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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 exploitedveterans’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 control4,6 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 smoking16,17 and reducing its visibility18 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.
Our primary data source was internal tobacco industry documents released following the Master Settlement Agreement20 and housed at the University of California, San Francisco’s Legacy Tobacco Documents Library.21 Initial search terms included “veterans, smoke free” and “Veterans Canteen Service.” Employing a snowball approach, we located additional material pertinent to tobacco sales and use at the VA.22 Out of more than 9000 hits, we analyzed approximately 700 relevant industry documents, which we included if they made reference to VA services, policies, or practices. Additional sources augmented these data (Table 1). Applying the Freedom of Information Act, we asked all 171 veterans’ facilities to provide data on costs related to compliance with the law requiring accommodation of smoking. Because they are obliged to retain documents only for a limited period of time, most facilities informed us they had no pertinent documents. We conducted a telephone and e-mail survey to learn how many smoking shelters had been constructed at each facility, what they were made of, whether they were indoors or outdoors, and whether they were climate controlled. In addition to analyzing industry documents, we evaluated approximately 250 documents from other sources using an interpretive approach, organizing our findings as a descriptive case study.23,24
In the 1980s, most of the 171 VA facilities sold tobacco in their canteens (Table 2). In the mid-1980s, a growing number of VA canteens began to request permission to discontinue sales,25 attracting the attention of the Tobacco Institute (TI), the tobacco industry’s lobbying group. David Satterfield, former congressional representative (D-VA) and tobacco industry consultant, warned that such a precedent could lead to “an agency-wide ban not only in the Veterans Administration but in the Armed Services as well.”26
Philip Morris military sales executives Rita Walters and Jim Juliana met with the director of Veterans Canteen Service Robert Mantica, who opposed the sales ban. At their urging, Mantica enlisted support from the American Logistics Association, which represented suppliers to the military resale system.27 The association wrote to VA administrator Thomas Turnage, arguing against ending tobacco sales.28 Satterfield suggested to the TI that Congress should remove canteen oversight from the VA Department of Medicine and Surgery.25
The TI also encouraged veterans’ service organizations to contact Turnage. In response, more than a dozen leaders of military and veterans’ organizations signed a letter to Turnage, arguing that it violated veterans’ freedom to deny them access to a legal product; that canteen profits would be reduced, harming veterans; that a tobacco ban could lead to removal of other goods such as candy; and that a black market would ensue.29 They argued that veterans needing medical attention would be alienated by the policy and would shun the VA altogether, jeopardizing their health.29 TI vice president Susan Stuntz, director of issues management, received approval for a quid pro quo with the Paralyzed Veterans of America: $10 000 in exchange for the organization’s opposition to VA smoking restrictions. Paralyzed Veterans of America was also supplied with a consultant to draft a “model smoking policy written for veterans by veterans.”30
Fleishman Hillard, Philip Morris’s public relations firm, engaged military organizations to drum up opposition to any sales ban by generating phone calls, letters, and meetings with VA policymakers.31 Fleishman Hillard also urged its American Legion contact to solicit a letter of protest to Turnage from Representative Kenneth Gray (D-IL), member of the House Committee on Veterans Affairs.32 In his letter, Gray decried the possibility of a tobacco sales ban at VA facilities, citing the potential loss of revenue and the specter of prohibition.32
At Satterfield’s instigation, the Oversight and Investigations Subcommittee of the House Veterans Affairs Committee convened a hearing on the Veterans Canteen Service in June 1988.33 A partner at accounting firm Price Waterhouse reported the results of a study commissioned by the Veterans Canteen Service on the financial feasibility of discontinuing tobacco sales,34 concluding that nothing could compensate for the loss of tobacco income and that long-term VA facilities’ residents would suffer hardship in having to pay more for cigarettes elsewhere.34 (Price Waterhouse conducted many studies for the tobacco industry or third parties acting on behalf of the industry, reporting industry-favorable results that were often challenged as unreliable.35-38) Five Veterans Canteen Service operational employees testified, all against discontinuing sales.34 TI president Samuel Chilcote Jr noted that as a result of the hearing, the full committee would likely attempt to remove the canteen service from the Department of Medicine and Surgery “to ensure its independence.”39 Congressional representative Sonny Montgomery (D-MS) included such a provision in legislation introduced in February 1989,40 but it did not pass.41
In March 1989, the Veterans Administration became the cabinetlevel Department of Veterans Affairs, headed by former congressional representative Edward Derwinski (R-IL). Derwinski declared that as of January 1990, smoking would be prohibited indoors at every VA facility.42 In response, TI engaged Willard and Auge (W&A), a West Virginia public relations firm, to organize opposition.43
W&A retained John Payne, former West Virginia state Veterans of Foreign Wars (VFW) commander, as principal spokesperson.44-47 In April 1989, W&A drafted a resolution opposing smoke-free VA hospitals, which a West Virginia VFW post passed.48 They then enlisted West Virginia VFW leaders to write to other veterans, urging them to contact legislators.48,49 By June, the West Virginia VFW state convention had endorsed the resolution.50 In August, the VFW national conference passed a resolution opposing smoke-free VA facilities.51 Payne sent a copy of the resolution to Senators Robert Byrd (D-WV) and Jay Rockefeller (D-WV) and received a response from Byrd indicating agreement.52 In August 1990, the American Legion National Convention in Indianapolis followed the VFW’s lead and passed a resolution, also drafted by W&A,52 against smoke-free VA facilities.53
In late 1989, W&A created the Veterans for Smokers Rights Coalition (VSRC),44,54 eventually claiming board members from all 50 states.44,55 In most interactions with the media and Congress, VSRC members suggested that they were part of a veteran-initiated grassroots campaign: “The Coalition was originated in Charleston, West Virginia in 1989 by four veterans who opposed the elimination of indoor designated smoking areas in VA hospitals.”54
In a list of “interview points,” W&A proposed answering the question “Who funds your group?” as follows:
Our organization is the perfect example of a grass-roots campaign. All of our members are volunteers who are dedicated to helping their fellow veterans. The only time costs incur is when we have to develop materials promoting our cause. When this happens, we seek funding from anyone who wants to contribute—ranging from individual personal donations, contributions from veterans organizations and posts, to companies that care about veterans.56
In actuality, TI was paying W&A a retainer of $6000 monthly and covering tens of thousands of dollars in VSRC costs, including payments to Payne.57 In private correspondence and invoices, W&A claimed responsibility for “developing”52 the organization and “assisting in association management.”52 W&A described the VSRC as “a resource that will assist [TI] in lobby efforts.”57
The VSRC mobilized against Derwinski’s policies, distributing newsletters, brochures, posters, postcards, and a video.58,59 W&A “tried to make the brochures have a simple, inexpensive look to them,”60 presumably to give the impression that they were produced by grassroots activists with limited resources rather than by a corporate lobbying group and its consulting firm. By early 1992, the VSRC was staging an increasing number of protests against Derwinski’s policies, generating press and shoring up congressional support.62-66
VSRC statements characterized veterans as pathetic victims, further injured by Derwinski’s tobacco control policies. For example, the VSRC’s brochures featured a photo of an elderly wheelchair-bound veteran smoking in a parking lot in bad weather (Figure 1).60 VSRC made health arguments in this frame, suggesting that smoking’s hazards were outweighed by veterans’ other health risks. Health risks to nonsmoking veterans exposed to secondhand smoke went unmentioned. Payne argued that the no smoking policy created health problems such as pneumonia and heat stroke because veterans went outdoors in bad weather to smoke.67 He also suggested that infirm veterans ran risks when they left VA premises to purchase cigarettes.68 Payne told a reporter that smoking was “one of the few joys these guys have. You are not going to rehabilitate a 75-year-old guy who is going to die anyway.”69
Smoking was described as a “right” or “freedom.”1 Payne deplored the denial of “a basic right” to veterans who “fought in foreign countries so that we can all our [sic] enjoy the daily freedoms.”68 He argued, “They [veterans] have already given so much,”69 they should not be asked to make another sacrifice. Inside, the brochure asked, “Is this how we reward veterans who put their lives on the line to defend our country and freedom?”60
Finally, the VSRC suggested that Derwinski and health advocates were making a moral judgment, saying, “This is not a question of whether smoking is right or wrong but a question of whether we are going to treat our veterans with the dignity they deserve.”67 A Missouri veteran wrote an op-ed, claiming, “A criminal who has committed robbery, rape, or murder is not required to have to sit or stand out in the cold weather to enjoy his cigarette and coffee, but us [sic] veterans are.”70
Unbowed by industry-coordinated pressure, in June Derwinski formally announced that in addition to going smoke-free, all VA hospitals were to stop selling tobacco as of October 1, 1991. Derwinski argued that it was a matter of health and of consistency: “We cannot on the one hand prohibit smoking and on the other hand sell cigarettes.”69 In a 2010 interview, Derwinski explained, “We couldn’t be respected or accepted as a positive health provider if we were indifferent to smoking” (oral communication, April 30, 2010).
At the August 1991 national VFW conference, several state VFW chapters demanded Derwinski’s ouster.71 W&A reported on the conference to TI: “Fully a third of the VFW delegates partly at John’s [Payne’s] encouragement, booed Secretary Derwinski.”71 However, issues other than tobacco control motivated veterans’ displeasure, including Derwinski’s proposal to open 2 VA hospitals to nonveterans, his sending surplus medical supplies to Vietnam, and his support for a commission to study the future of the VA health care system.72
That same month, congressional representative Bob Wise (D-WV) introduced a bill compelling VA facilities to provide indoor smoking areas and to sell tobacco.42 Cosponsored by the entire West Virginia House delegation, it was called the Veterans Dignity in Health Care Act of 1991.67 In September 1991, Payne sought support from Senate members, including Byrd, Don Nickles (R-OK), and Wyche Fowler Jr (D-GA).73-76 Responding to a letter from Fowler, Derwinski wrote that he would not rescind his policy, citing the surgeon general’s evidence and the Joint Commission on the Accreditation of Healthcare Organizations’ smoke-free requirements.11,77,78 By late September, a conference committee report directed Derwinski to “reassess his decision to prohibit tobacco sales in VA hospital canteens effective October 1.”79 Derwinski did not yield; the sales ban went into effect as scheduled.
Derwinski wrote to his former congressional colleagues, appealing to them to reject the legislation that would undo his efforts to establish smoke-free hospitals. He noted that active smoking was “responsible for more than one of every six deaths nation-wide.”80 Derwinski also directed the VA’s chief medical examiner to write to veterans across the country to ask them to oppose legislation that would thwart his tobacco control policies.81 The Coalition on Smoking OR Health, composed of the American Heart Association, the American Lung Association, and the American Cancer Society, also wrote to Congress, supporting Derwinski’s efforts.82
By fall 1992, the text of the Veterans Dignity in Health Care Act of 1991 made its way into a broader VA health bill, HR 5193, the Veterans Health Care Amendments of 1992. After political wrangling between the House and Senate, the bill passed with the requirement that every VA facility provide an indoor or enclosed smoking shelter. However, Senators Alan Cranston (D-CA) and Arlen Specter (R-PA), influential opponents of the bill, forced a compromise whereby tobacco products would not be sold at VA canteens.83 The tobacco industry and its allies in Congress were displeased with the compromise but relieved to have reinstated the smoking areas.83 The industry apparently calculated that requiring smoking shelters was more important than was maintaining canteen sales for 2 reasons. First, veterans could buy cigarettes elsewhere and continue to smoke at the VA, but had smoking been banned entirely at VA facilities, sales would likely have stopped. Second, the tobacco industry’s long-term plans emphasized assuring smoking spaces84 to preserve the visibility of smoking as an accepted activity.
Derwinski resigned on September 26, 1992,83 accepting a post in the George H. W. Bush presidential campaign.85 In a 1996 report on its history, the VSRC claimed credit for having persuaded Bush to remove Derwinski.55 We found no evidence that the VSRC had such influence, and Derwinski disputed the claim (oral communication, April 30, 2010). However, it is clear that many politically active veterans were pleased to see him go, having objected to many of Derwinski’s actions, especially what they perceived to be his failure to consult with them.72 The VFW had said it would withhold its endorsement of Bush as long as Derwinski remained secretary.72
Shortly after enactment of the legislation, now called Public Law 102–585, the General Accounting Office estimated that it would cost between $4 million and $24 million to construct VA smoking shelters,86,87 not including maintenance and replacement costs86,87 or hazardous duty pay for employees (Box 1) who had to attend to the smoking areas.88 VA officials said that “providing a comfortable setting for smoking provides patients with the wrong message”86 and expressed concerns about the possibility of patient liability lawsuits and increased worker’s compensation claims. We found no evidence that such claims were filed.
When Congress mandated VA smoking areas, it stirred up a controversy already brewing between VA management and labor. The National Association of Government Employees demanded that VA employees exposed to secondhand smoke in the course of their jobs, for example while cleaning smoking shelters, receive hazardous duty pay.88 The VA resisted until the Federal Labor Relations Authority compelled them to make the payments.88 Only a limited number of employees at 14 VA facilities received hazard pay,88 but tobacco industry executives noted the precedent.88
The VA requested that the office of personnel management award hazard pay to all government employees exposed to secondhand smoke on the job.88 Because secondhand smoke had recently been classified as a carcinogen, the office of personnel management felt that no employee should be exposed to it, even if they were willing to be and were compensated for the risk.88 The suggestion that employees be equipped with special protective gear was seen as expensive and cumbersome.88 An outright ban on smoking in all government buildings was seen as he most cost-effective solution.88 One Philip Morris consultant argued that improved ventilation was the answer “so that patients could smoke (as their doctors say they should).”88 Ultimately, the Federal Labor Relations Authority’s decision awarding hazard pay for exposure to secondhand smoke was reversed but not before the industry expressed its concern that “permitting government agencies to pay hazardous duty pay or an environmental differential appears to confirm and be responsive to EPA’s designation of ETS [secondhand smoke] as a carcinogen.”88 VA employees who clean smoking shelters remain exposed to secondhand and thirdhand smoke.
A 2005 Veterans Health Administration survey of 158 of the 171 veterans’ facilities counted 783 enclosed smoking sites. A quarter were indoors and the remainder were freestanding structures,89 and temperature was controlled as needed, as mandated by the law. Some were for patients or employees only; 73% accommodated both.89 Some facilities reported as many as 32 smoking shelters onsite.89
In 2008, new guidelines from the General Services Administration prohibited smoking in all federal buildings,90 forcing the VA to provide smoking venues only in outdoor shelters91 and prompting a flurry of additional construction. Nearly all the 82 facilities responding to our telephone and e-mail survey corroborated that their smoking shelters were enclosed outbuildings. Only 1 reported a smoking hut attached to but apart from the main hospital; 1 reported it had no smoking shelter and was entirely smoke-free; and 1 said it would soon remove its shelter and become smoke-free.
The 42 facilities responding to our Freedom of Information Act request reported costs ranging from $6500 to $198 000 per shelter. Eighty-five shelters were built at a cost of $2 900 000, averaging $34 100. A conservative estimate, using the lowest figure of $6500 per shelter, yields a total of $5 million for 783 smoking sites. Using the average expense of $34 100, the cost rises to nearly $27 million. An unknown number of additional shelters were constructed in response to the 2008 guidelines, so the total cost would almost certainly be higher. All funds for construction and maintenance of smoking shelters come from the main VA budget,87 diverting resources that could otherwise be allocated to medical care, research, and other services86—including services for the entire veteran population, not just veterans who smoke.
The tactics that the industry has used to thwart tobacco control measures in the VA—challenging the legitimacy of regulatory authorities; minimizing concern about disease; framing the issue around freedom, personal choice, and individual rights; and emphasizing short-term financial gain over societal costs—have also been used to oppose clean indoor air laws, tobacco tax increases, and advertising regulations.92-95 Another common industry tactic is using front groups to convey the impression of grassroots support for industry-favored policies.4,84,96–99 Aware of its own credibility problems, the industry engages well-respected community leaders and organizations to represent its interests.1,100 By exploiting others’ reputations, industry arguments that might appear self-serving if the industry proffered them may be advanced. In this manner, the industry’s responsibility for the pandemic of tobacco-caused disease is rendered less visible. The tactics are familiar, and we have shown how weakened and inadequate tobacco control policies systematically disadvantaged veterans specifically.1,4–6,10,101–109
Because of the tobacco industry’s influence, particularly on Congress, veterans’ facilities have fallen behind the civilian sector in progress on tobacco control policies. Despite strong advocacy from within the VA, tobacco control efforts have been characterized by a pattern of “advance and retreat”4 and inconsistent messages about tobacco that have had negative effects on the health of veterans. In this case, existing relationships between the industry and the military procurement system, Congress, and public relations groups were employed to counter reasonable and scientifically valid public health measures that were then becoming the norm in civilian health facilities. Although every human being will indeed eventually “die anyway,” the tobacco industry cynically exploited veterans’ other concerns to advance its aims, even claiming the mantle of health protector.
Second, we have demonstrated how important each policy battle is. When the industry succeeded in getting Congress to require smoking shelters at VA facilities, it established a policy that would last for decades, redirecting VA funds for shelter construction and maintenance that could otherwise have gone to veterans’ health services. Furthermore, the opportunity was lost to make VA facilities a tobacco-free exemplar, promoting cessation through social and institutional norms. Instead, despite advances in the understanding of the benefits of smoking cessation for populations like veterans, VA health facilities are compelled to facilitate smoking on their grounds. The industry’s legislative success in 1992 thus continues to undermine cessation messages among veterans, and public health advocates must now fight battles that should have been won long ago.
This situation is exacerbated because VA and military policies are made at the federal level. Most advances in US tobacco control policy have occurred at local levels, with state or federal law following once municipal or county policies have proven successful.110 It is harder for the industry to interfere in local politics, because they are geographically dispersed and because local officials have historically received less financial support from the industry and have been more responsive to their constituents. Although the civilian focus on local policy-making has been successful, it may also have contributed to the neglect of military and veteran populations.
The Institute of Medicine, calling for a tobacco-free military, proposed repealing the law requiring VA smoking shelters.3 Achieving this repeal will be challenging. The federal arena has not been hospitable to tobacco control, and new approaches and alliances may be necessary. When Congress voted in 1998 to deny disability payments to tobacco-sickened veterans who started smoking in the military,109 primarily because of the cost, it angered veterans’ service organizations, such as the American Legion and the Disabled American Veterans, who have repeatedly called for a repeal of that policy.111,112 Such organizations might be amenable to shutting down the VA smoking shelters at this time. Outreach to these and other veterans’ service organizations, and additional research to understand how best to appeal to this constituency, could forge important new alliances. If health-focused veterans were to play a prominent role in this debate, they could be a credible counterforce to industry efforts.
Funding for this research was provided solely by the National Cancer Institute (grant CA109153).
We thank Vera Harrell for her research assistance and the late VA secretary Edward Derwinski for his willingness to be interviewed. We thank the journal editors and reviewers for their helpful suggestions on earlier drafts of the article.
R. E. Malone holds 1 share each of Philip Morris (Altria), Philip Morris International, and Reynolds American stock for research and shareholder advocacy purposes.
Contributors N. Offen originated the study, conducted tobacco industry document searches, interviewed key informants, and wrote the first draft. E. A. Smith conducted document research. R. E. Malone supervised the study. All authors participated in the analysis and contributed to the writing and editing of successive drafts.
Human Participant Protection This study was approved by the Committee on Human Research at the University of California, San Francisco.