Family attitudes may also affect the perceived acceptability of smoking by either encouraging or discouraging tobacco use. For example, in response to “why military personnel started to smoke,” 5.6% reported that most members of their family smoked. With respect to acceptability, only 43% of respondents said that their “spouse, live-in partner, or the person I date disapproves of my smoking (or would disapprove if I did smoke).” Male military personnel who reported high levels of family-related stress were more likely to be current smokers than those with low stress (Cunradi et al., 2008). Married personnel were less likely to use smokeless tobacco than unmarried personnel (Ebbert et al., 2006).

COMMUNITY FACTORS

This section discusses organizational factors—such as culture, tolerance of tobacco use, organization-level activities, and policy and leadership—that may influence tobacco use by military personnel and veterans. The committee recognizes the numerous policies and practices implemented by DoD and VA (discussed in Chapters 5 and 6) that restrict and discourage use of tobacco by military personnel and veterans. However, the goal of this section is to indicate how a lack of policy or restriction may lead one to assume that tobacco use is condoned or tolerated by DoD and VA leadership.

To appreciate the origin and implementation of tobacco-use policies, one must understand the organizational structures of DoD and VA. These Cabinet-level departments are extensive, with budgets in the billions of dollars; DoD employs over 2 million people and VA over 280,000 people (Office of Citizen Services and Communications, 2009). The following is a brief overview of each organizational structure to indicate the chain of command and the location of responsibility for tobacco-use policies and programs.

Department of Defense

DoD is headed by the secretary of defense. Reporting to the secretary and deputy secretary of defense are the secretaries of the Department of the Army, Navy (which includes the Marine Corps), and Air Force. The secretary also oversees the Office of the Secretary of Defense, which is staffed by four under secretaries, including the under secretary of defense for personnel and readiness (USD[PR]). The assistant secretary of defense for health affairs reports to the USD(PR), as does the head of the TRICARE Management Activity. The Departments of the Army, Navy, and Air Force each have a surgeon general, who is responsible for service members’ health. The sections



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