Every year in the U.S., more than 435,000 people die of illnesses related to tobacco use.1 The CDC reported that from 2012 to 2013, 21.3% of adults used some form of tobacco daily or on some days.2 Veterans are not excluded from these numbers: A 2005 survey found 22.2% of VA patients were current smokers, and 71.2% of VA patients had smoked at least 100 cigarettes in their life.3
Military personnel have a higher propensity to be in situations that increase the risk of tobacco use than the general population does.3,4 These situations include alternating between periods of high stress and boredom, separation from loved ones, perceived camaraderie involved with tobacco use, and the limitation of healthier coping mechanisms.3,4 Stress and boredom have been cited as the top reasons for initiating tobacco use when deployed.3,4 Furthermore, once military personnel return from deployment, they may have difficulty quitting tobacco due to depression, sleeplessness, change in the structure of everyday life, or a second deployment.4
In 2009 Bondurant and Wedge predicted that the VA would spend $30.9 billion in preventable smoking-related expenditures by 2024.3 The negative health effects and the financial impact of tobacco make cessation programs an important investment for the VA.
In 2012, the CDC reported that 70% of veterans want to quit tobacco; therefore, veterans likely would be interested in tobacco cessation programs.4 Reasons veterans noted for quitting included family, changes in the social norm, better overall health, and better ability to breathe.4 Veterans also identified that tobacco cessation programs with convenience, personalization, reduced-cost medications, and peer support would be most helpful.4
According to a 2008 tobacco use and dependence guideline update, the most effective therapy for quitting tobacco is counseling plus pharmacotherapy.1 According to the guideline, the number of counseling sessions combined with pharmacotherapy is strongly related to the likelihood of quitting.1 A number of studies also have shown that telephone counseling is effective for tobacco cessation.5 However, a previous study in veterans found that scheduled face-to-face counseling sessions may be more effective than telephone counseling.6 Dent and colleagues found a statistically significant quit rate at 6 months of 28% in the face-to-face group vs 11.8% in the telephone group.6
After reviewing the guidelines, analyzing the studies, and learning what veterans find most helpful in tobacco cessation programs, the Sioux Falls VA Health Care System (SFVAHCS) in South Dakota took a unique approach to tobacco cessation. In 2012, SFVAHCS implemented a tobacco cessation drop-in group medical appointment (DIGMA) to improve tobacco quit rates. The DIGMA is a 1-hour, educational supportive clinic that allows veterans to drop in during any class anytime, regardless of their tobacco use status. This clinic mostly serves outpatients; however, inpatients also are welcome. Patients are informed of the DIGMA by a health care provider (HCP) or patient information flyers posted throughout SFVAHCS.
The DIGMA takes place once a week in a classroom next to a primary care waiting area, making it easily accessible. During the DIGMA, an HCP, such as a nurse or physician, provides behavioral education. VA materials (Primary Care and Tobacco Cessation Handbook and My Tobacco Cessation Workbook designed by Julianne Himstreet, PharmD, BCPS) are used to guide classes.7,8 These books address barriers to quitting, coping with nicotine withdrawal, planning for quit day, handling tobacco cravings, watching out for triggers, and staying tobacco free.7,8 Clinical pharmacists also are present at the DIGMA for patients who want to start or continue pharmacotherapy. The pharmacists can prescribe tobacco cessation medications and follow up on the success or adverse effects (AEs) of therapy.
The purpose of this study was to examine how a voluntary, drop-in, face-to-face tobacco cessation clinic impacts tobacco quit rates in veterans receiving pharmacotherapy.
Methods
A retrospective chart review was performed for all study site outpatients started on pharmacotherapy for tobacco cessation between September 1, 2012 and August 31, 2013, as determined by pharmacy dispensing records. Two groups were evaluated in this study: the pharmacotherapy-only (PO) group and the DIGMA group. Pharmacotherapy was most often prescribed by an HCP in the PO group. Other prescribers may have included pharmacists, mental health providers, and hospitalists. The second group was the DIGMA group, which included patients who were on tobacco cessation pharmacotherapy and attended at least 1 DIGMA class within a year of starting pharmacotherapy.
For this study, pharmacotherapy included nicotine gum, nicotine lozenge, nicotine patch, bupropion, varenicline, and any combination of these medications. Patients were excluded if they died, moved, or were lost to follow-up within 1 year of starting pharmacotherapy for a new quit attempt; were not at the beginning of a quit attempt; or were taking bupropion for mood or depression only.