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

Introduction: Tobacco treatment has been a VA priority since 2008, which has increased access to treatment. 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). Materials & Methods: This project was deemed minimal risk and, thus, exempt from IRB oversight by the local IRB. We interviewed 20 VA SMI providers and analyzed qualitative data using a rapid analysis matrix approach to determine how system-level barriers, such as administrative factors and social norms, influenced tobacco treatment delivery.Results: Providers often tried to stay current on VA 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. Finally, the ease of coordinating care between prescribers and non-prescribers facilitated tobacco treatment delivery. Conclusions: Tobacco treatment resources are available in VA, but providers in our sample had difficulty accessing them and worried that these resources would be inaccessible to Veterans with SMI. Coordination between tobacco treatment lead clinicians, frontline providers, and operational partners that aims to increase provider exposure to tobacco treatment resources without exacerbating information overload can help increase the accessibility of available tobacco treatment resources in VA, particularly for providers working with Veterans with SMI.