FACTORS THAT INFLUENCE TOBACCO USE

The decision to use tobacco depends on many factors, from personal ones such as self-image to societal ones such as easy access to cigarettes. Using a socioecologic approach to examine the factors that encourage and sustain tobacco use in military and veteran populations, the committee concluded that tobacco use is the result of the interplay among individual attributes (for example, genetic makeup and demographics), interpersonal factors (such as family and colleagues), community influences (including work and educational settings), and larger societal influences (such as political factors and commercial advertising). In the case of military personnel and veterans, those factors are in operation before entry into the military system and throughout different phases of military life, including recruitment, training, active duty, deployment, and discharge or retirement. At the individual level, nicotine addiction and physical and mental comorbidities contribute to the persistent use of tobacco. At the interpersonal level, peer and family influences and the role of tobacco in facilitating social connections are important. Leadership attitudes toward tobacco use in DoD and VA, their organizational structure, and their current practices and policies may contribute to the lack of progress in tobacco control. Congressional mandates, economic constraints, and military conflicts also affect the ability of DoD and VA to become tobacco-free.

TOBACCO-CONTROL PROGRAMS

The use of evidence-based best practices for tobacco control has been widely promoted and has succeeded in reducing tobacco use in the United States. Reducing tobacco use poses special challenges because tobacco products are legal and easy to acquire, highly addictive, and heavily promoted by the tobacco industry. About 50% of current everyday smokers attempt to quit each year, but only 4–7% of those are successful. Thus creation of a tobacco-free culture could be enhanced by the development of an environment that encourages abstinence, denormalizes tobacco use, and makes a variety of prevention and cessation services available.

Successful comprehensive tobacco-control programs with demonstrable, albeit incomplete, effectiveness have been developed and implemented by numerous organizations, including the National Cancer Institute and the Centers for Disease Control and Prevention; state governments, including those of California and Massachusetts; and commercial organizations. The programs use a combination of educational, clinical, social, and regulatory strategies to denormalize tobacco use. Comprehensive tobacco-control programs vary in target



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