Project Summary/Abstract Quitting smoking at any age can have significant health benefits which extend beyond its well-recognized impact on cancer. The Fire Department of the City of New York (FDNY) World Trade Center Health Program (WTCHP) is situated within its occupational health clinics. All participants in the FDNY WTCHP low dose computed tomography (LDCT) lung cancer screening program have access to a free, tobacco cessation program (typically cessation counseling plus nicotine replacement treatment). While many are now former smokers, 36% of LDCT program participants continue to smoke. Novel strategies are needed to engage WTCHP members who continue to smoke into evidence-based smoking cessation treatment. In the proposed trial, participants in the FDNY WTCHP LDCT screening program who are retired from FDNY will be randomized to receive Standard Care: a letter with information about LDCT screening and the free FDNY Tobacco Cessation program including varenicline treatment and cessation counselling via telemedicine or Enhanced Care: a letter informing them that they will be enrolled in the FDNY Tobacco Cessation Program unless they opt-out, similar access to varenicline treatment, but coupled with individually-tailored telemedicine sessions with our tobacco treatment specialist using that person’s most recent LDCT results to personalize cessation messaging. All participants will receive varenicline “preloading,” i.e., four weeks of treatment prior to their target quit date followed by 12 weeks of treatment, an approach shown to decrease pre-quit tobacco- associated reward. Each of the essential elements of this Enhanced Care method: opt-out enrollment and individually-tailored biofeedback linked to LDCT results has been shown to be effective in other settings.1-5 This protocol is the first to combine these elements plus varenicline treatment with preloading in a randomized trial of high-risk smokers (defined as those meeting LDCT screening criteria plus WTC exposure) who have either not enrolled in tobacco cessation or not succeeded in previous quit attempts under Standard Care. We hypothesize that the FDNY Enhanced Care Program will be associated with both increased enrollment and improved rates of tobacco treatment outcomes compared with Standard Care. Specific Aim 1: To compare enrollment (participation in a first visit with our tobacco treatment specialist) in the FDNY Tobacco Cessation Program by Standard Care vs. Enhanced Care methods. Specific aim 1a: To evaluate demographic and clinical characteristics associated with FDNY Tobacco Cessation Program enrollment. Specific Aim 2: To compare outcomes (retention to study end-date, varenicline and counseling adherence and tobacco quit rates) in the FDNY Tobacco Cessation Program by Standard Care vs. Enhanced Care methods. Specific Aim 2a: To evaluate demographic and clinical characteristics associated with tobacco treatment outcomes.