use—resources devoted to programs, and the programs themselves, vary among the centers. VA medical facilities are required to use electronic medical records and to meet the performance standard of asking veterans about smoking and then offering brief counseling sessions, but the tobacco-cessation programs vary. Health-care providers at VA community-based outpatient clinics (CBOCs) are required to ask patients about tobacco-use status and may conduct brief counseling, but CBOCs are not required to have tobacco-cessation programs or tobacco lead clinicians (Kim Hamlett-Berry, VA, personal communication, June 4, 2008).

Headquarters staff lack the authority to implement or enforce changes in VISNs, VA medical centers (VAMCs), or CBOCs regarding smoking-cessation activities. The director for the Public Health National Prevention Program in the Public Health Strategic Health Care Group at headquarters has responsibility for tobacco-use programs in VA. The director is “responsible for the development and oversight of public health policy and clinical programs for the VA Health Care System relating to smoking and tobacco-use cessation” and works with a technical advisory group of smoking-cessation clinicians from several VISNs (VA, 2009). Not all VISNs are represented on the technical advisory group.

Another major barrier limiting primary-care–based treatment is a lack of adequate provider time and knowledge regarding smoking treatment. Mental health-care providers may be veterans’ primary-care physicians, so they must understand the clinical-practice guidelines and be educated in simultaneous treatment for mental-health disorders and tobacco control (VA/DoD, 2004). Many VA CBOCs do not have smoking-cessation programs, and although patients can receive cessation medications at these clinics, they are referred to local health departments or state quitlines for programs. The lack of treatment coordination between VA health-care providers and community tobacco-cessation providers and the lack of structured follow-up by VA are likely to discourage a patient’s interest in tobacco cessation. Although the committee finds quitlines to be effective (see Chapter 4), it acknowledges that it may be difficult for VA health-care providers to determine whether a veteran uses a state quitline. However, a provider can take an active role by asking veterans about cessation interventions at each health-care appointment and noting their use of interventions in their medical records.

SOCIETAL FACTORS

This section discusses the more global influences on tobacco use—factors that act on the societal level and may promote the use of



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