Smoking Cessation

Best Practices in Tobacco Control within the VA

Levels of Treatment and Increasing Utilization

By Scott E. Sherman, MD, New York Harbor Veterans Health Care System

Introduction

The VA/DoD guidelines[1] suggest that there are four levels at which tobacco cessation treatment is routinely delivered – within smoking cessation programs, from individual primary care or mental health providers, via telephone, or during inpatient hospitalizations. Each of these represents an effective venue in which to provide smoking cessation medications and counseling. The challenge for health care systems is to decide how much emphasis to place on each of these approaches and how to maximize the utilization of the approach(es) chosen.

Increasing the Use of Smoking Cessation Programs

We recently completed the Quality Improvement Trial for Smoking cessation (QUITS), a group randomized trial of evidence-based quality improvement[2] to increase adherence to national clinical practice guidelines for smoking cessation.[3] As part of the process evaluation, we conducted a survey of the 20 sites initially participating in the project and another 20 sites participating in a separate VA-funded study of implementing smoking cessation practice guidelines (Guideline Implementation for Tobacco, Dr. Anne Joseph, Principal Investigator). We found that nearly all VA facilities (39/40) in our sample had an on-site smoking cessation program,[4,5] and for most, this was their preferred approach to smoking cessation treatment.

QUITS used a locally-designed approach to improve tobacco control efforts. Intervention sites were assisted in choosing tobacco control priorities and in creating and implementing a quality improvement plan to achieve these local goals. Most sites developed a strategy to increase use of their on-site smoking cessation program, since the majority of sites restricted smoking cessation medications to patients attending the program. Unfortunately, this intensive effort to increase use of VA smoking cessation clinics was unsuccessful, as patients at the intervention sites were no more likely than those at control sites to report being counseled about smoking cessation, being referred to a program, or actually attending a program.[6]

Given these results, it is important to think about why this approach (locally-designed, evidence-based quality improvement) didn’t work. We think there are three main reasons for our lack of benefit. First, all sites were already doing quite well on the existing smoking cessation performance measures, in most cases with more than 90 percent of patients being asked about smoking and more than 90 percent of smokers being advised to quit. In the face of many other competing demands on the time of providers7 and facilities, staff may have felt there was little incentive to do more than was already being done.

A second reason for the lack of benefit is that while top management at each site endorsed the project, few made it an institutional priority. As a result, the main site contacts also did not consider it a top priority. One of our expert consultants on the study, Dr. Bruce Chernof, Medical Director of HealthNet, advised us in advance that unless the project managers “brought the project home with them at night” and really cared about it, there was little chance of success. As a further example of this, one site had the most comprehensive quality improvement plan and the largest improvement. Just prior to the start of the site’s involvement in QUITS, its leadership decided that the current approach to tobacco control was not working, convened a local quality improvement team, restructured care, monitored outcomes, and documented that care had improved. Thus, the site’s leaders essentially did the entire study intervention prior to joining the project. In an interview featuring the site as a “best practice,” the chief of staff said that he had learned during his time in the military that what the commander cared about always got done, so he made it very clear to everyone that tobacco control was a top priority. Therefore, one very important way to foster change at the clinic and provider level is to ensure that there is strong and unequivocal support from top administration.

The third reason why our intervention had no effect is that it was an unstructured
intervention, which we had deliberately designed to be locally determined. Our study design was adapted from the intervention used in the Mental Health Awareness Project.8 In analyzing why some sites in that study were more effective than others at improving care for depression, Rubenstein et al.8 found that in supportive environments (high local support and expertise), both locally-designed and expert-designed interventions were likely to be successful. However, when conditions were not optimal, expert-designed interventions fared better than those that were locally-designed. As noted above, our sites had only moderate support. Furthermore, all of our site leaders had expertise in smoking cessation, but few were also expert in quality improvement techniques. Therefore, we might have had more success (although possibly less buy-in) with a more structured, externally-designed intervention rather than a locally designed one.

Our literature review for this manuscript found two other interventions that were successful either at increasing attendance at a smoking cessation program or in decreasing drop-out rates. In an abstract presentation at the Society of General Internal Medicine, Volpp et al.[9] reported the results of a randomized trial of financial incentives at the Philadelphia VA Medical Center. Smokers in the intervention group were offered $20 for each smoking cessation program class attended and $100 for completing the program. The incentive group had higher rates of program enrollment (43 percent vs. 20 percent) and program completion (26 percent vs. 12 percent). Longer follow-up was still underway, but financial incentives appeared to be effective among veterans.

At the New Orleans VA Medical Center, patients attending the smoking cessation program complained about having to wait in the pharmacy to pick up their smoking cessation medications. In the VA Virtual Learning Center, Rick Gibson and Sheila Corrigan reported on their experience restructuring care at the New Orleans VA Medical Center so that a pharmacist was available within the smoking cessation clinic to dispense medications.[10] They reported that this change increased patient satisfaction with the program and increased the percentage completing the program from 34 percent to 53 percent.

These last two strategies—financial incentives and use of a clinical pharmacist—are readily available within the VA. The first is perhaps the more difficult one, as a variety of VA regulations make incentive payments difficult to arrange. All VAs have clinical pharmacists on staff, so the main barrier to pharmacists’ increased involvement is competing demands on their time. This is not a major barrier for smoking cessation programs, however, as they typically meet only weekly or even less frequently.

About Us | PHSHG Staff | PHSHG News & Press | Contact Us

The Public Health Strategic Health Care Group is a part of the Office of Public Health and Environmental Hazards