policy is a barrier to ensuring that veterans have easy access to tobacco-cessation medications. Virtually all of the VAMCs have the nicotine patch on their center’s formulary, and over 73% of them have the nicotine patch, bupropion, and sustained-release bupropion available at their pharmacies; fewer than 10% of the pharmacies had other NRTs available (VA, 2006b). Participants in the Provider Feedback Forum indicated that special drug requests are required for NRTs at some VISNs and obtaining combination therapies, such as multiple NRTs or NRTs with another tobacco-cessation medication, is challenging (VA, 2007a).

The use of varenicline is of concern to VA because of recent adverse reactions to it in veterans. The PHSHCG Web site has a posting for the latest FDA public-health advisory on varenicline,3 and VA follows the FDA recommendations on its use. It is not a first-line medication in the VA National Formulary, and its use is restricted until a patient has failed to quit tobacco by using NRTs and bupropion. The Provider Feedback Forum found that most patients were receptive to using varenicline, but a nonformulary request was required to prescribe it, although this practice may have changed. It was also noted that many VA pharmacies were not following National Formulary guidelines for varenicline, and this was preventing patients from receiving it. Another concern was that the VA National Formulary does not include the varenicline starter pack, thus ensuring that the patient is receiving the correct dosage is problematic (VA, 2007a).

The committee considers the requirement that veterans have a prescription for over-the-counter NRTs and that these prescriptions be filled at VA pharmacies to be a barrier to access for veterans. Another barrier is that all VA pharmacies do not have all tobacco-cessation medications available that are listed on the VA National Formulary.

Combined Behavioral Interventions and Medication

The VA/DoD guideline echoes the 2000 PHS guideline by advocating a combination of behavioral interventions with tobacco-cessation medications to achieve long-term abstinence. Combinations of medications, such as NRTs and bupropion, may also be used (VA/DoD, 2004).

Most VAMCs that offer tobacco-cessation programs provide both behavioral therapy (group or individual) and medications. Almost every VAMC in the 2005 Smoking and Tobacco Use Cessation Survey

3

Food and Drug Administration. 2008. Public Health Advisory: Important Information on Chantix (Varenicline). http://www.fda.gov/CDER/Drug/advisory/varenicline.htm. Accessed April 9, 2009.



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