Taking Smoking Cessation to All Care Settings, VA Lowers Smoking Rate

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WASHINGTON, DC—No one has ever said that quitting smoking was easy. For servicemembers and veterans, who may already be under considerable stress, giving up something they perceive as relieving their stress can be especially tough. VA recognizes this and, over the last decade, has restructured how it delivers smoking cessation treatment, integrating it into other healthcare treatment modalities. This has drastically reduced smoking rates.

Promoting Cessation Systemwide

In 1999, 33% of veterans in VA care smoked. This was compared to 24% in the general population. In 2005, the rate among veterans had dropped to 22.2% and the most recent statistics for veterans in VA care is 19.7%—lower than the 21% rate nationally. This reduction has been credited to an effort by VA to take smoking cessation out of a specialty clinic and make it part of an integrated care model.

“Prior to 2000, VA had only specialty clinics. There was a smoking cessation clinic and if you smoked as a veteran, odds are you were just referred there,” Kim Hamlet-Berry, PhD, director of VA’s Office of Public Health told U.S. Medicine. “But we know that what we needed to do as a system was to say that smoking cessation needs to happen at as many different points of care as possible.”

With that goal in mind, VA began taking its smoking cessation efforts system-wide. Patients began being screened in the primary care setting, as well as outpatient primary care and mental health. Currently, once a year all veterans in VA care are asked about their tobacco use. If they answer in the affirmative, treatment is offered, including counseling and drug therapy.

“We routinely screen patients for tobacco use, provide messages for why it’s important to quit, and offer counseling,” Hamlet-Berry said. “We also make sure providers have ongoing education about talking to patients about their smoking or tobacco use and what constitutes effective care.”

VA does not have the issue with insurance coverage for smoking cessation that other systems sometimes face, which has allowed them to pull out all the stops. In 2005, VA worked to implement a federal rule change that removed the copayment for veterans receiving outpatient cessation counseling.

Targeting Those Who Need to Quit

VA is also targeting specific populations and adapting their message and treatment options to match.

The Palo Alto VAMC, with input from women veterans’ focus groups, has created a booklet titled I Quit, which includes strategies for women veterans to quit smoking and details the ways that smoking affects a woman’s health across her lifespan. “They also created a pocket card that has strategies for quitting,” Hamlet-Berry said. “So as you’re trying to quit, and you run up against barriers, it tells you how to overcome them”

At the Washington DC VAMC, the HIV clinic has a smoking cessation clinic built right in, since it has been shown that smoking can impact an HIV-positive patient’s health to a greater extent than an HIV-negative patient. “That clinic had moved to chronic disease model, since people were doing much better with HIV,” Hamlet-Berry said. “But those that smoked were not doing as well. There were higher rates of opportunistic infections. So the clinic set up a model to address cessation as part of HIV care.”

The improvement of therapies over the last decade has also greatly affected VA’s success, since they offer more hope to veterans looking to quit. While the medications have stayed relatively the same, understanding of how best to use those medications has improved. “We know a lot more to do in terms of combination therapies that are effective for patients. It’s really important that in some cases a combination of first-line medication may be most effective. And it’s sometimes important for a clinician to see if a medication failed for a person previously, they may benefit from a combination therapy.”

For example, a patient using a nicotine patch may still experience craving severe enough to make them reach for a cigarette. However, the addition of nicotine gum during those periods of intense craving may be enough to get the patient through those difficult moments.

Hamlet-Berry pointed at prescription rates for tobacco cessation medications as one measurement that VA has expanded its cessation efforts. In 1999, about 8.5% of smokers were getting cessation medication. In 2006, that number had doubled, and in 2008, the rate was 30.5%.

If a veteran tries to quit and fails, VA will help them try again. The average person takes five to six attempts to successfully quit. Every time a veteran who has been identified as a smoker comes into a VA clinic, a note will appear in his or her electronic medical record, prompting the physician to ask if they want assistance. “Smoking is a chronic relapsing condition,’ Hamlet-Berry said. “It’s not a matter of a single encounter or a single intervention. It’s something that has to be revisited with the patient on a regular basis.”

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