Maryland's Tobacco Resource Center - Linking Professionals to Best Practices

Active Military/Veterans

Active military members and military veterans are disproportionately affected by tobacco use. Active military smoke at a higher rate compared to the general population1, while veterans experience greater health consequences2. Recently, the Department of Defense (DoD) has enforced efforts to reduce smoking in the armed forces1. Resources for cessation are listed below:

Active Military: 
https://tricare.mil/HealthWellness/Tobacco -- Tobacco cessation resources 
https://tricare.mil/HealthWellness/Tobacco/UCanQuit2/-- Text message support program for tobacco cessation 

Veterans
https://www.maryland.va.gov/publications/healthwatch/summer2012/03.asp -- Maryland Veteran’s Affairs clinicians contact information 
https://www.publichealth.va.gov/smoking/quit/counseling.asp -- US Veteran’s Affairs smoking quitline, cessation tips, and counseling services 
https://smokefree.gov/veterans -- Comprehensive website containing cessation tools, resources, and support 


Military Culture and Tobacco Use: 

Despite the DoD’s efforts to reduce smoking in the military, only half of service members report that leadership deters cigarette use1. Furthermore, both branch leaders and tobacco control managers report inconsistent support from military commanders as a weakness in the military’s tobacco control program3.  

When compared with nearby stores, military installations sell cigarettes at a discounted range. The average discount on military installations is 25.4%, while some discounts are as large as 73% compared to nearby retailers.  Tobacco companies have been found to target military instillations by advertising towards military service members and providing free samples to military installations3.

Current Tobacco Use Trends: 

Active Military: 

Nearly a quarter of military service members report smoking in the past 30 days. These rates are significantly higher than the Healthy People goal of less than 12%. The most common reasons reported for smoking were to help relax and relieve stress. In addition to heightened smoking rates, almost half of all service members report nicotine use in the last 12 months1

Those deployed to combat zones were significantly more likely to be current and/or heavy smokers than those who were not combat deployed1

Smokeless tobacco use is also elevated, with 12.8% of service members reporting use in the last 30 days. These rates are significantly higher than both the general population (2.3%) and the Healthy People goal (0.3%)1

Veterans: 

Of veteran who rely on the VA for healthcare, 20% report that they are current smokers4. Most current smokers in the VA are 45-64 years old and earn less than $36,000 yearly2. Smoking rates are nearly three times higher for veterans who have a substance use disorder (SUD) than those without an SUD2,6,7.  This highlights the importance of tobacco cessation’s incorporation into SUD treatment. Additionally, nicotine dependence prevalence was 71.2% for veterans with post-traumatic stress disorder (PTSD) in comparison to 40% of those without PTSD2

Effects of Tobacco Use: 

Active Military: 

Smoking in the military has serious implications for military readiness, including8:

• reduced oxygen capacity/exercise duration and night vision capacity 
• greater frequency of hearing loss, absenteeism, and motor vehicle accidents 

Active military members are impacted by withdrawal systems when smoking breaks are not available. This is evidenced by smokers experiencing lower vigilance and cognitive function, poorer performance in flying/diving exercises, and irritability/moodiness8

Active military members identified as heavy cigarette users were also more likely to report mental health symptoms. This sub population experienced an increase of overall stress (61.1%), anxiety (35.4%), depression (21.2%), and PTSD symptoms (16.2%)1.  

In total, the DoD spends over $1.6 billion annually in tobacco related costs, including tobacco related health care, increased hospitalizations, and lost days of work4

Veterans: 

Due to historically higher smoking levels of active duty military personnel, veterans are more likely to have smoking-related illness and death. In veterans, tobacco use is a major cause of chronic disease, disability, and death2.  

Over the next 10 years, the VA projects that $19.685 billion will go towards smoking-related healthcare expenses2.  

Tobacco Cessation: 

Active Military: 

TRICARE offers cessation resources including counseling and tobacco-cessation medications. For more information regarding TRICARE’s programs, please follow this external link: https://tricare.mil/HealthWellness/Tobacco.  

While these programs exist, deployed service members are often unable to utilize the resources. The stress present in war/intense military conflict often limits the ability to seek/complete treatment4. Carrying on their mission, which is a priority, is a large barrier in cessation accessibility, and still needs to be analyzed further.  

The Institute of Medicine’s Committee on Smoking Cessation in Military and Veteran Populations (2009) posits that a larger solution to military tobacco use might be found through combining prevention of smoking initiation in military admits, policies blocking access to tobacco products, and expanded evidence-based cessation for those seeking treatment. 

Veterans

The VA is working towards making tobacco-cessation aid more accessible to its clients. Using evidence-based initiatives, the VA has expanded access to tobacco-cessation medications, eliminated copayments for smoking-cessation counseling, and incorporated smoking cessation into healthcare for the veteran mental-health population2.  

Despite making strides in tobacco cessation, the VA is still shown to underemphasize tobacco cessation2,7. While counseling and tobacco-cessation resources are offered, they are often underused. Kelly, Sido, and Rosenheck (2016) found that only 3.8% of veterans who currently smoke utilized the VA’s cessation programs. The research team found that if the VA were to increase supply of cessation services by 1 visit for every 100 veterans, tobacco-cessation counseling involvement would increase by 35%, and VA locations that offered programs witnessed more tobacco-cessation program usage7

Several controlled trials have established effective cessation services tailored to a veteran population9,10. These advancements in cessation research and treatment, servicing those who served our country, will hopefully lead to higher cessation rates and more years lived.   

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References: 

1. Barlas, F. M., Higgins, W. B., Pflieger, J. C., & Dicker, K. (2013). 2011 Department of Defense survey of health related behaviors among active duty military personnel. Report prepared for TRICARE Management Activity, Office of the Assistant Secretary of Defense (Health Affairs) and U.S. Coast Guard under Contract No. GS-23F-8182H.  

2. Bondurant, Stuart., Wedge, Roberta (2009). Combatting Tobacco Use in Military and Veteran Populations.  Washington (DC): National Academies Press (US). 

3. Jahnke, S. A., Haddock, C. K., Poston, W. S., Hoffman, K. M., Hughey, J., & Lando, H. A. (2010). A qualitative analysis of the tobacco control climate in the U.S. military. Nicotine and Tobacco Research, 12, 88-95.  

4. Department of Veterans Affairs (2011). 2011 Survey of Veteran Enrollees’ Health and Reliance upon VA: With Selected Comparison to the 1999-2010 Surveys. Veterans Health Administration. Retrieved from https://www.va.gov/HEALTHPOLICYPLANNING/SOE2011/SoE2011_Report.pdf 

6. Gass, Julie C., Morris, David H., Winters, Jamie., VanderVeen, Joseph W., Chermack, Stephen (2017). Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorder clinic. Journal of Substance Abuse Treatment, 84(2018), 1-8. Doi: https://doi.org/10.1016/j.jsat.2017.10.006 

7. Kelly, Megan M., Sido, Hanah., Rosenheck, Robert (2016). Rates and Correlates of Tobacco Cessation Services Use Nationally in the Veterans Health Administration. Psychological Services, 13 (2), 183-192. Doi: http://dx.doi.org/10.1037/ser0000076  

8. Bray, R. M., Spira, J. L., Olmsted, K. R., & Hout, J. J. (2010). Behavioral and occupational fitness. Military Medicine, 175(8S), 39-56.  

9. McFall, M., et. al. (2010). Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial. Journal of American Medical Association, 304(22), 2485-93. doi: 10.1001/jama.2010.1769. 

10. Rogers, E., et. al. (2016). Telephone smoking-cessation counseling for smokers in mental health clinics: a patient-randomized controlled trial. American Journal of Preventive Medicine, 50(4), 518-527. doi: 10.1016/j.amepre.2015.10.004.