disorder (PTSD) and depression, may increase the demand for tobacco-relapse prevention services. People with mental-health disorders use tobacco at far higher rates than those without such disorders. The committee advocates the use of tobacco-cessation therapy in conjunction with therapy for mental-health disorders for patients interested in quitting tobacco use. The evidence indicates that treatment for tobacco use does not adversely affect treatment for mental-health disorders.

The VA patient population is not only older than that served by the DoD Military Health System, but it has a higher incidence of tobacco-related morbidity—such as cardiovascular disease, COPD, and lung cancer—than the DoD active-duty population. The prevalence of smoking in veterans is not substantially higher than the general population (22% vs. 20%), so veterans must be quitting smoking after they leave the military or have died as a result of their tobacco use. VA, with its electronic medical records for all patients, should be able to track when patients stop smoking and whether they do so in response to treatment received through VA or from another source. That information will prove to be valuable in tailoring tobacco-cessation programs to veterans.

The committee concurs with the VA/DoD clinical-practice guideline that tobacco-cessation services should be offered to all patients, including hospitalized patients and those in primary-care clinics for other reasons. The committee believes that having a dedicated smoking and tobacco-use cessation lead clinician in each VA medical facility is a good start toward ensuring that VA staff are familiar with the most effective tobacco-cessation treatments and also have a point of contact for more information.

Like DoD, VA does not have a dedicated national quitline. The committee believes that such a quitline, available toll-free to all veterans and their dependents, would provide a valuable and cost-effective service for veterans. Veterans, like active-duty and retired military, have concerns about tobacco cessation that should be addressed by counselors who are trained to deal with these issues. Although veterans may move less frequently than military personnel, continuity of service would be enhanced by a nationwide quitline. The committee also recommends that quitline counselors be able to provide nicotine-replacement therapy (NRT) to veterans who are participating in telephone counseling and, with proper training, prescription tobacco-cessation medications as well. If the latter is not feasible, the committee recommends that counselors at least be able to refer patients to an appropriate health-care provider in their areas to provide prescriptions or payment vouchers for NRTs at local pharmacies. In essence, the committee believes that VA should act to make tobacco-cessation medications easily accessible for veterans



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