Combating Tobacco Use in Military and Veteran Populations (2009) / Chapter Skim
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6 DEPARTMENT OF VETERANS AFFAIRS TOBACCO CONTROL ACTIVITIES
6 DEPARTMENT OF VETERANS AFFAIRS TOBACCO CONTROL ACTIVITIES
Pages 263-306
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. VA employs almost 280,000 people, the overwhelming majority of them in the Veterans Health Administration (VHA)
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. Veterans Health Administration VHA is charged with providing medical and rehabilitation services to veterans, medical research, graduate medical education, and emergency management.
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The number of veterans enrolled in VA health care grew from 4.18 million in 1999 to 7.42 million in 2004, and VA's medical budget grew from about $20 billion in 1999 to about $28 billion in 2004 (Congressional Budget Office, 2005)
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From page 266... ...
It has provided support for several VA tobaccocontrol initiatives, such as the elimination of copays for tobaccocessation counseling, the need for smoke-free VAMC facilities, and activities to increase tobacco cessation among VA employees. Finding: The NLB has the authority and expertise to develop and encourage the implementation of a VA-wide tobacco-control strategic plan and to ensure that VA leadership is engaged in the success of the plan.
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From page 267... ...
of VA health-care practitioners from the VISNs that provides consultation and expert advice on best practices in tobacco-use cessation for veteran populations, on the health effects of tobacco use and related illness, and on new treatment services. Those practitioners represent pulmonary and critical care, primary care, preventive medicine, mental health, and substance-use treatment and are administrators, researchers, and educators, including a representative of the Pharmacy Benefits Management Strategic Health Care Group.
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268 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS TABLE 6-1 Veterans Integrated Service Networks and Numbers of Facilitiesa Hospitals and Other Medical Outpatient Veterans Other VISN Centers CBOCs Clinics Centers Facilitiesb VISN 1: New 11 18 0 21 0 England VISN 2: Upstate 6 29 0 6 0 New York VISN 3: New 8 28 0 12 1 Jersey, New York VISN 4: Stars 12 47 0 13 0 and Stripes VISN 5: VA 5c 15 0 9 0 Capitol VISN 6: Mid- 8 13 5 10 Atlantic VISN 7: 9 31 3 9 0 Southeast VISN 8: 8c 39 8 19 2 Sunshine VISN 9: Mid- 9 30 6 11 0 South VISN 10: Ohio 5 29 3 6 0 VISN 11: 8 23 22 9 0 Partnership VISN 12: Great 7 0 33 9 0 Lakes VISN 13 and 14: now 23 VISN 15: 9 42 1 7 0 Heartland VISN 16: South 11 32 14 13 0 Central VISN 17: Heart 7c 18 11 9 0 of Texas VISN 18: 7 41 1 14 0 Southwest
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CBOCs were established in the 1990s to provide access to, and continuity of care for, underserved veteran populations, many of them in
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; elimination of copayments for smokingcessation counseling; and integration of smoking cessation into care for the growing veteran mental-health population. The VA has developed training programs to educate mental-health providers on integrating tobacco cessation in the treatment of mental-health disorders (HamlettBerry et al., 2009; VA, 2006c)
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From page 271... ...
The key components already in place -- including many effective and enforceable policies, communication mechanisms, surveillance activities in the form of performance measures, and periodic evaluation of tobacco-control practices throughout the VISNs -- can be leveraged to expand and coordinate tobacco-control activities throughout VA. The agency lacks a strategic plan, senior leadership that believes that tobacco cessation should have high public-health priority for VA, a dedicated funding source for tobacco-control activities, and innovative approaches for raising veterans' awareness of available tobacco-cessation services.
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. VHA Directive 2008-081 mandates that the director of each VAMC designate a smoking and tobacco-use cessation lead clinician to be the point of contact for all clinical and other communication on tobacco cessation.
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Although the PHSHCG is the VA organizational lead for tobacco-use cessation programs, unless the secretary of veterans affairs and the Executive Office of the administration are actively concerned with the issue, individual VISNs are unlikely to be completely engaged in tobaccocontrol programs. Finding: VA has adopted several tobacco-control policies and programs, including its National Smoking and Tobacco Use Cessation Program, but they are not comprehensive, and implementation varies among VISNs, VAMCs, and CBOCs as a result of organizational discrepancies, lack of accountability, and inadequate funding.
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There are also Web sites for specific VA health-care facilities with information on tobacco cessation, but the pages are not easily accessed through the VA home page and require the user to search for individual medical facilities. For example, the Web site for the Overton Brooks VA Medical Center in Shreveport, Louisiana, outlines how its smoking-cessation program
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From page 275... ...
, participants thought that VA should explore ways to promote tobacco cessation for veterans at VA medical facilities, including use of the My HealtheVet Web site. Suggestions for increasing participation in the programs included motivational videos in waiting rooms, audio messages for people holding on the telephone, and informational kiosks with computers that could show patients how the cessation programs work.
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From page 276... ...
required VA to establish and maintain either indoor smoking areas in VAMCs, nursing homes, and domiciliary-care facilities for veterans or detached smoking areas that are accessible to patients and have heating and airconditioning. Several VA circulars and directives specify who may use the smoking areas, but they vary to some degree by facility.
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Finding: VA has worked to develop and implement tobacco-free medical facilities; however, it has been hampered in its efforts by congressional mandates that require each VAMC to maintain a smoking area for veterans. The language of the Veterans Health Care Act of 1992 prevents VA from eliminating tobacco use at its medical facilities and thus prevents VA from following the national trend toward tobacco-free facilities, in which it was initially a leader.
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Tobacco-use cessation is one of the services offered to both inpatients and outpatients. After leaving active duty, veterans who participated in tobacco-cessation programs while on active duty in the military and want to continue in such programs must find new ones
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Evidence-Based Interventions The gold standard in VA for tobacco-cessation treatment is the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use. The guideline, published in 2004, is modeled on the 2000 Treating Tobacco Use and Dependence: Clinical Practice Guideline (Fiore et al.
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. Although the 2003 National Smoking and Tobacco Use Cessation Program stated that tobacco-cessation medications must be available for all patients regardless of whether they attend a tobaccocessation program, the 2005 Smoking and Tobacco Use Cessation Report suggested that some VAMCs were still restricting patients' access to NRTs and bupropion (VA, 2006b)
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The Provider Feedback Forum found that most patients were receptive to using varenicline, but a nonformulary request was required to prescribe it, although this practice may have changed. It was also noted that many VA pharmacies were not following National Formulary guidelines for varenicline, and this was preventing patients from receiving it.
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From page 282... ...
However, as noted in Chapter 4, the evidence base on the effectiveness of those treatments for longterm tobacco cessation in the general population and in veteran populations is unclear. Finding: VA has a long history of attempting to reduce smoking by veterans and has been responsible for numerous scientific advances regarding the health effects of smoking.
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Many of the smaller outpatient clinics and CBOCs that do not have staff available or trained to run tobacco-cessation programs cannot offer more than brief counseling and prescriptions and refer veterans to local health departments or state quitlines for more intensive counseling (Jean Beckham, VA, personal communication, July 18, 2008; Timothy Carmody, VA, personal communication, July 15, 2008; Clint McSherry, VA, personal communication, July 29, 2008)
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and the Quality Improvement Trial for Smoking Cessation (QUITS) study (Sherman et al., 2006a)
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. Primary-care providers' attitudes about tobacco cessation are strongly associated with the likelihood that they will counsel patients to quit tobacco use or refer them to a tobacco-cessation program; VA providers who perceived barriers to such counseling and referrals were less likely to use them (Meredith et al., 2005)
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. Finding: Many VA health-care providers are in a position to counsel patients about tobacco cessation, but many of them do not take the opportunity to do so because of lack of time and training.
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VA has conducted several demonstration programs for telephone counseling for tobacco-use and smoking cessation for veterans with trained VA counselors or external quitlines. The first program was TELESTOP, conducted at five VAMCs in the upper Midwest, which compared telephone care with usual care (mailed self-help materials and access to referral-based tobacco-cessation programs and medications)
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. Quitlines are effective in increasing tobacco cessation in veterans.
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. Finding: VA has conducted several short-term quitline demonstration projects that have shown that referring veterans to quitlines, particularly proactive ones with multiple counseling sessions, is more effective than usual care in promoting tobacco cessation.
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. The site provides information on self-management for tobacco cessation, but VA does not include tobacco use as one of its vital signs for veterans who may use the site to track their health.
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To provide such motivation and assistance, a veteran's health-care provider must be both knowledgeable about how to help patients quit tobacco and be consistent and comfortable in providing advice and referrals. Each VAMC has a smoking-cessation lead clinician trained in tobaccocessation services, but, as was shown in the 2005 Smoking and Tobacco Use Cessation Survey, no VAMC has a full-time staff member dedicated solely to tobacco cessation (VA, 2006b)
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The Preceptor Training Program trained over 160 preceptors representing all 21 VISNs in an integrated-care approach to incorporate tobacco-cessation treatments into mental-health treatment. Trainers monitored preceptors' progress at their medical facilities; preceptors were assisted in overcoming barriers to change through "best practices" information, site progress reports, consultations with peers and mentors during regular conference calls, and dissemination of patient-health promotion materials and provider-education videos, print materials, and Web-based materials (VA, 2006c)
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Reducing tobacco use in those populations poses a challenge to VA. The VA/DoD Clinical Practice Guideline for the Management of Tobacco Use addresses tobacco cessation in several special populations that are treated by VA, including pregnant women, hospitalized patients, older patients, and psychiatric and mental-health patients.
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VA continues to hold train-the-trainer national conferences on such topics as the PHS Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update. In 2004, VA sponsored a conference titled "VA in the Vanguard: Building on Success in Smoking Cessation" on best practices in tobacco cessation in veteran populations served by VA; it included a session on mental health and PTSD (VA, 2004)
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For many VA patients, the VA mental health-care provider is the de facto source of primary care. VA advocated an integrative approach to tobacco cessation for patients who have mental-health disorders in which mental healthcare providers address both the mental illness and tobacco use rather than referring patients to a separate tobacco-cessation program (VA, 2006c)
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The individual sessions were conducted during visits for PTSD or comorbid mental disorders. The integrated care was modeled on that given in the 2000 PHS clinical-practice guideline.
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Some VA cessation counselors, however, allow and even encourage veteran smokers to bring another person for support and to participate in cessation counseling sessions, but this practice is at the discretion of each counselor. The evidence shows that it is more difficult for a person to quit smoking if his or her spouse
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VA has also conducted surveys of tobacco use and control throughout its health-care system. In particular, the 2005 Smoking and Tobacco Use Cessation Report (VA, 2006b)
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The VA/DoD guideline and the 2008 PHS guideline for tobacco cessation recommend that VA health-care providers use the 5 A's for each patient. Before 2007, performance measures for VA health-care providers were based on whether patients were asked about tobacco use and whether they were advised to quit if they were users.
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This composite measure comprises "the evidence and outcomes-based measures for high-prevalence and high-risk diseases that have significant impact on overall health status. The indicators within the Index are comprised of several clinical practice guidelines in the areas of ischemic heart disease, hypertension, diabetes mellitus, major depressive disorder, schizophrenia, and tobacco use cessation.
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2001. Provider feedback improves adherence with AHCPR Smoking Cessation Guideline.
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2004. Pharmacist-managed tobacco cessation program in Veterans Health Administration community-based outpatient clinic.
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2005. National trends in the provision of smoking cessation aids within the Veterans Health Administration.
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2006. Integrating tobacco cessation treatment into mental health care for patients with posttraumatic stress disorder.
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2006b. Assessing the institutional approach to implementing smoking cessation practice guidelines in Veterans Health Administration facilities.
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2009b. Locations: Veterans Health Administration.
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