 150 interventions occurring in the 3-month span. Of the 36
patients (24%) reached for follow-up, 13 (36%) attempted to quit and 6 (17%)
succeeded. Overall, 45% of the patients reached for follow-up either cut down or
quit tobacco use.

Conclusions: Staff members' attitudes toward tobacco cessation are not a firm
barrier to the successful implementation of an ED tobacco cessation program. In
addition, the ED provides an important opportunity to encourage patients to quit
or cut down tobacco use.


ABSTRACT

Most hospital house staff agree that they should facilitate tobacco-intervention
efforts for patients whose medical conditions are adversely affected by smoking.
However only slightly more than half of these individuals (60%) were comfortable
advising patients to cease tobacco use. Staff referrals increased with program
incentives.

Adult racial and ethnic minority populations, Americans living in poverty, and
younger patients are more likely than other US populations to use the emergency
department (ED) as their primary source of healthcare.1 In addition, the
prevalence of tobacco use among ED patients, who are most often from such
patient populations, is high.2,3 Surprisingly, even though nearly half of ED
tobacco users are “ready” to quit, many state that they have never been told to
do so by a physician.1-4 In fact, one study5 revealed that although most
physicians discussed tobacco use habits with patients, only 56% of such
discussions included advice to quit.

Considering these data, the effectiveness—and appropriateness—of preventive
health measures implemented in the ED is frequently discussed.1-12 Although a
consensus statement on the value of such programs remains to be seen, the ED
continues to be a safety net for indigent and underinsured patients.1,13 If
clinical preventive services are demonstrated to be effective and
time-efficient, ED healthcare providers might be more likely to deliver such
services, therefore positively impacting the health of the community.

Staff attitudes toward the delivery of ED preventive and public health services
are a potential barrier not only to the willingness of staff to participate in
such programs but also to the success of an intervention program. As part of a
community service project, the present study sought to evaluate how ED staff
attitudes toward community service, patient education, and preventive health
affected their participation in referring patients to an ED tobacco cessation
program. The success of the intervention in decreasing tobacco use among
patients was also assessed.


METHODS

The institutional review board at Lehigh Valley Hospital in Allentown, Pa,
reviewed the present study's methods. Because it was determined to be minimal
risk as a patient education and evaluation project, the current study was exempt
from full review. Also, because the outcome measures were dependent on patients'
self report and because patients' knowledge of participation in the study may
have resulted in artificially inflated results, patients' consent was not
obtained.

In 2001, a nonvalidated survey was mailed to the ED staff at the Lehigh Valley
Hospital. A second mailing was sent to staff who had not yet responded 1 month
after the first mailing. The ED nurse responsible for coordinating patient care
and the primary investigator (M.R.G.) provided e-mail and verbal reminders to ED
staff. A 90% response rate was used as the survey endpoint.

The 8-question survey asked respondents to rate their agreement with statements
regarding their role in patient education and disease prevention. A 1 to 5
Likert scale was used, with 1 indicating “strongly agree” and 5 indicating
“strongly disagree.” Respondents were also asked to indicate their job title
(eg, nurse), years working in an ED, and personal tobacco use. Although staff
members did not include their names, each survey was numbered to track
responses.

After all completed surveys were received, an educational session was provided
by Coalition for a Smoke Free Valley, a community agency that sponsors
professional healthcare training and education in accordance with the standards
set by the National Cancer Institute.14 This session was designed to increase ED
staff's knowledge about tobacco use and intervention as well as to provide
guidelines for the implementation of a tobacco cessation program. Attendance was
encouraged but not required. Departmental meetings and informal updates were
used to reinforce the teachings from this session.


PROGRAM IMPLEMENTATION

Patients were eligible to participate in the tobacco cessation program if they
were 18 years or older and if they used tobacco. In addition, ED staff
physicians recommended inclusion criteria based on diagnoses that might be
adversely affected by continued tobacco use. Although all patients were eligible
for the intervention, those who presented to the ED with heart disease,
gastritis, pregnancy, or a respiratory illness were targeted by ED staff. These
patient popluations were selected by ED staff physicians for two reasons: (1) to
help those patients who would receive the most benefit from reduced or ceased
tobacco use, and (2) to narrow the patient population so that adequate staff
would be available to administer the interventions. Patients were excluded from
participation in the program if the severity of their condition precluded
intervention.

To determine patient eligibility, staff members (ie, physicians, nurses, and
administrative and technical partners) simply asked patients—particularly those
with the previously defined conditions—if they were tobacco users. If a patient
said yes, he or she was referred to the cessation program. The intervention was
provided within the physical space of the ED proper and was administered by an
onsite social worker, when available. In the event that a social worker was not
available, an ED physician or nurse administered the intervention.

For the first month after program implementation, ED staff was encouraged simply
to refer patients to the intervention program. In the second month, a gift
basket valued at approximately $100 was displayed within the ED as an incentive
for staff participation. Gift baskets were awarded to the doctor and to the
nurse or other staff member who made the most referrals into the cessation
program. Weekly referrals were tallied, and the winner-to-date was posted
prominently within the department and distributed via e-mail to further
encourage competition for the basket.

The number of referrals to the tobacco cessation program was assessed for the
month before and the 2 months after the incentive. Participation was evaluated
not only for the number of referrals or consults done but also in relation to
the total number of hours an employee worked in the department during the
specified time period. Survey responses and personal tobacco use among staff
were evaluated to determine potential influences on staff participation in the
tobacco cessation program.


INTERVENTION

The tobacco use intervention consisted of a 1-page, nonvalidated form to record
and assess tobacco use attitudes and behaviors among patients. The form, which
was already in use for inpatient consultations throughout the hospital,
consisted of the items listed in Figure 1. As it did after inpatient
consultations, the completed form became a part of the ED patients' permanent
medical records.

The intervention administrator assessed and determined patients' “impression
stage of change” for tobacco use cessation to be in one of the following
categories: precontemplation, contemplation, preparation, action, or
maintenance/relapse prevention. Depending on this initial impression, the
administrator provided an appropriate action (eg, education on health risks) and
recorded a treatment plan. For example, if a patient was determined to be
contemplating tobacco cessation, he or she would be instructed on the various
quitting methods and programs available and then would be advised to contact the
Center for Health Promotion and Disease Prevention when he or she was ready to
quit tobacco use.

Staff was instructed to provide additional encouragement and resources (eg,
educational brochures from the National Institute of Health) to patients in
preparation and action stages when time permitted. Information provided to
patients was recorded on the intervention form. Staff was also asked to obtain
the name of the patient's primary care physician when available and include it
in the “Comments” section of the intervention form. If a primary care physician
was indicated in the form, ED administrative staff sent him or her a form letter
regarding the patient's evaluation and treatment. The form included the ED's
telephone and fax number in case the primary care physician wanted additional
information.

Staff was encouraged to conduct the intervention during “dead” time (eg, when
the ED was backed up and wait times were long) to minimize disruption of flow
within the ED or any delay in the discharge of the patient. Total time allocated
to the intervention was not recorded. Although a 2- to 3-minute intervention was
described as ideal, as little as 30 seconds was considered influential, as
indicated in previous studies.15,16 Variability in actual time spent on the
intervention was expected by nature of the logistics.

Figure 1.

Components of the intervention form used in the tobacco cessation program
implemented at the emergency department at Lehigh Valley Hospital in Allentown,
Pa.


FOLLOW-UP TELEPHONE SURVEY

Telephone follow-up with patients occurred 1 to 3 months after the intervention.
The primary investigator (M.R.G.) attempted to reach all patients. For those
patients reached, the following five items were assessed and recorded:



 * the patient's overall attitude (positive or negative) toward tobacco
   cessation

 * whether or not an evaluation by a primary care physician occurred since the
   ED visit

 * the patient's attempts to cut down or quit tobacco use since the ED visit
   (indicated by “Yes,” “No,” or “Cut Down,” with recorded current tobacco use)

 * the patient's stage of change (precontemplative, contemplative, etc)

 * whether or not the caller instructed the patient on available tobacco
   cessation programs




STATISTICAL ANALYSIS

Responses to the ED staff survey were dichotomized into agree (scores of 1 or 2)
and did not agree (scores 3, 4, or 5) and reported frequencies between
individuals' mean attitudes toward the four general questions and the two
tobacco-specific questions. Attitudes were compared between “nonsmokers”
(tobacco-free for at least 1 year) and “smokers” (tobacco use within the past
year). Respondents were also dichotomized above and at or below the median for
the mean score of the general ED questions and opinions regarding personal
effectiveness in improving patients' health through preventive measures.

Results were confirmed using the general linear model to adjust results for
gender, length of ED employment, and job role. However, because we found no
differences when controlling for these variables, we only report the results of
univariate analyses. We reported confidence intervals (CI); however, our
analysis included P values by using the paired t test when comparing responses
from the same respondents and when comparing responses across groups. When
comparing multiple-item scales, we verified the equality of variances before
reporting results, using .4 as a minimal P value for the test of equivalence.
Findings were consistent in both forms of analysis.

Generalized estimator equations analyzed univariate and multivariate
relationships between individuals' attitudes and the number of referrals to the
tobacco cessation intervention program. However, the relationship of the
attendance at the educational session to referral patterns was not assessed
because of the staff's documented high attendance.


RESULTS


STAFF SURVEY AND REFERRAL PARTICIPATION

A total of 63 (90%) staff members—comprising 29 (46%) attending physicians, 16
(25%) nursing staff, and 18 (28%) administrative and technical
partners—responded to the ED survey (Table 1). Nearly half of the respondents
(46%) admitted ever having used tobacco (smoked cigarettes, cigars, or both) on
a regular or occasional basis. Time working in an ER ranged from less than 1
year to 20 years or more. In general, staff agreed that the ED was appropriate
for patient education (79%), preventive health activities (81%), and community
service programs (78%). Staff attitudes were also favorable toward educating
patients about preventive health (76%) (Table 2).

Table 1

Characteristics of Emergency Department Staff (n=63)

--------------------------------------------------------------------------------

Characteristic

--------------------------------------------------------------------------------

--------------------------------------------------------------------------------

No. (%) *

--------------------------------------------------------------------------------

▪ Job Title □ Physician 29 (46) □ Nurse 16 (25) □ Other 18 (28) ▪ Years Worked
in Any Emergency Department □ Less than 1 9 (15) □ 1-5 16 (26) □ 6-10 13 (21) □
11-19 14 (23) □ 20 or more 10 (16) □ Unknown 1 (2) ▪ Tobacco Use† □ Cigarette 29
(46) □ Cigar‡ 4 (6) □ Other (eg, snuff, pipe, chew)

--------------------------------------------------------------------------------

0

--------------------------------------------------------------------------------

[*] [†] [‡]
Table 2

Emergency Department (ED) Staff Agreement With Survey Statements * (n=63)

--------------------------------------------------------------------------------

Survey Question

--------------------------------------------------------------------------------

--------------------------------------------------------------------------------

Agreement, %

--------------------------------------------------------------------------------

▪ Our ED should participate in patient education. 79 ▪ Our ED and its staff
should have a role in community service. 78 ▪ Our ED and its staff should
facilitate clinical prevention when possible. 81 ▪ I am interested in helping to
educate my patients and the community in preventive health. 76 ▪ Our ED staff
should help people to stop using tobacco. 51 ▪ I feel comfortable with advising
people to quit using tobacco. 60 ▪ We should do more education, prevention, or
community service projects to assist patients to improve their health. 69 ▪ I
feel my efforts toward patient education, prevention, or community service
projects could make a direct impact on a patient's health.

--------------------------------------------------------------------------------

73

--------------------------------------------------------------------------------

[*]

Seventeen respondents were less favorably disposed to the ED as a site for
prevention than the median score for the four-item construct. These respondents
were less comfortable with tobacco education in the ED (two question mean,
average difference, 1.5; 95% CI, 0.9-2.0), felt less able to impact patient
health through education, prevention, or community service (mean difference,
1.5; 95% CI, 1.0-2.0), and were less comfortable advising patients to quit
tobacco use (mean difference, 1.7; 95% CI, 1.0-2.4). These respondents represent
sizable differences on a 5-point scale. In addition, the seventeen respondents
who had less than the median belief in their effectiveness were less likely to
have favorable attitudes toward a smoking cessation program (mean difference,
1.6; 95% CI, 1.0-2.1). These respondents also expressed much less interest in
providing preventive health education (mean difference, 1.3; 95% CI, –0.8-1.8).

A total of 19 staff members (30%) reported current or recent tobacco use (ie, at
least once in the past year) in the form of cigarette and cigar smoking. These
respondents viewed the ED's role in prevention and community service more
favorably, though this difference was not statistically significant (mean
difference, 0.4; 95% CI, –0.2-0.9). Smokers were less likely to support tobacco
cessation in the ED (mean difference, 0.5; 95% CI, –0.1-1.2) and were much less
likely to feel comfortable advising patients to stop smoking (P=.06; mean
difference, 1.0; 95% CI, 0.2-1.7). By statistical analysis, employees who smoked
were more likely to view the ED as an appropriate site for patient education
(P=.01).

Overall, staff respondents (76%) were interested in educating patients about
preventive health but were less likely to feel comfortable advising patients
about tobacco cessation (60%, P<.03) or to agree that ED staff should assist in
tobacco cessation activities (51%, P<.001), as noted in the Table 2.

All 70 staff members (ie, not just the staff who responded to the survey) were
encouraged to participate in the tobacco cessation program. Despite survey
findings, staff characteristics (eg, tobacco use, job title, years working in
the ED) did not correlate with referral performance in univariate or
multivariate analysis. However, the gift basket incentive offered during month 2
and 3 correlated with a significant increase in staff referral rates (P=.008).

A total of 150 referrals and interventions occurred, with 33 (22%) occurring
before the incentive, and the remaining 117 (78%) occurring after the incentive.
Increased participation was more likely among the nurses and among others who
favored education, community service, and clinical prevention. Interestingly,
the nursing incentive for the most referrals was won by an employee who smoked
cigarettes.


TELEPHONE FOLLOW-UP

Telephone follow-up was successful at reaching 36 patients (24%). As related by
the patient in the telephone interview, the primary ED diagnosis of patients
receiving the intervention was respiratory disease (39%) followed by cardiac,
gastrointestinal, and infectious disease (14% each). Because pregnancy tests
were not administered for all patients, the number of pregnant patients who
received the intervention is unknown. Although 33 patients (22%) of the total
number of patients who received the intervention identified primary care
physicians, a negligible number reported a visit with their primary care
physician between the ED intervention and telephone follow-up.

Because a proportionately small number of patients used tobacco in a form other
than cigarette smoking, the follow-up survey measured changes in tobacco use
according to the number of packs of cigarettes smoked. Thirteen (36%) of the 36
patients reached by telephone reported that they had attempted to quit tobacco
use after the intervention, and 6 (17%) were no longer smoking at follow-up. Of
note, 2 of the 6 patients who quit tobacco use reported being pregnant.

Reports of current smoking behavior among all 36 patients indicated that 17% of
patients (95% CI, 4%-39%) no longer smoked, 28% (95% CI, 13%-42%) had cut down
tobacco use by at least half a pack of cigarettes per unit of time in their
quantitative estimate of the number of cigarettes smoked, and 56% (95% CI,
39%-72%) still smoked at a level comparable to the time of the initial ED visit
(Figure 2).


DISCUSSION

While staff attitudes and personal habits may be important, they do not appear
to be a firm barrier to participation in a tobacco cessation program in the ED.
In the present study, we were unable to identify specific demographics that
predicted staff members' responses to the incentive. Although attitudes toward
tobacco cessation interventions were less supportive than general attitudes
about prevention and community service in the ED, the latter was most important
for predicting successful participation in an incentive program designed to
increase referrals from ED staff to tobacco cessation.

In the present study, more than one-third of ED patients reached for follow-up
attempted to quit smoking following a brief intervention in the ED. Nearly half
of them succeeded. Overall, 45% of patients reached for follow-up either had
quit smoking or had cut down meaningfully in their smoking, according to
self-reports. These research data implications are amplified by the fact that
78% of this patient population expressed either no relationship with or no
access to a primary care physician.

A potential unexpected benefit may have occurred soon after the tobacco
cessation program began. The primary investigator of the current study (M.R.G.)
observed an increased desire among staff to stop personal tobacco use. In fact,
several staff members were noted to be attempting to quit. If this observation
was accurate, improved employee health might be an unexpected benefit of the
implementation of a tobacco cessation program. However, further study is needed
to quantify staff tobacco cessation rates.

Of course, there are a number of limitations to the present study. For example,
the tobacco cessation program reported in the present study was performed at a
single urban hospital. Future studies may consider investigating varied
patient-payer mix and ED volume using multiple ED sites.

Also, the present study had a small sample size, both in terms of the number of
patients who received the intervention and the number of patients who were
reached for follow-up, limiting the strength of the reported results. For
example, during the 3-month period of the present study, hospital records
indicated that a total of 5064 patients were treated in the ED. Previous
analysis17 revealed that the prevalence of tobacco use of the population is
approximately 28%. Accordingly, 1400 patients used tobacco during the study
period—indicating that the 150 patients who received the intervention accounted
for only 11% of the ED patients who used tobacco.

The number of patients in the present study who were reached for telephone
follow-up was modest (36 [24%]). Yet, the phenomenon of unreliable phone numbers
for follow-up in ED patient populations is well documented.18,19 In addition to
inaccurate phone numbers, factors such as a language barriers and patient fear
that phone calls were related to bill collection may be potential causes for low
survey follow-up rates.

Figure 2.

Smoking behavior of patients after emergency department referral to a tobacco
cessation program. Follow-up occurred 1 to 3 months after the patients were
discharged from the hospital.

Also, a greater success rate was expected in patients counseled by physicians
(rather than nurses or social workers) and those who visited their primary care
physician in the interval between consultation and follow up. However, the
actual number of those reached for follow-up was too small to generate any
reliable conclusion in this regard. Although the patients' stage of change was
recorded before and after the intervention, the raw number is too small to
identify the relationship of patient stage at intervention and success at
quitting. In follow-up studies, closer attention should be given to obtaining
accurate follow-up information.

In addition to the need to improve patient follow-up, the final results of the
tobacco cessation program would benefit from a long-term follow-up (eg, 1 y).
Although one study12 suggested that tobacco cessation counseling was ineffective
in the ED, that study's results may simply reflect an incomplete outcome
measurement. In order to understand addiction and the tobacco cessation process,
a study cannot consider only those inidividuals who quit. Although it is a
difficult endeavor, the process of change itself must be assessed.20 For
example, a physician just bringing up the topic of tobacco cessation (screening)
might cause a patient to consider quitting. During a teachable moment, patients
might have a personal level of change (eg, precontemplative to contemplative).
Although such change—or progress toward cessation—might have been unmeasured in
previous research, it may bring patients one step closer to quitting tobacco
use.

In addition, successes might not have been as great as possible as a result of
lack of confidence of staff in making a difference in the patient's future
tobacco use.9,20 Interventions have been shown to be more effective when the
provider has confidence in their own ability to influence the patient's
success—something difficult for ED staff to envision because they have little or
no opportunity to see the positive effects of their efforts.15

If healthcare providers deliver brief smoking cessation messages, the potential
positive impact on public health is great.21 For example, if only half of all US
physicians gave brief advice to their patients and were successful with only 10%
of them, there would still be 2 million new nonsmokers in the United States each
year.22 With such compelling reasons to promote smoking cessation, why don't all
physicians do so? A common reason related to emergency medicine is “lack of
time.”1,16,20 However, even a 30-second intervention can influence a patient's
success in tobacco cessation.15,16 Also, “lack of time” may be a result of the
lack of training focus and culture within the ED setting.

The Agency for Health Care Policy and Research and the US Public Health Service
recommend that all physicians ask all of their patients about smoking status and
offer cessation assistance at every visit.23 However, lack of training, support
staff, and backup materials or programs are legitimate issues to be resolved in
any department preparing to initiate this type of program.4 The opportunity for
physicians to encourage the discontinuation of tobacco use is vital to any ED
patient population.

Our findings demonstrate that an incentive-based program can increase
intervention rates in the ED, thereby encouraging successful cessation through
brief counseling interventions. In future studies, more consideration should be
given to length of time from intervention to follow-up and the amount of time
spent counseling patients. The interventions in this study were considered by
design to be minimal and of low intensity (fewer than 10 minutes), but other
research in the area suggests that success is related to intensity of
treatment.24 The use of more sensitive measures of behavioral change might
generate more positive findings in future studies.


CONCLUSION

The ED presents an important opportunity for hospital staff to intervene with
patients who use tobacco. With a change of focus and dedication to the concept
of tobacco cessation, ED staff can make a significant contribution to the
overall health of their community—and the nation.

--------------------------------------------------------------------------------

From the Lehigh Valley Hospital in Allentown, Pa.
Address correspondence to Marna Rayl Greenberg, DO, 1909 Earls Ct, Allentown, PA
18103-6980. E-mail: mrgdo@ptd.net

--------------------------------------------------------------------------------



 1. Editor's Note: Readers interested in obtaining a copy of the intervention
    form used in the present study are encouraged to contact Marna Rayl
    Greenberg, DO, at mrgdo@ptd.net.

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Received: 2007-04-30
Revised: 2007-09-13
Accepted: 2007-09-19
Published Online: 2008-08-01
Published in Print: 2008-08-01

The American Osteopathic Association

This work is licensed under the Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Greenberg, Marna Rayl, Weinstock, Michael, Fenimore, Deborah Gaston and
Sierzega, Gina M.. "Emergency Department Tobacco Cessation Program: Staff
Participation and Intervention Success Among Patients" Journal of Osteopathic
Medicine, vol. 108, no. 8, 2008, pp. 391-396.
https://doi.org/10.7556/jaoa.2008.108.8.391
Greenberg, M., Weinstock, M., Fenimore, D. & Sierzega, G. (2008). Emergency
Department Tobacco Cessation Program: Staff Participation and Intervention
Success Among Patients. Journal of Osteopathic Medicine, 108(8), 391-396.
https://doi.org/10.7556/jaoa.2008.108.8.391
Greenberg, M., Weinstock, M., Fenimore, D. and Sierzega, G. (2008) Emergency
Department Tobacco Cessation Program: Staff Participation and Intervention
Success Among Patients. Journal of Osteopathic Medicine, Vol. 108 (Issue 8), pp.
391-396. https://doi.org/10.7556/jaoa.2008.108.8.391
Greenberg, Marna Rayl, Weinstock, Michael, Fenimore, Deborah Gaston and
Sierzega, Gina M.. "Emergency Department Tobacco Cessation Program: Staff
Participation and Intervention Success Among Patients" Journal of Osteopathic
Medicine 108, no. 8 (2008): 391-396. https://doi.org/10.7556/jaoa.2008.108.8.391
Greenberg M, Weinstock M, Fenimore D, Sierzega G. Emergency Department Tobacco
Cessation Program: Staff Participation and Intervention Success Among Patients.
Journal of Osteopathic Medicine. 2008;108(8): 391-396.
https://doi.org/10.7556/jaoa.2008.108.8.391
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