them. DoD should also require that each military installation designate such persons and give them appropriate training.

DoD and VA are both adept at outreach and public-education campaigns and have used their expertise in the past for alcohol-abuse and weight-management programs. The committee believes that such public-education expertise, along with counteradvertising campaigns to change social norms around tobacco use, can be applied to tobacco cessation. Engaging such groups as veteran service organizations, the United Service Organizations, VA volunteer services, and military family organizations can raise the profile of tobacco-control issues and stimulate support and services for military members and veterans who are trying to quit. Local military installations and VA outpatient clinics can establish relationships with local chapters of such groups as the American Cancer Society and the American Lung Associations. Such relationships can help health professionals access patient-education materials, provide advice to their patients on support groups, and keep abreast of new developments in tobacco-control research.

Both the VA/DoD guideline and the 2008 Public Health Service (PHS) guideline advocate the use of the 5 A’s for each patient seen by a health-care provider. Although many of the health-care facilities in each organization follow the guidelines and virtually all patients are asked about tobacco use, advised to quit, and given assistance in the form of a referral to tobacco-cessation programs, many do not assess the likelihood that patients are willing to quit and do not arrange for follow-up with easily accessed treatment. The committee recommends that all healthcare providers be trained in the 5 A’s and in the use of the tobacco-cessation approaches in the guidelines. All of these efforts will help to reduce barriers to accessing tobacco-cessation services for military personnel, their families, and veterans.

The committee is aware that surveillance of tobacco use and cessation is time-consuming and that VA and DoD may not have enough personnel to accomplish this task. The committee recommends that VA and DoD evaluate their personnel needs for tobacco surveillance, prevention, and cessation and make appropriate requests for additional staff through regular channels.

In reviewing the comprehensive tobacco-control programs used by states and other organizations, the committee was struck by one component that served as a driver for developing and implementing each program: strong, committed, and dynamic leadership. VA and DoD are top-down organizations, and leadership initiatives are most likely to result in organizational change. This has been seen in the reorganization of the Veterans Health Administration from an inpatient-based system to an outpatient-based system under the auspices of the under secretary for



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