whether or not they see a primary-care physician about quitting tobacco use or attend a tobacco-cessation program. It should also put into place systems of continuing evaluation and oversight to measure the effectiveness of its tobacco-cessation programs.

VA does not provide health-care services to dependents of veterans, with a few exceptions. The evidence shows that smokers whose partners smoke are less likely to quit and more likely to relapse. Some VA medical facilities permit partners of smokers to attend counseling sessions but cannot cover the costs of their tobacco-cessation medications. Inclusion of partners is at the discretion of the clinicians conducting the sessions. The committee recommends that partners of smokers be allowed access to treatment. The committee also recommends that VA explore the additional costs that might be incurred by providing tobacco medications to partners, either free or at reduced cost.

VA has been in the forefront of the use of electronic medical records. The records might be used to enable primary-care providers and other appropriately trained health-care personnel to indicate that tobacco-cessation medications (especially NRTs) are to be mailed to interested patients without going to pharmacies and without the need for healthcare providers who lack prescription privileges to obtain them from providers who do. Each of these steps would make it more likely that a motivated patient will use the medications and thus increase the chances of quitting tobacco use.

Unlike DoD, VA does not have to respond to the sale of tobacco products, having discontinued such sales several years ago. However, it does have a congressional mandate to maintain smoking areas for patients. The committee finds that this congressional requirement is in conflict with current understanding of the harm caused by exposure to tobacco smoke. The committee also finds that maintaining such smoking areas is not in compliance with the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) tobacco-control standard that bans smoking in hospital buildings. In light of VA’s leadership in numerous health-care fields, and its repeated attempts to make its facilities entirely tobacco-free (both indoor and outdoor), the committee finds it lamentable that Congress continues to require that VA maintain smoking shelters at its health-care facilities.

VA has been in the forefront of the development and implementation of performance measures to ensure that health-care providers ask patients about tobacco use, advise them to quit, and assist patients who are willing to quit in obtaining tobacco-cessation treatment. Although compliance with the performance measures is extremely high—almost 100% in some VA facilities—there is little documentation



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