and VA; programs vary among services, among military installations, and within each VA medical facility.

Numerous national and international organizations have considered the issue of tobacco use and have developed comprehensive programs to aid in its reduction. For example, IOM, the National Quality Forum, the Public Health Service (PHS), the Agency for Healthcare Research and Quality, the National Cancer Institute (NCI), the American Cancer Society, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO) have all provided guidance on tobacco-control policies and practices. The committee found several reports to be important reference points for its deliberations, including the recent IOM report Ending the Tobacco Problem: Blueprint for the Nation (IOM, 2007), the PHS’s Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update (Fiore et al., 2008), the CDC’s Best Practices for Comprehensive Tobacco Control Programs (CDC, 2007), the NCI’s ASSIST: Shaping the Future of Tobacco Prevention and Control (NCI, 2005) and Evaluating ASSIST: A Blueprint for Understanding State-Level Tobacco Control (NCI, 2006), and the WHO’s Building Blocks for Tobacco Control: A Handbook (WHO, 2004). Although both CDC and NCI provide a framework for developing and implementing a comprehensive tobacco-control program, the committee found that many aspects of the frameworks were not applicable to DoD or VA; rather, they were intended for state or local governments. Neither department has taxing capability, both must answer to Congress for any substantial changes in operations, military and veteran populations are not representative of the general US population, and their missions differ from those of state or local governments. Furthermore, DoD and especially VA have populations with a high prevalence of comorbid health problems such as psychiatric disorders (particularly PTSD), which may make them more susceptible to tobacco addiction as well as cardiovascular, pulmonary, and other diseases that may make them more susceptible to adverse health effects of tobacco use. Therefore, although the committee discusses the use of numerous evidence-based methods for effective tobacco-cessation programs, the unique characteristics of DoD and VA make parallels difficult.

In some cases in which there is no direct evidence to support specific findings and recommendations, the committee has used its expert judgment making its findings and recommendations.

ORGANIZATION OF THE REPORT

Chapter 2 provides background information on why tobacco use is of concern for DoD and VA. It discusses impairment of military



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