Background: Tobacco use is the most widespread preventable cause of cancer and is linked to 30% of cancer-related deaths.(1) Many smokers want to quit but are unsuccessful; tools such as nicotine replacement therapy (NRT) products can increase quit rates by 50-60%.(2) While smoking cessation is the ideal way to combat tobacco-related diseases, screening for diseases can reduce morbidity and mortality in the long term. Annual lung cancer screening with low-dose computed tomography (LDCT) in high-risk smokers and recently quit ex-smokers has been found to reduce lung cancer related mortality, however compliance with guideline recommendations remains low.(3, 4) Historically, preventive care and cancer screening has fallen to primary care, however access to primary care is suboptimal.(5) Hospitalization serves as a teachable moment where perceived vulnerability alters patients’ motivation to make health related changes, and it may be an opportunity to improve rates of tobacco use treatment and lung cancer screening.
Methods: Retrospective cohort study of adult patients in a university-based patient-centered medical home from 2012-2021 evaluated the proportion of adults who smoke who received at least one prescription for NRT using electronic health record data. Logistic regression models were used to analyze the association of being hospitalized and receipt of a NRT prescription. Within the cohort, patients aged 55-80 were evaluated for completion of at least one LDCT from 2014-2021 using hospitalization as the primary exposure. Univariate analysis and logistic regression models evaluated the association of hospitalization and completion of LDCT. The secondary outcome was completion of any CT of the chest.
Results: Of the 4,072 current smokers identified, 1,182 (29%) received at least one prescription for NRT during the study period. Hospitalization was associated with increased odds of receiving a NRT prescription (OR 1.68). Of 1,844 current smokers with a hospitalization during the study period, 1,078 (58%) never received a prescription for NRT at any point. Only 87 (5%) of the smokers received a prescription for NRT during hospitalization or at the time of hospital discharge.Of patients aged 55-80, 1,935 current smokers were identified, 47% had at least one hospitalization, and 21% completed a LDCT during the study period. While a higher proportion of patients with a hospitalization had a LDCT (24%) compared to patients without a hospitalization (18%, p< 0.001), there was no association between hospitalization and completion of a LDCT after adjusting for potentially confounding covariates (95%CI 0.680 – 1.149). 38% completed any CT of the chest, and hospitalization was associated with increased odds of receiving chest CT imaging in the adjusted model (OR 1.72; 95%CI 1.37 – 2.17).
Conclusions: In a cohort of patients who smoke and experienced a hospitalization during the study period, less than a third were prescribed NRT and only 1 in 5 completed lung cancer screening with at least one LDCT. Hospitalization is an underutilized opportunity for both hospitalists and primary care physicians to intervene on smoking cessation and lung cancer screening. As negative health effects of tobacco use have been identified for over 50 years, yet its use remains prevalent, there is a need and an opportunity for hospital practitioners to join primary care providers in delivering evidence-based preventive medicine to decrease tobacco related morbidity and mortality for our patients.