Laura C. Feemster, MD, MS

Up to one‐third of the 700,000 patients admitted annually for an exacerbation of chronic obstructive pulmonary disease (COPD) continue to smoke tobacco.[1, 2] Smokers with COPD are at high risk for poor health outcomes directly attributable to tobacco‐related conditions, including progression of lung disease and cardiovascular diseases.[3, 4, 5] Treatment for tobacco addiction is the most essential intervention for these patients.

Hospital admission has been suggested as an opportune time for the initiation of smoking cessation.[6] Hospitalized patients are already in a smoke‐free environment, and have access to physicians, nurses, and pharmacists who can prescribe medications for support.[7] Documenting smoking status and offering smoking cessation treatment during and after discharge are quality metrics required by the Joint Commission, and recommended by the National Quality Forum.[8, 9] Hospitals have made significant efforts to comply with these requirements.[10]

Limited data exist regarding the effectiveness and utilization of treatments known to reduce cigarette use among COPD patients in nontrial environments. Prescribing patterns of medications for smoking cessation in the real world following admission for COPD are not well studied. We sought to examine the utilization of inpatient brief tobacco counseling and postdischarge pharmacotherapy following discharge for exacerbation of COPD, as well as to (1) examine the association of postdischarge pharmacotherapy with self‐reported smoking cessation at 6 to 12 months and (2) assess differences in effectiveness between cessation medications prescribed.

METHODS

We conducted a cohort study of current smokers discharged following a COPD exacerbation within the Veterans Affairs (VA) Veterans Integrated Service Network (VISN)‐20. This study was approved by the VA Puget Sound Health Care System Institutional Review Board (#00461).

We utilized clinical information from the VISN‐20 data warehouse that collects data using the VA electronic medical record, including demographics, prescription medications, hospital admissions, hospital and outpatient diagnoses, and dates of death, and is commonly used for research. In addition, we utilized health factors, coded electronic entries describing patient health behaviors that are entered by nursing staff at the time of a patient encounter, and the text of chart notes that were available for electronic query.

Study Cohort

We identified all smokers aged 40 years hospitalized between 2005 and 2012 with either a primary discharge diagnosis of COPD based on International Classification of Diseases, 9th Revision codes (491, 492, 493.2, and 496) or an admission diagnosis from the text of the admit notes indicating an exacerbation of COPD. We limited to patients aged 40 years to improve the specificity of the diagnosis of COPD, and we selected the first hospitalization that met inclusion criteria. We excluded subjects who died within 6 months of discharge (Figure 1).

Figure 1

To establish tobacco status, we built on previously developed and validated methodology,[11] and performed truncated natural language processing using phrases in the medical record that reflected patients' tobacco status, querying all notes from the day of admission up to 6 months prior. If no tobacco status was indicated in the notes, we identified the status encoded by the most recent health factor. We manually examined the results of the natural language processing and the determination of health factors to confirm the tobacco status. Manual review was undertaken by 1 of 2 trained study personnel. In the case of an ambiguous or contradictory status, an additional team member reviewed the information to attempt to make a determination. If no determination could be made, the record was coded to unknown. This method allowed us to identify a baseline status for all but 77 of the 3580 patients admitted for COPD.

RESULTS

Among these 1334 subjects at 6 to 12 months of follow‐up, 63.7% reported ongoing smoking, 19.8% of patients reported quitting, and 17.5% of patients had no reported status and were presumed to be smokers. Four hundred fifty (33.7%) patients were dispensed a smoking cessation medication within 90 days of discharge. Patients who were dispensed medications were younger and more likely to be female. Nearly all patients who received medications also received documented predischarge counseling (94.6%), as did the majority of patients who did not receive medications (83.8%) (Table 1).

Of patients dispensed a study medication, 246 (18.4% of patients, 54.7% of all medications dispensed) were dispensed medications within 48 hours of discharge (Table 2). Of the patients dispensed medication, the majority received nicotine patches alone (Table 3), and 18.9% of patients received combination therapy, with the majority receiving nicotine patch and short‐acting nicotine replacement therapy (NRT) or patch and buproprion. A significant number of patients were prescribed medications within 90 days of discharge, but did not have them dispensed within that timeframe (n = 224, 16.8%).

DISCUSSION

In this observational study, postdischarge pharmacotherapy within 90 days of discharge was provided to a minority of high‐risk smokers admitted for COPD, and was not associated with smoking cessation at 6 to 12 months. In comparison to nicotine patch alone, varenicline was associated with a higher odds of cessation, with decreased odds of cessation among patients treated with short‐acting NRT alone. The overall quit rate was significant at 19.8%, and is consistent with annual quit rates observed among patients with COPD in other settings,[21, 22] but is far lower than quit rates observed after admission for acute myocardial infarction.[23, 24, 25] Although the proportion of patients treated at the time of discharge or within 90 days was low, our findings are in keeping with previous studies, which demonstrated low rates of pharmacologic treatment following hospitalization, averaging 14%.[26] Treatment for tobacco use is likely underutilized for this group of high‐risk smokers. However, a significant proportion of patients who were prescribed medications in the postdischarge period did not have medications filled. This likely reflects both the rapid changes in motivation that characterize quit attempts,[27] as well as efforts on the part of primary care physicians to make these medications available to facilitate future quit attempts.

There are several possible explanations for the findings in our study. Pharmaceutical therapies were not provided at random. The provision of pharmacotherapy and the ultimate success of a quit attempt reflects a complex interaction of patient beliefs concerning medications, level of addiction and motivation, physician behavior and knowledge, and organizational factors. Organizational factors such as the structure of electronic discharge orders and the availability of decision support materials may influence a physician's likelihood of prescribing medications, the choice of medication prescribed, and therefore the adequacy of control of withdrawal symptoms. NRT is often under dosed to control ongoing symptoms,[28] and needs to be adjusted until relief is obtained, providing an additional barrier to effectiveness during the transition out of the hospital. Because most smokers with COPD are highly addicted to nicotine,[29] high‐dose NRT, combination therapy, or varenicline would be necessary to adequately control symptoms.[30] However, a significant minority of patients received short‐acting NRT alone.

Despite a high observed efficacy in recent trials,[31, 32] few subjects in our study received varenicline. This may be related to both secular trends and administrative barriers to the use of varenicline in the VA system. Use of this medication was limited among patients with psychiatric disorders due to safety concerns. These concerns have since been largely disproven, but may have limited access to this medication.[33, 34, 35] Although we adjusted for a history of mental illness, patients who received varenicline may have had more past quit attempts and less active mental illness, which may be associated with improved cessation rates. Despite the high prevalence of mental illness we observed, this is typical of the population of smokers, with studies indicating nearly one‐third of smokers overall suffer from mental illness.[36]

Although the majority of our patients received a brief, nurse‐based counseling intervention, there is considerable concern about the overall effectiveness of a single predischarge interaction to produce sustained smoking cessation among highly addicted smokers.[37, 38, 39, 40] The Joint Commission has recently restructured the requirements for smoking cessation treatment for hospitalized patients, and it is now up to hospitals to implement treatment mechanisms that not only meet the national requirements, but also provide a meaningful clinical effect. Though the optimum treatment for hospitalized smokers with COPD is unknown, previous positive studies of smoking cessation among hospitalized patients underscore the need for a higher‐intensity counseling intervention that begins during hospitalization and continues after discharge.[13, 41] Cessation counseling services including tobacco cessation groups and quit lines are available through the VA; however, the use of these services is typically low and requires the patient to enroll independently after discharge, an additional barrier. The lack of association between medications and smoking cessation found in our study could reflect poor effectiveness of medications in the absence of a systematic counseling intervention. Alternatively, the association may be explained that patients who were more highly addicted and perhaps less motivated to quit received tobacco cessation medications more often, but were also less likely to stop tobacco use, a form of indication bias.

Our study has several limitations. We do not have addiction or motivation levels for a cessation attempt, a potential unmeasured confounder. Although predictive of quit attempts, motivation factors are less predictive of cessation maintenance, and may therefore have an unclear effect on our outcome.[42, 43] Our outcome was gathered as part of routine clinical care, which may have introduced bias if patients over‐reported cessation because of social desirability. In healthcare settings, however, this form of assessing smoking status is generally valid.[44] Exposure to counseling or medications obtained outside of the VA system would not have been captured. Given the financial incentive, we believe it is unlikely that many patients admitted to a VA medical center obtained medications elsewhere.[45] The diagnosis of COPD was made administratively. However, all subjects were admitted for an exacerbation, which is associated with more severe COPD by Global Initiative for Obstructive Lung Disease (GOLD) stage.[46] Patients with more severe COPD are often excluded from studies of smoking cessation due to concerns of high dropout and lower prevalence of smoking among patients with GOLD stage IV disease,[47, 48] making this a strength of our study. Subjects who died may have quit only in extremis, or failed to document their quit attempts. However, our sensitivity analysis limited to survivors did not change the study results. There may have been some misclassification in the use of buproprion, which may also be prescribed as an antidepressant. Finally, although representative of the veterans who seek care within the VISN‐20, our patients were primarily white and male, limiting the ability to generalize outside of this group.

Our study had several strengths. We examined a large cohort of patients admitted to a complete care organization, including patients from a diverse group of VA settings comprising academically and nonacademically affiliated centers. We performed an unbiased collection of patients, including all smokers discharged for COPD. We had access to excellent completeness of medications prescribed and filled as collected within the VA system, enabling us to observe medications dispensed and prescribed at several time points. We also had near complete ascertainment of outcomes including by using natural language processing with manual confirmation of smoking status.

In summary, we found that provision of medications to treat ongoing tobacco use among patients discharged for COPD was low, and receipt of medications was not associated with a reduction in smoking tobacco at 6 to 12 months postdischarge. However, among those treated, varenicline appears to be superior to the nicotine patch, with short‐acting nicotine replacement potentially less effective, a biologically plausible finding. The motivation to quit smoking changes rapidly over time. Providing these medications in the hospital and during the time after discharge is a potential means to improve quit rates, but medications need to be paired with counseling to be most effective. Collectively, these data suggest that systems‐based interventions are needed to increase the availability of intense counseling and the use of tailored pharmacotherapy to these patients.

Up to one‐third of the 700,000 patients admitted annually for an exacerbation of chronic obstructive pulmonary disease (COPD) continue to smoke tobacco.[1, 2] Smokers with COPD are at high risk for poor health outcomes directly attributable to tobacco‐related conditions, including progression of lung disease and cardiovascular diseases.[3, 4, 5] Treatment for tobacco addiction is the most essential intervention for these patients.

Hospital admission has been suggested as an opportune time for the initiation of smoking cessation.[6] Hospitalized patients are already in a smoke‐free environment, and have access to physicians, nurses, and pharmacists who can prescribe medications for support.[7] Documenting smoking status and offering smoking cessation treatment during and after discharge are quality metrics required by the Joint Commission, and recommended by the National Quality Forum.[8, 9] Hospitals have made significant efforts to comply with these requirements.[10]

Limited data exist regarding the effectiveness and utilization of treatments known to reduce cigarette use among COPD patients in nontrial environments. Prescribing patterns of medications for smoking cessation in the real world following admission for COPD are not well studied. We sought to examine the utilization of inpatient brief tobacco counseling and postdischarge pharmacotherapy following discharge for exacerbation of COPD, as well as to (1) examine the association of postdischarge pharmacotherapy with self‐reported smoking cessation at 6 to 12 months and (2) assess differences in effectiveness between cessation medications prescribed.

METHODS

We conducted a cohort study of current smokers discharged following a COPD exacerbation within the Veterans Affairs (VA) Veterans Integrated Service Network (VISN)‐20. This study was approved by the VA Puget Sound Health Care System Institutional Review Board (#00461).

We utilized clinical information from the VISN‐20 data warehouse that collects data using the VA electronic medical record, including demographics, prescription medications, hospital admissions, hospital and outpatient diagnoses, and dates of death, and is commonly used for research. In addition, we utilized health factors, coded electronic entries describing patient health behaviors that are entered by nursing staff at the time of a patient encounter, and the text of chart notes that were available for electronic query.

Study Cohort

We identified all smokers aged 40 years hospitalized between 2005 and 2012 with either a primary discharge diagnosis of COPD based on International Classification of Diseases, 9th Revision codes (491, 492, 493.2, and 496) or an admission diagnosis from the text of the admit notes indicating an exacerbation of COPD. We limited to patients aged 40 years to improve the specificity of the diagnosis of COPD, and we selected the first hospitalization that met inclusion criteria. We excluded subjects who died within 6 months of discharge (Figure 1).

Figure 1

To establish tobacco status, we built on previously developed and validated methodology,[11] and performed truncated natural language processing using phrases in the medical record that reflected patients' tobacco status, querying all notes from the day of admission up to 6 months prior. If no tobacco status was indicated in the notes, we identified the status encoded by the most recent health factor. We manually examined the results of the natural language processing and the determination of health factors to confirm the tobacco status. Manual review was undertaken by 1 of 2 trained study personnel. In the case of an ambiguous or contradictory status, an additional team member reviewed the information to attempt to make a determination. If no determination could be made, the record was coded to unknown. This method allowed us to identify a baseline status for all but 77 of the 3580 patients admitted for COPD.

RESULTS

Among these 1334 subjects at 6 to 12 months of follow‐up, 63.7% reported ongoing smoking, 19.8% of patients reported quitting, and 17.5% of patients had no reported status and were presumed to be smokers. Four hundred fifty (33.7%) patients were dispensed a smoking cessation medication within 90 days of discharge. Patients who were dispensed medications were younger and more likely to be female. Nearly all patients who received medications also received documented predischarge counseling (94.6%), as did the majority of patients who did not receive medications (83.8%) (Table 1).

Of patients dispensed a study medication, 246 (18.4% of patients, 54.7% of all medications dispensed) were dispensed medications within 48 hours of discharge (Table 2). Of the patients dispensed medication, the majority received nicotine patches alone (Table 3), and 18.9% of patients received combination therapy, with the majority receiving nicotine patch and short‐acting nicotine replacement therapy (NRT) or patch and buproprion. A significant number of patients were prescribed medications within 90 days of discharge, but did not have them dispensed within that timeframe (n = 224, 16.8%).

DISCUSSION

In this observational study, postdischarge pharmacotherapy within 90 days of discharge was provided to a minority of high‐risk smokers admitted for COPD, and was not associated with smoking cessation at 6 to 12 months. In comparison to nicotine patch alone, varenicline was associated with a higher odds of cessation, with decreased odds of cessation among patients treated with short‐acting NRT alone. The overall quit rate was significant at 19.8%, and is consistent with annual quit rates observed among patients with COPD in other settings,[21, 22] but is far lower than quit rates observed after admission for acute myocardial infarction.[23, 24, 25] Although the proportion of patients treated at the time of discharge or within 90 days was low, our findings are in keeping with previous studies, which demonstrated low rates of pharmacologic treatment following hospitalization, averaging 14%.[26] Treatment for tobacco use is likely underutilized for this group of high‐risk smokers. However, a significant proportion of patients who were prescribed medications in the postdischarge period did not have medications filled. This likely reflects both the rapid changes in motivation that characterize quit attempts,[27] as well as efforts on the part of primary care physicians to make these medications available to facilitate future quit attempts.

There are several possible explanations for the findings in our study. Pharmaceutical therapies were not provided at random. The provision of pharmacotherapy and the ultimate success of a quit attempt reflects a complex interaction of patient beliefs concerning medications, level of addiction and motivation, physician behavior and knowledge, and organizational factors. Organizational factors such as the structure of electronic discharge orders and the availability of decision support materials may influence a physician's likelihood of prescribing medications, the choice of medication prescribed, and therefore the adequacy of control of withdrawal symptoms. NRT is often under dosed to control ongoing symptoms,[28] and needs to be adjusted until relief is obtained, providing an additional barrier to effectiveness during the transition out of the hospital. Because most smokers with COPD are highly addicted to nicotine,[29] high‐dose NRT, combination therapy, or varenicline would be necessary to adequately control symptoms.[30] However, a significant minority of patients received short‐acting NRT alone.

Despite a high observed efficacy in recent trials,[31, 32] few subjects in our study received varenicline. This may be related to both secular trends and administrative barriers to the use of varenicline in the VA system. Use of this medication was limited among patients with psychiatric disorders due to safety concerns. These concerns have since been largely disproven, but may have limited access to this medication.[33, 34, 35] Although we adjusted for a history of mental illness, patients who received varenicline may have had more past quit attempts and less active mental illness, which may be associated with improved cessation rates. Despite the high prevalence of mental illness we observed, this is typical of the population of smokers, with studies indicating nearly one‐third of smokers overall suffer from mental illness.[36]

Although the majority of our patients received a brief, nurse‐based counseling intervention, there is considerable concern about the overall effectiveness of a single predischarge interaction to produce sustained smoking cessation among highly addicted smokers.[37, 38, 39, 40] The Joint Commission has recently restructured the requirements for smoking cessation treatment for hospitalized patients, and it is now up to hospitals to implement treatment mechanisms that not only meet the national requirements, but also provide a meaningful clinical effect. Though the optimum treatment for hospitalized smokers with COPD is unknown, previous positive studies of smoking cessation among hospitalized patients underscore the need for a higher‐intensity counseling intervention that begins during hospitalization and continues after discharge.[13, 41] Cessation counseling services including tobacco cessation groups and quit lines are available through the VA; however, the use of these services is typically low and requires the patient to enroll independently after discharge, an additional barrier. The lack of association between medications and smoking cessation found in our study could reflect poor effectiveness of medications in the absence of a systematic counseling intervention. Alternatively, the association may be explained that patients who were more highly addicted and perhaps less motivated to quit received tobacco cessation medications more often, but were also less likely to stop tobacco use, a form of indication bias.

Our study has several limitations. We do not have addiction or motivation levels for a cessation attempt, a potential unmeasured confounder. Although predictive of quit attempts, motivation factors are less predictive of cessation maintenance, and may therefore have an unclear effect on our outcome.[42, 43] Our outcome was gathered as part of routine clinical care, which may have introduced bias if patients over‐reported cessation because of social desirability. In healthcare settings, however, this form of assessing smoking status is generally valid.[44] Exposure to counseling or medications obtained outside of the VA system would not have been captured. Given the financial incentive, we believe it is unlikely that many patients admitted to a VA medical center obtained medications elsewhere.[45] The diagnosis of COPD was made administratively. However, all subjects were admitted for an exacerbation, which is associated with more severe COPD by Global Initiative for Obstructive Lung Disease (GOLD) stage.[46] Patients with more severe COPD are often excluded from studies of smoking cessation due to concerns of high dropout and lower prevalence of smoking among patients with GOLD stage IV disease,[47, 48] making this a strength of our study. Subjects who died may have quit only in extremis, or failed to document their quit attempts. However, our sensitivity analysis limited to survivors did not change the study results. There may have been some misclassification in the use of buproprion, which may also be prescribed as an antidepressant. Finally, although representative of the veterans who seek care within the VISN‐20, our patients were primarily white and male, limiting the ability to generalize outside of this group.

Our study had several strengths. We examined a large cohort of patients admitted to a complete care organization, including patients from a diverse group of VA settings comprising academically and nonacademically affiliated centers. We performed an unbiased collection of patients, including all smokers discharged for COPD. We had access to excellent completeness of medications prescribed and filled as collected within the VA system, enabling us to observe medications dispensed and prescribed at several time points. We also had near complete ascertainment of outcomes including by using natural language processing with manual confirmation of smoking status.

In summary, we found that provision of medications to treat ongoing tobacco use among patients discharged for COPD was low, and receipt of medications was not associated with a reduction in smoking tobacco at 6 to 12 months postdischarge. However, among those treated, varenicline appears to be superior to the nicotine patch, with short‐acting nicotine replacement potentially less effective, a biologically plausible finding. The motivation to quit smoking changes rapidly over time. Providing these medications in the hospital and during the time after discharge is a potential means to improve quit rates, but medications need to be paired with counseling to be most effective. Collectively, these data suggest that systems‐based interventions are needed to increase the availability of intense counseling and the use of tailored pharmacotherapy to these patients.

Up to one‐third of the 700,000 patients admitted annually for an exacerbation of chronic obstructive pulmonary disease (COPD) continue to smoke tobacco.[1, 2] Smokers with COPD are at high risk for poor health outcomes directly attributable to tobacco‐related conditions, including progression of lung disease and cardiovascular diseases.[3, 4, 5] Treatment for tobacco addiction is the most essential intervention for these patients.

Hospital admission has been suggested as an opportune time for the initiation of smoking cessation.[6] Hospitalized patients are already in a smoke‐free environment, and have access to physicians, nurses, and pharmacists who can prescribe medications for support.[7] Documenting smoking status and offering smoking cessation treatment during and after discharge are quality metrics required by the Joint Commission, and recommended by the National Quality Forum.[8, 9] Hospitals have made significant efforts to comply with these requirements.[10]

Limited data exist regarding the effectiveness and utilization of treatments known to reduce cigarette use among COPD patients in nontrial environments. Prescribing patterns of medications for smoking cessation in the real world following admission for COPD are not well studied. We sought to examine the utilization of inpatient brief tobacco counseling and postdischarge pharmacotherapy following discharge for exacerbation of COPD, as well as to (1) examine the association of postdischarge pharmacotherapy with self‐reported smoking cessation at 6 to 12 months and (2) assess differences in effectiveness between cessation medications prescribed.

METHODS

We conducted a cohort study of current smokers discharged following a COPD exacerbation within the Veterans Affairs (VA) Veterans Integrated Service Network (VISN)‐20. This study was approved by the VA Puget Sound Health Care System Institutional Review Board (#00461).

We utilized clinical information from the VISN‐20 data warehouse that collects data using the VA electronic medical record, including demographics, prescription medications, hospital admissions, hospital and outpatient diagnoses, and dates of death, and is commonly used for research. In addition, we utilized health factors, coded electronic entries describing patient health behaviors that are entered by nursing staff at the time of a patient encounter, and the text of chart notes that were available for electronic query.

Study Cohort

We identified all smokers aged 40 years hospitalized between 2005 and 2012 with either a primary discharge diagnosis of COPD based on International Classification of Diseases, 9th Revision codes (491, 492, 493.2, and 496) or an admission diagnosis from the text of the admit notes indicating an exacerbation of COPD. We limited to patients aged 40 years to improve the specificity of the diagnosis of COPD, and we selected the first hospitalization that met inclusion criteria. We excluded subjects who died within 6 months of discharge (Figure 1).

Figure 1

To establish tobacco status, we built on previously developed and validated methodology,[11] and performed truncated natural language processing using phrases in the medical record that reflected patients' tobacco status, querying all notes from the day of admission up to 6 months prior. If no tobacco status was indicated in the notes, we identified the status encoded by the most recent health factor. We manually examined the results of the natural language processing and the determination of health factors to confirm the tobacco status. Manual review was undertaken by 1 of 2 trained study personnel. In the case of an ambiguous or contradictory status, an additional team member reviewed the information to attempt to make a determination. If no determination could be made, the record was coded to unknown. This method allowed us to identify a baseline status for all but 77 of the 3580 patients admitted for COPD.

RESULTS

Among these 1334 subjects at 6 to 12 months of follow‐up, 63.7% reported ongoing smoking, 19.8% of patients reported quitting, and 17.5% of patients had no reported status and were presumed to be smokers. Four hundred fifty (33.7%) patients were dispensed a smoking cessation medication within 90 days of discharge. Patients who were dispensed medications were younger and more likely to be female. Nearly all patients who received medications also received documented predischarge counseling (94.6%), as did the majority of patients who did not receive medications (83.8%) (Table 1).

Of patients dispensed a study medication, 246 (18.4% of patients, 54.7% of all medications dispensed) were dispensed medications within 48 hours of discharge (Table 2). Of the patients dispensed medication, the majority received nicotine patches alone (Table 3), and 18.9% of patients received combination therapy, with the majority receiving nicotine patch and short‐acting nicotine replacement therapy (NRT) or patch and buproprion. A significant number of patients were prescribed medications within 90 days of discharge, but did not have them dispensed within that timeframe (n = 224, 16.8%).

DISCUSSION

In this observational study, postdischarge pharmacotherapy within 90 days of discharge was provided to a minority of high‐risk smokers admitted for COPD, and was not associated with smoking cessation at 6 to 12 months. In comparison to nicotine patch alone, varenicline was associated with a higher odds of cessation, with decreased odds of cessation among patients treated with short‐acting NRT alone. The overall quit rate was significant at 19.8%, and is consistent with annual quit rates observed among patients with COPD in other settings,[21, 22] but is far lower than quit rates observed after admission for acute myocardial infarction.[23, 24, 25] Although the proportion of patients treated at the time of discharge or within 90 days was low, our findings are in keeping with previous studies, which demonstrated low rates of pharmacologic treatment following hospitalization, averaging 14%.[26] Treatment for tobacco use is likely underutilized for this group of high‐risk smokers. However, a significant proportion of patients who were prescribed medications in the postdischarge period did not have medications filled. This likely reflects both the rapid changes in motivation that characterize quit attempts,[27] as well as efforts on the part of primary care physicians to make these medications available to facilitate future quit attempts.

There are several possible explanations for the findings in our study. Pharmaceutical therapies were not provided at random. The provision of pharmacotherapy and the ultimate success of a quit attempt reflects a complex interaction of patient beliefs concerning medications, level of addiction and motivation, physician behavior and knowledge, and organizational factors. Organizational factors such as the structure of electronic discharge orders and the availability of decision support materials may influence a physician's likelihood of prescribing medications, the choice of medication prescribed, and therefore the adequacy of control of withdrawal symptoms. NRT is often under dosed to control ongoing symptoms,[28] and needs to be adjusted until relief is obtained, providing an additional barrier to effectiveness during the transition out of the hospital. Because most smokers with COPD are highly addicted to nicotine,[29] high‐dose NRT, combination therapy, or varenicline would be necessary to adequately control symptoms.[30] However, a significant minority of patients received short‐acting NRT alone.

Despite a high observed efficacy in recent trials,[31, 32] few subjects in our study received varenicline. This may be related to both secular trends and administrative barriers to the use of varenicline in the VA system. Use of this medication was limited among patients with psychiatric disorders due to safety concerns. These concerns have since been largely disproven, but may have limited access to this medication.[33, 34, 35] Although we adjusted for a history of mental illness, patients who received varenicline may have had more past quit attempts and less active mental illness, which may be associated with improved cessation rates. Despite the high prevalence of mental illness we observed, this is typical of the population of smokers, with studies indicating nearly one‐third of smokers overall suffer from mental illness.[36]

Although the majority of our patients received a brief, nurse‐based counseling intervention, there is considerable concern about the overall effectiveness of a single predischarge interaction to produce sustained smoking cessation among highly addicted smokers.[37, 38, 39, 40] The Joint Commission has recently restructured the requirements for smoking cessation treatment for hospitalized patients, and it is now up to hospitals to implement treatment mechanisms that not only meet the national requirements, but also provide a meaningful clinical effect. Though the optimum treatment for hospitalized smokers with COPD is unknown, previous positive studies of smoking cessation among hospitalized patients underscore the need for a higher‐intensity counseling intervention that begins during hospitalization and continues after discharge.[13, 41] Cessation counseling services including tobacco cessation groups and quit lines are available through the VA; however, the use of these services is typically low and requires the patient to enroll independently after discharge, an additional barrier. The lack of association between medications and smoking cessation found in our study could reflect poor effectiveness of medications in the absence of a systematic counseling intervention. Alternatively, the association may be explained that patients who were more highly addicted and perhaps less motivated to quit received tobacco cessation medications more often, but were also less likely to stop tobacco use, a form of indication bias.

Our study has several limitations. We do not have addiction or motivation levels for a cessation attempt, a potential unmeasured confounder. Although predictive of quit attempts, motivation factors are less predictive of cessation maintenance, and may therefore have an unclear effect on our outcome.[42, 43] Our outcome was gathered as part of routine clinical care, which may have introduced bias if patients over‐reported cessation because of social desirability. In healthcare settings, however, this form of assessing smoking status is generally valid.[44] Exposure to counseling or medications obtained outside of the VA system would not have been captured. Given the financial incentive, we believe it is unlikely that many patients admitted to a VA medical center obtained medications elsewhere.[45] The diagnosis of COPD was made administratively. However, all subjects were admitted for an exacerbation, which is associated with more severe COPD by Global Initiative for Obstructive Lung Disease (GOLD) stage.[46] Patients with more severe COPD are often excluded from studies of smoking cessation due to concerns of high dropout and lower prevalence of smoking among patients with GOLD stage IV disease,[47, 48] making this a strength of our study. Subjects who died may have quit only in extremis, or failed to document their quit attempts. However, our sensitivity analysis limited to survivors did not change the study results. There may have been some misclassification in the use of buproprion, which may also be prescribed as an antidepressant. Finally, although representative of the veterans who seek care within the VISN‐20, our patients were primarily white and male, limiting the ability to generalize outside of this group.

Our study had several strengths. We examined a large cohort of patients admitted to a complete care organization, including patients from a diverse group of VA settings comprising academically and nonacademically affiliated centers. We performed an unbiased collection of patients, including all smokers discharged for COPD. We had access to excellent completeness of medications prescribed and filled as collected within the VA system, enabling us to observe medications dispensed and prescribed at several time points. We also had near complete ascertainment of outcomes including by using natural language processing with manual confirmation of smoking status.

In summary, we found that provision of medications to treat ongoing tobacco use among patients discharged for COPD was low, and receipt of medications was not associated with a reduction in smoking tobacco at 6 to 12 months postdischarge. However, among those treated, varenicline appears to be superior to the nicotine patch, with short‐acting nicotine replacement potentially less effective, a biologically plausible finding. The motivation to quit smoking changes rapidly over time. Providing these medications in the hospital and during the time after discharge is a potential means to improve quit rates, but medications need to be paired with counseling to be most effective. Collectively, these data suggest that systems‐based interventions are needed to increase the availability of intense counseling and the use of tailored pharmacotherapy to these patients.