摘要：In this descriptive case study, we analyze the unsuccessful struggle to access disability pensions by veterans sickened by tobacco use begun during service. Drawing on tobacco industry documents and other material, we show how the US government, tobacco industry, and veterans' organizations each took inconsistent positions to protect their interests. Congress and Department of Veterans Affairs leadership, concerned about costs, characterized veterans' smoking as “willful misconduct,” thereby contradicting the government's position in a federal lawsuit that tobacco companies addicted smokers. Veterans' groups supported the pensions, despite previously defending smoking as a “right.” The tobacco industry wavered, fearing liability. Securing pensions was complicated by the notion that smoking is primarily a personal choice. The US government should compensate veterans fairly and should abolish military practices that encourage tobacco addiction. US POLITICIANS COMMONLY praise military veterans as heroes and express the thanks of a grateful nation, but many veterans lack health care coverage 1 and veterans' claims for service-related health and disability benefits are often granted only after protracted political struggles. For example, veterans exposed to radiation poisoning from atomic testing during the 1950s, 2 Vietnam veterans exposed to Agent Orange, 3 veterans suffering from Gulf War syndrome, 4 and those filing claims for posttraumatic stress disorder 5 all had to fight for recognition of their claims. In the early 1990s, a similar struggle emerged over whether the Department of Veterans Affairs (VA) would recognize veterans' tobacco-related disease and disability. We examined this case and considered its contemporary implications. Tobacco use has long been part of military culture. Cigarettes were distributed in rations through 1975, 6 and on-base tobacco promotions were common. 7 Tobacco products are still sold on military bases at discounted prices, 8 and VA medical facilities are mandated to provide indoor smoking areas. 9 Military culture encourages smoking as one of few “choices” available in a regimented environment. 10 As a result, smoking rates are higher in the military than among civilians. 11 Military service is estimated to have increased the smoking rates of World War II and Korean War veterans by 30%. 12 Nicotine's addictiveness means that many veterans who began smoking as young recruits continued to smoke after leaving the tobacco-promoting environment of the military. 13 Approximately 74% of veterans report past or current smoking, compared with 48% of nonveterans. 14 Today, smoking is increasing in the military, reversing a nearly 20-year decline. 15 Tobacco-caused diseases are thus an important problem for military veterans and a significant expense for the VA. 9 In 2008, the VA spent over $5 billion to treat chronic obstructive pulmonary disease, more than 80% of which is attributed to smoking. 9 The VA provides disability pensions to qualified military veterans. Similar to civilian workers' compensation claims, these pensions provide replacement income for those whose earning capacity is compromised by work-related injury or illness. Pensions are provided “in recognition of the effects of disabilities … incurred or aggravated during active military service.” 16 Disabling conditions need not be linked to military activities, such as combat duty, but must be traceable to time spent in service (K. W. Kizer, written memorandum, October 28, 1997). 17 Once a veteran's disability is deemed “service-connected” and eligible for a disability pension, the pension amount is determined by ranking the degree of disability. Veterans with disability pensions may also qualify for free medical care, which increases the importance of the service-connected designation. The higher veterans' disabilities are ranked, the higher priority access to free medical treatment. If smoking-related disease and consequent disability were deemed service-connected, many veterans who began smoking during service might be pension-eligible. In the early 1990s, veterans and their advocates began to argue this case. Previous research has shown that the tobacco industry is aggressive and proactive in its efforts to shape public opinion and policy regarding all aspects of tobacco use. 8 , 18 – 23 These efforts have often led to defeat of tobacco control policies 8 , 24 and have perpetuated tobacco's social normalization. 25 We hypothesized that the tobacco industry would be a key player in the debate over veterans' disability pensions for tobacco-caused diseases. We examined the politics of veterans' claims and how the social positioning of tobacco use influenced the outcome.
