Overview
ED visits are unique in that there is a ‘teachable moment’ often where patients are receptive to quitting smoking, even when visiting for other medical issues. Smoking effects nearly every organ system so there is an opportunity for teaching and intervention
ED’s represent a healthcare setting that serves a population that often experiences barriers to routine primary care – multifactorial due to Social Determinants of Health.
Mainstays of smoking cessation are behavioral therapy and pharmacotherapy
“A 2017 meta-analysis of randomized controlled trials of ED-initiated tobacco control demonstrated that tobacco-use abstinence up to 12 months after intervention was possible, and that ED-led initiatives may be a crucial public health location for engaging hard-to-reach smokers “
ED Interventions
Based on the public health model known as Screening, Brief Intervention, and Referral to Treatment (SBIRT) : effective in smoking, OUD, AUD
ED interventions also include a “Treatment Initiation” component
Easy interventions include brief, 1 minute counseling, quitline referral, and nicotine replacement therapy (NRT)
5 A’s framework: Ask , Advise, Assess, Assist, Arrange
Ask: systematically identify all tobacco users at every visit
Advise: strongly urge all tobacco users to quit
Assess: determine readiness to make a quit attempt
Assist: Aid by offering counseling/behavioral therapy referral, medication, referral to telephone Quitline
Arrange: Assist with follow ups (VEMAH can help with this)
Referral for behavioral therapy is important: shown to increase smoking cessation
Mindfulness is a component of smoking cessation: ask patient so track when & why they smoke, how good days differ from bad, which cigarettes they might be able to cut out.
Pharmacotherapies
Include NRT, bupropion and varenicline: Using a combo of NRT + medication more effective than monotherapy. However, if intentionally doing monotherapy only; varenicline more effective than NRT or bupropion.
Controller Medication (varenicline 1st line, bupropion or nicotine patches, or more than one) + Short-acting NRT for cravings (gum, lozenge, inhaler)
Counsel patients about side effects: likely to continue with cravings for 2 weeks, and can experience vivid dreams and nausea. Doses can be adjusted as needed.
VEMAH order sets in CPRS can help with ordering these
Long term safety data not yet available for electronic cigarettes, however for current smokers may be a useful cessation tool.
References
Stahl N. #11 Smoking Cessation: It’s Not a Drag - The Curbsiders. The Curbsiders - An Internal Medicine Podcast. September 15, 2022. Accessed March 4, 2026. https://thecurbsiders.com/addiction-medicine-podcast/11-smoking-cessation-its-not-a-drag
Pettit N, Pope I, Neuner B, Lash R, Bernstein SL. A selective review of smoking cessation interventions in the emergency department. Emerg Cancer Care. 2022;1(1):5. doi:10.1186/s44201-022-00006-5
Tobacco Cessation in the Emergency Department. Yale Medicine. Accessed March 4, 2026. https://www.yalemedicine.org/conditions/tobacco-cessation-in-the-emergency-department