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

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. DESIGN: Extrapolation from experience in improving the quality of smoking cessation care in the Veterans Health Administration (VHA) to propose a conceptual framework describing the stages for improving the reach and effectiveness of organisations’ tobacco control efforts. SETTING: United States Department of Veterans Affairs healthcare system. KEY MEASURES FOR IMPROVEMENT: Improved rates of screening patients for smoking status, advising smokers to quit, and helping smokers with a quit attempt. STRATEGIES FOR CHANGE: The framework identifies four stages of organisational change during quality improvement for smoking cessation. In stage 1, no system exists to structure tobacco cessation care. Stage 2 is characterised by a systematic approach to asking about smoking and advising tobacco users to quit. In stage 3 there is an organised approach to helping tobacco users quit at their healthcare visits. The final stage focuses on providing tailored help for smoking cessation to the entire population within a healthcare system. EFFECTS OF CHANGE: By moving from stage 1 to stage 3, the VHA greatly improved tobacco use screening rates and tobacco counselling rates. Although prescription rates for smoking cessation drugs have shown a promising rise over the past four years, it is too early to evaluate the effect of system changes on the VHA’s rate of helping smokers to quit. LESSONS LEARNT: Six key lessons can be drawn from the VHA’s experience with improving tobacco control: tobacco control is a system issue; practice guidelines are necessary; measuring performance is essential; performance measures should be tied to incentives; achieving guideline adherence requires additional system support; and best practices should be systematically identified and disseminated. Healthcare organisations as well as small practices can adapt these lessons to improve treatment for smokers, and the lessons can be modified to improve care delivery for other conditions, such as alcohol misuse and depression.

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Full citation:
Sherman S (2008).
A framework for tobacco control: lessons learnt from Veterans Health Administration
BMJ, 336, 1016-1019. doi: 10.1136/bmj.39510.805266.BE. PMCID: PMC2364861.