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Implementing tobacco interventions in the real world of managed care
  1. Jack F Hollisa,
  2. Richard Billsa,
  3. Evelyn Whitlocka,
  4. Victor J Stevensa,
  5. John Mulloolya,
  6. Ed Lichtensteinb
  1. aCenter for Health Research, Kaiser Permanente, 3800 N Interstate Avenue, Portland, OR 97227-1110, USA, bOregon Research Institute, Portland, Oregon, USA
  1. Dr Hollishollisja{at}

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Over the years we have been working to develop, test, and implement tobacco control interventions as a part of routine care within Kaiser Permanente. Most of our work has been in Kaiser Permanente's northwest division, based in Portland, Oregon, but we have also implemented similar approaches in several other divisions, including Ohio, Hawaii, and Georgia. I will first describe our general approach, which we call the TRAC model (“tobacco reduction, assessment, and care”), and then share both our progress and some very real difficulties we have encountered in trying to implement the program throughout the health care system.

The rationale for delivering brief tobacco intervention during routine care is familiar to those who work in cessation.1 Tobacco remains the most important cause of preventable disease. We know that most smokers see clinicians frequently, and that these visits create teachable moments when patients are receptive to advice and intervention. When we routinely ignore these intervention opportunities, we are, in effect, failing our patients. Indeed, meta-analyses from the Agency for Health Care Policy and Research (AHCPR) clinical guideline2 show that brief advice and support lead to modest but consistent long term effects on smoking cessation. We also know that brief tobacco interventions are among the most cost effective of all medical care procedures we routinely offer.3 4 It is for these reasons that the Health Plan Employer Data Information Set (HEDIS) and other quality monitoring groups are holding health care systems accountable for addressing tobacco during clinical care. For me, however, the most important reasons to offer cessation advice and assistance are that our patients want, need, and expect this kind of support.

How are we doing as a nation in delivering cessation advice during medical care visits? Figure 1 displays time trend data5 from the National Household …

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