needed relaxation time. Programs tailored specifically to both deployed and nondeployed personnel are needed.

Given the command-and-control structure of DoD, it is not surprising that surveillance data on personnel health status are available. Some performance metrics have been developed by individual services to assess short-term tobacco-cessation rates and the number of personnel who attend counseling sessions or receive medications, but the impact of the metrics on improving tobacco-cessation rates and services is unclear, and the information is not publicly available. Furthermore, more information should be gathered on the long-term success rates of tobacco-cessation programs so that human and financial resources and treatments can be adjusted to increase their effectiveness. For example, the committee was frustrated in its attempts to obtain a report that evaluated tobacco-cessation programs across the armed services, although a fact sheet on the evaluation was eventually published (DoD, 2008). This does not inspire confidence that the programs are meeting the needs of military personnel, and it prevents contributions by outside experts on how the programs might be improved.

TOWARD A TOBACCO-FREE VETERAN POPULATION

The tobacco-cessation programs used by VA are similar to those of DoD, but VA’s organizational structure and population being served are considerably different. Unlike DoD, VA (with a few exceptions) provides health care only to veterans and does not provide health care to their families or dependents. VA is a health leader in many fields, such as electronic medical records and mental-health research, and its medical-research advances are widely recognized. VA has a long history of attempting to reduce tobacco use by veterans and has been responsible for numerous scientific advances regarding health effects of smoking. In addition, its organizational structure provides for considerable autonomy for medical facilities to address the needs of its patient populations. The committee finds that this autonomy has advantages in allowing the tobacco-cessation lead clinician in each VA medical center to modify programs to meet specific patient needs. However, the lack of systematic information on tobacco-control programs offered in outpatient clinics, including community-based outpatient clinics, needs to be addressed. Evaluative data are spotty, and there is no information on whether clients at VA Veterans Centers have much interest in such programs.

Given the older patient population in the VA health-care system, the need for prevention of tobacco-use initiation is less than that in DoD; there is, however, a great need for prevention of tobacco-use relapse. The committee believes that the growing number of veterans returning from deployment with mental-health disorders, especially posttraumatic stress



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