Abstract: Objective: Tobacco dependence treatment (TDT) should be offered to all lung cancer screening (LCS) participants who smoke. We sought to examine the provision of TDT among patients referred for LCS. Methods: We performed a multi-center, retrospective observational analysis of patients referred for LCS at seven regionally-affiliated Veterans Affairs Medical Centers and associated clinics from 9/2022-9/2023. We identified LCS referrals and tobacco use using administrative data. We extracted TDTs (+/- 45 days from referral or Low-dose computed tomography [LDCT]) including medications and tobacco-related visits (TRVs). Outcomes included any pharmacotherapy, any TRV, and combined TDT (pharmacotherapy + two or more TRVs). Results were analyzed using generalized linear mixed effects models. Results: 9319 patients were referred for LCS, of whom 58.6 % currently smoked. Of those, 47.9 % resided in rural areas, 6.9 % were Black, 6.7 % were female; mean age was 67.7. Among those who currently smoked, 17.4 % received any pharmacotherapy, 13.6 % had at least one TRV, and 6.4 % had combined TDT. Participants in the LCS program were significantly more likely to receive medications around the time of the initial LDCT, with odds ratios (OR) < 1 for all comparison groups: interval scan OR 0.60 (95 %CI 0.48,0.76) no scan OR 0.65 (95 %CI 0.52,0.83), subsequent annual scan OR 0.59 (95 %CI 0.46,0.75). This pattern held for all three outcomes. Rural-residing individuals were less likely to have a TRV or receive combined TDT. Conclusions: We found low rates of TDT and a concerning drop off in treatment after initial LDCT. Failure to address tobacco throughout the longitudinal process represents a missed opportunity. Primary funding source: Veterans Affairs Quality Enhancement Research Institute (PII I50 HX003692-01) and a Health Systems Research Career Development Award (CDA 19-180).