A framework for tobacco control: lessons learnt from Veterans Health Administration

In this article, I describe how the Veterans Health Administration (VHA; one of the largest managed care organisations in the United States) has carried out a large scale quality improvement and system change in tobacco control.This created a framework for how organisations approach tobacco control, moving through four increasingly complex stages (table 1).By anticipating these stages and approaching the challenges of each in sequence, systems may be able to set goals for quality improvement appropriate to their levels of readiness.A four stage framework for tobacco control Stage 1-No system for tobacco control The chief feature of the first stage (in the VHA, before 1996) is the lack of a system.Providers act independently and care is haphazard, with major variations between sites and between providers.Before the 1990s, smoking cessation was not a high priority for the VHA.Though many medical centres had smoking cessation programmes, few offered drugs for cessation.All facilities were required to have a smoking cessation coordinator, but this role was not clearly or consistently defined.Nor was there a system for collecting data on clinical performance.The only data available were from researchers.Within the VHA, it was difficult to determine the answers to basic questions, such as the percentage of patients who use tobacco, how many were screened or advised to quit, and whether smokers were offered counselling or treatment.What led to the transition to the next stage was the mandated use of evidence based guidelines and measurement of the level of adherence.Stage 2-Systematic screening Stage 2 (in the VHA, 1996-2002) is characterised by an organised approach to asking about smoking and advising smokers to quit.Practice guidelines advocate systematically asking about smoking at every visit, and Abstract Problem Existing clinical guidelines provide recommendations for treating smokers but little guidance on how to implement changes that will improve the delivery of smoking cessation care.