promote cessation (Pizacani et al., 2004) and reduce initiation (Farkas et al., 2000). Likewise, the effectiveness of individual-level and school-based interventions, such as home smoking bans and school-based smoking-prevention programs, is enhanced when they take place in the context of strong communitywide tobacco-control efforts that support and reinforce changes effected at these levels (Perry, 2001).

The socioecologic approach has been applied to analyses of health behaviors and the design of interventions to address a variety of other public-health issues, including physical activity (Booth et al., 2001; Sallis et al., 2006), diet and eating behaviors (Glanz et al., 2005), condom use (Cohen et al., 1999), and chronic-disease self-management (Norris et al., 2002). The framework has also been used as a guide to public-health programs nationally and internationally, including Healthy People 2010 (HHS, 2000) and the World Health Organization (WHO) Framework Convention on Tobacco Control (WHO, 2003) (see Chapter 4 and Appendix A).

A SOCIOECOLOGIC ANALYSIS OF TOBACCO USE IN MILITARY AND VETERAN POPULATIONS

The socioecologic analysis of tobacco use includes attention to the individual, interpersonal, community, and societal factors in military and veteran populations and considers the role of the broader social, cultural, and political context in creating an environment that may increase use. That dynamic interplay may account for increasing trends of tobacco use in the military and veteran populations over the last decade. At the individual level, the physiologic processes that underlie nicotine addiction and the high rates of physical and mental comorbidity found in these populations are addressed. At the interpersonal level, the psychosocial factors that characterize life in the military—including separation from family and friends, alternation of high levels of stress with periods of boredom, peer influences, and the perceived role of tobacco use in facilitating social connectedness—and the limited opportunities to adopt alternative, healthier coping strategies are considered. Attitudes toward tobacco use in DoD and VA, their organizational structure, and their current practices and policies that may be exacerbating the tobacco epidemic and preventing the progress in tobacco control are addressed. Variable taxation of tobacco products by the federal and state governments and the role of the tobacco industry in keeping tobacco prices low contribute to the use of tobacco by adults and children. Finally, current congressional mandates, economic constraints on a national scale, and the sustained military conflicts in Iraq and Afghanistan operate to reduce the ability of DoD and VA to become tobacco-free and increase the rates of tobacco use by active-duty and



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