program in the occupational-health clinic. The committee was unable to identify tobacco-use rates in DoD civilian employees or their need for tobacco-cessation services.

Primary-Care Providers

Medical-care and health-promotion activities are often conducted by different but complementary staff on military installations. In each service, the major responsibility for tobacco-prevention and -cessation education and programs falls to the health-promotion staff. Depending on the professional discipline, the health-promotion staff might not have the authority to prescribe NRTs or other tobacco-cessation medications, such as bupropion and varenicline. That authority resides in the medical staff, that is, physicians, physician assistants, and nurse practitioners (Kathy Green, US Air Force, personal communication, December 12, 2008). In most cases, the health-promotion and medical staff deliver their care concurrently as part of a comprehensive tobacco-cessation program, but this approach requires that military personnel interested in quitting tobacco use to seek assistance from two sources. The committee believes that this multilevel process may be a barrier to using evidence-based treatment for achieving tobacco cessation. Implementation of the VA/DoD guideline that primary-care providers use brief counseling, as well as prescriptions for medications, might help motivate patients to quit. Alternatively, allowing health-promotion staff to write prescriptions for NRTs that can be obtained over the counter in the civilian sector might encourage tobacco users to use those medications.

Other Health Professionals

Some health professionals conduct tobacco-cessation programs at military treatment facilities, although this varies by service. The 2007 DoD evaluation of tobacco-use–cessation programs at 130 medical treatment facilities found that most cessation classes were conducted by health educators (63%) or nurses (36%), with fewer classes conducted by providers (the survey does not specify what type of provider), technicians, behavioral health professionals, and others (DoD, 2008).

Air Force Instruction 40-102 states that “health-promotion personnel ensure installation health-promotion programs … incorporate education programs and information on resources available in the community to discourage tobacco use.” Health-promotion staff are also the lead advocates for tobacco cessation on Navy installations, as are Semper Fit (health-promotion) staff on Marine Corps installations (Navy BUMED Position Statement, February 2, 2008). The health-promotion staff coordinate tobacco-prevention and -cessation programs and



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