摘要：Tobacco use is prevalent among service members, but civilian public health groups have not effectively addressed military tobacco control policy issues. We conducted focus groups in 2010 and 2012 with participants from public health and tobacco control organizations regarding their understanding of the military and of tobacco use in that context. Misperceptions were common. Military personnel were believed to be young, from marginalized populations, and motivated to join by lack of other options. Tobacco use was considered integral to military life; participants were sometimes reluctant to endorse stronger tobacco control policies than those applied to civilians, although some believed the military could be a social policy leader. Engaging public health professionals as effective partners in tobacco-free military efforts may require education about and reframing of military service and tobacco control policy. Tobacco use prevalence is high among service members 1 and military tobacco policy conveys mixed messages about tobacco use. For example, military personnel have access to comprehensive cessation services 2 but stores on military installations sell tobacco products at discounted prices. 3 Though the harms of smoking have been known since the 1950s, civilian public health groups have not effectively addressed military tobacco control policy issues. In 2009, the Institute of Medicine called for the Department of Defense to phase in policies that would lead to a tobacco-free military. 2 However, this call was rejected by then–Secretary of Defense Robert Gates. 4 More surprisingly, public health and tobacco control leaders were largely silent, the exception being the American Lung Association. 5 Recently, Secretary of the Navy Ray Mabus, supported by Secretary of Defense Chuck Hagel, 6 proposed eliminating tobacco sales from Navy and Marine Corps commissaries and exchanges. 7 The leading voluntary health organizations supported the move, 8 but there has been little public activism or engagement to counter efforts in Congress to block the Navy initiative. 9 This is only the latest in a long history of efforts by the military to strengthen its tobacco control policies that have been prevented by congressional action while public health groups remained uninvolved. 10–12 Effectively framing a problem is crucial to gaining support for a proposed solution. Frames define a problem and implicitly or explicitly suggest the solution. 13 For example, personal responsibility frames for public health issues suggest that they are the fault of individuals who must solve their problems themselves. The tobacco industry has framed tobacco control advocates as moralizing zealots and tobacco control policies as interfering with civil liberties. 14 Industry frames emphasize the freedom of citizens “to pursue happiness . . . by making their own choices,” 14 (p321) a value shared by many, including tobacco control advocates. The tobacco industry has also used alliances with veterans’ organizations to help frame military tobacco control issues. Veterans’ groups (sometimes using language crafted by the tobacco industry) 15 have opposed clean indoor air laws by referencing rights, freedom, or sacrifice. For example, supporters of legislation mandating smoking areas in veterans’ hospitals argued that veterans had “fought for the right of all Americans, themselves included, to be free from unwarranted interference in their lives by government.” 16 This framing can be difficult for civilian groups to counter. Previous research showed that public health and tobacco control leaders were unfamiliar with military tobacco control developments and the role that their organizations might play. 17 Although they supported policies such as prohibiting smoking in uniform, they opposed prohibiting tobacco use altogether, as a violation of personnel’s rights. Some believed that policies had to be developed democratically, despite the authoritarian structure of the military. Leaders of organizations who advocate policies may either follow initiatives that arise from the membership, or attempt to educate or persuade the membership to support their own proposals. In either case, for an organization to act effectively on an issue, the opinions and understandings of leaders and membership should agree. To gain further insight into the absence of public health action on this issue, and to explore whether leaders’ perceptions were reflective of those held by public health professionals more generally, we conducted focus groups with members of public health and tobacco control organizations.
