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Tobacco Use/Nicotine Dependence
Goal 3: Enhancing Effective Treatment for Tobacco Use/Nicotine Dependence
Background
Our approach to treatment is based primarily on the recently updated VA/DoD Guideline for Management of Tobacco Use. This guideline takes a public health approach to tobacco use/smoking cessation (TU/SC), focusing on providing care to the entire population of smokers seen in the VHA. The guideline also clearly recommends that all tobacco users receive counseling and smoking cessation medications in the most intensive setting they are willing to attend. The SUD QUERI is focusing on implementing these guideline recommendations. The aims and strategies described below highlight many of the gaps in current knowledge. For example, although we know a great deal about the number of patients receiving smoking cessation prescriptions within the VHA, we still know relatively little about how VHA TU/SC care is structured and delivered
The TU/SC goal of the SUD QUERI is to develop, implement and evaluate cost-effective interventions for increasing access to and use of evidence-based smoking cessation treatment, with the long-term objective of decreasing the high level of medical morbidity and premature mortality associated with tobacco use among VHA patients. In addition, we are particularly interested in interventions that target special populations with a high prevalence of smoking, such as veterans recently released from military service or veterans with mental health disorders.
Based on overwhelming evidence of the cost-effectiveness of smoking cessation treatment and the revised VA/DoD Guideline for Management of Tobacco Use, the Tobacco Use/Smoking Cessation (TU/SC) Work Group remains focused on the development, implementation and evaluation of cost-effective interventions for increasing the use of evidence-based smoking cessation treatment. Work group accomplishments include:
- Quality improvement. After 2-3 years of advocacy, the VA adopted more stringent evidence-based Performance Measures (consistent with HEDIS), which shifted emphasis from screening and advice to offering all tobacco users effective behavioral treatments and pharmacotherapy. The measures were tested for the first three quarters of FY07 and then counted fully in Q4. The Work Group continued their collaborations with the OQP and PHSHG to analyze SHEP data to assess the quality of smoking cessation care for hospitalized VA patients.
- Increased access to TU/SC via telephone interventions. Since approximately 2 of 3 patients referred to smoking cessation clinics fail to attend, telephone interventions remain a key focus in tobacco control in general and in the VA in particular. Several ongoing projects are testing the use of telephone quit lines, including a multi-site study testing different approaches to telephone care coordination, a collaboration with HIV-QUERI, and a network-based contract with Free & Clear (a private organization that runs many state Quitlines).
- Focus on smokers with mental illness. Smoking is highly prevalent among patients with mental illness with disproportionate disease burden. Ongoing projects addressing this special population include a VA Cooperative study evaluating the integration of smoking cessation care into ongoing treatment for post traumatic stress disorder (PTSD) and a QUERI LIP conducting a 2-site pilot evaluation of motivational incentives to promote engagement in TUC interventions for patients with schizophrenia. A telephone care coordination intervention for mental health patients was resubmitted as a SDP by Dr. Sherman and is currently under review.
- Determine an implementation research agenda for smoking cessation. In order to focus future implementation research studies on the most important tobacco control areas, the TU/SC Work Group will be helping to create a research agenda as an SUD QUERI-funded LIP. This process will consist of several steps – a diverse panel will initially prioritize potential research goals. The panel will then refine these initial rankings, key stakeholders will provide additional input, and the Public Health Strategic Healthcare Group will help to create the final prioritized list.
Progress and Accomplishments
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