Military Personnel

Tobacco use in the United States military is common and generally accepted. Recently, the Department of Defense (DoD) has enforced efforts to reduce smoking in the armed forces. The most recent national information regarding this population was based on data collected in 2008. ¹

Research has shown:

• Military Base Realignment and Closure (BRAC) is estimated to create as many as 60,000 new military and civilian positions in Maryland in the upcoming years.²,³
• The two areas gaining the most BRAC jobs are Fort Meade in Anne Arundel County and Aberdeen Proving Ground in Harford County.²
• Other military bases that are expanding include the National Naval Medical Center at Bethesda, Andrews Air Force Base, and Fort Detrick.²
• DoD has made recent efforts to implement policy changes related to smoking cessation and the regulation of environmental smoking among military personnel.⁴
• The prevalence of any smoking among military personnel declined significantly from 51% in 1980 to 33.8% in 2002.¹
• Despite the total decline over the past 28 years, there was a recent rise in the prevalence of any smoking reported by military personnel, from 29.9% in 1998 to 31.0% in 2008.¹⁵
• Army males 18-25 years old are more likely to smoke than are their civilian counterparts (47.6% vs. 42%).¹
• The use of cigars, pipes, and smokeless tobacco is prevalent among male military personnel, suggesting a need for tobacco prevention and cessation programming targeting the use of these products.⁵
• Smoking bans in the military prohibit tobacco use in official buildings and vehicles.⁶, ⁷
• Upon entry into the military, personnel receive information regarding the health consequences of tobacco use.⁶
• Health care providers in military settings are encouraged to inquire about tobacco use among their patients.⁴
• Almost a third of survey respondents reported that they started smoking after joining the military, which highlights a need for more effective smoking prevention programs in the Armed Forces.¹

Unique Concerns of the Military Population:

Readiness to perform: The use of tobacco products reduces the ability of individuals to be ready to use force, to function in top form, and complete military missions. Short-term tobacco use can lead to poorer night vision, decreased stamina and mental sharpness, difficulty dealing with stress, poorer hand-eye coordination, and increased sickness. It is also related to increased injuries during trainings and cold weather as smoking reduces the body's ability to heal quickly.⁸

PTSD: One study found that male soldiers with a history of nicotine dependence were at nearly double the risk of developing Post-Traumatic Stress Disorder (PTSD) as compared to non-smoking soldiers. Additionally, those exposed to trauma are more likely to initiate smoking following such exposure. Though the biological mechanisms behind this link are not yet clear, the findings were robust and cannot be fully explained by genetic risk factors. This study emphasizes the need to address smoking and tobacco use among military, particularly those exposed to traumatic situations.⁹

Weight gain: Weight gain is sometimes associated with quitting tobacco use. Because people in the armed forces are required to maintain certain weight standards, this can have formal repercussions. Some have recommended the military use a temporary single exemption, as exists for pregnancy-related weight gain, for those trying to quit smoking.¹⁰

What is being done:

• More effective smoking prevention programs are needed that specifically target military personnel, focusing on alternative ways to relieve stress and boredom.¹
• Over the past decade, each branch of the armed services in the United States has initiated wellness and health promotion programs with standards that exceed typical occupational health efforts.

Clinical Practice Guideline for the Management of Tobacco Use (2004) in Military Personnel includes:4

• Assessment & Treatment Algorithms
• Strategies for Tobacco Use Cessation
• Getting Patients to Quit using the 5 A's
• Increasing Motivation to Quit using the 5 R's
• Key Points for using NRT & Pharmacotherapy

The guide emphasizes the following 7 key elements:4

1. Every tobacco user should be advised to quit.
2. Tobacco use is a chronic relapsing condition that requires repeated interventions.
3. Several effective treatments are available in assisting users to quit.
4. It is essential to provide access to effective evidence-based tobacco use counseling treatments and pharmacotherapy.
5. Collaborative tailored treatment strategies result in better outcomes.
6. Quitting tobacco leads to improved health and quality of life.
7. Prevention strategies aim at reducing initiation, decreasing relapse, and eliminating exposure to environmental tobacco smoke.

How efficacious are treatments when they are required of military personnel rather than presented as a choice? A 1999 study of a forced smoking ban and the effects of a brief behavioral counseling cessation program with active military trainees suggested that forced cessation with brief counseling can be effective long-term (18% of regular smokers were quit at the one year follow-up). Females, individuals from ethnic minority groups, and those who reported intentions to stay quit at the beginning of the forced ban were more likely to be abstinent at the follow-up. The brief intervention was also effective among those who did not plan to stay quit after the forced ban, in that those who received the intervention were almost twice as likely to stay quit than those who were part of the forced ban but did not receive the brief intervention. Unfortunately, initiation of regular smoking during the follow-up year was rather high (43% of former smokers, 26% of experimental smokers, and 8% of never smokers), pointing to the need for prevention efforts in addition to cessation programming.¹⁴

What has research told us about cessation with military groups? Study of Pharmacological Tobacco Cessation Treatments: A study on Pharmacological Tobacco Cessation treatments implemented 4 types of interventions. Each group received ALA's Freedom From Smoking (FFS) course and one of the following pharmacological interventions: 1) Zyban and Nicotine Replacement Therapy (NRT) Patch, 2) Zyban only, 3) NRT Patch only, and 4) NRT Patch and nicotine gum. This trial found moderately higher cessation effects in condition 4, where subjects received NRT Patches and nicotine gum. The author suggests that there may also be reduced relapse rates associated with effective long-term NRT, including nicotine gum, for heavy smokers.¹¹

Study of Tobacco Cessation Programs: Another study examined tobacco cessation programs among military, retired military and dependent adults. In this study, which compared the US Army Center for Health Promotion and Prevention Medicine (USACHPPM) Tobacco Cessation Program, the ACS Fresh Start program and the ALA Freedom from Smoking program, the factors identified as those necessary for success were:

• The use of group support
• The use of pharmacotherapy (NRT and bupropion)
• Personalized attention and flexibility of scheduling was also important for the success of these programs.8

¹ Bray, R.M., Hourani, L.L, Rae, K.L., Dever, J.A., Brown, J.M. et al. (2003). 2002 Department of Defense Survey of Health Related Behaviors Among Military Personnel. RTI International. ² BRAC State of Maryland Impact Analysis: 2006-2020 (2005). Executive Summary, A Report to the U.S. Department of Labor. ³ Base Realignment and Closure (BRAC) Subcabinet: A Letter from the Governor. Retrieved August 30, 2007 from http://www.gov.state.md.us/brac/index.asp. ⁴Department of Veterans Affairs and Health Affairs, Department of Defense. (2004). Management of Tobacco Use. Washington, DC: VA/DoD Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense, December 1999 (Update 2004). Office of Quality and Performance publication 10Q-CPG/TUC-04. ⁵ Sanchez, R.P. & Bray, R.M. (2001). Cigar and pipe smoking in the U.S. military: Prevalence, trends, and correlates. Military Medicine, 166, 903-908. ⁶ Department of Defense Instruction Number 1010.15 January 2, 2001. ⁷ Department of Defense Directive Number 1010.10 August 22, 2003. ⁸ Health Promotion and Prevention Initiatives (HPPI) Program. (2006). Technical report: Tobacco cessation program comparison. Retrieved October 25, 2007 http://chppm-www.apgea.army.mil/dhpw/Population/TobaccoCessationProgramC.... ⁹ Koenen, K.C., Hitsman, B., Lyons, M.J., Niaura, R., McCaffery, J., Goldberg, J., Eisen, S.A., True, W., & Tsuang, M. (2005). A twin registry study of the relationship between posttraumatic stress disorder and nicotine dependence in men. Archives of General Psychiatry, 62, 1258-1265. ¹⁰Peterson, A. L., & Helton, J. (2000). Smoking cessation and weight gain in the military. Military Medicine, 165, 536-538. ¹¹ McMurray, T.B. (2006). A comparison of pharmacological tobacco cessation relapse rates. Journal of Community Health Nursing, 23, 15-28. ¹² Hepburn, M. J. & Longfield, J.N. (2001). Availability of smoking cessation resources for U.S. Army General officers. Military Medicine, 166, 328-330. ¹³ Harris, K. (2007, April 29). Air Force tobacco bans are gaining steam. Stars and Stripes, mideast edition. ¹⁴ Klesges, R. C., Haddock, C. K., Lando, H., & Talcott, G. W. (1999). Efficacy of forced smoking cessation and an adjunctive behavioral treatment on long-term smoking rates. Journal of Consulting and Clinical Psychology, 67, 952-958. ¹⁵Bray RM, Pembenon MR, Hourani LL. et al: 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Mililary Personnel, Research Triangle Park, NC. Research Triangle Institute, 2009.