indoor smoking in areas such as long-term-care inpatient, locked psychiatry wards, resident rooms, and nursing-home units; and 94% have separate ventilation systems. Almost half of the facilities allow smoking only in designated areas; the rest allow smoking outside a specified distance from buildings. VHA Circular 10-90-141 (November 23, 1990) prohibits employees from using indoor smoking areas intended for patients, so they must smoke outside.

Finding: VA has worked to develop and implement tobacco-free medical facilities; however, it has been hampered in its efforts by congressional mandates that require each VAMC to maintain a smoking area for veterans. The language of the Veterans Health Care Act of 1992 prevents VA from eliminating tobacco use at its medical facilities and thus prevents VA from following the national trend toward tobacco-free facilities, in which it was initially a leader. VA does not sell tobacco products at its medical facilities.

Tobacco Use by Department of Veterans Affairs Employees

The committee was unable to determine how many VA employees use tobacco. However, more health providers at a primarily psychiatric VA hospital were smokers (30%) (Essenmacher et al., 2009) than at a general VA hospital (11%) (Duffy et al., 2008). This suggests that VA tobacco-cessation programs should include both employees and veterans.

In keeping with general VHA policy favoring tobacco abstinence, VHA facilities have taken steps to help their employees who want to quit tobacco use. The majority of VAMCs provide outdoor smoking areas for employees; many of them have 3 to 10 employee shelters. However, at 91% of the VAMCs, patients and staff use the same smoking shelters (VA, 2006b). The 2008 VHA Directive 2008-052 requires that, whenever possible, patients and staff have separate smoking areas and that VAMC directors work toward a goal of having a single smoking area for patients and a single one for staff.

Most VAMCs (65%) offer tobacco-cessation services for employees who are not veterans, and 85% of VAMCs refer employees to VA tobacco-cessation programs. Of facilities that offer employee tobacco-cessation programs, 84% allow staff to participate in them during work hours (VA, 2006b). Staff members who are not veterans cannot receive NRTs from the VA pharmacy, but some facilities offer NRTs to employees at reduced cost. It has been suggested that VA



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