have a mental illness; diagnoses range from mild depression to severe forms of psychiatric illnesses. These veterans smoke at nearly twice the rate of people without mental-health disorders, and they smoke more heavily (VA, 2006c). VA is situated to care for veterans returning from the conflicts in Iraq and Afghanistan, one-third of whom are estimated to have a mental-health disorder; smoking is reported to have increased by 50% in those deployed veterans (Smith et al. 2008). Many of them also have diagnoses of more than one psychiatric disorder.

VA is an acknowledged leader in research in the diagnosis and treatment of mental-health disorders, such as PTSD (Beckham et al., 2005, 2007, 2008; Dennis et al., 2007; Fu et al., 2007; Kirby et al., 2008). It has worked to improve tobacco-cessation services for those with mental illness. As described above, VA established a Preceptor Training Program to integrate tobacco-cessation treatment into mental health care. That program had 3 training sessions over 3 years and trained more than 160 preceptors representing all 21 VISNs; however, it has been discontinued. VA continues to hold train-the-trainer national conferences on such topics as the PHS Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update. In 2004, VA sponsored a conference titled “VA in the Vanguard: Building on Success in Smoking Cessation” on best practices in tobacco cessation in veteran populations served by VA; it included a session on mental health and PTSD (VA, 2004).

Pharmacotherapy for treating nicotine dependence has been shown to be effective in people who have mental illness. This population faces additional challenges—studies have indicated that those with comorbid conditions, particularly mental illness, are more likely to smoke and have a lower quit rate (see Chapter 4). The committee notes some important points regarding the use of smoking-cessation medications to treat tobacco dependence in people who have mental illness: this treatment requires a tailored approach to meet individual needs, it can be enhanced through a combination of pharmacotherapy and psychosocial therapy, and tobacco use can alter the effectiveness of a variety of medications used to treat mental illness, particularly antipsychotics, and should be monitored closely.

The VA National Formulary contains all the FDA-approved tobacco-cessation medications that can be used by veterans with and without a mental illness. The formulary also has medications prescribed for psychiatric disorders. Mental-health professionals, primary-care physicians, and medical specialists need to be aware of all medications that their patients are taking, including such over-the-counter medications as NRTs.



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