TED MARCY (Pulmonary physician, University of Vermont): I have been impressed that interventions that are aimed at current smokers are often based on behavioural theories. Are we working on using interventions aimed at other important targets such as physicians and administrators? And are those interventions also based on behavioural theories—such as social learning theory, and the stages of change?

SUSAN CURRY: That is an easy question to answer: yes. It’s important to go back to the individual level principles, those which pertain to getting providers to change their behaviour, as well as those which involve individuals. If you examine the methods we have described—one size does not fit all. It is important to tailor programmes to the clinics which they serve. It is also important in helping to change provider behaviour that we help them adopt the kind of perspective which we have with behavioural interventions. This is a process which unfolds over time. Attention must be paid to how people identify intermediate success markers which will keep them engaged in the process.

MICHAEL FIORE: In the AHCPR guideline, interventions at various levels are described, along with the research supporting them—at the provider level and at the system level. There are a variety of modalities to change and promote smoking cessation interventions.

ROB SIMMONS (Christiana Care, Wilmington, Delaware): Are there any differences in clinical practice guidelines or system changes related to smokeless tobaccovs cigarette smoking? Secondly, the directors and leaders in our managed care organisation are very supportive in building consensus around tobacco, but they raised the question: “If we did this in a real systematic way, wouldn’t we also have to address nutrition education, lipid management, stress reduction and physical activity as major health promotion components? Wouldn’t the cost be very significant?”

MICHAEL FIORE: Unfortunately, there is a …