PHSHCG take the lead in identifying a certification program, such as that offered by the Mayo Clinic or the University of Pittsburgh School of Pharmacy, or designing one of its own (VA, 2007a). The QuitSmart program used by some VAMCs requires certification of its program counselors.

Interventions that include VA provider education have mixed results. A 90-minute education session for primary-care providers resulted in increases in advising smokers to quit, in assisting them in quitting (with treatment or referral), and in arranging follow-up (Andrews et al., 2001). Having an on-call counselor perform monthly educational visits to VA primary-care providers and adding small financial incentives for the providers increased patient referrals for brief counseling, medications, and referral to a smoking-cessation program, but the rate of referrals was not sustained at 6 months (Sherman et al., 2007). Yano et al. (2008) found that quality-improvement plans for primary-care providers resulted in improved patient attendance at cessation clinics but no increase in cessation rates (Yano et al., 2008).

The GIFT study of a multicomponent intervention (Joseph et al., 2004) showed that train-the-trainer education for two staff members at each VAMC and removal of restrictions on prescribing of tobacco-cessation medications resulted in a slight increase in the number of patients being asked their tobacco-use status and an increase in documentation of that status; however, it had no effect on the number of patients being counseled to quit or receiving medications. VA has also conducted train-the-trainer programs, such as its Preceptor Training Program, that have been effective in increasing tobacco-cessation awareness among VA mental health-care providers. The Preceptor Training Program trained over 160 preceptors representing all 21 VISNs in an integrated-care approach to incorporate tobacco-cessation treatments into mental-health treatment. Trainers monitored preceptors’ progress at their medical facilities; preceptors were assisted in overcoming barriers to change through “best practices” information, site progress reports, consultations with peers and mentors during regular conference calls, and dissemination of patient-health promotion materials and provider-education videos, print materials, and Web-based materials (VA, 2006c).

Staff members are needed to obtain and disseminate educational materials for other staff and patients. Moreover, all staff should be knowledgeable about discussing tobacco use with their patients and making any necessary referrals for additional services; this may include referrals to community resources for veterans’ dependents who use tobacco. Lack of dedicated staff to conduct those tobacco-cessation

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