RESEARCH PAPER
 
KEYWORDS
TOPICS
ABSTRACT
Introduction:
While initiation rates of tobacco cessation pharmacotherapy have improved both inside and outside the Department of Veteran Affairs (VA), prescribing rates remain low. The objective of this study was to examine correlation of the characteristics of providers, clinics, and facilities with initiation of tobacco cessation pharmacotherapy.

Methods:
This retrospective, observational study used VA outpatient electronic medical record data from federal fiscal year 2011. Logistic regression models estimated the adjusted odds ratio associated with provider characteristics for pharmacotherapy initiation.

Results:
For the 639507 veterans who used tobacco, there were 30388 providers caring for them. Younger (p<0.001) and female (p<0.001) providers were more likely to initiate tobacco cessation pharmacotherapy. Compared to physicians, pharmacists were 74% more likely to initiate pharmacotherapy, while all groups of nurses were 5–8% and physicians’ assistants were 12% less likely (p<0.001). Compared to those seen in primary care clinics, patients assessed in substance use treatment clinics were 16% more likely to have pharmacotherapy initiated (p<0.001), while those in psychiatry were 10% less likely (p<0.001), and those in outpatient surgery were 39% less likely to initiate pharmacotherapy (p<0.001). Compared to almost all other classes of VA facilities, patients seen in primary care community-based outpatient clinics (CBOCs) were 7–28% more likely to initiate pharmacotherapy (p<0.0001).

Conclusions:
While the VA is at the leading edge of providing tobacco cessation pharmacotherapy, targeting quality improvement efforts towards providers, clinics, and facilities with low prescribing rates will be essential to continue the declining rates of tobacco use among VA patients.

ACKNOWLEDGEMENTS
The project was supported by Merit Review Award (Number I01 HX001764) from the United States Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. We gratefully acknowledge the contribution of Adam Chow of the VA Health Economics Resource Center, Menlo Park, CA for his help in identifying tobacco use status.
CONFLICTS OF INTEREST
The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. P.G. Barnett reports that his institution received payment from Merit Review Award I01 HX001764 from the U.S. Department of Veterans Affairs Health Services Research & Development Service.
FUNDING
This work was supported by the Health Services Research and Development Service of the U.S. Department of Veterans Affairs (Proposal number IIR 14-301) awarded to SD. This funding was in the form of an unrestricted allocation. The sponsor did not directly shape the design or conduct of the study, the collection, management, analysis, and interpretation of the data, or the preparation, review, or approval of the manuscript.
ETHICAL APPROVAL AND INFORMED CONSENT
Ethical approval and informed consent were not required as all data used were from existing databases.
DATA AVAILABILITY
The data supporting this research cannot be made available for privacy reasons.
AUTHORS' CONTRIBUTIONS
ACB, SAD, MCG, RVI, HMK and PGB made substantial contributions to the conception, interpretation of analysis and findings, and critical revision for intellectual content. RVI made substantial contributions to analysis and interpretation of data. All authors read and approved the final manuscript.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
 
REFERENCES (38)
1.
U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2020. Accessed March 30, 2021. https://www.hhs.gov/sites/defa...
 
2.
Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. U.S. Department of Health and Human Services; 2008. Accessed March 30, 2021. https://www.ncbi.nlm.nih.gov/b...
 
3.
Department of Veteran Affairs. National Smoking and Tobacco Use Cessation Program. VHA DIRECTIVE 1056. VHA Publications; 2014. Accessed March 30, 2021. https://www.oklahoma.va.gov/10...
 
4.
Ignacio RV, Barnett PG, Kim HM, et al. Trends and Patient Characteristics Associated with Tobacco Pharmacotherapy Dispensed in the Veterans Health Administration. Nicotine Tob Res. 2018;20(10):1173-1181. doi:10.1093/ntr/ntx229
 
5.
Srivastava B, Ramsey AT, McIntosh LD, et al. Tobacco Use Prevalence and Smoking Cessation Pharmacotherapy Prescription Patterns Among Hospitalized Patients by Medical Specialty. Nicotine Tob Res. 2019;21(5):631-637. doi:10.1093/ntr/nty031
 
6.
Hartmann-Boyce J, Chepkin SC, Ye W, Bullen C, Lancaster T. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database Syst Rev. 2018;5(5):CD000146. doi:10.1002/14651858.CD000146.pub5
 
7.
King BA, Dube SR, Babb SD, McAfee TA. Patient-reported recall of smoking cessation interventions from a health professional. Prev Med. 2013;57(5):715-717. doi:10.1016/j.ypmed.2013.07.010
 
8.
Duffy SA, Reeves P, Hermann C, Karvonen C, Smith P. In-hospital smoking cessation programs: what do VA patients and staff want and need? Appl Nurs Res. 2008;21(4):199-206. doi:10.1016/j.apnr.2006.11.002
 
9.
US Department of Veterans Affairs. Veterans Health Administration. August 10, 2020. Accessed March 30, 2021. https://www.va.gov/health/
 
10.
Barnett P, Ignacio Rosalinda V, Kim HM, et al. Cost-Effectiveness of Real World Administration of Tobacco Pharmacotherapy in the Veterans Health Administration. Addiction. 2019;114(8):1436-1445. doi:10.1111/add.14621
 
11.
Cunningham FE, Hur K, Dong D, et al. A comparison of neuropsychiatric adverse events during early treatment with varenicline or a nicotine patch. Addiction. 2016;111(7):1283-1892. doi:10.1111/add.13329
 
12.
Duffy SA, Ignacio RV, Kim HM, et al. Effectiveness of tobacco cessation pharmacotherapy in the Veterans Health Administration. Tob Control. 2018;28(5):540-547. doi:10.1136/tobaccocontrol-2018-054473
 
13.
U.S. Department of Veteran Affairs. HERC: Average Cost. 2019. Accessed March 30,2021. https://www.herc.research.va.g...
 
14.
U.S. Department of Veteran Affairs. HERC: Other data. 2019. Accessed March 30, 2021. https://www.herc.research.va.g...
 
15.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Medical care. 1998:8-27. doi:10.1097/00005650-199801000-00004
 
16.
Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Medical Care. 2005;43(11):1130-1139. doi:10.1097/01.mlr.0000182534.19832.83
 
17.
Herold R, Schiekirka S, Brown J, et al. Structured smoking cessation training for medical students: a prospective study. Nicotine Tob Res. 2016;18(12):2209-2215. doi:10.1093/ntr/ntw191
 
18.
Baumhäkel M, Müller U, Böhm M. Influence of gender of physicians and patients on guideline‐recommended treatment of chronic heart failure in a cross‐sectional study. Eur J Heart Fail. 2009;11(3):299-303. doi:10.1093/eurjhf/hfn041
 
19.
Frank E, Dresner Y, Shani M, Vinker S. The association between physicians’ and patients’ preventive health practices. CMAJ. 2013;185(8):649-653. doi:10.1503/cmaj.121028
 
20.
Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008;(2):CD000165. doi:10.1002/14651858.CD000165.pub3
 
21.
Rice VH, Heath L, Livingstone-Banks J, Hartmann-Boyce J. Nursing interventions for smoking cessation. Cochrane Database Syst Rev. 2017;12(12):CD001188. doi:10.1002/14651858.CD001188.pub5
 
22.
Sui CF, Ming LC. Pharmacist-led Smoking Cessation Services: Current and Future Perspectives, in Neuroscience of Nicotine. Elsevier. 2019:441-449.
 
23.
Gong J, Baker LC, Zou KH, et al. A pragmatic randomized trial comparing telephone-based enhanced pharmacy care and usual care to support smoking cessation. J Manag Care Spec Pharm. 2016;22(12):1417-1425. doi:10.18553/jmcp.2016.22.12.1417
 
24.
Binnal A, Gururaghavendran R, Denny C, Ahmed J, Tallada AK. Tobacco Cessation Scenarios Among Healthcare Profession Students: A Multidisciplinary Study. Asian Pac J Cancer Prev. 2018;19(4):1081-1088. doi:10.22034/APJCP.2018.19.4.1081
 
25.
Morgan PA, Smith VA, Berkowitz TSZ, et al. Impact of physicians, nurse practitioners, and physician assistants on utilization and costs for complex patients. Health Affairs. 2019;38(6):1028-1036. doi:10.1377/hlthaff.2019.00014
 
26.
Kelly CW, Davis JM, DiCocco M. Assessing the current status of tobacco dependence education curricula in US physician assistant programs. Journal of Physician Assistant Education. 2011;22(3):4-14. doi:10.1097/01367895-201122030-00001
 
27.
Katz DA, Stewart K, Paez M, et al. “Let Me Get You a Nicotine Patch”: Nurses' Perceptions of Implementing Smoking Cessation Guidelines for Hospitalized Veterans. Mil Med. 2016;181(4):373-382. doi:10.7205/MILMED-D-15-00101
 
28.
Gass JC, Morris DH, Winters J, VanderVeen JW, Chermack S. Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic. J Subst Abuse Treat. 2018;84:1-8. doi:10.1016/j.jsat.2017.10.006
 
29.
Substance Abuse and Mental Health Services Administration. Implementing Tobacco Cessation Programs in Substance Use Disorder Treatment Settings: A Quick Guide for Program Directors and Clinicians. HHS Publication No. SMA18-5069QG. U.S. Department of Health and Human Services; 2018. Accessed March 30, 2021. https://store.samhsa.gov/sites...
 
30.
Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the 2001–2004 national ambulatory medical care survey (NAMCS). Prev Med. 2006;43(6):472-476. doi:10.1016/j.ypmed.2006.07.009
 
31.
Wang ZJ, Dhanireddy P, Prince C, Larsen M, Schimpf M, Pearman G. 2019 Survey of Veteran Enrollees’ Health and Use of Health Care. Contract No: VA245-17-C-0178. U.S. Department of Veterans Affairs; 2020. Accessed March 30, 2021. https://www.va.gov/HEALTHPOLIC...
 
32.
Alpert HR, Connolly GN, Biener L. A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation. Tob Control. 2013;22(1):32-37. doi:10.1136/tobaccocontrol-2011-050129
 
33.
Institute of Medicine (US) Committee on Smoking Cessation in Military and Veteran Populations. Bondurant S, Wedge R, eds. National Academies Press; 2009. Accessed March 30, 2021. https://www.ncbi.nlm.nih.gov/b...
 
34.
Veterans Health Administration. Smoke-Free VA Healthcare Facilities. U. S. Department of Veterans Affairs; 2019. Accessed March 30, 2021. https://www.va.gov/health/smok...
 
35.
Bae J, Ford EW, Kharrazi HHK, Huerta TR. Electronic medical record reminders and smoking cessation activities in primary care. Addict Behav. 2018;77:203-209. doi:10.1016/j.addbeh.2017.10.009
 
36.
Odani S, Agaku IT, Graffunder CM, Tynan MA, Armour BS. Tobacco product use among military veterans—United States, 2010–2015. Morbidity and Mortality Weekly Report. 2018;67(1):7-12. doi:10.15585/mmwr.mm6701a2
 
37.
Smith MW, Chen S, Siroka AM, Hamlett-Berry K. Using policy to increase prescribing of smoking cessation medications in the VA healthcare system. Tob Control. 2010;19(6):507-511. doi:10.1136/tc.2009.035147
 
38.
Shah D, Shah A, Tan X, Sambamoorthi U. Trends in utilization of smoking cessation agents before and after the passage of FDA boxed warning in the United States. Drug Alcohol Depend. 2017;177:187-193. doi:10.1016/j.drugalcdep.2017.03.021
 
 
CITATIONS (2):
1.
Changes in Tobacco Use Patterns among Veterans in San Diego during the Recent Peak of the COVID-19 Pandemic
Javad Fatollahi, Sean Bentley, Neal Doran, Arthur Brody
International Journal of Environmental Research and Public Health
 
2.
Pharmacist-led telehealth tobacco cessation services compared with usual care in a community health center
Ariel McDuffie, Shibu Varughese, Allyson Duffy, Andrew Faiella, Laura Wegener, Kaeli Singer, Jangus Whitner, Alexa Valentino
Journal of the American Pharmacists Association
 
eISSN:1617-9625
Journals System - logo
Scroll to top