tobacco-use cessation lead clinician to be the point of contact for all clinical and other communications on tobacco cessation. However, the committee finds that this position is typically not full-time, and the lead clinician may have other responsibilities that take precedence. The committee also finds that the availability of tobacco-cessation services in VA community-based outpatient clinics (CBOCs), other than the required access to medications and brief counseling, is highly variable: some CBOCs have trained staff who offer group or individual counseling, and others only refer patients to outside community services.

Use of the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use has been encouraged by the VA Office of Public Health Policy and Prevention, and it has been included in its National Smoking and Tobacco Use Cessation Program. The guideline highlights the effectiveness of using the 5 A’s for each patient. VA has been successful in ensuring that all patients are asked about their tobacco status, are advised to quit, and are referred to a tobacco-cessation program; these prompts are included in patients’ electronic medical records and are performance metrics for evaluating VA health-care providers. However, adherence to the guidelines beyond the minimal effort required by the prompts in the medical records is variable.

VA appears to offer a broad array of tobacco-cessation counseling interventions to patients, but there is little information on the effectiveness of these interventions for veterans. The guideline does not specify particular tobacco-cessation programs to be used, and VA uses several standard programs, including those of the American Cancer Society and the American Lung Association, in addition to the procedures in the guideline. The committee does not know whether VA tailors the programs to address special needs of veterans.

The VA/DoD clinical-practice guideline and the PHS guideline provide recommendations for evidence-based treatment of special populations that seek medical care at the VA. These populations include older patients, hospitalized patients, and patients who have mental-health disorders. The committee believes that the guidelines provide a good treatment framework.

The committee believes that veterans would benefit from a national VA quitline for tobacco, possibly supplemented by a computer-based cessation campaign similar to the DoD “Quit Tobacco. Make Everyone Proud” Web site. A national quitline has the advantage of consistency of service regardless of where veterans are. Quitline counselors should be trained to deal with veteran-specific issues, such as PTSD. Evidence shows that people who have mental-health disorders may be willing and able to engage in tobacco cessation and should be encouraged to do so. The committee believes that VA should assess



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