Although the development and publication of a national evidence based clinical guideline for smoking cessation from the Agency for Health Care Policy and Research (AHCPR)1 has clarified the approach that should be used in medical practice settings, clinicians are still a long way from following it consistently.2-7 Cromwellet al have studied the cost effectiveness of applying the recommendations in the AHCPR guideline and concluded that at $1915 per quality adjusted life year, it is one of the most cost effective of all preventive services.8

However, if we are to realise the potential that clinicians have to facilitate cessation and achieve these health and life gains, we shall have to find some way to make large changes in the current behaviour of clinicians. One of the obvious resources for stimulating this type of change is the managed care health plans that have contracts with most of the primary care clinics in the country.9 If the excess medical costs of smokers to the age of 65 years are really $9000 to $11 000,10 Cromwell calculates that the medical care savings per quitter should average about $6000 per quitter.8 If so, and if health plans could count on enough member continuity to achieve some portion of those savings, they would have a real incentive to try to change clinician behaviour in this area.

Fortunately, it is now also becoming clear what types of changes will lead to more effective implementation of this guideline. As with the implementation of any guideline, simple educational efforts will have little effect.11 12 Instead, office systems that start with making identification of smoking status a vital sign are clearly the key to consistent adherence to the guideline.13-20

Thus, the question becomes what can a health plan do to try to …