April 26, 2011

The Department of Veterans Affairs (VA) has a long history of attempting to reduce smoking among veterans and has worked very hard to make evidence-based smoking cessation a routine part of the health care it provides.  Smoking prevalence among veterans enrolled for outpatient care in 2010 was under 20%, down significantly from a prevalence of about 33% in 1999.  Outpatients with co-morbidities in the mental health clinics had a 39% smoking prevalence.  This differential is also seen in other populations.

The Veterans Health Administration (VHA) is the arm of the VA that provides health care for about 6 million veterans  in medical centers, community-based outpatient clinics, nursing homes, readjustment counseling centers (Vet Centers), and domiciliaries (facilities providing residential  rehabilitation and health maintenance programs).  The veterans it serves are among those at high risk for smoking.  Many of the veterans carry over tobacco use from their service in the military, where use is higher relative to the general population.  The fact that people who have not started smoking by age 18 are unlikely to smoke as adults does not hold for those in the military.  Many non-smokers begin to smoke after they join the military.  This is the population that the VA serves.

Responsibility for smoking and tobacco use cessation is assigned to the Public Health Strategic Health Care Group of the VHA.  This group has undertaken a number of policy initiatives to make smoking cessation counseling and medications more accessible to veterans.  The 2008 U.S. Clinical Practice Guidelines: Treating Tobacco Use and Dependence were adopted by the VA and the Department of Defense two years ago.  All FDA-approved smoking cessation medications are available on the VHA National Formulary.  Veterans with a service-connected disability or condition or who have an income below a certain threshold do not have a co-pay for medication.

To help veterans quit smoking and tobacco use, the VA offers screening for tobacco use during primary care visits; individual counseling;  prescriptions for nicotine replacement therapy, such as a nicotine patch or gum, or other medications; and participation in evidence-based smoking cessation programs.  All outpatients in Primary Care and Mental Health clinical settings are screened at least once a year for tobacco use in the last 12 months.  If the patient is a current user, he or she is provided with brief counseling, offered medications to assist with quitting, and offered a referral for more intensive counseling. 

An electronic clinical reminder is used to give a prompt to the provider on how to offer the appropriate care and then document the encounter in the electronic medical record.   Electronic medical records facilitate promotion of cessation by providing electronic reminders to check for smoking status.  Prompts can help providers work with the patient to set a quit date, offer medication to help with quitting, encourage patients to get rid of tobacco products in the home, and similar tips.  These real time prompts are very useful, especially for those providers not trained in tobacco cessation and also for those in busy primary care practices.

A recent review of medical charts found that of the veterans seen in outpatient mental health or primary care settings who reported tobacco use in the last 12 months, 90% were provided with brief counseling and offered smoking cessation medications and additional referrals for more intensive counseling to help them quit tobacco use.

One recent VA initiative has helped expand the reach of cessation services for veterans.  Following on the 2009 Institute of Medicine study, “Combating Tobacco in Military and Veteran Populations,” the Department of Defense/TRICARE has partnered with the VA to give veterans access to their tobacco cessation website including online tools, personalized quit plans and live chat services.  The ”Quit Tobacco, make everyone proud”  Web site is available 24/7 for veterans who want help with quitting.  It was developed to appeal to younger populations of service members and veterans, such as those concerned about being role models for their children and worried about physical fitness and stamina.  The site has a special section for VA veterans.

Another initiative is working to integrate smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD).  A study of over 900 smokers with military-related PTSD published in the December 8, 2010 issue of JAMA, ‘Integrating tobacco cessation into mental health for posttraumatic stress disorder: A randomized controlled trial’, by Drs. Miles McFall and Andrew Saxon and associates, found that the integrated service was twice as effective as referral to specialized cessation service.  The VA is now working to train mental health care professionals to integrate cessation into the care they are already providing and to make broadly available the model developed for the study.  Because the health care providers have already established therapeutic relationships with these patients, they can help with preventing relapse in these difficult-to-treat patients.  They are enthusiastic about working on this effort to decrease smoking among PTSD patients.

Based on her experience with the VA smoking cessation program, Kim Hamlett-Berry, PhD, Director, Public Health Policy and Prevention, Public Health Strategic Health Care Group, VHA, has some important lessons learned to share with those who want to integrate cessation in health care settings.  She has identified:

• The need to identify and eliminate barriers to cessation care.
• Provide models of care that can be integrated easily into the care that is already delivered.
• Adopt a public health approach to extend the reach of tobacco cessation care so that all care providers, not just specialists, are involved:
  ◦ Work with mental health and substance use disorder providers to help them with integrating smoking cessation treatment into routine care.
  ◦ Enlist health care professionals other than physicians.
• Electronic health records with a readily identifiable field to determine current smoking status can be an important tool in prompting providers and documenting care.
• Develop gender-specific messages to appeal to women who smoke and want help with quitting.

Dr. Hamlett-Berry also stresses the importance of providing training for health care professionals.  She notes that many health care providers do not receive any training in evidence-based tobacco cessation as part of their formal curriculum. As a result, they may not know the basics and if they do, they may not be confident in their ability to deliver care.  Training is an important tool in addressing health care professionals’ attitudes about the efficacy of tobacco cessation care and in helping them recognize this as a chronic, relapsing disorder.