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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