[House Report 115-1033]
[From the U.S. Government Publishing Office]


115th Congress }                                          { REPORT
                        HOUSE OF REPRESENTATIVES
  2d Session   }                                          { 115-1033

======================================================================
 
   TO AMEND TITLE 38, UNITED STATES CODE, TO PROHIBIT SMOKING IN ANY 
 FACILITY OF THE VETERANS HEALTH ADMINISTRATION, AND FOR OTHER PURPOSES

                                _______
                                

 November 16, 2018.--Committed to the Committee of the Whole House on 
            the State of the Union and ordered to be printed

                                _______
                                

    Mr. Roe of Tennessee, from the Committee on Veterans' Affairs, 
                        submitted the following

                              R E P O R T

                        [To accompany H.R. 1662]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 1662) to amend title 38, United States Code, to 
prohibit smoking in any facility of the Veterans Health 
Administration, and for other purposes, having considered the 
same, report favorably thereon without amendment and recommend 
that the bill do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     3
Subcommittee Consideration.......................................     4
Committee Consideration..........................................     4
Committee Votes..................................................     4
Committee Oversight Findings.....................................     4
Statement of General Performance Goals and Objectives............     4
New Budget Authority, Entitlement Authority, and Tax Expenditures     4
Earmarks and Tax and Tariff Benefits.............................     4
Committee Cost Estimate..........................................     5
Congressional Budget Office Estimate.............................     5
Federal Mandates Statement.......................................     6
Advisory Committee Statement.....................................     6
Constitutional Authority Statement...............................     6
Applicability to Legislative Branch..............................     6
Statement on Duplication of Federal Programs.....................     6
Disclosure of Directed Rulemaking................................     6
Section-by-Section Analysis of the Legislation...................     7
Changes in Existing Law Made by the Bill as Reported.............     7

                          Purpose and Summary

    H.R. 1662 was introduced by Representative Brad Wenstrup of 
Ohio, the Chairman of the Committee on Veterans' Affairs 
Subcommittee on Health on March 21, 2017.
    H.R. 1662 would prohibit smoking inside any Veterans Health 
Administration (VHA) facility. It would also prohibit smoking 
outside any VHA facility beginning October 1, 2022.

                  Background and Need for Legislation


Section 1. Prohibition of smoking in facilities of the Veterans Health 
        Administration

    The negative health effects of both smoking and second-hand 
smoke exposure are well documented. According to the American 
Cancer Society, illnesses related to tobacco use are 
responsible for 1 out of every 5 deaths in the United States 
while secondhand smoke is known to cause lung cancer even in 
those who have never smoked and may be linked to larynx, 
pharynx, nasal sinus, brain, bladder, rectum, stomach and 
breast cancer.\1\\2\
---------------------------------------------------------------------------
    \1\American Cancer Society. Health Risks of Smoking Tobacco. 
https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/health-
risks-of-smoking-tobacco.html. Accessed May 15, 2017.
    \2\American Cancer Society. Health Risks of Secondhand Smoke. 
https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/
secondhand-smoke.html. Accessed May 15, 2017.
---------------------------------------------------------------------------
    However, the Veterans Health Care Act of 1992 (Public Law 
102-585; 106 STAT. 4943) requires each VA medical facility to 
establish and maintain suitable designated smoking areas. 
Accordingly, VA medical centers across the country provide 971 
outdoor smoking areas and 18 indoor smoking areas for veteran 
patients and VA employees. According to information VA provided 
to the Committee, VA estimates that the total cost to maintain 
all outdoor smoking areas at VA medical centers is 
approximately $1.2 million per year and that the total cost to 
maintain all indoor smoking areas at VA medical centers is 
approximately $35,469 per year. Of note, these estimated costs 
do not include costs associated with maintaining smoking areas 
at other VHA facilities.
    Since FY 2013, VA's annual budget submission has included a 
legislative proposal to prohibit smoking in VHA facilities, in 
line with industry standards and best practices. In support of 
this proposal, the Department of Veterans Affairs (VA) cites 
100 percent smoke-free policies that have been adopted on the 
facilities, grounds, and office buildings of many Department of 
Defense medical treatment facilities, four large national 
healthcare systems (Kaiser Permanente, Mayo Clinic, SSM Health 
Care, and CIGNA Corporation), and more than 4,000 local and/or 
state/territory/commonwealth hospitals, health care systems and 
clinics.\3\ Yet, ``VHA health care providers and visitors do 
not have the same level of protection from the hazardous 
effects of second-hand smoke exposure as do patients and 
employees in these other systems.''\4\ This is particularly 
concerning given that, while only about 20 percent of veteran 
enrollees smoke, VA's non-smoking veteran enrollee population 
includes veterans who may be particularly vulnerable to 
cardiovascular events associated with secondhand smoke 
exposure.\5\ For those veteran enrollees who are smokers, 7 out 
of 10 want to quit.\6\ VA provides a number of smoking 
cessation resources for those veterans. Those resources include 
nicotine replacement therapies, medication, counseling, a 
smoking ``quitline,'' and text messaging support.\7\
---------------------------------------------------------------------------
    \3\United States Cong. House Committee on Veterans' Affairs 
Subcommittee on Health. Legislative Hearing. March 29, 2017. 115th 
Cong. 1st sess. Washington: GPO, 2017 (statement from Jennifer S. Lee, 
Deputy Under Secretary for Health for Policy and Services, Veterans 
Health Administration, U.S. Department of Veterans Affairs)
    \4\Ibid.
    \5\Ibid.
    \6\U.S. Department of Veterans Affairs. Tobacco and Health. https:/
/www.publichealth.va.gov/smoking/index.asp Accessed May 15, 2017.
    \7\Ibid.
---------------------------------------------------------------------------
    There is evidence to suggest that quitting smoking can be 
particularly beneficial for veteran patients. VA has found 
that--while many veterans, particularly those with mental 
health conditions, smoke--smokers are more likely than non-
smokers to have experienced anxiety, panic, stress, depression, 
and suicidal thoughts and tobacco smoke can make some 
medications--particularly those used for depression, anxiety, 
and psychotic disorders--less effective.\8\ On the other hand, 
one year after quitting, former smokers reporting feeling 
happier and better able to concentrate.\9\
---------------------------------------------------------------------------
    \8\Ibid.
    \9\Ibid.
---------------------------------------------------------------------------
    Section 1 of the bill would prohibit smoking inside any VHA 
facility within 90 days and outside any VHA facility on or 
after October 1, 2022. ``Smoke'' would be defined to include 
cigarettes, electronic cigarettes (e-cigarettes), cigars, 
pipes, and any other combustion of tobacco and ``facility of 
VHA'' would be defined as any land or building (to include any 
medical center, nursing home, domiciliary facility, outpatient 
clinic, or readjustment counseling center) that is under VA's 
jurisdiction, under VHA's control, and not under the control of 
the General Services Administration. During a legislative 
hearing on March 29, 2017, VA estimated that enactment of H.R. 
1662 would result in approximately $8.3 million in savings in 
fiscal year 2023.\10\
---------------------------------------------------------------------------
    \10\United States Cong. House Committee on Veterans' Affairs 
Subcommittee on Health. Legislative Hearing.
---------------------------------------------------------------------------

                                Hearings

    There were no full Committee hearings held on H.R. 1662.
    On March 29, 2017, the Subcommittee on Health conducted a 
legislative hearing on a number of bills including H.R. 1662.
    The following witnesses testified:
          The Honorable David. P. Roe M.D. of Tennessee; The 
        Honorable Jackie Walorski of Indiana; The Honorable 
        Doug Collins of Georgia; The Honorable Mike Coffman of 
        Colorado; The Honorable Stephen Knight of California; 
        The Honorable Ann M. Kuster of New Hampshire; Jennifer 
        S. Lee, M.D., the Deputy Under Secretary for Health for 
        Policy and Services for the Veterans Health 
        Administration of the U.S. Department of Veterans 
        Affairs who was accompanied by Susan Blauert, the Chief 
        Counsel for the Health Care Law Group of the Office of 
        the General Counsel for the U.S. Department of Veterans 
        Affairs; Kayda Keleher, Legislative Associate for the 
        National Legislative Service of the Veterans of Foreign 
        Wars of the United States; Shurhonda Y. Love, the 
        Assistant National Legislative Director for the 
        Disabled American Veterans; and, Sarah S. Dean, the 
        Associate Legislative Director for the Paralyzed 
        Veterans of America.
    Statements for the record were submitted by:
          The Honorable Lee Zeldin of New York; The American 
        Legion; the National Association of State Veteran 
        Homes; Swords to Plowshares; and, the Wounded Warrior 
        Project.

                       Subcommittee Consideration

    On April 6, 2017, the Subcommittee on Health met in an open 
markup session, a quorum being present, and ordered H.R. 1662 
to be reported favorably to the full Committee by voice vote.

                        Committee Consideration

    On May 17, 2017, the full Committee met in open markup 
session, a quorum being present, and ordered H.R. 1662 to be 
reported favorably to the House of Representatives by voice 
vote. A motion by Representative Tim Walz of Minnesota, Ranking 
Member of the Committee on Veterans' Affairs, to report H.R. 
1662 favorably to the House of Representatives was agreed to by 
voice vote.

                            Committee Votes

    In compliance with clause 3(b) of rule XIII of the Rules of 
the House of Representatives, there were no recorded votes 
taken on amendments or in connection with ordering H.R. 1662 
reported to the House.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII and clause 
(2)(b)(1) of rule X of the Rules of the House of 
Representatives, the Committee's oversight findings and 
recommendations are reflected in the descriptive portions of 
this report.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are to prohibit smoking inside or outside 
VA medical facilities.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee adopts as its 
own the estimate of new budget authority, entitlement 
authority, or tax expenditures or revenues contained in the 
cost estimate prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

                  Earmarks and Tax and Tariff Benefits

    H.R. 1662 does not contain any Congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9 of rule XXI of the Rules of the House of 
Representatives.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate on H.R. 
1662 prepared by the Director of the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 1662 provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, May 24, 2017.
Hon. Phil Roe, M.D.
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 1662, a bill to 
amend title 38, United States Code, to prohibit smoking in any 
facility of the Veterans Health Administration, and for other 
purposes.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann E. 
Futrell.
            Sincerely,
                                                Keith Hall,
                                                          Director.
    Enclosure.

H.R. 1662--A bill to amend title 38, United States Code, to prohibit 
        smoking in any facility of the Veterans Health Administration, 
        and for other purposes

    H.R. 1662 would prohibit smoking indoors at medical 
facilities of the Department of Veterans Affairs (VA) and 
eliminate the current requirement that VA provide smoking areas 
for staff and patients at its major medical facilities. Those 
provisions would be effective within 90 days of the bill's 
enactment. (The department already prohibits indoor smoking at 
its medical facilities.) Beginning in 2023, the bill also would 
prohibit individuals from smoking outdoors at VA medical 
facilities. Based on information from VA, we expect that the 
department would continue to provide outdoor smoking areas 
through 2022. While the bill would eventually reduce costs for 
maintaining those smoking areas, CBO expects that those 
effects, which would probably be small, would occur after 2022. 
Thus, CBO estimates that implementing the bill would have no 
significant budgetary effects over the 2018-2022 period.
    Enacting H.R. 1662 would not affect direct spending or 
revenues; therefore, pay-as-you-go procedures do not apply. CBO 
estimates that enacting H.R. 1662 would not increase net direct 
spending or on-budget deficits in any of the four consecutive 
10-year periods beginning in 2028.
    H.R. 1662 contains no intergovernmental mandates as defined 
in the Unfunded Mandates Reform Act (UMRA) and would not affect 
the budgets of state, local, or tribal governments.
    The bill would impose new private-sector mandates, as 
defined in UMRA, on individuals by prohibiting smoking indoors 
in any Veterans Health Administration (VHA) facility upon 
enactment and by prohibiting smoking outside of a VHA facility 
on or after October I, 2022. CBO estimates that the cost of the 
mandates, if any, would fall well below the annual threshold 
established in UMRA for private-sector mandates ($156 million 
in 2017, adjusted annually for inflation).
    The CBO staff contact for this estimate is Ann E. Futrell. 
The estimate was approved by H. Samuel Papenfuss, Deputy 
Assistant Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 1662 prepared by the Congressional 
Budget Office pursuant to section 423 of the Unfunded Mandates 
Reform Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
1662.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, H.R. 1662 is authorized by Congress' power to 
``provide for the common Defense and general Welfare of the 
United States.''

                  Applicability to Legislative Branch

    The Committee finds that H.R. 1662 does not relate to the 
terms and conditions of employment or access to public services 
or accommodations within the meaning of section 102(b)(3) of 
the Congressional Accountability Act of 1995.

              Statement on Duplication of Federal Programs

    Pursuant to section 3(g) of H. Res. 5, 114th Cong. (2015), 
the Committee finds that no provision of H.R. 1662 establishes 
or reauthorizes a program of the Federal Government known to be 
duplicative of another Federal program, a program that was 
included in any report from the Government Accountability 
Office to Congress pursuant to section 21 of Public Law 111-
139, or a program related to a program identified in the most 
recent Catalog of Federal Domestic Assistance.

                   Disclosure of Directed Rulemaking

    Pursuant to section 3(i) of H. Res. 5, 114th Cong. (2015), 
the Committee estimates that H.R. 1662 contains no directed 
rulemaking that would require the Secretary to prescribe 
regulations.

             Section-by-Section Analysis of the Legislation


Section 1. Prohibition on smoking in facilities of the Veterans Health 
        Administration

    Section 1(a) of the bill would amend section 1715 of title 
38 U.S.C. to prohibit smoking indoors in any VHA facility upon 
enactment and prohibit smoking outside of a VHA facility on or 
after October 1, 2022. Section 1(a) of the bill would also 
define ``smoke'' to include the smoking of cigarettes 
(including e-cigarettes or electronic cigarettes), cigars, 
pipes, and any other combustion of tobacco and define 
``facility of the Veterans Health Administration'' to mean any 
land or building that is under the jurisdiction of VA, under 
the control of VHA, and not under the control of the General 
Services Administration.
    Section 1(b) of the bill would amend the table of sections 
at the beginning of chapter 17 of title 38 U.S.C. by striking 
the item relating to section 1715 and inserting, ``1715. 
Prohibition on smoking in facilities of the Veterans Health 
Administration.''. Section 1(b) of the bill would also repeal 
section 526 of the Veterans Health Care Act of 1992 (Public Law 
102--585; 106 STAT. 4943).
    Section 1(c) of the bill would establish an effective date 
of 90 days after enactment.

         Changes in Existing Law Made by the Bill, as Reported

    In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, and existing law in which no 
change is proposed is shown in roman):

                      TITLE 38, UNITED STATES CODE




           *       *       *       *       *       *       *
PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *


   CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE


                          SUBCHAPTER I--GENERAL

Sec.
1701. Definitions.
     * * * * * * *

 SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL 
                                TREATMENT

     * * * * * * *
[1715. Tobacco for hospitalized veterans.]
1715. Prohibition on smoking in facilities of the Veterans Health 
          Administration.

           *       *       *       *       *       *       *


SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL 
TREATMENT

           *       *       *       *       *       *       *



[Sec. 1715. Tobacco for hospitalized veterans

  [The Secretary may furnish tobacco to veterans receiving 
hospital or domiciliary care.]

Sec. 1715. Prohibition on smoking in facilities of the Veterans Health 
                    Administration

  (a) Prohibition.--(1) No person may smoke indoors in any 
facility of the Veterans Health Administration.
  (2) No person may smoke outdoors in any facility of the 
Veterans Health Administration on or after October 1, 2022.
  (b) Definitions.--In this section:
          (1) The term ``smoke'' includes the smoking of 
        cigarettes (including e-cigarettes or electronic 
        cigarettes), cigars, pipes, and any other combustion of 
        tobacco.
          (2) The term ``facility of the Veterans Health 
        Administration'' means any land or building (including 
        any medical center, nursing home, domiciliary facility, 
        outpatient clinic, or center that provides readjustment 
        counseling) that is--
                  (A) under the jurisdiction of the Department 
                of Veterans Affairs;
                  (B) under the control of the Veterans Health 
                Administration; and
                  (C) not under the control of the General 
                Services Administration.

           *       *       *       *       *       *       *

                              ----------                              


          SECTION 526 OF THE VETERANS HEALTH CARE ACT OF 1992


[SEC. 526. USE OF TOBACCO PRODUCTS IN DEPARTMENT FACILITIES.

  [(a) In General.--The Secretary of Veterans Affairs shall 
take appropriate actions to ensure that, consistent with 
medical requirements and limitations, each facility of the 
Department described in subsection (b)--
          [(1) establishes and maintains--
                  [(A) a suitable indoor area in which patients 
                or residents may smoke and which is ventilated 
                in a manner that, to the maximum extent 
                feasible, prevents smoke from entering other 
                areas of the facility; or
                  [(B) an area in a building that--
                          [(i) is detached from the facility;
                          [(ii) is accessible to patients or 
                        residents of the facility; and
                          [(iii) has appropriate heating and 
                        air conditioning; and
          [(2) provides access to an area established and 
        maintained under paragraph (1), consistent with medical 
        requirements and limitations, for patients or residents 
        of the facility who are receiving care or services and 
        who desire to smoke tobacco products.
  [(b) Covered Facilities.--A Department facility referred to 
in subsection (a) is any Department of Veterans Affairs medical 
center, nursing home, or domiciliary care facility.
  [(c) Reports.--(1) Not later than 180 days after the date of 
the enactment of this Act, the Comptroller General shall submit 
to the Committees on Veterans' Affairs of the Senate and House 
of Representatives a report on the feasibility of the 
establishment and maintenance of areas for smoking in 
Department facilities under this section. The report shall 
include information on--
          [(A) the cost of, and a proposed schedule for, the 
        establishment of such an area at each Department 
        facility covered by this section;
          [(B) the extent to which the ventilating system of 
        each facility is adequate to ensure that use of the 
        area for smoking does not result in health problems for 
        other patients or residents of the facility; and
          [(C) the effect of the establishment and maintenance 
        of an area for smoking in each facility on the 
        accreditation score issued for the facility by the 
        Joint Commission on the Accreditation of Health 
        Organizations.
  [(2) Not later than 120 days after the effective date of this 
section, the Secretary shall submit to the committees referred 
to in paragraph (1) a report on the implementation of this 
section. The report shall include a description of the actions 
taken at each covered facility to ensure compliance with this 
section.
  [(d) Effective Date.--The requirement to establish and 
maintain areas for smoking under subsection (a) shall take 
effect 60 days after the date on which the Comptroller General 
submits to the committees referred to in subsection (c)(1) that 
report required under that subsection.]

                                  [all]