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The immediacy of illness creates a strong \u201cteachable moment,\u201d 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.<\/jats:p>","DOI":"10.1007\/s11739-026-04528-2","type":"journal-article","created":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T10:41:04Z","timestamp":1790246464000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Smoking cessation in emergency departments: a reality check"],"prefix":"10.1007","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8440-0121","authenticated-orcid":false,"given":"D.","family":"Campagna","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"F.","family":"Cucuzza","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C.","family":"Russo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J. 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Reduction Programme, an independent public health organization based in the UK and funded by Global Action to End Smoking, a US-based independent non-profit 501(c)(3) grant-making organization, for a project focused on oral health. The content of the present paper is unrelated to that project. She also received funding through the Tobacco Harm Reduction Scholarship Programme in 2024\/2025.\n                      RP\n                      is full tenured professor of Internal Medicine at the University of Catania (Italy) and Medical Director of the Institute for Internal Medicine and Clinical Immunology at the same University. He has received grants from U-BIOPRED and AIR-PROM, Integral Rheumatology & Immunology Specialists Network (IRIS), Global Action to End Smoking (formerly known as Foundation for Smoke-Free World), Pfizer, GlaxoSmithKline, CV Therapeutics, NeuroSearch A\/S, Sandoz, Merk Sharp & Dohme, Boehringer Ingelheim, Novartis, Arbi Group Srl., Duska Therapeutics, Forest Laboratories, Ministero dell Universita\u2019 e della Ricerca (MUR) Bando PNRR 3277\/2021 (CUP E63C22000900006) and 341\/2022 (CUP E63C22002080006), funded by NextGenerationEU of the European Union (EU), and the ministerial grant PON REACT-EU 2021 GREEN- Bando 3411\/2021 by Ministero dell Universita\u2019 e (MUR)\u2014PNRR EU Community. He is founder of the Center for Tobacco Prevention and Treatment (CPCT) at the University of Catania and of the Center of Excellence for the Acceleration of Harm Reduction at the same university. He receives consultancy fees from Pfizer, Boehringer Ingelheim, Duska Therapeutics, Forest Laboratories, CV Therapeutics, Sermo Inc., GRG Health, Clarivate Analytics, Guidepoint Expert Network, and GLG Group. He receives textbooks royalties from Elsevier. He is also involved in a patent application for ECLAT Srl. He is a pro bono scientific advisor for Lega Italiana Anti Fumo (LIAF) and the International Network of Nicotine Consumers Organizations (INNCO); and he is Chair of the European Technical Committee for Standardization on \u201cRequirements and test methods for emissions of electronic cigarettes\u201d (CEN\/TC 437; WG4). The other authors have nothing to declare.","order":1,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not Applicable.","order":2,"name":"Ethics","label":"Human and animal rights statement and Informed consent","group":{"name":"EthicsHeading","label":"Declarations"}}]}}