VA has worked toward a tobacco-free policy that is applicable to all its health-care facilities since 1991. However, the Veterans Health Care Act of 1992 (Public Law 102-585, Section 526) required VA to establish and maintain either indoor smoking areas in VAMCs, nursing homes, and domiciliary-care facilities for veterans or detached smoking areas that are accessible to patients and have heating and air-conditioning. Several VA circulars and directives specify who may use the smoking areas, but they vary to some degree by facility. VHA Directive 2008-052, Smoke-Free Policy for VA Health Care Facilities, issued in August 2008, states that all VA health-care facilities are to be smoke-free and restricts required smoking areas to detached buildings that must be accessible, heated, and air-conditioned and meet the Joint Commission (formerly the Joint Commission on the Accreditation of Healthcare Organizations) requirements for ventilation. All acute-care patients, ambulatory-care patients, outpatients, and domiciliary patients must use the detached smoking areas. Smoking may be allowed on the grounds of a facility, but smoking areas may not be situated within 35 feet of any facility entrance that is routinely used by staff or patients. Smoking areas for VA employees should be separate from those for patients. Specifically designated indoor smoking areas are still maintained at some long-term care and mental-health program facilities, and they must have a ventilation system that meets American Society of Heating, Refrigerating and Air-Conditioning Engineers Standard 62-2001. All remaining indoor smoking areas in long-term-care, spinal-care injury, and inpatient psychiatric facilities were to be phased out by February 2009, provided that appropriate outdoor areas were made available. The directive also prohibits the sale or distribution of tobacco products to long-term-care patients, inpatients, residents, employees, staff, and volunteers on VHA grounds. Finally, the VHA directive states that NRTs should be used by inpatients to prevent nicotine withdrawal unless medically contraindicated (VHA, Directive 2008-052, 2008).
According to the 2005 Smoking and Tobacco Use Cessation Report on tobacco-use practices at 158 VA hospital facilities (VA, 2006b), 51 VA facilities provide 134 smoking shelters for patients only, 41 facilities provide 76 shelters for employees only, and 137 facilities provide 573 shelters for use by both patients and employees, with some facilities providing up to 32 shelters for combined use by patients and employees. Almost all (91%) of the VHA facilities indicated that patients and employees smoke in the same designated smoking areas. Of the 158 facilities surveyed, 77% are smoke-free indoors; 23% (36) permit some