Smoking cessation in emergency departments: a reality check.

Emergency Departments (EDs) see a high prevalence of people who smoke, many of whom present with acute smoking-related conditions (e.g., myocardial infarction, stroke, pneumonia, and asthma/COPD exacerbations). The immediacy of illness creates a strong "teachable moment," increasing receptiveness to risk communication and behavior change. Evidence indicates that pairing brief counseling with point-of-care therapeutic support and structured follow-up improves abstinence, although effects vary with local infrastructure, product availability, and staffing models. Despite this promise, scale-up is often constrained by economic barriers, limited staffing and training, and weak integration of cessation workflows into routine ED practice. The aim of this article is to provide a reality check on ED-based smoking cessation by synthesizing evidence on effectiveness, feasibility, cost-effectiveness, and safety across health-system contexts, and by outlining pragmatic delivery models and research priorities. Embedding low-friction, clinically governed cessation bundles within EDs has the potential to convert acute presentations into durable quit attempts and reduce smoking-related harm at scale, though this population-level impact remains a hypothesis to be tested. Future work should prioritize pragmatic and implementation trials with biochemically verified outcomes, integration metrics, equity impacts, and cost-utility analyses to guide sustainable adoption across diverse settings.