when they enter the VHA health-care system. DoD and VHA health services are distinct, both jurisdictionally and geographically, so there is a lack of continuity between military and VA services that may interrupt or end a new veteran’s efforts to quit tobacco use. Evidence-based treatments can be offered by DoD and VA to help to bridge the gap in health-care service. In this section, the committee discusses the treatments currently offered by VA and identifies treatments that VA could add to develop a more comprehensive program.

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. 2000) sponsored by the Public Health Service (PHS); the PHS guideline was updated in 2008 (Fiore et al., 2008). In VA’s 2005 Smoking and Tobacco Use Cessation report, 51% of the 158 VAMCs in the survey used the VA/DoD clinical-practice guideline often (76–99% of the time), 24% used them always, and only 1% never used them; 1% of the VAMCs reported not knowing about them. Most often, a nurse is responsible for assessing a patient’s tobacco use, and a primary-care provider is able to provide smoking-cessation treatment, whether it be brief counseling, telephone counseling, or medications. The VA/DoD guideline presents evidence-based recommendations for assessment and treatment of veterans and prevention of tobacco use, and it includes several appendixes that provide specific information on counseling strategies and techniques, medications, and relapse prevention.

Behavioral Interventions

VA appears to offer a broad array of tobacco-cessation–counseling interventions to patients, but there is little information on their effectiveness in veterans as a separate population. In 2006, VA eliminated the copay for smoking-cessation counseling (individual and group sessions) to reduce one barrier to access to care (38 Code of Federal Regulations 17). As with tobacco users in the Military Health System (see Chapter 5), for veterans who are tobacco users the VA/DoD guideline advocates the 5 A’s and recommends intensive counseling of at least 4 sessions of 10 minutes each (VA/DoD, 2004). A variety of counseling formats are effective, including group and individual counseling in person and individual counseling over the telephone. Self-help materials may also be appropriate for patients who receive brief



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