PROJECT SUMMARY Tobacco use remains the leading cause of death in the United States and contributes to more than 7 million hospitalizations annually. Hospitalization offers a critical window for intervention: hospital policies prohibit smoking, patients are highly motivated to quit, and societal guidelines recommend that clinicians should counsel patients and prescribe smoking cessation pharmacotherapy (SCP) to virtually all smokers. Nevertheless, only 22% of patients are ever prescribed SCP while hospitalized and only 1% of patients are prescribed guideline-concordant SCP. This failure ultimately contributes to a 70-80% smoking relapse rate, most of which occurs within a few days of hospital discharge – well before outpatient follow-up can occur. If we are to capitalize on the opportunity that hospitalization provides to maximize smoking cessation treatment and outcomes, new strategies are needed to overcome the low uptake of guideline-concordant SCP by physicians and patients. To address this problem, we propose to deploy a nurse practitioner-led, hospital- based tobacco treatment team to: 1) prescribe individually tailored and guideline-concordant SCP; 2) counsel and motivate patients to use SCP properly; and 3) and manage a mobile phone-based text-messaging system to keep patients motivated and adherent to SCP. Our preliminary data suggest that such an approach is feasible and acceptable to patients, physicians, and hospital administrators. In Aim 1, we will perform a parallel-group implementation-effectiveness randomized trial among 424 hospitalized smokers with a cardiopulmonary disease in a large tertiary hospital. We will compare rates of SCP use and smoking cessation between patients who received the intervention and those who did not. In Aim 2, we will measure the economic value of the intervention from both a hospital and payer perspective to better inform hospital and insurance policies and sustainability. In Aim 3, we will perform qualitative interviews with patients, physicians, staff members, and hospital administrators to evaluate the acceptability and sustainability of our strategies. We hypothesize that our intervention will: improve guideline-concordant SCP use; increase 6- month smoking cessation rates; be acceptable to patients, clinicians, and administrators; and be cost-effective and sustainable. Our multi-disciplinary team has broad experience in cardiopulmonary medicine, tobacco treatment, implementation science, medication adherence, qualitative methods, health economics, and text message technology. At the conclusion of this grant, our team will develop a detailed, evidence-informed implementation guide for a hospital-based tobacco treatment team. Ultimately, we anticipate the knowledge gained from this study will facilitate widespread and effective hospital-based tobacco treatment so that more patients lead lives free from tobacco and cardiopulmonary disease.

PROJECT NARRATIVE Although smoking is the leading cause of premature non-communicable death in the United States and contributes to millions of hospitalizations annually, most hospitalized smokers are rarely prescribed any kind of smoking cessation medication to help them quit. In this project, we will employ a nurse practitioner-led, hospital-based tobacco treatment team to prescribe effective medications, counsel patients on how to use them properly, and manage a text messaging system with the goal to maximize medication use, adherence, and smoking cessation. We anticipate demonstrating the effectiveness, feasibility, acceptability, cost- effectiveness, and sustainability of this program, so that, in the future, more hospitals will be able to capture the “teachable moment” of hospitalization to help smokers quit permanently.