counseling, might be motivated to quit, or as a supplement to other interventions.

Participants in the 2007 Provider Feedback Forum on Smoking and Tobacco Cessation report stated that in addition to providing pharmacotherapeutic interventions for veterans who use tobacco, it would be advantageous to provide more behavioral counseling to improve long-term outcomes, particularly therapy that would address stress management and other coping skills to prevent relapse. Motivational interviewing and the use of incentives were also suggested as adjunct interventions. Some participants suggested that behavioral interventions should be incorporated into other behavioral programs, such as those for weight loss, stress management, and substance-abuse treatment (VA, 2007a).

Tobacco-Cessation Medications

The use of tobacco-cessation medications among VA patients has more than doubled in the last several years (Michael Valentino, VA, presentation to the committee, June 2, 2008). The VA National Formulary provides many of the tobacco-cessation medications approved by the Food and Drug Administration (FDA), including varenicline; however, it does not include nicotine nasal spray or nicotine inhaler, because these are rarely used by the VA population (Michael Valentino, VA, presentation to committee, June 2, 2008). Nevertheless, participants in the 2007 Provider Feedback Forum cited a lack of uniformity among and within VISNs with regard to policies related to access to NRTs. Although NRTs are available as over-the-counter medications in non-VA pharmacies, for a veteran to receive them free of charge from VA, the medications must be prescribed by a VA health-care provider and the prescriptions must be filled at a VA pharmacy. Forum participants noted that it could take considerable effort for health-care providers without prescribing privileges to obtain an NRT prescription for a patient (VA, 2007a).

Although the 2003 National Smoking and Tobacco Use Cessation Program stated that tobacco-cessation medications must be available for all patients regardless of whether they attend a tobacco-cessation program, the 2005 Smoking and Tobacco Use Cessation Report suggested that some VAMCs were still restricting patients’ access to NRTs and bupropion (VA, 2006b). Of the 104 VAMCs responding, 23% indicated that a patient must be in a tobacco-cessation program to receive NRTs or bupropion, in spite of a VA policy that tobacco-cessation medications must be available to all patients regardless of whether they participate in a tobacco-cessation program. Lack of adherence to the VA

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