Another noteworthy finding was that 16% reported they were not ready to quit in spite of accepting a referral for counseling. In addition, 13% offered “other” reasons as barriers to tobacco cessation, suggesting that these 2 groups may not have been properly assessed as to their “readiness-to-change” status at the time the referral was generated. Another possibility is the “demand characteristics” of the referral: For example, patients did not want to disappoint their provider, although they were not fully committed to treatment at the time of their visit.
Six percent of the respondents reported they did not attend the treatment program because they had already quit tobacco between the time of the original referral and the time of the survey. This time frame could have been from 6 weeks to 7 months for the respondents. However, these responses were not verified with biomarker testing but, rather, relied on self-reported status. For this reason, these responses could be suspect and may be the result of “demand characteristics” as well.
Another category of respondents of particular interest is the 9% who reported “counseling is not important to my quitting.” This group represents a segment of respondents who failed to appreciate the evidence that demonstrates the benefits of counseling and medical adjunct therapy. Further patient education is clearly needed to ensure patients understand how important smoking cessation is to their health and how important counseling is to their quitting efforts. To accomplish this goal, patient education concerning tobacco cessation in the form of televideo programming placed in the clinic wait areas is underway at the Atlanta VAMC.
Less frequently reported as barriers were “forgot” (6%), “counseling doesn’t work for me” (3%), and “parking concerns” (1%), suggesting that in this limited sample, these were not central reasons for not utilizing these services.
The small sample size and that it was a convenience sample pose some concerns as to whether the results are truly representative of the population under study and whether the results can be extrapolated to similar populations. In addition, the results are from self-reported replies, relying on the integrity of the respondents to provide honest answers. Prefacing the study questions with an explanation that this was an opportunity to help the VA improve the quality of its programs was intended to ward off the desire to provide “acceptable” answers.
It is important to understand that patients within the VA system in certain categories of disability and financial means are reimbursed travel expenses for attending tobacco cessation treatment. It is possible that reimbursement factors might motivate patients to accept referrals for counseling that they may not be particularly committed to attend, contributing to a higher-than-expected number of referrals for patients who were not ready to quit.
The results of this study highlight several patient-reported barriers to tobacco cessation treatment, including scheduling conflicts, distance, and cost of travel. Only a small percentage (16%) actually reported they were not yet ready to quit or they did not feel counseling would work for them (3%). A slightly larger percentage reported they did not feel counseling is important (9%), and since it is well established that combining medication with behavioral counseling yields the greatest results for smoking cessation, it is clear that this segment of the patient population will require more education and attention.13
Accessibility issues were the biggest reason for nonattendance to the program (77%), and these issues highlight the need for continued work, at least at the Atlanta VAMC, on providing easier patient access to tobacco cessation treatment. Since the completion of this study, many updates have been implemented at the Atlanta VAMC to improve access, including the provision of telehealth education and the use of telephone quit lines.
Telehealth education, a technique that is highly compatible with lifestyle change counseling, has been shown to be cost-effective while providing intervention and education for patients who are too distant or unable to travel for other reasons.14
Tobacco quit lines are another option for patients with accessibility conflicts and are now operational in all 50 states. Most operate 24/7, manned by counselors trained in motivational interviewing and specifically tobacco cessation counseling. A meta-analysis of quit-line efficacy performed by Stead and colleagues demonstrated that quit lines improve long-term cessation for smokers who use them and even suggested a possible dose-response effect.15 Quit-line counseling, therefore, seems to offer a useful option for veterans who cannot easily access that counseling within the VA.
Motivational interviewing principles have also been proposed by VA as a new approach with great promise for application with veterans who are unmotivated, resistant, or ambivalent about changing unhealthy habits.16 At the Atlanta VAMC, training in motivational interviewing for primary care clinicians is ongoing. It is the provider’s responsibility to strongly encourage patients who use tobacco to utilize alternative tobacco cessation resources when attending a VA treatment program is not a viable option.