Smoking Cessation Efforts for Patients with Asthma and COPD

A 2024 analysis of the Mount Sinai Health System reveals that despite higher cessation treatment rates for smokers with asthma or COPD compared to those without, only a minority (ranging from 9.9% to 32.6%) received counseling or pharmacotherapy, highlighting a critical gap in care that necessitates system-wide quality improvement.

The Gist

Imagine your lungs are like a delicate garden. For some people, this garden is prone to getting choked by weeds (Asthma) or worn down by erosion (COPD). Now, imagine that smoking is like pouring gasoline on those weeds and sandpaper on that erosion. It makes the problems much worse, much faster.

This paper is essentially a report card for a giant hospital network in New York (Mount Sinai) on how well they are helping their patients put out that fire and stop pouring gasoline on the garden.

Here is the breakdown of what they found, using some everyday analogies:

The Big Picture: The "Missed Opportunity"

The researchers looked at nearly 1 million patients who visited their hospitals and clinics in 2024. They found about 58,000 people who were still smoking.

Think of the doctors as firefighters. When a house is on fire (a patient with Asthma or COPD who smokes), the guidelines say the firefighters should grab the hose and spray water (offer help to quit) every single time they see the smoke.

The Reality Check:

• The Good News: The firefighters were a little more alert when the house was already burning down (patients with COPD or Asthma). They offered help about 33% of the time for these high-risk patients.
• The Bad News: That still means two out of every three high-risk patients left the hospital without getting the hose turned on. For smokers without lung disease, the firefighters barely even looked at the smoke (only about 10% got help).

The Tools in the Toolbox

When doctors did try to help, they had a few tools in their toolbox:

1. The Patch/Gum (Nicotine): The most common tool, like using a standard fire extinguisher. It's everywhere and easy to grab.
2. The Heavy Duty Spray (Varenicline): This is the "super-extinguisher" that works best, but it's used less often. Interestingly, the specialists (Pulmonologists) were the only ones who reached for this heavy-duty spray most of the time.
3. The Conversation (Counseling): This is the most important part—sitting down and talking to the patient about how to quit. The study found that doctors almost never combined the "spray" (medication) with the "talk" (counseling). It's like handing someone a fire extinguisher but forgetting to tell them how to aim it.

The "Specialist" vs. The "Generalist"

The study looked at different types of clinics, like different rooms in a house:

• The Pulmonary Clinic (The Experts): These are the specialists who know the garden best. They were the most active, offering help in 17% of visits. They were also the ones most likely to use the "super-extinguisher" (Varenicline).
• The Primary Care Clinic (The Generalists): These are the doctors who see everyone. They were decent, offering help in about 6% of visits.
• The Allergy Clinic (The Surprising Gap): This was the most shocking finding. Even though these doctors treat asthma, they offered almost zero help to smokers. It's like a gardener who knows exactly how to prune roses but refuses to pull the weeds choking them.

Why Does This Matter?

The authors argue that this isn't just about health; it's about efficiency.

• For the Patient: If you have Asthma or COPD and you keep smoking, your garden will die faster. You will end up in the Emergency Room more often, which is expensive and scary.
• For the System: Helping people quit is actually a money-saver in the long run. The paper suggests that if hospitals treated smoking like a standard part of care (like checking blood pressure), they could save millions of dollars in future medical bills.

The Bottom Line

The paper concludes that while the hospital system is doing a little better for patients with serious lung diseases than for healthy smokers, they are still missing a huge number of opportunities.

The Analogy: Imagine a doctor telling a patient, "Your car engine is smoking and making a terrible noise." The doctor then hands the patient a map and says, "Good luck," without offering to fix the engine or even suggest a mechanic. That is essentially what is happening to two-thirds of these patients.

The authors are calling for a "system-wide upgrade"—like installing a smoke alarm that automatically calls the fire department every time a patient walks into a room—so that no one leaves without getting the help they need to stop smoking.

Technical Summary

1. Problem Statement

Despite established clinical guidelines (GOLD, GINA, NAEPP) recommending that clinicians address smoking cessation at every visit for patients with Asthma and Chronic Obstructive Pulmonary Disease (COPD), there is a significant gap between recommendation and practice.

• Clinical Impact: Smoking exacerbates asthma and COPD, leading to increased exacerbations, hospitalizations, and accelerated disease progression.
• Systemic Failure: National data indicates that while two-thirds of smokers wish to quit, only about half receive assistance from a physician. Furthermore, the combination of counseling and medication—the most effective intervention—is rarely utilized.
• Knowledge Gap: There is a need for granular, health-system-level data to understand the specific rates of intervention, the types of treatments prescribed (medication vs. counseling), and how these rates vary across different patient populations (e.g., those with comorbid respiratory diseases) and clinical settings.

2. Methodology

This study is a cross-sectional analysis of de-identified electronic medical record (EMR) data from the Mount Sinai Health System (MSHS) in New York City.

• Data Source & Scope:
  • Population: 961,997 adult patients (≥18 years) with at least one ambulatory encounter in the calendar year 2024.
  • Smoker Identification: Patients identified as "current smokers" via the EMR smoking status tool or ICD-10 codes for current smoking.
  • Cohort Stratification: Patients were categorized into four groups based on ICD-10 codes:
    1. Asthma only ($n=6,532$)
    2. COPD only ($n=4,467$)
    3. Both Asthma and COPD ($n=2,389$)
    4. Other smokers (no respiratory diagnosis) ($n=45,178$)
• Treatment Definitions:
  • Pharmacotherapy: Prescriptions for Varenicline, Bupropion (specifically sustained-release 150mg BID), and Nicotine Replacement Therapy (NRT).
  • Counseling: Documented via CPT codes 99406 (3–10 mins) and 99407 (>10 mins).
  • Treatment Intensity Score: A composite metric (0–3) assigned per patient: +1 for one medication, +1 for a second medication, +1 for counseling.
• Statistical Analysis:
  • Descriptive statistics for treatment rates.
  • Kruskal-Wallis test (non-parametric) to identify global differences between diagnosis groups and clinic types.
  • Dunn's post-hoc pairwise comparison for specific group differences.
  • Chi-square tests (with Bonferroni correction) to evaluate associations between diagnoses and treatment types.
  • Significance level: $p < 0.05$.

3. Key Contributions

• Baseline for NCQA HEDIS 2026: The study provides a critical baseline for the upcoming National Committee for Quality Assurance (NCQA) HEDIS measures regarding Tobacco Use Screening and Cessation Intervention.
• Granular Specialty Breakdown: Unlike many broad studies, this analysis breaks down treatment rates by specific clinical specialties (Pulmonology, Primary Care, Allergy, Cardiology, Psychiatry, etc.), revealing stark disparities in care delivery.
• Comorbidity Analysis: It specifically isolates the "Asthma + COPD" cohort, demonstrating that patients with dual diagnoses receive the highest intervention rates, yet still face significant undertreatment.
• Medication Trends: The study documents the shift in pharmacotherapy preferences, noting the dominance of NRT over Varenicline in most settings, contrasting with guidelines that favor Varenicline as the most efficacious agent.

4. Key Results

• Prevalence: 6.1% ($n=58,566$) of the ambulatory population were identified as current smokers.
• Overall Treatment Rates:
  • Only 12.5% of all identified smokers received any form of treatment (counseling or medication).
  • Dual Diagnosis (Asthma + COPD): Highest treatment rate at 32.6%.
  • COPD Only: 26.7% received treatment.
  • Asthma Only: 13.0% received treatment.
  • Other Smokers: Lowest rate at 9.9%.
• Treatment Modality:
  • Medication Dominance: Medication alone was the most common intervention. NRT was the most prescribed medication across all groups (except Pulmonary clinics).
  • Counseling Deficit: Counseling alone or in combination with medication was extremely rare. Only 0.7% of all encounters involved both medication and counseling.
  • Varenicline Usage: While Varenicline is the most efficacious, it was prescribed less frequently than NRT overall. However, in Pulmonary clinics, Varenicline was the predominant treatment.
• Specialty Variation (Table 3):
  • Pulmonary Clinics: Highest treatment intensity (17.4% of encounters) and highest use of Varenicline.
  • Primary Care/Internal Medicine: Moderate treatment rate (6.6%).
  • Allergy Clinics: 0% treatment rate for smokers seen in this specialty.
  • Cardiology & Psychiatry: Significantly better than average surgical/medical clinics but still low overall.
• Intensity: The average treatment intensity score was very low across the system (0.04 for all clinics), indicating that even when treatment occurred, it was rarely comprehensive (i.e., rarely included both counseling and multiple medications).

5. Significance and Implications

• Systemic Undertreatment: The data confirms that despite guidelines, the vast majority of smokers with respiratory diseases are not receiving evidence-based cessation care. The "missed opportunity" is substantial, particularly in primary care and allergy settings.
• Economic Impact: The authors highlight that proper billing for cessation services (which are often under-billed) represents a significant lost revenue stream for health systems. Furthermore, effective cessation programs have been shown to reduce monthly healthcare costs (e.g., a Wisconsin study cited showed a $35/month reduction).
• Quality Improvement: The study underscores the need for system-wide interventions, such as:
  • EMR modifications to prompt cessation discussions.
  • Identification of "champions" within specialties (especially Allergy and Primary Care) to drive behavior change.
  • Addressing the "Varenicline gap" to ensure patients receive the most effective pharmacotherapy.
• Future Directions: As NCQA implements new HEDIS measures in 2026, this study serves as a benchmark. It suggests that without structural changes to EMR workflows and clinician accountability, health systems will struggle to meet these new quality metrics.

Conclusion: The Mount Sinai Health System, like the broader US healthcare landscape, demonstrates a critical failure to operationalize smoking cessation guidelines for patients with asthma and COPD. While patients with respiratory comorbidities are treated at higher rates than the general smoking population, the absolute rates remain unacceptably low, and the combination of counseling and medication is virtually absent.