The cost of medications for comorbid disorders in both DoD and VA is likely to decrease substantially if military personnel and veterans quit smoking. Patients with serious mental illnesses, such as schizophrenia and bipolar disorder, are commonly prescribed antipsychotic medications, such as olanzapine or clozapine. Those medications are expensive, and smokers who use them tend to need about twice the dose that nonsmokers need, because smoking increases their metabolism.
VA uses several approaches to provide tobacco-use interventions to patients who have mental-health disorders and use tobacco. For many VA patients, the VA mental health-care provider is the de facto source of primary care. VA advocated an integrative approach to tobacco cessation for patients who have mental-health disorders in which mental healthcare providers address both the mental illness and tobacco use rather than referring patients to a separate tobacco-cessation program (VA, 2006c). Specifics of how and why tobacco cessation should be integrated into mental health care in VA are given in the VA conference proceedings Integrating Tobacco Cessation Treatment into Mental Health Care: A Preceptor Training Program to Improve Delivery of Tobacco Cessation Treatment for Veterans with Mental Disorders (VA, 2006c). As described in Chapter 4, an integrative approach to tobacco cessation and mental health care has several advantages:
Tobacco cessation works best when counseling is frequent and long-term; given the long-term nature of mental-health counseling, there is an opportunity for the therapist to provide continuing tobacco-cessation counseling.
Patients may be more receptive to a combination of treatments at an appointment, inasmuch as many patients have substantial commutes or must take time out of their workday to attend a session, thus, the notion of a “one-stop” session may be appealing.
Given the potential for drug interactions, both favorable and adverse, between tobacco-cessation medications and medications for psychiatric disorders, the mental-health therapist can more effectively monitor side effects or psychologic changes that the patient experiences when taking multiple medications.
The committee finds that the patient, provider, and programmatic barriers identified in the VA report are accurate, but believes that the evidence indicates that many of the barriers, particularly those related to providers and programs, can be overcome by establishing a more comprehensive program and emphasizing that the population in question