System-Level Barriers to Delivering Tobacco Treatment to Veterans With Serious Mental Illness: A Qualitative Analysis

Tobacco treatment has been a Veterans Health Administration (VHA) priority since 2008, which has increased access to treatment. However, additional system-level efforts are needed to reduce the disparities in smoking rates and tobacco treatment access that have persisted between veterans with and without serious mental illness (SMI).

The local Institutional Review Board deemed this project exempt because of minimal risk to human subjects. We interviewed 20 VHA providers (psychiatrists, nurse practitioners, pharmacists, physicians, social workers, nurses, psychologists, peer specialists, and occupational therapists) from a local VHA health care system's outpatient SMI clinics and analyzed qualitative data using a rapid analysis inductive-deductive approach to determine how system-level barriers, such as administrative factors and social norms, influenced tobacco treatment delivery.

Providers often tried to stay current on VHA tobacco treatment resources, but said that too much or too little information would stymie efforts. For example, high volumes of information sent via email and available on the intranet made it challenging to find smoking-related resources, while restricted information about changes to medication availability complicated prescribing. Providers described these barriers as interfering with their delivery of smoking treatment. Some also viewed tobacco discussions as antithetical to their mission of providing veteran-centered care, which dissuaded them from initiating such discussions. In addition, providers working in rural settings questioned the accessibility of certain VHA smoking cessation resources, like in-person groups or the VA Quit Line, for veterans with SMI. Finally, nonprescribers shared that the ease of coordinating care with prescribers facilitated tobacco treatment delivery.

Mental health providers in a VHA health care system had difficulty accessing VHA tobacco treatment resources. Adjustments to medical record and electronic communication infrastructure, as well as more consistent communication between facility-level tobacco champions and frontline providers could make tobacco treatment resources more accessible to providers, though care is needed to ensure this information does not exacerbate information overload. Training and education that helps providers feel comfortable integrating tobacco treatment into routine mental health care is also critical to ensuring equitable access to tobacco treatment for veterans with SMI in rural areas.