brief counseling, was highly variable; some CBOCs had trained staff who offered group or individual counseling on site, and others only referred patients to outside tobacco-counseling services (Timothy Carmody, VA, personal communication, July 15, 2008; Clint McSherry, VA, personal communication, July 29, 2008).

VA funds tobacco-control programs from its general public-health budget rather than as a separate budget item. Funding for tobacco control varies by VAMC, personnel available, and interest on the part of staff and patients. It is difficult for VAMC directors to justify having a staff member dedicated to tobacco-control services without a dedicated funding mechanism for a smoking-cessation lead clinician. VA healthcare providers who conduct tobacco-cessation programs indicated that lack of dedicated staff and resources makes it difficult to provide services and to obtain educational materials (VA, 2007a). The National Prevention Program does have a budget for tobacco-control activities and can leverage funding from other sources, including the Employee Education System, for training (Kim Hamlett-Berry, VA, personal communication, December 3, 2008).

VISNs and their medical facilities are required to provide many health services, such as suicide prevention and treatment for PTSD, and tobacco use is only one high-priority concern among many. Although the PHSHCG is the VA organizational lead for tobacco-use cessation programs, unless the secretary of veterans affairs and the Executive Office of the administration are actively concerned with the issue, individual VISNs are unlikely to be completely engaged in tobacco-control programs.

Finding: VA has adopted several tobacco-control policies and programs, including its National Smoking and Tobacco Use Cessation Program, but they are not comprehensive, and implementation varies among VISNs, VAMCs, and CBOCs as a result of organizational discrepancies, lack of accountability, and inadequate funding.

Finding: The infrastructure to support VA tobacco-control programs varies among VISNs and VAMCs, especially with respect to staffing and funding, and is inadequate in some geographic areas.

Recommendation: VA can develop a comprehensive tobacco-control program by expanding and coordinating its

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