THE Department of Veterans Affairs (VA), the largest health care provider in the United States, implemented an agency policy on January 7, 1991, requiring all 172 acute-care hospitals to be completely smoke-free.1-3 The VA initiative followed directives by other government agencies for smoke-free environments, such as the US Army4 and the Indian Health Service.5 Smoke-free hospitals have been endorsed by the American Medical Association, the American College of Physicians, and the US Preventive Services Task Force, as well as other organizations.6 This policy was written in a national climate that is increasingly intolerant of environmental tobacco smoke, although hospitals commonly continue to allow smoking in designated areas. Several medical centers have become completely smoke-free,7-13 and the states of Minnesota and Maine have passed legislation requiring health care institutions to be smoke-free. Because of the national trend in legislation of public smoking (including the Joint Commission