Clinical Settings

Of the VAMC tobacco-cessation programs, 53% are in the mental-health divisions, 22% in primary care, 9% in psychology, and 16% in other medical services (VA, 2006b). The 2006 VA survey found that over half the programs offered individual counseling, with 60% of the patients receiving three or more sessions. Only about 20% of the programs offered more than three individual sessions. Most sessions were 10–30 minutes long. The overwhelming majority (93%) of the programs offered group counseling, most being four or more sessions of 30–60 minutes, although many of the programs (46%) had sessions longer than an hour (VA, 2006b). Although the committee has no information on how often such counseling programs are offered, it notes that should veterans not be able to attend a program once they have decided to quit, the lack of access to a program may prove to be a barrier to their quit attempts.

The Guideline Implementation for Tobacco (GIFT) study (Joseph et al., 2004) and the Quality Improvement Trial for Smoking Cessation (QUITS) study (Sherman et al., 2006a) reported that for many veterans referred to a specialty smoking-cessation clinic, the wait for an appointment is a month or longer at most of the facilities. In their chapter in VA in the Vanguard: Building on Success in Smoking Cessation, Sherman and Farmer (2004) note that many patients may forgo using tobacco-cessation medications because of long waits to have the VA pharmacy fill their prescriptions. Again, the committee notes that a lengthy wait for a counseling session may pose a barrier to veterans’ accessing a tobacco-cessation program. Not all cessation programs require that the veteran be referred to it by a health-care provider; veterans may self-refer (VA, 2006b).

The 2005 Smoking and Tobacco Use Cessation Survey found that 13% of the VAMCs in the survey use telemedicine to deliver tobacco-cessation services to their patients (VA, 2006b). VA is working to expand its use of telemedicine for this and other health programs, but most clinics are not yet able to provide such services (Timothy Carmody, VA, personal communication, July 15, 2008); and the effectiveness of this approach is unknown.

Primary-Care Providers

In most VAMC primary-care clinics, nurses or physicians are responsible for assessing a patient’s tobacco-use status (Sherman et al., 2006b; VA, 2006b). According to the 2005 Smoking and Tobacco Use



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