Improving Equity by Making Tobacco Treatment Routine in the Hospital

Hospitalization represents a critical opportunity to support patients who use tobacco in making a quit attempt, yet tobacco use disorder remains a relatively low priority in many inpatient settings.¹ As of 2025, despite expanded coverage for tobacco cessation treatment through the Affordable Care Act and Medicaid expansion—and although nearly 70% of patients express a desire to quit—nicotine dependence is still too often treated as a personal responsibility rather than an essential component of clinical care.²

One barrier to addressing tobacco use in the hospital setting is the time-intensive nature of traditional treatment models, such as the 5A framework. This approach requires clinicians to ask about tobacco use, advise patients to quit, assess readiness and barriers, assist with behavioral counseling and pharmacotherapy, and arrange follow-up.³ While evidence-based, this therapeutic approach can be difficult to implement amid the time pressures and competing demands of inpatient care. However, deferring tobacco cessation treatment is especially consequential for patients from marginalized communities, who bear a disproportionate burden of tobacco-related diseases.⁴

A recent snapshot of our hospital medicine service showed that nearly 30% of 273 admitted patients were people who used tobacco, offering clinicians a meaningful opportunity to engage a sizeable at-risk population and support quit attempts that otherwise may not occur in outpatient settings. By incorporating systematic, evidence-based treatment into routine inpatient care, hospitalization can serve as a supportive setting for progress toward quitting and may contribute to improving the quality of care we deliver. Meeting this need will require practical, scalable approaches that integrate tobacco cessation treatment as a consistent element of hospital medicine practice without adding clinician burden.

Solution Overview

A clinician-led quality-improvement initiative introduced a streamlined “ask-and-offer” model to replace the traditional 5A framework for delivering tobacco cessation treatment during hospitalization. The goal was to normalize treatment as part of routine hospital care and promote equitable access by ensuring all identified tobacco users receive a consistent, proactive offer of evidence-based therapy.

Stakeholders

Key participants included the hospitalist delivering frontline care, nursing staff responsible for standardized tobacco-use documentation, adult patients who use tobacco, social services, and pharmacy staff supporting rapid medication fulfillment.

Implementation Process

The intervention was conducted from April 9 to June 8, 2025, using a structured plan–do–study–act (PDSA) framework. To establish a baseline, historical prescribing patterns from 2024 were extracted via Epic Cogito SliceDicer, providing a full-year reference for the lead clinician’s prior tobacco-cessation prescribing behavior. The project took place in a large urban academic medical center serving a racially and socioeconomically diverse patient population. Implementation occurred within a hospital medicine service over 33 clinical days during which the lead clinician provided direct inpatient care.

Upon arrival to the medical floor, adult patients aged 18 years or older underwent routine nursing intake, during which tobacco use was documented in structured electronic health record (EHR) fields. Selection of “every day” or “some days” use of cigarettes, cigars, or pipes triggered a red cigarette icon in the Epic interface—a passive, standardized prompt visible to the treating clinician. This automated cue effectively embedded the “ask” component within the existing workflow, eliminating the need for additional clinician-initiated screening steps.

After focusing on acute medical issues during the initial encounter, the clinician delivered a single, standardized offer: “May I offer you a medication to help you quit smoking?” This simple, inclusive invitation supported shared decision making without requiring prior rapport or multiple encounters. The phrasing emphasized immediacy, normalized offering tobacco treatment within routine care, and promoted equity-informed standardization. These steps are further illustrated in the key driver diagram (see Figure 1), which outlines the core components of the intervention—from standardized identification to facilitated pharmacotherapy access.

Patients who accepted the pharmacotherapy offer were prescribed varenicline via the EHR, with prescriptions routed to the hospital’s on-campus outpatient pharmacy for bedside delivery upon initiation of a discharge order. The EHR included a preset varenicline order featuring the standard one-month titration schedule (0.5 mg orally once daily for three days, 0.5 mg orally twice daily for the next three days, then 1 mg orally twice daily for the remainder of the month). A separately linked varenicline order (1 mg orally twice daily; 112 tablets) was entered to complete a standard 12-week course. For patients with a creatinine clearance under 30 mL/min or experiencing end-stage renal disease, a reduced dose of 0.5 mg orally once daily was prescribed for the duration of therapy. Varenicline, a partial nicotinic receptor agonist, was selected as the first-line agent due to its demonstrated superiority over bupropion and nicotine replacement therapy.⁵ It promotes tobacco cessation by modulating dopamine pathways and blocking nicotine binding. A secondary analysis of the EAGLES trial further showed that varenicline was more effective across racial subgroups, supporting its use in diverse clinical populations.⁶

Pharmacotherapy was paired with behavioral support by including within the discharge instructions enrollment information for accessible resources such as the National Cancer Institute’s mobile cessation program (text “QUIT” to 47848) and the national quit line (1-800-QUIT-NOW).

Obstacles

Due to formulary restrictions, varenicline could not be administered during the inpatient stay, limiting the ability to directly monitor patients for common adverse effects such as nausea or vivid dreams. Furthermore, prescriptions sent to the outpatient pharmacy occasionally require up to one business day for processing, delaying access for patients discharging that same day. To minimize these delays, varenicline prescriptions were submitted to the pharmacy the same day they were offered, regardless of the anticipated discharge date.

Insurance barriers included one request for prior authorization, ultimately approved the following business day through the CoverMyMeds platform. An uninsured patient received varenicline at no cost through the hospital’s 340B program, facilitated by social services. Two patients faced a copay, which they accepted.

Readmission data showed that varenicline was not consistently continued across care transitions, highlighting gaps in EHR interoperability and the need for stronger continuity mechanisms—particularly for patients receiving care across multiple systems.

Although all patients had mobile phones, many were unreachable after discharge because their devices were powered off, raising concerns about the use of digital tools such as the National Cancer Institute’s SmokefreeTXT program.

Outcomes and Impact

The ask-and-offer model significantly increased prescribing rates of tobacco cessation therapy. Over the eight-week intervention, 14 of 19 eligible patients (74%) accepted a prescription for varenicline, nearly tripling the number (5) prescribed by the same clinician during the entire previous year. Patients who declined pharmacotherapy cited a lack of readiness to quit smoking. This increase is illustrated in Figure 2, which shows the lead clinician’s monthly prescribing rates before and after implementation of the ask-and-offer model.

The clinical and demographic characteristics of the intervention cohort reflected populations disproportionately affected by tobacco-related diseases (see Table 1). The median age was 61 years (range, 41 to 82); 86% of patients identified as Black, and most (84%) were insured through Medicaid, Medicare Advantage, or dual-eligibility programs. Tobacco-related diagnoses were documented in 86% of patients, while more than half (57%) had behavioral health or co-occurring substance use disorders. One patient was unhoused at the time of admission.

Geographic data provides important context. Among the 13 housed patients, 12 (92%) lived in ZIP codes where smoking prevalence exceeded the national average of 11.6%, with some areas surpassing 24%.

Of the four patients who self-reported outcomes, one quit smoking without starting varenicline, another achieved full tobacco cessation while using the medication, a third reduced smoking from 10 to one cigarette per day, and a fourth shared, “I used to go through a pack a day. Now—it’s been 14 days, and I still have the pack I bought two weeks ago.” While anecdotal, these reports indicate meaningful behavioral changes and strong engagement with treatment.

Lessons Learned

A simplified ask-and-offer model for tobacco cessation treatment can be integrated into existing hospital workflows without additional staffing, new funding, or major disruptions to clinical operations. Multiple disciplines—including hospital medicine, nursing, social services, and pharmacy—were able to rely on familiar processes to deliver evidence-based tobacco-cessation therapy consistently and efficiently.

Proactively offering treatment to every identified tobacco user expanded access for patients who have historically and disproportionately been affected by tobacco-related diseases, including those experiencing financial hardship or managing behavioral health disorders. Contrary to common assumptions that these patients are uninterested in quitting, many accepted pharmacotherapies readily, without the need for lengthy assessments of readiness or motivation.

Future Directions

Future PDSA cycles of the ask-and-offer model should focus on evaluating its long-term impact, particularly durable behavioral change. Further work should incorporate more robust measures of varenicline adherence and biochemical verification of tobacco cessation. As the model expands across multiple clinicians, it will be important to monitor variability in uptake and patient response to ensure consistency and equity.

Nicotine dependence should not be treated as a personal challenge but as a chronic, treatable disease—no different from diabetes or heart failure. To support this effort, hospital medicine groups can cultivate a culture in which clinicians are equipped and expected to address tobacco use consistently, supported by onboarding, continuing education, and ongoing reinforcement.

The ask-and-offer model was developed to address a local, practical need—to help a clinician reliably incorporate tobacco treatment into routine practice. Yet its simplicity, alignment with existing workflows, and reliance on existing infrastructure suggest that it could be scalable. If meaningful outcomes result from this approach—such as tobacco harm reduction or increased tobacco cessation—it could justify incorporating value-based reimbursement models to encourage greater uptake. By linking tobacco cessation efforts to quality measures and organizational priorities, health systems can reaffirm that tobacco treatment is fundamental clinical care and support broader efforts to reduce inequities in tobacco-related diseases. 

Dr. Douglass is an assistant professor of medicine in the division of hospital medicine at Emory University Hospital Midtown in Atlanta. Dr. Douglass thanks the nursing staff at Emory University Hospital Midtown for their consistent and meticulous documentation of tobacco use status for every admitted patient. Their dedication was instrumental in streamlining the implementation of this model and exemplifies the excellence reflected in the hospital’s recent Magnet designation.

References

1. Srivastava AB, et al. Tobacco use prevalence and smoking cessation pharmacotherapy prescription patterns among hospitalized patients by medical specialty. Nicotine Tob Res. 2019;21(5):631-637. doi:10.1093/ntr/nty031. 
2. Mejia P, et al. The origins of personal responsibility rhetoric in news coverage of the tobacco industry. Am J Public Health. 2014;104(6):1048-51. doi:10.2105/AJPH.2013.301754.
3. Fiore MC, et al. Treating tobacco use and dependence: 2008 update: clinical practice guideline. US Department of Health and Human Services website. https://stacks.cdc.gov/view/cdc/6964. Published May 2008. Accessed March 25, 2026.
4. Garrett BE, et al. Addressing the social determinants of health to reduce tobacco-related disparities. Nicotine Tob Res. 2015;17(8):892-897. doi:10.1093/ntr/ntu266.
5. Burke MV, et al. Varenicline for smoking cessation: a narrative review of efficacy, adverse effects, use in at-risk populations, and adherence. Patient Prefer Adherence. 2016;10:435-41. doi:10.2147/PPA.S83469.
6. Nollen NL, et al. Assessment of racial differences in pharmacotherapy efficacy for smoking cessation: secondary analysis of the EAGLES randomized clinical trial. JAMA Netw Open. 2021;4(1):e2032053. doi:10.1001/jamanetworkopen.2020.32053.