The Emergency Department Action in Smoking Cessation (EDASC) Trial: Impact on Delivery of Smoking Cessation Counseling
dc.contributor.author | Katz, David A. | en_US |
dc.contributor.author | Vander Weg, Mark W. | en_US |
dc.contributor.author | Holman, John | en_US |
dc.contributor.author | Nugent, Andrew | en_US |
dc.contributor.author | Baker, Laurence | en_US |
dc.contributor.author | Johnson, Skyler | en_US |
dc.contributor.author | Hillis, Stephen L. | en_US |
dc.contributor.author | Titler, Marita | en_US |
dc.date.accessioned | 2012-05-21T15:47:40Z | |
dc.date.available | 2013-06-11T19:15:49Z | en_US |
dc.date.issued | 2012-04 | en_US |
dc.identifier.citation | Katz, David A.; Vander Weg, Mark W.; Holman, John; Nugent, Andrew; Baker, Laurence; Johnson, Skyler; Hillis, Stephen L.; Titler, Marita (2012). "The Emergency Department Action in Smoking Cessation (EDASC) Trial: Impact on Delivery of Smoking Cessation Counseling." Academic Emergency Medicine 19(4). <http://hdl.handle.net/2027.42/91133> | en_US |
dc.identifier.issn | 1069-6563 | en_US |
dc.identifier.issn | 1553-2712 | en_US |
dc.identifier.uri | https://hdl.handle.net/2027.42/91133 | |
dc.description.abstract | Objectives: The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse–initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask–advise–assess–assist–arrange) and 2) assess ED nurses’ and physicians’ perceptions of smoking cessation counseling. Methods: The authors conducted a pre–post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face‐to‐face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses’ and physicians’ self‐efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates. Results: Of 650 smokers who completed the post‐ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow‐up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses’ self‐efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in “pros” and “cons” attitudes toward smoking cessation in either ED nurses or physicians. Conclusions: Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time‐efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED. | en_US |
dc.publisher | Wiley Periodicals, Inc. | en_US |
dc.publisher | Blackwell Publishing Ltd | en_US |
dc.title | The Emergency Department Action in Smoking Cessation (EDASC) Trial: Impact on Delivery of Smoking Cessation Counseling | en_US |
dc.type | Article | en_US |
dc.rights.robots | IndexNoFollow | en_US |
dc.subject.hlbsecondlevel | Medicine (General) | en_US |
dc.subject.hlbtoplevel | Health Sciences | en_US |
dc.description.peerreviewed | Peer Reviewed | en_US |
dc.contributor.affiliationum | From the Departments of Medicine (DAK, MWV, JH), Emergency Medicine (AN), Epidemiology (DAK), Biostatistics (SLH), and Psychology (MWV), University of Iowa, Iowa City, IA; the Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Iowa City VA Hospital (DAK, MWV, JH, SJ, SLH), Iowa City, IA; the Department of Emergency Medicine, Iowa Methodist Medical Center (LB), Des Moines, IA; and the University of Michigan School of Nursing (MT), Ann Arbor, MI. Dr. Katz is a Core Investigator in the Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Department of Veterans Affairs Medical Center, Iowa City, IA. | en_US |
dc.description.bitstreamurl | http://deepblue.lib.umich.edu/bitstream/2027.42/91133/1/ACEM_1331_sm_DataSupplementS1.pdf | |
dc.description.bitstreamurl | http://deepblue.lib.umich.edu/bitstream/2027.42/91133/2/j.1553-2712.2012.01331.x.pdf | |
dc.identifier.doi | 10.1111/j.1553-2712.2012.01331.x | en_US |
dc.identifier.source | Academic Emergency Medicine | en_US |
dc.identifier.citedreference | Flay B, Best J. Overcoming design problems in evaluating health behavior programs. Eval Health Prof. 1982; 5: 43 – 69. | en_US |
dc.identifier.citedreference | Schroeder SA. Should emergency physicians help smokers quit? Ann Emerg Med. 2006; 48: 415 – 6. | en_US |
dc.identifier.citedreference | Bernstein SL, Bernstein E, Boudreaux ED, et al. Public health considerations in knowledge translation in the emergency department. Acad Emerg Med. 2007; 14: 1036 – 41. | en_US |
dc.identifier.citedreference | Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall, 1980. | en_US |
dc.identifier.citedreference | Godin G, Belanger‐Gravel A, Eccles M, Grimshaw J. Healthcare professionals’ intentions and behaviours: a systematic review of studies based on social cognitive theories. Implement Sci. 2008; 3: e36. | en_US |
dc.identifier.citedreference | Pipe A, Sorensen M, Reid R. Physician smoking status, attitudes toward smoking, and cessation advice to patients: an international survey. Patient Educ Couns. 2009; 74: 118 – 23. | en_US |
dc.identifier.citedreference | Carrier E, Tracy Y, Holzwart R. Coordination Between Emergency and Primary Care Physicians. Research Brief No. 3: National Institute for Health Care Reform. Available at: http://www.nihcr.org/ED‐Coordination.pdf. Accessed Jan 15, 2012. | en_US |
dc.identifier.citedreference | Solberg LI. Guideline implementation: what the literature doesn’t tell us. Jt Comm J Qual Improv. 2000; 26: 525 – 37. | en_US |
dc.identifier.citedreference | Rycroft‐Malone J, Kitson A, Harvey G, et al. Ingredients for change: revisiting a conceptual framework. Qual Saf Health Care. 2002; 11: 174 – 80. | en_US |
dc.identifier.citedreference | Antonacci M, Eyck R. Utilization and effectiveness of an emergency department initiated smoking cessation program [abstract]. Acad Emerg Med. 2000; 7: 1166. | en_US |
dc.identifier.citedreference | Greenberg MR, Weinstock M, Fenimore DG, Sierzega GM. Emergency department tobacco cessation program: staff participation and intervention success among patients. J Am Osteopath Assoc. 2008; 108: 391 – 6. | en_US |
dc.identifier.citedreference | Boudreaux ED, Baumann BM, Perry J, et al. Emergency department initiated treatments for tobacco (EDITT): a pilot study. Ann Behav Med. 2008; 36: 314 – 25. | en_US |
dc.identifier.citedreference | Ersel M, Kitapcioglu G, Solak ZA, Yuruktumen A, Karahalli E, Cevrim O. Are emergency department visits really a teachable moment? Smoking cessation promotion in emergency department. Eur J Emerg Med. 2010; 17: 73 – 9. | en_US |
dc.identifier.citedreference | Neuner B, Weiss‐Gerlach E, Miller P, Martus P, Hesse D, Spies C. Emergency department‐initiated tobacco control: a randomised controlled trial in an intercity university hospital. Tob Control. 2009; 18: 283 – 93. | en_US |
dc.identifier.citedreference | Jaén C, Crabtree B, Palmer R, et al. Methods for evaluating practice change toward a patient‐centered medical home. Ann Fam Med. 2010; 8 ( Suppl 1 ): S9 – 20. | en_US |
dc.identifier.citedreference | Williams JM, Chinnis AC, Gutman D. Health promotion practices of emergency physicians. Am J Emerg Med. 2000; 18: 17 – 21. | en_US |
dc.identifier.citedreference | Ward J, Sanson‐Fisher R. Accuracy of patient recall of opportunistic smoking cessation advice in general practice. Tob Control. 1996; 5: 110 – 3. | en_US |
dc.identifier.citedreference | Thibodeau LG, Chan L, Reilly KM, Reyes VM. Improving telephone contract rates of patients discharged from the emergency department. Ann Emerg Med. 2000; 35: 564 – 7. | en_US |
dc.identifier.citedreference | Woolard RH, Carty K, Wirtz P, et al. Research fundamentals: follow‐up of subjects in clinical trials: addressing subject attrition. Acad Emerg Med. 2004; 11: 859 – 66. | en_US |
dc.identifier.citedreference | Boudreaux ED, Ary RD, St. John B, Mandry CV. Telephone contact of patients visiting a large, municipal emergency department: can we rely on numbers given during routine registration? J Emerg Med. 2000; 18: 409 – 15. | en_US |
dc.identifier.citedreference | Lovell ME, Morcuende JA. Patient location strategies for pediatric long‐term follow‐up studies. Iowa Orthop J. 2006; 26: 91 – 5. | en_US |
dc.identifier.citedreference | McCaig L. National Hospital Ambulatory Medical Care Survey: 1998 Emergency Department Summary. Advance Data From Vital and Health Statistics, No. 313. Hyattsville, MD: National Center for Health Statistics, 2000. | en_US |
dc.identifier.citedreference | Center for Disease Control and Prevention. Healthy People 2020. Available at: http://www.healthypeople.gov/2020/default.aspx. Accessed Jan 15, 2012. | en_US |
dc.identifier.citedreference | Center for Disease Control. Vital Signs: current cigarette smoking among adults aged ≥ 18 years‐‐United States, 2009. MMWR Morb Mortal Wly Rep. 2010; 59: 1135 – 40. | en_US |
dc.identifier.citedreference | Lowenstein S, Koziol‐McLain J, Thompson M, et al. Behavioral risk factors in emergency department patients: a multisite survey. Acad Emerg Med. 1998; 5: 781 – 7. | en_US |
dc.identifier.citedreference | Rhodes K, Gordon J, Lowe R, Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Preventive care in the emergency department, Part I: clinical preventive services‐‐are they relevant to emergency medicine? Acad Emerg Med. 2000; 7: 1036 – 41. | en_US |
dc.identifier.citedreference | McBride C, Emmons K, Lipkus I. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res. 2003; 18: 156 – 70. | en_US |
dc.identifier.citedreference | Bock BC, Becker B, Niaura R, Partridge R. Smoking among emergency chest pain patients: motivation to quit, risk perception and physician intervention. Nicotine Tob Res. 2000; 2: 93 – 6. | en_US |
dc.identifier.citedreference | Bock BC, Becker B, Monteiro R, Partridge R, Fisher S, Spencer J. Physician intervention and patient risk perception among smokers with acute respiratory illness in the emergency department. Prev Med. 2001; 32: 175 – 81. | en_US |
dc.identifier.citedreference | Boudreaux ED, Hunter GC, Bos K, Clark S, Camargo CA Jr. Predicting smoking stage of change among emergency department patients and visitors. Acad Emerg Med. 2006; 13: 39 – 47. | en_US |
dc.identifier.citedreference | Lowenstein S, Tomlinson D, Koziol‐McLain J, Prochazka A. Smoking habits of emergency department patients: an opportunity for disease prevention. Acad Emerg Med. 1995; 2: 165 – 71. | en_US |
dc.identifier.citedreference | Klinkhammer M, Patten C, Sadosty A, Stevens S, Ebbert J. Motivation for stopping tobacco use among emergency department patients. Acad Emerg Med. 2005; 12: 568 – 71. | en_US |
dc.identifier.citedreference | Rodrigues R, Kreider W, Baraff L. Need and desire for preventive care measures in emergency department patients. Ann Emerg Med. 1995; 26: 615 – 20. | en_US |
dc.identifier.citedreference | Bernstein S, Becker B. Preventive care in the emergency department: diagnosis and management of smoking and smoking‐related illness in the emergency department: a systematic review. Acad Emerg Med. 2002; 9: 720 – 9. | en_US |
dc.identifier.citedreference | Fiore M, Bailey W, Cohen S, et al.. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, US Public Health Service, 2008. | en_US |
dc.identifier.citedreference | Jaen CR, Crabtree BF, Zyzanski SJ, Goodwin MA, Stange KC. Making time for tobacco cessation counseling. J Fam Pract. 1998; 46: 425 – 8. | en_US |
dc.identifier.citedreference | Prochaska JO, Koziol‐McLain J, Tomlinson D, Lowenstein S. Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs. Acad Emerg Med. 1995; 2: 211 – 6. | en_US |
dc.identifier.citedreference | Tong EK, Strouse R, Hall J, Kovac M, Schroeder SA. National survey of U.S. health professionals’ smoking prevalence, cessation practices, and beliefs. Nicotine Tob Res. 2010; 12: 724 – 32. | en_US |
dc.identifier.citedreference | Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta‐analysis. Ann Intern Med. 2002; 136: 641 – 51. | en_US |
dc.identifier.citedreference | Mojica WA, Suttorp MJ, Sherman SE, et al. Smoking‐cessation interventions by type of provider: a meta‐analysis. Am J Prev Med. 2004; 26: 391 – 401. | en_US |
dc.identifier.citedreference | Green JS, Briggs L. Tobacco cessation in acute and critical care nursing practice: challenges and approaches. Crit Care Nurs Clin North Am. 2006; 18: 81 – 93. | en_US |
dc.identifier.citedreference | Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care behavioral counseling interventions: an evidence‐based approach. Am J Prev Med. 2002; 22: 267 – 84. | en_US |
dc.identifier.citedreference | McCarty M, Hennrikus D, Lando H, Vessey J. Nurses’ attitudes concerning the delivery of brief cessation advice to hospitalized smokers. Prev Med. 2001; 33: 674 – 81. | en_US |
dc.identifier.citedreference | Solberg L, Brekke M, Kottke T. How important are clinician and nurse attitudes to the delivery of clinical preventive services? J Fam Pract. 1997; 44: 451 – 61. | en_US |
dc.identifier.citedreference | Williams GC, Levesque C, Zeldman A, Wright S, Deci EL. Health care practitioners’ motivation for tobacco‐dependence counseling. Health Educ Res. 2003; 18: 538 – 53. | en_US |
dc.identifier.citedreference | Berwick D. Disseminating innovations in health care. JAMA. 2003; 289: 1969 – 75. | en_US |
dc.identifier.citedreference | Glasgow RE, Magid DJ, Beck A, Ritzwoller D, Estabrooks PA. Practical clinical trials for translating research to practice: design and measurement recommendations. Med Care. 2005; 43: 551 – 7. | en_US |
dc.identifier.citedreference | Shadish W, Cook T, Campbell D. Experimental and Quasi‐experimental Designs for Generalized Causal Inference. Boston, MA: Houghton Mifflin, 2002. | en_US |
dc.identifier.citedreference | Vollset SE, Tverdal A, Gjessing HK. Smoking and deaths between 40 and 70 years of age in women and men. Ann Intern Med. 2006; 144: 381 – 9. | en_US |
dc.identifier.citedreference | Shiffman S, Paty JA, Gnys M, Kassel JD, Elash C. Nicotine withdrawal in chippers and regular smokers: subjective and cognitive effects. Health Psychol. 1995; 14: 301 – 9. | en_US |
dc.identifier.citedreference | An LC, Foldes SS, Alesci NL, et al. The impact of smoking‐cessation intervention by multiple health professionals. Am J Prev Med. 2008; 34: 54 – 60. | en_US |
dc.identifier.citedreference | Miller W, Rollnick S. Motivational Interviewing. New York, NY: Guilford Press, 1991. | en_US |
dc.identifier.citedreference | Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. New York, NY: Churchill Livingstone, 2000. | en_US |
dc.identifier.citedreference | Lai DT, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev. 2010; 20: CD006936. | en_US |
dc.identifier.citedreference | Goldberg D, Hoffman A, Anel D. Understanding people who smoke and how they change: a foundation for smoking cessation in primary care, part 2. Dis Mon. 2002; 48: 445 – 85. | en_US |
dc.identifier.citedreference | Schiebel NE, Ebbert JO. Quitline referral vs. self‐help manual for tobacco use cessation in the emergency department: a feasibility study. BMC Emerg Med. 2007; 7: e15. | en_US |
dc.identifier.citedreference | Wise C, Billi J. A model for practice guideline adaptation and implementation: empowerment of the physician. Jt Comm J Qual Improv. 1995; 21: 465 – 76. | en_US |
dc.identifier.citedreference | Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidu O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004; 82: 581 – 629. | en_US |
dc.identifier.citedreference | Boudreaux ED, Baumann BM, Friedman K, Ziedonis DM. Smoking stage of change and interest in an emergency department‐based intervention. Acad Emerg Med. 2005; 12: 211 – 8. | en_US |
dc.identifier.citedreference | Biener L, Abrams D. The contemplation ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol. 1991; 10: 360 – 5. | en_US |
dc.identifier.citedreference | Bock B, Becker B, Niaura R, Partridge R, Fava J, Trask P. Smoking cessation among patients in an emergency chest pain observation unit: outcomes of the Chest Pain Smoking Study (CPSS). Nicotine Tob Res. 2008; 10: 1523 – 31. | en_US |
dc.identifier.citedreference | Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom test for nicotine dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict. 1991; 86: 1119 – 27. | en_US |
dc.identifier.citedreference | Piper ME, McCarthy D, Baker T. Assessing tobacco dependence: a guide to measure evaluation and selection. Nicotine Tob Res. 2006; 8: 339 – 51. | en_US |
dc.identifier.citedreference | Richman P, Dinowitz S, Nashed A, et al. The emergency department as a potential site for smoking cessation intervention: a randomized, controlled trial. Acad Emerg Med. 2000; 7: 348 – 53. | en_US |
dc.identifier.citedreference | Rigotti NA, Arnsten JH, McKool KM, Wood‐Reid KM, Pasternak R, Singer DE. Efficacy of a smoking cessation program for hospital patients. Arch Intern Med. 1997; 157: 2653 – 60. | en_US |
dc.identifier.citedreference | Kroenke K, Spitzer R, Williams J. The PHQ‐9: validity of a brief depression severity measure. J Gen Intern Med. 2001; 16: 606 – 13. | en_US |
dc.identifier.citedreference | Park E, Eaton CA, Goldstein MG, et al. The development of a decisional balance measure of physician smoking cessation interventions. Prev Med. 2001; 33: 261 – 7. | en_US |
dc.identifier.citedreference | Katz D, Muehlenbruch D, Brown R, Fiore M, Baker T. Effectiveness of implementing the Agency for Healthcare Research and Quality Smoking Cessation clinical practice guideline: a randomized controlled trial. J Nat Cancer Inst. 2004; 96: 594 – 603. | en_US |
dc.identifier.citedreference | Hinshaw A, Atwood J. Anticipated turnover among nursing staff study. Final Report: National Institute of Health. Bethesda MD: National Center for Nursing Research. 1985, No. R01NU00908. | en_US |
dc.identifier.citedreference | Leveck M, Jones C. The nursing practice environment, staff retention, and quality of care. Res Nurs Health. 1996; 19: 331 – 43. | en_US |
dc.identifier.citedreference | Shader K, Broome ME, Broome CD, West ME, Nash M. Factors influencing satisfaction and anticipated turnover for nurses in an academic medical center. JONA. 2001; 31: 210 – 6. | en_US |
dc.identifier.citedreference | Lake ET. Development of the Practice Environment Scale of the Nursing Work Index. Res Nurs Health. 2002; 25: 176 – 88. | en_US |
dc.identifier.citedreference | Neter J, Kutner M, Nachtsheim C, Wasserman W. Applied Linear Statistical Models. 4th ed. Homewood, IL: Irwin, 1996. | en_US |
dc.identifier.citedreference | Goldstein M, Niaura R, Willeylessne C, et al. Physicians counseling smokers‐‐a population‐based survey of patients perceptions of health care provider‐delivered smoking cessation interventions. Arch Intern Med. 1997; 157: 1313 – 9. | en_US |
dc.identifier.citedreference | McBride P, Plane M, Underbakke G, Brown R, Solberg L. Smoking screening and management in primary care practices. Arch Fam Med. 1997; 6: 165 – 72. | en_US |
dc.identifier.citedreference | Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998; 279: 604 – 8. | en_US |
dc.identifier.citedreference | Wilson A, Hippisley‐Cox J, Coupland C, Coleman T, Britton J, Barrett S. Smoking cessation treatment in primary care: prospective cohort study. Tob Control. 2005; 14: 242 – 6. | en_US |
dc.identifier.citedreference | Bernstein SL, Boudreaux ED, Cabral L, et al. Efficacy of a brief intervention to improve emergency physicians’ smoking cessation counseling skills, knowledge, and attitudes. Subst Abuse. 2009; 30: 158 – 81. | en_US |
dc.identifier.citedreference | Hernández AV, Steyerberg EW, Habbema DF. Covariate adjustment in randomized controlled trials with dichotomous outcomes increases statistical power and reduces sample size requirements. J Clin Epidemiol. 2004; 57: 454 – 60. | en_US |
dc.identifier.citedreference | Newgard CD, Haukoos JS. Advanced Statistics: missing data in clinical research‐‐part 2: multiple imputation. Acad Emerg Med. 2007; 14: 669 – 78. | en_US |
dc.identifier.citedreference | Raghunathan TE. What do we do with missing data? Some options for analysis of incomplete data. Annu Rev Public Health. 2004; 25: 99 – 117. | en_US |
dc.identifier.citedreference | Zeger S, Liang K. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986; 42: 121 – 30. | en_US |
dc.identifier.citedreference | Bernstein S, Boudreaux ED, Cydulka RK, et al. Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations. Ann Emerg Med. 2006; 48: e417 – 25. | en_US |
dc.identifier.citedreference | Vokes NI, Bailey JM, Rhodes KV. “Should I give you my smoking lecture now or later?” Characterizing emergency physician smoking discussions and cessation counseling. Ann Emerg Med. 2006; 48: 406 – 14. | en_US |
dc.owningcollname | Interdisciplinary and Peer-Reviewed |
Files in this item
Remediation of Harmful Language
The University of Michigan Library aims to describe library materials in a way that respects the people and communities who create, use, and are represented in our collections. Report harmful or offensive language in catalog records, finding aids, or elsewhere in our collections anonymously through our metadata feedback form. More information at Remediation of Harmful Language.
Accessibility
If you are unable to use this file in its current format, please select the Contact Us link and we can modify it to make it more accessible to you.