Tobacco Treatment in the Inpatient Setting: An American College of Chest Physicians Clinical Practice Guideline

Cigarette smoking remains the leading cause of preventable death in the United States, with high prevalence among hospitalized patients. Hospitalization presents an opportunity to initiate and engage patients in tobacco treatment, yet guidance for tobacco treatment in this setting has been limited. This clinical practice guideline provides evidence-based recommendations for tobacco treatment in the inpatient setting.

A multidisciplinary panel followed CHEST's standardized clinical practice guideline methodology, including systematic literature searches in MEDLINE, Embase, and the Cochrane Database. Key clinical questions were framed using the PICO format. Eligible studies included randomized controlled trials and cohort studies. Evidence was appraised using GRADE, and recommendations were formulated through a modified Delphi process to achieve consensus.

We identified 9330 abstracts, assessed 252 full texts, and included 142 studies. The literature review and analysis, based on 6 PICO questions, yielded 8 recommendations. No recommendations were supported by high-certainty evidence specific to inpatient tobacco treatment settings. Of the eight recommendations, four were supported by moderate-certainty evidence, two by low-certainty evidence, and two by very low-certainty evidence, supplemented by expert consensus.

Hospitalization offers a critical window to initiate tobacco treatment. This guideline synthesizes the existing literature to inform key components of inpatient tobacco treatment, including an opt-out population-based approach that proactively provides counseling and pharmacotherapy to all patients who smoke unless they explicitly decline; the initiation and selection of pharmacotherapies during hospitalization; counseling approaches delivered during the inpatient stay; and post-discharge counseling approaches following hospital discharge. Implementing these approaches is likely to improve smoking-cessation outcomes and reduce hospital readmissions and costs. The guideline also evaluates the strength and limitations of the current evidence base and identifies priority areas for future research, including identifying optimal implementation strategies, equity considerations, and the evaluation of cost-effectiveness across diverse hospital settings and patient populations.