approved medications as a TRICARE Prime preventive services benefit” (D.2); to “support partnership with TRICARE managed care support contractors to identify interventions that work and to facilitate tobacco-use avoidance education” (D.2.3); and to “assess installation tobacco-cessation programs for flexibility to accommodate individual needs, to include: individual or group contact, recognition of problems encountered in quitting (skills training), at least 4 encounters and encouragement to use [NRT] appropriately [and] prepare policy recommendations as necessary” (D.2.4).

With the publication in 2000 of the clinical-practice guideline Treating Tobacco Use and Dependence sponsored by the Public Health Service (PHS), DoD and VA established a working group to develop a similar guideline that would provide guidance to health-care providers in the MHS and the VA health-care system on assessment of, and treatment for, tobacco use in the military and veteran populations served by these systems. The resulting VA/DoD Clinical Practice Guideline for the Management of Tobacco Use, published in 2004, met that need by providing guidance on treatment for tobacco use in military and veteran populations and addressed Requirement D.2 of the strategic plan (VA/DoD, 2004). The VA/DoD guideline adheres closely to the 2000 PHS clinical-practice guideline (Fiore et al., 2000). The VA/DoD guideline presents evidence-based recommendations for assessment and treatment of military personnel and veterans and for prevention of tobacco use, and it includes several appendixes that provide specific information on counseling strategies and techniques, medications, and relapse prevention.

Behavioral Interventions

DoD follows the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use to determine which behavioral interventions should be offered by the MHS. For veterans who are tobacco users, the VA/DoD guideline advocates the 5 A’s (ask, advise, assess, assist, and arrange). It also recommends the most intensive counseling that a patient is willing to attend—four or more sessions of at least 10 minutes each, with brief counseling (under 3 minutes) as a minimal intervention. The guideline indicates that there is a dose–response relationship between the length of counseling and the rate of abstinence. It states that effective counseling can be conducted in person or by telephone and that both group and individual counseling are effective when delivered in multiple sessions of sufficient duration. Self-help materials are also suggested for patients who receive brief

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