activities is a barrier to improved tobacco-cessation treatment (VA, 2007a).

Finding: VA has instituted many provider-education programs that have been effective in raising awareness of the need for tobacco-cessation services for veterans. However, the programs may not be reaching all primary-care providers or other health professionals serving veterans. The use of reminders and prompts in patient medical records for tobacco-cessation counseling, referrals, and prescribing is one way in which VA has made innovative and effective advances.

Recommendation: The committee recommends that all VA health-care providers receive training in tobacco-cessation interventions.


The VA health system provides care for a number of populations that may require special attention for tobacco-cessation treatment, including veterans with mental-health disorders, those with medical comorbidities, smokeless-tobacco users, female veterans (whose numbers are increasing), and veterans who are inpatients in hospitals, nursing homes, and psychiatric residences. As described in Chapter 2, VA serves a veteran population that tends to be older, less healthy, and of lower socioeconomic status than the general population. Reducing tobacco use in those populations poses a challenge to VA.

The VA/DoD Clinical Practice Guideline for the Management of Tobacco Use addresses tobacco cessation in several special populations that are treated by VA, including pregnant women, hospitalized patients, older patients, and psychiatric and mental-health patients. The guideline encourages health-care providers to advise all of these patients to quit and to offer tobacco-cessation treatment. Additional recommendations on treating those patients refer to the population as a whole (including the general population, the military, and veterans); there are no modified recommendations for dealing with veterans in particular (VA/DoD, 2004).

Veterans with Mental-Health Disorders

VA provided mental-health care to an estimated 800,000 veterans in 2003 at a cost of more than $2 billion (Ziedonis et al., 2004). It is estimated that 25–40% of veterans in the VA health-care system

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