Table 1 Systems change strategies chosen by each system

Identification and documentation (required): Implement a clinic-wide system that ensures for every patient at every clinic visit, tobacco-use status is queried and documented.

Training and education: provide adequate training, resources and education to motivate clinic personnel to address tobacco and increase tobacco treatment knowledge and skills.

Referrals: establish a referral system for tobacco users interested in counseling. Referrals can be internal and/or to external, evidence-based cessation services as is most appropriate for the patient population being served by the system.

Brief interventions: Institutionalize brief tobacco cessation interventions into clinic protocols.

Reporting and feedback: Establish a reporting and feedback system that facilitates regular retrieval of and consistent feedback on tobacco use and treatment data to clinic personnel and that can be used to track tobacco-related performance measures and quality improvement initiatives.

Follow up care: systematically follow up with patients who receive brief tobacco cessation interventions or referral to cessation services to determine actual provision of services and ongoing needs.

System integration: Integrate tobacco cessation approaches into disease management protocols.

Quality improvement, Accreditation and Standards: Systematically integrate tobacco cessation strategies into existing programs or initiatives that address quality improvement, accreditation and evaluative standards in a way that will lead to improvements in the use of selected cessation strategies.

Organizational goals and policies: Ensure that organizational goals and policies related to tobacco cessation are consistent and supportive of systems change strategies and activities.

Hospital policies and services: Implement hospital policies that support and facilitate inpatient tobacco dependence services.

Performance measures and follow up: provide regular feedback to clinic personnel to ensure providers consistently deliver effective tobacco cessation treatment or referrals as per the established protocol.

Reimbursement: if relevant, establish a system to consistently seek and obtain reimbursement for tobacco cessation services.

Tobacco cessation coverage: Improve patient education about and use of existing cessation benefits (counseling and medication).