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DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES

The Department of Veterans Affairs (VA) is responsible for providing health care and benefits to veterans and their dependents. Given the growing number of veterans leaving active military service and the recent rise in the proportion of these veterans who use tobacco, tobacco-cessation services will be an increasingly important element of VA programs. This chapter describes the services offered by VA, its structure and resources, and the population it serves with a view to identifying opportunities for improving and coordinating tobacco-control programs.

VA estimates that there are about 24 million living veterans, many of whom have served in a US military conflict. Living veterans, their spouses and dependent children, and survivors of deceased veterans make up about 20% of the US population (VA, 2008a). VA provides health care, disability compensation, pensions, assistance with education and training, home-loan assistance, life insurance, vocational rehabilitation, and burial benefits to eligible veterans. In 2007, about 7.8 million veterans were enrolled in the VA health-care system (see Chapter 2 for a description of eligibility requirements for enrollment in the system), and 5.5 million individual veterans were treated (VA, 2008b). VA’s fiscal year (FY) 2009 spending is projected to be about $93.4 billion, including $40 billion for health care, $46.9 billion for benefits, and $230 million for the national cemetery system (VA, 2009a). VA employs almost 280,000 people, the overwhelming majority of them in the Veterans Health Administration (VHA). VA’s other two service organizations are the Veterans Benefits Administration and the National Cemetery Administration.

ORGANIZATIONAL OVERVIEW

In this section, the committee briefly describes the organizational structure of VA with an emphasis on identifying where responsibilities



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6 DEPARTMENT OF VETERANS AFFAIRS TOBACCO- CONTROL ACTIVITIES The Department of Veterans Affairs (VA) is responsible for providing health care and benefits to veterans and their dependents. Given the growing number of veterans leaving active military service and the recent rise in the proportion of these veterans who use tobacco, tobacco-cessation services will be an increasingly important element of VA programs. This chapter describes the services offered by VA, its structure and resources, and the population it serves with a view to identifying opportunities for improving and coordinating tobacco-control programs. VA estimates that there are about 24 million living veterans, many of whom have served in a US military conflict. Living veterans, their spouses and dependent children, and survivors of deceased veterans make up about 20% of the US population (VA, 2008a). VA provides health care, disability compensation, pensions, assistance with education and training, home-loan assistance, life insurance, vocational rehabilitation, and burial benefits to eligible veterans. In 2007, about 7.8 million veterans were enrolled in the VA health-care system (see Chapter 2 for a description of eligibility requirements for enrollment in the system), and 5.5 million individual veterans were treated (VA, 2008b). VA’s fiscal year (FY) 2009 spending is projected to be about $93.4 billion, including $40 billion for health care, $46.9 billion for benefits, and $230 million for the national cemetery system (VA, 2009a). VA employs almost 280,000 people, the overwhelming majority of them in the Veterans Health Administration (VHA). VA’s other two service organizations are the Veterans Benefits Administration and the National Cemetery Administration. ORGANIZATIONAL OVERVIEW In this section, the committee briefly describes the organizational structure of VA with an emphasis on identifying where responsibilities 263

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264 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS and activities related to tobacco control reside. The relevant structure includes VHA, which provides health care for veterans; the National Leadership Board (NLB, a senior advisory group); the Public Health Strategic Health Care Group (PHSHCG) in VA headquarters, which develops policies and programs related to several major public-health concerns, including tobacco; and the Veterans Integrated Service Networks (VISNs, the regional units that administer VA health facilities). Veterans Health Administration VHA is charged with providing medical and rehabilitation services to veterans, medical research, graduate medical education, and emergency management. The VHA mission has shifted since the 1990s from a focus on inpatient care toward outpatient care. The changing focus has been reflected in the growth of outpatient clinics in the VA medical centers (VAMCs) and community-based outpatient clinics (CBOCs) to serve veterans who do not live near VA medical centers. VHA continues to provide long-term care for veterans in VA nursing homes and state-owned and -operated veterans’ homes, and contract care in private nursing homes, home health services, and adult day care. VHA does not provide health-care services for dependents or survivors of veterans, with a few exceptions. VHA is directed by the VA under secretary for health, who reports to the secretary for veterans affairs, a member of the Cabinet. Headquarters staff report to the principal deputy under secretary for health, as does the deputy under secretary for health for operations and management (see Figure 6-1). The VA health-care system provides direct health care, including outpatient and inpatient services. Veterans who enroll in the VA health system are assigned to one of eight priority groups (see Chapter 2, Box 2-8, for a description of the priority groups) on the basis of whether they have service-connected disabilities and on the basis of their income. Veterans who have medical conditions related directly to military service, those with lower incomes, and those who are uninsured are given higher priority than those with higher incomes or non–service- connected disabilities. Reservists and National Guard members who are called to active duty by a federal executive order may qualify for VA health-care benefits. Returning service members, including reservists and National Guard members who served on active duty in a theater of combat operations (for example, Iraq and Afghanistan), have special eligibility for hospital care, medical services, and nursing-home care for 5 years after discharge from active duty.

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265 DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES Secretary -------------------- Deputy Secretary Under Secretary for Health Veterans Health Administration Principal Deputy Under Secretary for Health -------------------- Assistant Deputy Under Secretary for Health for Clinical and Organizational Support Chief Public Health and Deputy Under Secretary for Health Environmental Hazards Officer for Operations and Management 21 VISN Directors FIGURE 6-1 VA organizational chart for tobacco-control responsibilities. SOURCE: Adapted from VA (2008c). VHA is a discretionary program and thus relies on annual budget appropriations from Congress. 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). If, in a given year, VA does not have sufficient funds to care for all enrollees, care is allocated to higher-priority groups first; when necessary, VA can freeze enrollment of veterans in lower-priority groups. The Congressional Budget Office notes that only a small fraction of eligible veterans are enrolled in the VA health-care system; about 20% of veterans in priority groups 7 and 8 were enrolled in 2004 (Congressional Budget Office, 2005). Many veterans are enrolled in private health-insurance programs through their employers or receive Medicare or Medicaid; some veterans have no insurance but have not enrolled in the VA system. Over 78% of

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266 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS enrollees have some type of public or private health insurance: 40.7% are covered by Medicare B, 25.9% by Medigap, 16.2% by a health- maintenance organization (HMO) or managed care, 11.6% by non-HMO or non–managed-care insurance, and 9.4% by Medicaid (VA, 2006a). Of veterans eligible for VHA medical care as of 2004, including enrolled and nonenrolled veterans, priority groups P1, P2, P3, and P4 together made up only 13% of the total veteran population. Most veterans are in priority groups P8, P7, and P5—37%, 22%, and 24%, respectively (Congressional Budget Office, 2005). National Leadership Board The VHA NLB was established by VA Directive 2008-035 to serve as a forum to advise the under secretary for health regarding the department’s mission, goals, and priorities. According to the directive, the NLB has “an active and extensive role in determining VHA policy, strategy, and oversight of organizational performance [and in] determining standards and measures for organizational performance, including financial performance, and ensuring that those standards and measures are met” (VA, Directive 2008-035, 2008). The NLB comprises the under secretary for health, all directors of VISNs, all chief officers, and other senior leaders. It has provided support for several VA tobacco- control initiatives, such as the elimination of copays for tobacco- cessation 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. Public Health Strategic Health Care Group National oversight of tobacco-use cessation and tobacco-control policy and advocacy for tobacco control resides in the PHSHCG in the Office of the Chief Public Health and Environmental Hazards Officer (see Figure 6-1). The Public Health National Prevention Program, directed by the PHSHCG, is responsible for developing and overseeing public-health policy and clinical programs in VHA related to smoking and tobacco-use cessation. In headquarters, the director of the National Prevention Program is the primary staff member working on tobacco issues. The director administers a budget that includes policy development, dissemination, and training and is also responsible for

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267 DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES non–tobacco-related programs, such as human immunodeficiency virus prevention. The director of the National Prevention Program is assisted by a technical advisory group (TAG) 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. The TAG has monthly conference calls to discuss tobacco-related issues and meets twice a year; it also can arrange emergency calls to deal with special issues, such as VA use of varenicline for patients who have mental-health disorders (Kim Hamlett-Berry, VA, personal communication, December 3, 2008). The committee notes that the TAG does not include representatives of all 21 VISNs or every VAMC, nor are there formal mechanisms for disseminating information from the TAG to the lead clinicians in VAMCs or for the lead clinicians and other health providers to request advice from the TAG. The PHSHCG also participates in the Interagency Committee on Smoking and Health (ICSH), sponsored by the Department of Health and Human Services (HHS) and convened by the US Surgeon General. The ICSH coordinates research, educational programs, and other smoking and health efforts for HHS, in addition to similar activities of other federal, state, local, and private agencies. Other federal agencies engaged in health care—such as the several institutes of the National Institutes of Health, the Department of Education, and the Centers for Disease Control and Prevention (CDC)—are also members of the ICSH. Veterans Integrated Service Networks In addition to VHA headquarters staff, 21 VISNs provide health care to veterans (see Table 6-1). The VISNs include hospitals and medical centers, residential rehabilitation centers, outpatient clinics (including CBOCs), and Veterans Centers for treating posttraumatic stress disorder (PTSD) and other mental-health disorders. The VISN directors report to the deputy under secretary for health for operations and management. All outpatient clinics and CBOCs are affiliated with a VAMC.

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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 Centers Facilitiesb VISN Centers CBOCs Clinics 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 5c 15 0 9 0 VISN 5: VA Capitol VISN 6: Mid- 8 13 5 10 Atlantic VISN 7: 9 31 3 9 0 Southeast 8c VISN 8: 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 7c 18 11 9 0 VISN 17: Heart of Texas VISN 18: 7 41 1 14 0 Southwest

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269 DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES Hospitals and Other Medical Outpatient Veterans Other Centers Facilitiesb VISN Centers CBOCs Clinics 6c VISN 19: Rocky 37 2 14 0 Mountain 9c VISN 20: 26 1 15 2 Northwest VISN 21: Sierra 8 9 26 20 0 Pacific VISN 22: Desert 5 29 5 11 1 Pacific VISN 23: 12 40 3 14 0 Midwest Total 170 576 144 251 6 a As of April 10, 2009. b Includes domiciliaries, federal hospitals, rehabilitation facilities, PTSD clinics, and care facilities. c Includes at least one VA health-care system in addition to the medical centers. SOURCE: Adapted from VA (2009b). The VISN administrators are responsible for implementing the many policies and programs for health-care services in the hospitals and clinics in each VISN, including tobacco-use cessation. Although the VISN administrators report to the deputy under secretary for health for operations and management, they have substantial autonomy and authority for the medical services offered within their own VISNs, including tobacco control. They can be instrumental in emphasizing tobacco-cessation activities at all of their medical facilities. Virtually all of the VAMCs have some form of tobacco-control program although the programs are not standardized or uniform (VA, 2006b). The agency’s 2005 report Smoking and Tobacco Use Cessation indicated that although 99% of the facilities included in a survey had tobacco-control programs, they varied in who managed the programs, who was responsible for documenting patients’ smoking status in the electronic medical records, who could prescribe medications, and whether they accommodated special populations, such as women, inpatient psychiatric patients, and hospitalized patients (VA, 2006b). There is even greater variation among the CBOCs’ tobacco- control services, although each one is affiliated with a specific VAMC. 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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270 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS rural areas. They provide primary health care, and a growing number also provide primary mental-health services. CBOCs are staffed by VA employees or independent contractors engaged through an outside care provider. The quality of care provided by CBOCs, whether through VA or contract staff, has been studied extensively since their growth in the early 1990s (Borowsky et al., 2002a, 2002b; Chapko et al., 2002; Fortney et al., 2002; Kirchner et al., 2008; Liu et al., 2008; Maciejewski et al., 2007). Most of the studies have either compared the level of care provided by CBOCs with that provided by medical-center clinics or determined the types of care that CBOCs provide and the veteran populations served by them. Kirchner et al. (2008) looked at mental- health services offered at 13 VAMCs and 12 CBOCs that integrated mental-health care with primary care at a VISN in the south central United States. Tobacco-cessation services were offered in the integrated clinics at 17% of the VAMCs and 67% of the CBOCs (Kirchner et al., 2008). TOBACCO-CONTROL PROGRAMS IN THE DEPARTMENT OF VETERANS AFFAIRS VA has been a leader in addressing tobacco use as a health priority for veterans. For example, in 2004, it held the national conference “VA in the Vanguard: Building on Success in Smoking Cessation,” which brought together about 80 tobacco experts to identify successful approaches to smoking-cessation treatment and possible obstacles to their implementation. This conference helped provide a roadmap for VA policies and best practices on tobacco use with an emphasis on special veteran populations such as those with psychiatric disorders. (VA, 2004). VHA has translated a number of evidence-based initiatives into its health-care system, including policy revisions to expand access to tobacco-cessation medications, particularly nicotine- replacement therapy (NRT); elimination of copayments for smoking- cessation 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 (Hamlett- Berry et al., 2009; VA, 2006c), has identified clinicians at each VAMC as a resource for tobacco-cessation information, and discontinued the sale of tobacco products at its facilities. The VA has in place many elements that would enable it to implement a comprehensive tobacco- control program, including communication networks, restrictions on tobacco use, and effective tobacco-cessation interventions. In Chapter 4, the committee identified the key elements that are required of any organization that wants to establish a comprehensive

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271 DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES tobacco-control program: a strategic plan, dynamic leadership, essential intervention components (enforceable and enforced policies, communication interventions, and evidence-based treatments), adequate resources, surveillance and evaluation of the program’s effectiveness, and management capability to adjust the program in response to that evaluation. In this section, the committee describes VA’s tobacco-control efforts and highlights the policies and programs that are in place and working well. This section also provides guidance on where important activities are lacking or where existing ones could be enhanced to improve tobacco cessation in the VA patient population and in VA employees. 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. VA is ideally structured to ensure adequate capacity and collaboration at all program levels while each VISN tailors tobacco- cessation activities to local circumstances and the needs of veterans and health-care providers. VA has an advantage over private-sector health- care systems in that it is able to make institutional changes at the highest administrative levels without worrying about profits or stockholders. This does not mean that the secretary of veterans affairs or the under secretary for health can make changes without consulting their staff, the NLB, or the veterans; but they do have the ability to change policy, procedures, and the institutional culture in VA quickly and uniformly. If tobacco cessation has high priority for the secretary and the under secretary, it will have high priority for the VISNs and all of the VA heath-care providers. As noted earlier, the responsibility for developing VA tobacco- control programs resides in the PHSHCG at VA headquarters, and the programs are implemented as part of the National Prevention Program. VHA Directive 2008-081,1 dated November 26, 2008, outlines VA’s National Smoking and Tobacco Use Cessation Program and lists all of the necessary resources for program implementation. The directive requires that VA continue its commitment to prevention with a “strong 1 VHA Directive 2008-081, issued November 26, 2008, rescinded VHA Directive 2003-042.

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272 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS public health educational effort on the health benefits of quitting tobacco use . . . with a strong emphasis on outreach and an increasing awareness of the availability of the full range of evidence-based smoking and tobacco-use cessation treatment options in VA.” The specific components of the public-health education effort are not listed, but the directive identifies the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use as a key resource. The directive advocates the tobacco-use screening and cessation counseling program given in the guideline. In accordance with the guideline, the directive requires that smoking-cessation medication be made available to all smokers interested in quitting regardless of whether they attend a smoking- cessation program. The directive does not elaborate on how the guidelines are to be implemented, by whom, or how outcomes are to be evaluated. Nor does it encompass policy aspects of tobacco-use control, such as smoke-free policies at VA facilities, funding for the programs, or reporting requirements (VHA, Directive 2008-081, 2008). Leadership is necessary for the medical facilities in a VISN to develop and maintain comprehensive tobacco-use cessation programs (VA, 2007a). Lead staff members necessary to support tobacco-cessation programs reside in both Headquarters and VAMCs as evidenced by the National Prevention Program; at least one part-time employee assigned to the smoking-cessation program at each VISN is also necessary (VA, 2007a). 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. According to the 2005 Smoking and Tobacco Use Cessation Report, some type of smoking-cessation program was offered at 96% of the 158 VAMCs surveyed. Although virtually all VAMCs have a lead clinician of the smoking cessation program, this position is not full-time. A 2005 survey of lead clinicians at each of 151 VAMCs that had tobacco-cessation programs found that the equivalent of only 61 full- time employees were allocated to the programs (VA, 2006b). About one- third of the 423 full- and part-time employees of the programs had tobacco-cessation care as part of their job description; in most of the facilities, 2 or more part-time staff provided tobacco-cessation services. Most of the services were provided by psychologists (22%) or registered nurses (12%), but other health-care professionals also provided tobacco- cessation services, including social workers, physicians, nurse practitioners, and pharmacists. The number of staff at medical-center outpatient clinics or CBOCs who provided tobacco-use cessation services was not determined. The availability of staff at CBOCs for tobacco-use–cessation services, other than prescribing medications and

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273 DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES brief counseling, was highly variable; some CBOCs had trained staff who offered group or individual counseling on site, and others only referred patients to outside tobacco-counseling services (Timothy Carmody, VA, personal communication, July 15, 2008; Clint McSherry, VA, personal communication, July 29, 2008). VA funds tobacco-control programs from its general public- health budget rather than as a separate budget item. Funding for tobacco control varies by VAMC, personnel available, and interest on the part of staff and patients. It is difficult for VAMC directors to justify having a staff member dedicated to tobacco-control services without a dedicated funding mechanism for a smoking-cessation lead clinician. VA health- care providers who conduct tobacco-cessation programs indicated that lack of dedicated staff and resources makes it difficult to provide services and to obtain educational materials (VA, 2007a). The National Prevention Program does have a budget for tobacco-control activities and can leverage funding from other sources, including the Employee Education System, for training (Kim Hamlett-Berry, VA, personal communication, December 3, 2008). VISNs and their medical facilities are required to provide many health services, such as suicide prevention and treatment for PTSD, and tobacco use is only one high-priority concern among many. 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 tobacco- control 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. Finding: The infrastructure to support VA tobacco-control programs varies among VISNs and VAMCs, especially with respect to staffing and funding, and is inadequate in some geographic areas. Recommendation: VA can develop a comprehensive tobacco-control program by expanding and coordinating its

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296 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS requires the same considerations and appropriate treatment as any other veteran population. Some VA researchers have advocated a stepped-care harm- reduction approach for VA tobacco users who have schizophrenia, particularly if they lack the motivation to quit (McChargue et al., 2002). This approach combines setting simple and progressive smoking- reduction goals with the use of atypical antipsychotics that reduce smoking spontaneously and eventually with the use of standard NRTs and bupropion. The approach steps up treatment once smoking reduction is maintained for a long period, but its effectiveness has not been evaluated. The VA National Cooperative Studies Program is supporting a study to include a targeted brief smoking-cessation component in the standard mental-health sessions received by veterans who have psychiatric disorders (McFall et al., 2007). The goal of this large, randomized, multisite effectiveness trial of integration of smoking- cessation treatment into mental health care is to have selected mental health-care providers who are trained in smoking-cessation techniques educate other mental-health professionals at their own facilities (Sherman and Farmer, 2004). All mental health-care providers would ask their patients about tobacco-use status, abstinence history, and reasons for smoking. The providers would also educate those who use tobacco about how it affects their psychologic and physical health, what improvements they might expect if they stopped using tobacco, and healthier strategies for managing emotional distress (Ziedonis, 2004). Ambivalent smokers receive motivational interventions. McFall et al. (2006) reported on the results of an earlier observational study of the above techniques in 107 veterans who had PTSD and smoked cigarettes. The study participants received psychotropic medications for PTSD and supportive psychotherapy in the form of five weekly sessions of smoking-cessation behavior counseling (and one follow-up session), self-help reading materials, intrasession support and assistance in identifying extrasession social support, self- directed behavioral methods for reducing anxiety (a relaxation training tape and stress-management materials), and pharmacologic interventions (bupropion and NRTs) from their mental health-care providers, including their case managers. 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. Staff received 3 hours of training in smoking-cessation treatment. Results indicated that the integrated approach resulted in smoking quit rates comparable with those seen in studies involving smokers who had current mental disorders, such as schizophrenia and alcohol abuse. Those

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297 DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES who continued to smoke reduced their tobacco consumption. Furthermore, stopping smoking did not exacerbate the PTSD or comorbid depression (McFall et al., 2006). Beckham et al. (2008) found that smokers with PTSD were more likely to smoke when experiencing PTSD symptoms, anxiety, and stress. Finding: Veterans who have mental-health conditions may rely on the VHA for all of their health-care needs and may be unable to get access to tobacco-cessation treatment programs outside of VA. VA programs that integrate mental-health and tobacco-cessation treatment may increase cessation in veterans who have mental-health disorders. Recommendation: The VA should use an integrated approach for treating mental-health disorders and tobacco use. Mental-health providers should receive training in tobacco-cessation treatments and provide them to any patients who are willing to quit. Other Populations Smoking by veterans who have multiple sclerosis is common (28.5%). Many of them have attempted to quit, but most of those interested in quitting report that they do not receive smoking-cessation services (Turner et al., 2007). Veterans make up about one-third of the homeless population, and virtually all those veterans are male. Most homeless veterans are single, have poor and disadvantaged backgrounds, and are older and better educated than homeless nonveterans. About 45% of homeless veterans suffer from mental illness, and slightly more than 70% suffer from problems of alcohol or other drug abuse with substantial overlap in morbidities (VA, 2009c). There is virtually no information on tobacco use or tobacco-cessation services for homeless veterans. VA does not have a formal policy regarding tobacco-cessation services for spouses of veterans and nonveteran VA employees. Spouses of veterans and nonveteran VA employees are not eligible for VA pharmacy benefits that might cover the costs of tobacco-cessation medications or of formal counseling. 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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298 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS continues to smoke (Monden et al., 2003; Murray et al., 1995; Osier and Prescott, 1998). VA employees, including union employees, may not have health-insurance coverage for prescription tobacco-cessation medications and may have to pay for both over-the-counter NRTs and prescription medications themselves whereas veterans can receive both types of medications as a covered benefit. Recommendation: The VA should assess the costs and benefits that might result from providing tobacco-cessation medications to partners of veterans and to nonveteran VA employees. Medications might be offered free of charge or at cost to the VA. SURVEILLANCE AND EVALUATION Ensuring the quality of all VA health programs is a continuing task and one that requires constant surveillance to determine what programs and policies are working and what should be done to correct the ones that are not. VA has used quality measurements and performance standards for many years but has not integrated them into an evaluation process that helps it to meet its goal of providing veterans with high-quality health care (Rosenheck, 2006). An assessment of performance does not necessarily result in improvement unless problems are addressed (Fink, 2005). VA conducts periodic internal surveys of veterans’ health, for example, the 2005 Survey of Veteran Enrollees’ Health and Reliance upon VA with Selected Comparisons to the 1999–2003 Surveys. The surveys provide information on how many veterans use tobacco and how tobacco use varies by socioeconomic status, public and private insurance, health status, enrollee priority group, and VISN. That information is designed to assist VA decision-makers in policy development and strategic planning. The most recent survey shows that about 22% of veterans enrolled in the VA health service use tobacco (VA, 2006a). Evaluation programs can help VA in determining which of its programs have been most effective in helping various populations of veterans to cease tobacco use. 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), conducted for the Office of the Assistant Deputy Under Secretary for Health for Policy and Planning, provides a quantitative snapshot of smoking and tobacco-use cessation activities and smoke-free policies in VA. This survey of 158 VAMCs assessed facility resources to improve outcomes, identify best practices,

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299 DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES and promote collaborations among facilities. The smoking-cessation lead clinician at each VA facility completed the survey. The VA PHSHCG also held a Provider Feedback Forum on smoking- and tobacco-use cessation (VA, 2007a) to ask VA front-line health-care providers about their experiences in conducting smoking- and tobacco-cessation programs for VA patients. The forum addressed the implementation of evidence-based tobacco-use cessation interventions, special populations, pharmacy issues, tobacco-free policies, and current resources and future opportunities. However, beyond the data on required brief counseling and offer of medications, VA does not appear to have any data on whether its outpatient clinics and CBOCs offer tobacco-cessation programs, what types of services or referrals are offered and to whom, or how many veterans avail themselves of these services. 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. Over 90% of providers were in compliance with these measures. The VA Office of Quality and Performance (OQP) is responsible for implementing and monitoring performance measures for VHA health-care providers, including adherence to the use of clinical reminders to ask about tobacco use and follow-up. In 2006, VA developed new performance measures that are used by the OQP to increase the provision of tobacco-cessation treatment to outpatients. The three performance measures are: (1) how many patients were provided with brief counseling in the preceding year, (2) how many patients who used tobacco were offered medication to assist in cessation, and (3) how many patients who used tobacco were offered referral to a smoking-cessation clinic to assist in cessation. Compliance with the performance measures for FY 2008 ranged from 75% to 99% among the VISNs (VA, 2007b). VA compliance with smoking-cessation care metrics exceeds that of the commercial sector or Medicaid for smoking-cessation counseling (89% vs. 76% vs. 70%, respectively), the offer of smoking- cessation medications (84% vs. 51% vs. 39%), and referral or use of smoking-cessation strategies (92% vs. 48% vs. 39%) (Kim Hamlett- Berry, VA, personal communication, November 10, 2008). Although VA is one of the health-care leaders in asking patients about tobacco use and has instituted electronic prompts in the patients’ medical records to ensure that patients can receive tobacco-cessation medications and referrals if they want them, there is an almost total lack of information on whether the performance measures have had an effect on tobacco-use rates, although they have improved health-provider practices.

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300 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Furthermore, data on performance measures, the number of veterans who smoke, types of tobacco-cessation treatments available and their use, and costs and benefits of the programs are maintained in a variety of VA offices and facilities. Such scattering of the dataset makes evaluation of tobacco-control efforts difficult and opaque. The cost of treating veterans for tobacco use is comparatively small compared with the cost of treating veterans for tobacco-related diseases (Jonk et al., 2005), but the efficacy of the tobacco-cessation treatments is unclear. Without systematic and periodic evaluation of the outcomes of VA’s tobacco-cessation efforts, it is impossible for it to modify programs for maximum effectiveness or to introduce new and perhaps more successful approaches. The committee notes that VA does prepare an annual Performance and Accountability Report that includes a Clinical Practice Guidelines Index measure. 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. . . . The measure demonstrates the degree to which VA provides evidence-based clinical interventions to veterans seeking care in VA. The measure targets elements of care that are known to have a positive impact on the health of our patients who suffer from commonly occurring acute and chronic illnesses” (VA, 2008d). The measure, however, does not specifically report annual compliance with the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use. Finding: The VA does conduct periodic surveys of its tobacco-cessation programs, but it has no central repository of information about the nature and implementation of tobacco-cessation activities. There is a lack of information about which treatment methods have been most sought by veterans and which have been most effective in enabling veterans to cease tobacco use. Recommendation: The VA should assess the reach and effectiveness of its tobacco-cessation programs.

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305 DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES Sherman, S. E., A. M. Joseph, E. M. Yano, B. F. Simon, N. Arikian, L. V. Rubenstein, P. Parkerton, and B. S. Mittman. 2006b. Assessing the institutional approach to implementing smoking cessation practice guidelines in Veterans Health Administration facilities. Military Medicine 171(1):80-87. Sherman, S. E., M. Estrada, A. B. Lanto, M. M. Farmer, and I. Aldana. 2007. Effectiveness of an on-call counselor at increasing smoking treatment. Journal of General Internal Medicine 22(8):1125-1131. Sherman, S. E., N. Takahashi, P. Kalra, E. Gifford, J. W. Finney, J. Canfield, J. F. Kelly, G. J. Joseph, and W. Kuschner. 2008. Care coordination to increase referrals to smoking cessation telephone counseling: A demonstration project. American Journal of Managed Care 14(3):141-148. Smith, B., M. A. Ryan, D. L. Wingard, T. L. Patterson, D. J. Slymen, and C. A. Macera. 2008. Cigarette smoking and military deployment a prospective evaluation. American Journal Preventive Medicine 35(6): 539-546. Turner, A. P., D. R. Kivlahan, L. E. Kazis, and J. K. Haselkorn. 2007. Smoking among veterans with multiple sclerosis: Prevalence correlates, quit attempts, and unmet need for services. Archives of Physical Medicine and Rehabilitation 88(11):1394-1399. VA (Department of Veterans Affairs). 2004. VA in the Vanguard: Building on Success in Smoking Cessation. Edited by S. Isaacs, S. Schroeder and J. Simon. San Francisco, CA: VA. VA. 2006a. 2005 Survey of Veteran Enrollees’ Health and Reliance upon VA with Selected Comparisons to the 1999–2003 Surveys. Washington, DC: Veterans Health Administration. VA. 2006b. Smoking and Tobacco Use Cessation Report—2005. Washington, DC: Veterans Health Administration, Office of the Assistant Deputy Under Secretary for Health for Policy Planning. VA. 2006c. Integrating Tobacco Cessation Treatment into Mental Health Care. Washington, DC: Veterans Health Administration. VA. 2007a. Provider Feedback Forum on Smoking and Tobacco Use Cessation. Atlanta, GA: Veterans Health Administration, Public Health Strategic Health Care Group. VA. 2007b. Q1 Technical Manual for the VHA Performance Measurement System. Washington, DC: Department of Veterans Affairs, Office of Quality and Performance. VA. 2008a. FY07 Annual VA Information Pamplet. http://www1.va.gov /vetdata /docs/Pamphlet_2-1-08.pdf (accessed February 2, 2009).

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