What are the recommended smoking‑cessation options for a hospitalized patient who reports current tobacco use?

Smoking Cessation Options for Hospitalized Patients

Every hospitalized smoker should receive intensive bedside counseling combined with nicotine replacement therapy (NRT) or varenicline, with mandatory follow-up support extending at least one month after discharge. 1, 2

Core Intervention Components

In-Hospital Counseling

• Provide intensive bedside counseling to all hospitalized smokers regardless of admitting diagnosis, as this forms the foundation of effective cessation interventions. 1
• Set a definite quit date, ideally during hospitalization when smoking is already restricted. 1
• Emphasize complete abstinence as the goal rather than reduction. 1
• Check abstinence by measuring carbon monoxide in expired air to provide objective feedback. 1
• Hospitals should employ dedicated smoking cessation specialists to deliver this counseling, as routine staff advice alone is insufficient. 1

Pharmacotherapy Selection

First-line options (choose one):

• Combination NRT (patch + short-acting form) is the most effective pharmacotherapy, achieving 31.5% cessation rates and showing a 54% increase over counseling alone (RR 1.54). 3, 2

  • Nicotine patch for baseline coverage plus gum, lozenge, or inhaler for breakthrough cravings
  • Safe in cardiovascular disease patients, including those admitted for acute coronary syndrome or stroke 3
  • Start immediately during hospitalization to manage withdrawal symptoms 1

• Varenicline achieves 28% cessation rates and increases cessation 2-3 fold versus unassisted attempts. 3, 4

  • Dosing: 0.5 mg once daily days 1-3, then 0.5 mg twice daily days 4-7, then 1 mg twice daily for 12 weeks 4
  • Begin one week before quit date, or start during hospitalization with quit date between days 8-35 4
  • Most common side effect is mild-to-moderate nausea (33% of patients, only 3% discontinue) 1
  • Discontinue immediately if agitation, depressed mood, behavioral changes, or suicidal ideation occur 1

• Bupropion SR is less effective (RR 1.04, not statistically significant over counseling alone) and should be reserved for patients who cannot tolerate NRT or varenicline. 2

  • Contraindicated in seizure disorders, eating disorders, abrupt alcohol/benzodiazepine withdrawal 1

Critical Post-Discharge Support

The intervention fails without adequate follow-up. Counseling limited to the hospital stay shows no benefit; the effect depends entirely on post-discharge contact. 1, 2, 5

• Arrange weekly supportive contacts for at least 4 weeks after discharge, extending to one month minimum. 1, 2
• Schedule first follow-up within 2 weeks of discharge, then monthly contact for at least 4 months. 3
• Telephone counseling is as effective as face-to-face and removes barriers like cost and travel. 1
• Interactive voice response (IVR) systems are feasible but less effective than human counselor contact. 6
• Ensure primary care physician involvement in continued cessation support and medication management. 1

Special Populations

Cardiovascular Disease Patients

• Intensive intervention with counseling plus pharmacotherapy reduces all-cause mortality and hospital readmission rates over 2 years in patients admitted for cardiovascular disease. 2
• Smoking cessation reduces stroke recurrence risk by 36% and overall mortality by 25-50% after cardiovascular events. 3
• The same intensive intervention protocol applies (RR 1.42 for cessation). 2

Cancer Patients

• Continue offering smoking cessation throughout the entire oncology care continuum, including end-of-life care, with emphasis on patient preferences. 7
• Smoking worsens cancer prognosis, increases second primary tumors, reduces treatment effectiveness, and decreases quality of life across all cancer types. 1
• Cessation improves surgical outcomes, reduces pulmonary complications, and enhances chemotherapy/radiation effectiveness. 1

Renal Impairment

• No adjustment needed for mild-to-moderate renal impairment. 4
• Severe renal impairment (CrCl <30 mL/min): Varenicline 0.5 mg once daily, titrate to maximum 0.5 mg twice daily. 4
• End-stage renal disease on hemodialysis: Maximum varenicline 0.5 mg once daily. 4

Pregnant Smokers

• Provide intensive counseling to all pregnant smokers with clear information on fetal and maternal risks. 1
• Offer specialist smoking cessation support. 1
• Evidence for pharmacotherapy safety in pregnancy is insufficient; behavioral interventions are preferred. 1

Managing Nicotine Withdrawal During Hospitalization

Withdrawal symptoms peak within 24 hours, last acutely 3-4 days, and extend 3-4 weeks. 1

• Pharmacological treatment of withdrawal improves patient comfort, promotes post-discharge cessation, and increases compliance with hospital no-smoking policies. 1
• Assess all hospitalized smokers for withdrawal symptoms using the Fagerström Test for Nicotine Dependence (FTND) to determine appropriate NRT dosing. 1
• Withdrawal symptoms occur equally in high and low dependence smokers, so assess everyone. 1
• Cigarette craving peaks in the first week and may persist for months or years. 1

System-Level Requirements

• Document smoking status prominently in patient records at admission as a prerequisite for opportunistic intervention. 1
• List tobacco use on the admission problem list and as a discharge diagnosis. 1
• Hospitals should be completely smoke-free with strict policy enforcement. 1
• Provide written educational materials supplementing verbal counseling. 1

Common Pitfalls to Avoid

• Do not provide counseling without arranging post-discharge follow-up—this negates any benefit. 2, 5
• Do not rely on brief advice alone; intensive counseling is required. 2
• Do not withhold NRT from cardiovascular patients due to unfounded safety concerns. 3
• Do not assume motivated patients will succeed without pharmacotherapy—medication significantly increases success rates. 8
• Do not forget to facilitate prescription access and provide clear medication instructions including side effects. 1