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

doi:10.1136/bmj.39510.805266.BE

BMJ 2008;336:1016-1019 (3 May), doi:10.1136/bmj.39510.805266.BE

Practice

Quality Improvement Report

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

Scott E Sherman, associate professor of medicine¹

¹ VA New York Harbor Healthcare System/New York University School of Medicine, New York, NY 10010, USA

Correspondence to: S E Sherman, VA New York Harbor Healthcare System (111), 423 East 23rd Street, New York, NY 10010 scott.sherman@med.nyu.edu

The first 150 words of the full text of this article appear below.

Despite considerable progress, smoking remains the leading preventablecause of death in the United States, responsible each year for435 000 deaths¹ and $157bn (£79bn; ${euro}$ 103bn) in health relatedlosses.² Each pack of 20 cigarettes leads to $3.45 in medicalexpenditures and $3.73 in lost productivity.² When Macioseket al recently prioritised 25 preventive interventions, factoringin burden of disease and cost effectiveness, tobacco controlwas tied for the top priority, and better screening followedby brief intervention yielded a greater benefit in quality adjustedlife years than the next 10 interventions combined.³ Similarly,the Institute of Medicine recently identified improving treatmentfor tobacco use as one of the top 20 healthcare priorities.⁴⁵

No clear guidance exists for improving the performance of ahealthcare system to the goals set by Maciosek.³ The PublicHealth Service guidelines suggest that providers focus on fivesteps, outlined in figure 1,⁶ and these . . . [Full text of this article]

Abstract

A four stage framework for tobacco control

Stage 1—no system for tobacco control
Stage 2—systematic screening
Stage 3—systematic treatment
Smoking cessation strategies used at VHA
Stage 4—population health

Lessons learnt

Tobacco control is a systemissue
Practice guidelines are necessary
Measuring performance is essential
Performance measures must be tied to incentives
Achieving adherence to guidelines requires additional system support
Systematically identify and disseminate best practices