Changes in Veteran Tobacco Use Identified in Electronic Medical Records

Published:February 10, 2017DOI:


      Electronic medical records represent a new source of longitudinal data on tobacco use.


      Electronic medical records of the U.S. Department of Veterans Affairs were extracted to find patients’ tobacco use status in 2009 and at another assessment 12–24 months later. Records from the year prior to the first assessment were used to determine patient demographics and comorbidities. These data were analyzed in 2015.


      An annual quit rate of 12.0% was observed in 754,504 current tobacco users. Adjusted tobacco use prevalence at follow-up was 3.2% greater with alcohol use disorders at baseline, 1.9% greater with drug use disorders, 3.3% greater with schizophrenia, and lower in patients with cancer, heart disease, and other medical conditions (all differences statistically significant with p<0.05). Annual relapse rates in 412,979 former tobacco users were 29.6% in those who had quit for <1 year, 9.7% in those who had quit for 1–7 years, and 1.9% of those who had quit for >7 years. Among those who had quit for <1 year, adjusted relapse rates were 4.3% greater with alcohol use disorders and 7.2% greater with drug use disorders (statistically significant with p<0.05).


      High annual cessation rates may reflect the older age and greater comorbidities of the cohort or the intensive cessation efforts of the U.S. Department of Veterans Affairs. The lower cessation and higher relapse rates in psychiatric and substance use disorders suggest that these groups will need intensive and sustained cessation efforts.
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        • CDC
        Quitting smoking among adults--United States, 2001-2010.
        MMWR Morb Mortal Wkly Rep. 2011; 60: 1513-1519
        • CDC
        Smoking cessation during previous year among adults--United States, 1990 and 1991.
        MMWR Morb Mortal Wkly Rep. 1993; 42: 504-507
        • Gilpin E.A.
        • Pierce J.P.
        • Farkas A.J.
        Duration of smoking abstinence and success in quitting.
        J Natl Cancer Inst. 1997; 89: 572-576
        • Hawkins J.
        • Hollingworth W.
        • Campbell R.
        Long-term smoking relapse: a study using the British household panel survey.
        Nicotine Tob Res. 2010; 12: 1228-1235
        • Hyland A.
        • Li Q.
        • Bauer J.E.
        • Giovino G.A.
        • Steger C.
        • Cummings K.M.
        Predictors of cessation in a cohort of current and former smokers followed over 13 years.
        Nicotine Tob Res. 2004; 6: S363-S369
        • Wetter D.W.
        • Cofta-Gunn L.
        • Fouladi R.T.
        • Cinciripini P.M.
        • Sui D.
        • Gritz E.R.
        Late relapse/sustained abstinence among former smokers: a longitudinal study.
        Prev Med. 2004; 39: 1156-1163
        • Krall E.A.
        • Garvey A.J.
        • Garcia R.I.
        Smoking relapse after 2 years of abstinence: findings from the VA Normative Aging Study.
        Nicotine Tob Res. 2002; 4: 95-100
        • Hughes J.R.
        • Keely J.
        • Naud S.
        Shape of the relapse curve and long-term abstinence among untreated smokers.
        Addiction. 2004; 99: 29-38
        • Noonan D.
        • Jiang Y.
        • Duffy S.A.
        Utility of biochemical verification of tobacco cessation in the Department of Veterans Affairs.
        Addict Behav. 2013; 38: 1792-1795
        • Stevens V.J.
        • Solberg L.I.
        • Bailey S.R.
        • et al.
        Assessing trends in tobacco cessation in diverse patient populations.
        Nicotine Tob Res. 2016; 18: 275-280
        • Williams J.M.
        • Steinberg M.L.
        • Griffiths K.G.
        • Cooperman N.
        Smokers with behavioral health comorbidity should be designated a tobacco use disparity group.
        Am J Public Health. 2013; 103: 1549-1555
        • Solberg L.I.
        • Flottemesch T.J.
        • Foldes S.S.
        • Molitor B.A.
        • Walker P.F.
        • Crain A.L.
        Tobacco-use prevalence in special populations taking advantage of electronic medical records.
        Am J Prev Med. 2008; 35: S501-S507
        • Norris 3rd, J.W.
        • Namboodiri S.
        • Haque S.
        • Murphy D.J.
        • Sonneberg F.
        Electronic medical record tobacco use vital sign.
        Tob Induc Dis. 2004; 2: 109-115
        • McGinnis K.A.
        • Brandt C.A.
        • Skanderson M.
        • et al.
        Validating smoking data from the Veteran’s Affairs Health Factors dataset, an electronic data source.
        Nicotine Tob Res. 2011; 13: 1233-1239
        • Rogers E.S.
        • Fu S.S.
        • Krebs P.
        • et al.
        Proactive outreach for smokers using VHA mental health clinics: protocol for a patient-randomized clinical trial.
        BMC Public Health. 2014; 14: 1294
        • Volkman J.E.
        • DeRycke E.C.
        • Driscoll M.A.
        • et al.
        Smoking status and pain intensity among OEF/OIF/OND veterans.
        Pain Med. 2015; 16: 1690-1696
        • Barnett P.G.
        • Chow A.
        • Flores N.E.
        Using health factors data for VA Health Services Research.
        VA Health Economics Resource Center Technical Report #28. 2014;
        • Yu W.
        • Ravelo A.
        • Wagner T.H.
        • et al.
        Prevalence and costs of chronic conditions in the VA health care system.
        Med Care Res Rev. 2003; 60: 146S-167S
        • Yoon J.
        • Scott J.Y.
        • Phibbs C.S.
        • Wagner T.H.
        Recent trends in Veterans Affairs chronic condition spending.
        Popul Health Manag. 2011; 14: 293-298
        • Fishman P.
        • Von Korff M.
        • Lozano P.
        • Hecht J.
        Chronic care costs in managed care.
        Health Aff (Millwood). 1997; 16: 239-247
        • Ray G.T.
        • Collin F.
        • Lieu T.
        • et al.
        The cost of health conditions in a health maintenance organization.
        Med Care Res Rev. 2000; 57: 92-109
        • McNutt L.A.
        • Wu C.
        • Xue X.
        • Hafner J.P.
        Estimating the relative risk in cohort studies and clinical trials of common outcomes.
        Am J Epidemiol. 2003; 157: 940-943
        • Spiegelman D.
        • Hertzmark E.
        Easy SAS calculations for risk or prevalence ratios and differences.
        Am J Epidemiol. 2005; 162: 199-200
        • Zou G.
        A modified Poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706
        • Feigelman W.
        Cigarette smoking among former military service personnel: a neglected social issue.
        Prev Med. 1994; 23: 235-241
        • Hoerster K.D.
        • Lehavot K.
        • Simpson T.
        • McFall M.
        • Reiber G.
        • Nelson K.M.
        Health and health behavior differences: U.S. military, veteran, and civilian men.
        Am J Prev Med. 2012; 43: 483-489
        • McKinney W.P.
        • McIntire D.D.
        • Carmody T.J.
        • Joseph A.
        Comparing the smoking behavior of veterans and nonveterans.
        Public Health Rep. 1997; 112: 212-217
        • Bastian L.
        • Sherman S.
        Effects of the wars on smoking among veterans.
        J Gen Intern Med. 2010; 25: 102-103
        • Duffy S.A.
        • Ronis D.L.
        • Titler M.G.
        • et al.
        Dissemination of the nurse-administered Tobacco Tactics intervention versus usual care in six Trinity community hospitals: study protocol for a comparative effectiveness trial.
        Trials. 2012; 13: 125
        • Smith M.W.
        • Chen S.
        • Siroka A.M.
        • Hamlett-Berry K.
        Using policy to increase prescribing of smoking cessation medications in the VA healthcare system.
        Tob Control. 2010; 19: 507-511
        • Sherman S.E.
        A framework for tobacco control: lessons learnt from Veterans Health Administration.
        BMJ. 2008; 336: 1016-1019
        • Maheswaran H.
        • Petrou S.
        • Rees K.
        • Stranges S.
        Estimating EQ-5D utility values for major health behavioural risk factors in England.
        J Epidemiol Community Health. 2013; 67: 172-180
        • Vogl M.
        • Wenig C.M.
        • Leidl R.
        • Pokhrel S.
        Smoking and health-related quality of life in English general population: implications for economic evaluations.
        BMC Public Health. 2012; 12: 203
        • Fishman P.A.
        • Khan Z.M.
        • Thompson E.E.
        • Curry S.J.
        Health care costs among smokers, former smokers, and never smokers in an HMO.
        Health Serv Res. 2003; 38: 733-749
        • Fishman P.A.
        • Thompson E.E.
        • Merikle E.
        • Curry S.J.
        Changes in health care costs before and after smoking cessation.
        Nicotine Tob Res. 2006; 8: 393-401
        • Hockenberry J.M.
        • Curry S.J.
        • Fishman P.A.
        • et al.
        Healthcare costs around the time of smoking cessation.
        Am J Prev Med. 2012; 42: 596-601
        • Wu C.Y.
        • Chang C.K.
        • Robson D.
        • et al.
        Evaluation of smoking status identification using electronic health records and open-text information in a large mental health case register.
        PLoS One. 2013; 8: e74262