摘要：Military personnel and veterans are disadvantaged by inadequate tobacco control policies. We conducted a case study of a Department of Veterans Affairs (VA) effort to disallow smoking and tobacco sales in VA facilities. Despite strong VA support, the tobacco industry created a public relations–focused grassroots veterans’ opposition group, eventually pushing the US Congress to pass a law requiring smoking areas in every VA health facility. Arguing that it would be unpatriotic to deny veterans this “freedom” they had ostensibly fought for and that banning smoking could even harm veterans’ health, industry consultants exploited veterans’ organizations to protect tobacco industry profits. Civilian public health advocates should collaborate with veterans to expose the industry’s manipulation, reframe the debate, and repeal the law. THE US MILITARY, COMPOSED primarily of working-class young people, has long been an important source of new smokers for the tobacco industry. 1 Although approaching civilian prevalence in recent years, 2 tobacco use among military personnel has historically been much higher than that among civilian populations, resulting in greater morbidity and mortality among veterans. 3 The tobacco industry has repeatedly interfered with the military’s attempts to discourage smoking. 4–6 The tobacco industry exerts influence on civilian overseers of the military through campaign contributions to Congress members, especially those from tobacco-growing states. 7 Congress has berated and intimidated military leaders who promote tobacco control 4,6 and has written industry-favored policies into law. 5,6 On discharge from service, the interests of the 24 million veterans of the US armed services are overseen by the Department of Veterans Affairs (VA). 3 In 2007, one third of veterans were enrolled in the VA’s health care system, which includes 171 hospitals throughout the United States. 8 Veterans smoke at higher rates than do nonveterans, 9 are more likely to die prematurely, 10 and incur high costs for treating tobacco-caused illnesses. 3 For example, each year the VA spends $5 billion to treat chronic obstructive pulmonary disease, 80% of which is attributable to smoking. 3 Whether veterans or governments bear the costs, many veterans experience shortened lifespans, physical suffering, and financial hardship because of tobacco use. By the late 1980s, nearly all civilian hospitals prohibited indoor smoking. 11,12 In March 1991, the Joint Commission on the Accreditation of Healthcare Organizations, now the Joint Commission, declared that “Accredited hospitals will have to disseminate and enforce a hospitalwide no-smoking policy.” 11 Since that time, many hospitals have established not only smoke-free buildings but also smoke-free grounds, partly as a result of concerns about risks of exposure to outdoor secondhand smoke. 13 Knowledge about the benefits of cessation, even late in life, has expanded, 14 and studies now show that quitting smoking before surgery can lead to better outcomes. 15 Denormalizing smoking 16,17 and reducing its visibility 18 may improve cessation rates, and cessation tends to spread through social networks. 19 Smoke-free health facilities, thus, have the potential to improve the health of patients with direct cessation support and by establishing and promoting tobacco-free norms. Although, like many civilian hospital systems, the VA took steps to restrict smoking and tobacco sales at its health care facilities, the tobacco industry, acting through a front group, persuaded Congress to require smoking areas in all VA hospitals. In this archival case study, we explored the enduring legacy of this action and drew lessons for addressing tobacco’s contributions to veterans’ disease burden.
