higher rates of medical and psychiatric disorders than the general population. For example, over 36% of enrolled veterans reported fair or poor health status compared with excellent, very good, or good health. In addition, 26.3% of enrollees reported that they had experienced difficulty in concentrating, remembering, or making decisions because of a physical, mental, or emotional condition (VA, 2006). VA treats a large number of veterans returning from Operation Iraqi Freedom (OIF) in Iraq and Operation Enduring Freedom (OEF) in Afghanistan with psychiatric disorders. Seal et al. (2007) surveyed 103,788 OEF and OIF veterans seen at VA health-care facilities and found that 25% received mental-health diagnoses; of those, 56% had two or more distinct mental-health diagnoses.

INTERPERSONAL FACTORS

The experience of serving in the military is a risk factor for tobacco use and may play a role in the initiation of smoking among military personnel (Cronan and Conway, 1988). DoD (2006) found that 18.4% of military personnel who responded to a 2005 survey said that they started smoking after joining the military, including 37.5% of current smokers. Certain aspects of the military experience may encourage tobacco use, such as acceptability of smoking by one’s social networks. Family, friend, and peer influences are sources of behavioral models and social support that are predictors for smoking and its initiation (Vink et al., 2003).

Haddock et al. (1998) stated that social factors are the strongest predictors of tobacco use; for example, having friends who smoke and view smoking as attractive significantly increases one’s own risk of smoking. In addition, by modeling the influence of social networks on smoking behaviors, Christakis and Fowler (2008) found that people seem to act in accordance with and under the collective pressures of their social niche.

Surveys of health behaviors in the military have noted similar findings linking peer influence to tobacco use (DoD, 2006; Nelson et al., 2009). Nearly 9% of the participants in the 2005 DoD survey started smoking “to fit in with my friends”; this rate varied somewhat among the services—5.6% of Army personnel and 11% of Air Force personnel reported fitting in with others as a factor in smoking initiation. Servicewide, nearly 7% reported that they started smoking “to look ‘cool’ or be ‘cool’” (DoD, 2006) (see Table 3-4 for more detailed responses). In another survey of tobacco use in military personnel, a supervisor stated the following: “You’re an Airman and you are hanging out with fellow Airmen and the thing to do was go to the club. You could go to the gym too, but you also went to the club and at the club it was



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