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OBJECTIVE:To explore the perspectives of key stakeholders regarding advancement of the tobacco endgame in California. DESIGN:Interviews and focus groups exploring participants' knowledge of the tobacco endgame concept, their reactions to 4 endgame policy proposals (banning tobacco sales, registering smokers, retailer reduction, and permanently prohibiting tobacco sales to all those born after a certain year ["tobacco-free generation"]), and policy priorities and obstacles. PARTICIPANTS:Interviews with 11 California legislators/legislative staff members, 6 leaders of national tobacco control organizations, and 5 leaders of California-based organizations or California subsidiaries of national organizations. Focus groups (7) with professional and volunteer tobacco control advocates in Northern, Southern, and Central California. RESULTS:Advocates were more familiar with the endgame concept than legislators or legislative staff. All proposed endgame policies received both support and opposition, but smoker registration and banning tobacco sales were the least popular, regarded as too stigmatizing or too extreme. The tobacco-free generation and retailer-reduction policies received the most support. Both were regarded as politically feasible, given their focus on protecting youth or regulating retailers and their gradual approach. Concerns raised about all the proposals included the creation of black markets and the potential for disparate impacts on disadvantaged communities. CONCLUSION:Participants' willingness to support novel tobacco control proposals suggests that they understand the magnitude of the tobacco problem and have some appetite for innovation despite concerns about specific endgame policies. A preference for more gradual approaches suggests that taking incremental steps toward an endgame policy goal may be the most effective strategy.

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 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.

Secondhand smoke and thirdhand smoke (e.g., smoke residues found on walls and floors) are known to pose health hazards. Some landlords and cities have therefore established smoke-free policies for multiunit housing. The military is in effect the largest landlord in the United States, with approximately 630,000 units of housing. We reviewed the service-level tobacco control policies of the Army, the Air Force, and the Navy and Marine Corps (which share a policy) for references to housing, to see if personnel are adequately protected from secondhand and thirdhand smoke. Policies covering most family housing and all housing for single enlisted personnel fail to fully protect residents from secondhand or thirdhand smoke. The current review of tobacco control policy in the military should recommend a consistent policy of tobacco-free living quarters.

BackgroundTobacco use is a major cause of chronic disease, disability and death among military personnel and veterans. However, civilian public health and tobacco control advocates have been relatively silent on the issue. Research on the tobacco industry shows a long history of interference in military tobacco policy through relationships with the United States (US) Congress. The military cannot autonomously implement tobacco control, but is subject to Congressional oversight. Thus, the primary obstacles to effective tobacco control in the military are Congressional political opposition and tobacco industry influence, and by extension, a lack of civilian awareness and support in the policy arena.MethodsAs part of a larger project to explore the topic of civilian support for military tobacco control, we analyzed data from focus groups with public health professionals to better understand their sense of agency and authority in regards to military tobacco control. Researchers conducted 4 focus groups with a total of 36 public health professionals at key conferences for those working in public health and tobacco control. Data were coded and the research team developed an interpretive account that captured patterns and variations in the data.ResultsPublic health and tobacco control participants shared a sense of futility regarding civilian efforts to engage in military tobacco control. This stemmed from feeling ignorant of military culture and structure, identifying powerful discourses that opposed tobacco control, particularly in a military context, and the very-real presence of the tobacco industry lobby throughout the policy process.ConclusionsA strong public health voice on military tobacco control might serve to begin problematizing the tobacco industry's influence in the military policy arena. As the military moves to institute stronger tobacco control policy, public health and tobacco control professionals should work to engage with and aid its efforts from the outside. Only with such civilian side support can the goal of a tobacco free military be realized.

Abstract Background Tobacco use is a major cause of chronic disease, disability and death among military personnel and veterans. However, civilian public health and tobacco control advocates have been relatively silent on the issue. Research on the tobacco industry shows a long history of interference in military tobacco policy through relationships with the United States (US) Congress. The military cannot autonomously implement tobacco control, but is subject to Congressional oversight. Thus, the primary obstacles to effective tobacco control in the military are Congressional political opposition and tobacco industry influence, and by extension, a lack of civilian awareness and support in the policy arena. Methods As part of a larger project to explore the topic of civilian support for military tobacco control, we analyzed data from focus groups with public health professionals to better understand their sense of agency and authority in regards to military tobacco control. Researchers conducted 4 focus groups with a total of 36 public health professionals at key conferences for those working in public health and tobacco control. Data were coded and the research team developed an interpretive account that captured patterns and variations in the data. Results Public health and tobacco control participants shared a sense of futility regarding civilian efforts to engage in military tobacco control. This stemmed from feeling ignorant of military culture and structure, identifying powerful discourses that opposed tobacco control, particularly in a military context, and the very-real presence of the tobacco industry lobby throughout the policy process. Conclusions A strong public health voice on military tobacco control might serve to begin problematizing the tobacco industry's influence in the military policy arena. As the military moves to institute stronger tobacco control policy, public health and tobacco control professionals should work to engage with and aid its efforts from the outside. Only with such civilian side support can the goal of a tobacco free military be realized.

Military personnel and veterans are disadvantaged by inadequate tobacco control policies. We conducted a case study of a Department of Veterans Affairs (VA) effort to disallow smoking and tobacco sales in VA facilities. Despite strong VA support, the tobacco industry created a public relations-focused grassroots veterans' opposition group, eventually pushing the US Congress to pass a law requiring smoking areas in every VA health facility. Arguing that it would be unpatriotic to deny veterans this "freedom" they had ostensibly fought for and that banning smoking could even harm veterans' health, industry consultants exploited veterans' organizations to protect tobacco industry profits. Civilian public health advocates should collaborate with veterans to expose the industry's manipulation, reframe the debate, and repeal the law.

Military personnel and veterans are disadvantaged by inadequate tobacco control policies. We conducted a case study of a Department of Veterans Affairs (VA) effort to disallow smoking and tobacco sales in VA facilities.

Military personnel and veterans are disadvantaged by inadequate tobacco control policies. We conducted a case study of a Department of Veterans Affairs (VA) effort to disallow smoking and tobacco sales in VA facilities. Despite strong VA support, the tobacco industry created a public relations-focused grassroots veterans' opposition group, eventually pushing the US Congress to pass a law requiring smoking areas in every VA health facility. Arguing that it would be unpatriotic to deny veterans this "freedom" they had ostensibly fought for and that banning smoking could even harm veterans' health, industry consultants exploited veterans' organizations to protect tobacco industry profits. Civilian public health advocates should collaborate with veterans to expose the industry's manipulation, reframe the debate, and repeal the law.

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.

Smoking prevalence in the lesbian and gay community exceeds that in nearly all other demographic groups. In 2001, we undertook a four-year research project to study tobacco industry targeting of the lesbian and gay community. We researched formerly-secret tobacco industry documents, analyzed tobacco content in the gay press, interviewed leaders of LGBT organizations, and conducted focus groups with LGBT smokers and nonsmokers. We found that tobacco companies began to advertise in the gay press in the early 1990s, initially wary of unfavorable publicity and quick to deny doing so when confronted. At the same time, the tobacco industry began to sponsor community organizations and events, especially those for AIDS-related causes, which helped burnish the industry's reputation. Many leaders and members of the community viewed this attention from major corporations as a sign that the community was becoming visible and more acceptable. Our study found that most LGBT leaders did not consider tobacco a "gay issue". Focused on gay-specific concerns, such as homophobia, they saw tobacco as irrelevant or even a distraction from their missions. Twenty two percent of organizations we studied reported accepting financial support from the tobacco industry. Only 24% thought tobacco was one of the top three health concerns of the community. Many believed that smoking was solely a personal choice, not an issue of concern for the community as a whole. The queer press normalized smoking. Images of tobacco, most conveying positive or neutral messages, were common. We found that many ads for products other than cigarettes glamorized smoking, and many articles having nothing to do with smoking were illustrated with tobacco use images. Only 11% of all non-advertising items we found (images and text) imparted a negative message about tobacco use. Very few LGBT publications had policies against accepting tobacco ads. By the time the study ended, an increasing number of LGBT advocates were working in tobacco control. We recommend activities that promote a community dialogue about the real costs of accepting tobacco industry advertising and funding. For example, some groups are urging LGBT politicians and organizations to sign pledges not to take tobacco industry money. As mainstream tobacco control has begun to recognize the need of the LGBT community for services, we recommend that LGBT organizations apply for funding, perhaps using the infrastructures the community has developed to provide services for breast cancer and HIV. Additional research to develop models for getting tobacco on the community's agenda would be useful. For example, understanding how alcohol and other drugs became seen as gay-specific community concerns—even though, like tobacco, they affect everyone—could be helpful. Finding ways to challenge the views of some young gay people—that most queers smoke—might make it easier to help them remain smokefree. Perhaps a greater understanding of the coming out process—in which one's authentic self challenges societal norms—could help arm young people with the strength to resist tobacco. Finally, one of the lessons of the larger LGBT movement itself—the importance of holding institutions accountable for the harm they cause—might help the community stop thinking of smoking as a personal issue, and think of it instead as a systemic issue, with a culpable industry at the heart of the problem. * Many community organizations define themselves as lesbian, gay, bisexual and transgender (LGBT). When possible, we included bisexual and transgender people in our study. Throughout this paper, the terms LGBT, queer, and gay are used interchangeably to acknowledge the diversity of the community and to respect the variety of ways in which LGBT people identify themselves.