Denver Health has had outpatient cessation classes in the community health centres since the early 1980s. In 1994, we convened a tobacco control committee to address issues such as a tobacco free campus, smoking status assessment as a fifth vital sign, and publication of a tobacco control newsletter. In 1996, when nicotine gum had already gone over the counter (OTC) and nicotine patches were about to become OTC, our payers were deciding not to cover most OTC products. Our challenge was to convince two groups—the hospital pharmacy committee and the Medicaid managed care organisation—that nicotine replacement therapy should be covered. Our approach was to suggest that patches, when used in conjunction with outpatient counselling, are very cost effective—in the order of 10 times more cost effective than screening for hypertension. Knowing that both groups would want to contain costs, we proposed to put the controls on patch distribution listed in table 1. Interestingly, it was in the process of developing these restrictions that we finalised our plans for an inpatient tobacco intervention service (TIS).