Despite considerable progress, smoking remains the leading preventable cause of death in the United States, responsible each year for 435 000 deaths1 and $157bn (£79bn; €103bn) in health related losses.2 Each pack of 20 cigarettes leads to $3.45 in medical expenditures and $3.73 in lost productivity.2 When Maciosek et al recently prioritised 25 preventive interventions, factoring in burden of disease and cost effectiveness, tobacco control was tied for the top priority, and better screening followed by brief intervention yielded a greater benefit in quality adjusted life years than the next 10 interventions combined.3 Similarly, the Institute of Medicine recently identified improving treatment for tobacco use as one of the top 20 healthcare priorities.4 5

No clear guidance exists for improving the performance of a healthcare system to the goals set by Maciosek.3 The Public Health Service guidelines suggest that providers focus on five steps, outlined in figure 1⇓,6 and these are also relevant for healthcare systems. Systems that more consistently deliver these “5 A’s” to patients are providing better quality care for smoking cessation. The guidelines also include recommendations for healthcare systems (every clinic should implement a system to identify tobacco users, for example), but these are individual items rather than an approach to improve organisational performance. The task for healthcare systems is how to increase delivery of the five steps.

In this article I use the VHA’s experience with large scale quality improvement and system change in tobacco control to create a framework for how organisations approach tobacco control, moving through four increasingly complex stages, from no system for tobacco control to a system that provides tailored smoking cessation care to the entire population. By anticipating these stages and approaching the …