SUMMARY

Since the 1960s, tobacco use has declined in the United States, including in the military, but rates of smoking remain higher in the military than in the general population. In 2005, 32% of active-duty military personnel and 22% of all veterans smoked, compared with just over 20% of the US adult population. The prevalence of smoking is over 50% higher in military personnel who have been deployed than in those who have not, and an increasing number of service members use smokeless tobacco.

Tobacco use has broad implications for both the Department of Defense (DoD) and the Department of Veterans Affairs (VA). It adversely affects military readiness; harms the health and welfare of military families, retirees, and veterans; and costs the nation millions of dollars in health care and lost productivity each year. Tobacco use has been implicated in higher dropout rates during and after basic training, poorer visual acuity, and a higher rate of absenteeism in active-duty military personnel in addition to a multitude of health problems, such as cardiovascular and respiratory diseases and cancer. DoD and VA are working toward reducing tobacco consumption by military personnel and veterans, respectively, and each has initiated several tobacco-control efforts.

The military and veteran populations are not representative of the general US population: military populations are overwhelmingly male, younger, and healthier; and veteran populations served by the VA health-care system are predominantly male, older, of lower socioeconomic status, and tend to have poorer general health than the military population or the general population. Many military personnel and veterans have been deployed to war zones or participated in peacekeeping missions in conflict areas, and those experiences may influence tobacco use.



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SUMMARY Since the 1960s, tobacco use has declined in the United States, including in the military, but rates of smoking remain higher in the military than in the general population. In 2005, 32% of active-duty military personnel and 22% of all veterans smoked, compared with just over 20% of the US adult population. The prevalence of smoking is over 50% higher in military personnel who have been deployed than in those who have not, and an increasing number of service members use smokeless tobacco. Tobacco use has broad implications for both the Department of Defense (DoD) and the Department of Veterans Affairs (VA). It adversely affects military readiness; harms the health and welfare of military families, retirees, and veterans; and costs the nation millions of dollars in health care and lost productivity each year. Tobacco use has been implicated in higher dropout rates during and after basic training, poorer visual acuity, and a higher rate of absenteeism in active-duty military personnel in addition to a multitude of health problems, such as cardiovascular and respiratory diseases and cancer. DoD and VA are working toward reducing tobacco consumption by military personnel and veterans, respectively, and each has initiated several tobacco-control efforts. The military and veteran populations are not representative of the general US population: military populations are overwhelmingly male, younger, and healthier; and veteran populations served by the VA health-care system are predominantly male, older, of lower socioeconomic status, and tend to have poorer general health than the military population or the general population. Many military personnel and veterans have been deployed to war zones or participated in peacekeeping missions in conflict areas, and those experiences may influence tobacco use. 1

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2 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Many military tobacco users eventually enter the VA health system or the DoD TRICARE system. Most tobacco-related diseases take years to develop, so these two health-care systems bear much of the burden of care, and each has a vested interest in assisting active-duty and retired military personnel and veterans in quitting the use of tobacco. The Institute of Medicine (IOM) was asked to conduct a study in response to DoD’s and VA’s need to determine what the medical and public-health records can document as best practices for reducing tobacco consumption by military and veteran populations. CHARGE TO THE COMMITTEE DoD and VA asked IOM to convene a committee to recommend ways for the two agencies to work together to improve the health of active-duty and veteran populations with regard to tobacco-use initiation and cessation. The agencies asked that the committee consider the following: • Identify policies and practices that might by used by DoD and VA to prevent initiation of smoking and other tobacco use in the military. • Identify policies or potential barriers that might inhibit broader implementation of evidence-based tobacco-use cessation care in both DoD and VA. • Identify opportunities for increased access to evidence-based smoking and other tobacco-use cessation programs in VA and DoD. • Evaluate changes, including changes in policy, that could help to lower rates of smoking and other tobacco use in military and veteran populations. • Identify policies and practices that address unique tobacco- use prevention and cessation needs of special populations in DoD and VA, including those with psychiatric or substance- use disorders, those with chronic medical comorbidities, and women. • Recommend research approaches for reducing initiation of tobacco use and promoting tobacco-use cessation. In response to that request, IOM convened the Committee on Smoking Cessation in Military and Veteran Populations, which wrote this report.

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3 SUMMARY THE COMMITTEE’S APPROACH TO ITS CHARGE The committee held two information-gathering sessions with representatives of the DoD TRICARE Management Activity (part of the Military Health System [MHS]), the Air Force, the Navy, the Army, VA, veterans service organizations, and with experts in smoking-cessation programs and policies. In addition, literature searches were conducted, and information was requested directly from DoD and VA. To evaluate the current policies and programs systematically and to provide guidance for future directions for tobacco control in VA and DoD, the committee first identified what constitutes the evidence base that forms the best practices; in general, these are successful programs and approaches used in the general US population. The committee then attempted to determine whether DoD and VA were using those best practices by reviewing published studies of tobacco use in military and veteran populations; DoD and VA instructions, directives, and regulations; and other information sources, including Web sites. If the best practices were not being used, the committee identified possible obstacles to their implementation and made recommendations for overcoming them from policy and programmatic perspectives. It also developed a research agenda for DoD and VA. SCOPE OF THE PROBLEM The US military and dependent population consists of nearly 3.5 million people: about 1.1 million Army, 500,000 Air Force, 470,000 Navy, 215,000 Marine Corps, about 3 million family members, and more than 800,000 civilian employees. Although smoking prevalence dropped from 51% in 1980 to 32% in 2005 in the armed services, there has been an upturn in consumption in the last decade. Cigarette-smoking and use of smokeless tobacco are most prevalent in the Army and the Marine Corps and least prevalent in the Air Force. Smoking is also more prevalent among military men than women and among personnel 18–25 years old. There are more than 24 million US veterans, of whom 6.7 million are enrolled in the VA health-care system. Of the 6.7 million, 45% are 65 years old or older, 41% are 45–64 years old, and fewer than 1 million (14%) are less than 45 years old. Most of the veterans using the VA health-care system served during the Vietnam era (1965–1974). VA estimates that 75% of disabled and low-income veterans use the VA system. About 22.2% of all veterans enrolled in the VA health-care system are current smokers. Tobacco use adversely affects military performance. Military personnel who smoke have reduced physical-performance capacity,

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4 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS lower visual acuity, and poorer night vision than nonsmokers. Smoking is associated with hearing loss and increased risks of motor-vehicle collisions, physical injury, and hospitalization. Nicotine withdrawal can also impair performance as a result of irritability, restlessness, anger, difficulty in concentrating, anxiety, depressed mood, and decreased performance on cognitive tests. Short-term health effects associated with smoking include respiratory infections; adverse postoperative effects, delayed wound healing, and increased risk of postoperative hemorrhage; acute peptic ulcer disease; and periodontal disease. Smokers who become ill have more serious illnesses, are more likely to be hospitalized, and have more work-loss days. The long-term adverse health effects of tobacco use are well known and affect virtually every organ system. Smoking is causally linked to cancer, particularly lung cancer, and to a variety of other diseases, including stroke, cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes, and infectious diseases. About half of all lifelong smokers will die prematurely from a complication of smoking. Smokeless tobacco delivers as much nicotine as does cigarette- smoking, and although it does not expose the user to the toxicants in tobacco smoke, its use maintains nicotine addiction, promotes continued smoking, and causes oral and pancreatic cancer and periodontal disease. The societal costs of tobacco use are enormous. Tobacco-related costs to the MHS were estimated to be $564 million in 2006, primarily for care of people who had cardiovascular disease or respiratory problems. Military retirees and their dependents incur greater tobacco- related health costs than do active-duty military or their dependents. Considerable costs are also associated with productivity losses due to smoke breaks and absenteeism. Tobacco use affects and increases training costs for new recruits; tobacco users are less likely to complete basic training and more likely to leave the military earlier. At the same time that tobacco results in high health-care costs and productivity losses for DoD, the department earns substantial net revenues from the sale of tobacco products in military commissaries and exchanges, and this creates an impediment to any policy that might make tobacco less accessible in those venues. In 2005, $88 million of the $611 million in tobacco sales supported military morale, welfare, and recreation activities. In 2008, VA spent over $5 billion to treat COPD. More than 80% of COPD is attributed to smoking.

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5 SUMMARY FACTORS THAT INFLUENCE TOBACCO USE The decision to use tobacco depends on many factors, from personal ones such as self-image to societal ones such as easy access to cigarettes. Using a socioecologic approach to examine the factors that encourage and sustain tobacco use in military and veteran populations, the committee concluded that tobacco use is the result of the interplay among individual attributes (for example, genetic makeup and demographics), interpersonal factors (such as family and colleagues), community influences (including work and educational settings), and larger societal influences (such as political factors and commercial advertising). In the case of military personnel and veterans, those factors are in operation before entry into the military system and throughout different phases of military life, including recruitment, training, active duty, deployment, and discharge or retirement. At the individual level, nicotine addiction and physical and mental comorbidities contribute to the persistent use of tobacco. At the interpersonal level, peer and family influences and the role of tobacco in facilitating social connections are important. Leadership attitudes toward tobacco use in DoD and VA, their organizational structure, and their current practices and policies may contribute to the lack of progress in tobacco control. Congressional mandates, economic constraints, and military conflicts also affect the ability of DoD and VA to become tobacco-free. TOBACCO-CONTROL PROGRAMS The use of evidence-based best practices for tobacco control has been widely promoted and has succeeded in reducing tobacco use in the United States. Reducing tobacco use poses special challenges because tobacco products are legal and easy to acquire, highly addictive, and heavily promoted by the tobacco industry. About 50% of current everyday smokers attempt to quit each year, but only 4–7% of those are successful. Thus creation of a tobacco-free culture could be enhanced by the development of an environment that encourages abstinence, denormalizes tobacco use, and makes a variety of prevention and cessation services available. Successful comprehensive tobacco-control programs with demonstrable, albeit incomplete, effectiveness have been developed and implemented by numerous organizations, including the National Cancer Institute and the Centers for Disease Control and Prevention; state governments, including those of California and Massachusetts; and commercial organizations. The programs use a combination of educational, clinical, social, and regulatory strategies to denormalize tobacco use. Comprehensive tobacco-control programs vary in target

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6 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS audience, size, funding sources, and administrative oversight and governance, but they share several key components that contribute to their success: the development and implementation of a strategic plan, dynamic leadership, effective and enforceable policies, communication interventions, adequate resources, appropriate therapeutic interventions (including those for special populations), surveillance and evaluation of effectiveness, and management capacity to bring about change in response to the evaluation. If implemented in constructive harmony, these key components could provide DoD and VA with the capacity to develop and operate their own tobacco-control programs. Communication interventions can increase tobacco users’ awareness of the benefits and means of tobacco cessation, educate potential users about the hazards posed by tobacco, and change social norms and attitudes toward tobacco. Public-education campaigns can inform consumers about cessation medications or other interventions, such as quitlines. Conversely, the advertising of tobacco products, particularly aimed at young adults, can increase demand for tobacco products. Smoking restrictions are most effective when they apply to a variety of public and private settings, when they ban tobacco use completely rather than partially, and when they are strictly enforced. Many governments, businesses, education institutions, and health-care facilities have adopted and currently enforce tobacco-free policies. The tobacco retail environment encompasses the accessibility of tobacco products and the promotion of tobacco products, both at the point of sale and through advertising. Increased tobacco prices, restricted access to products, and decreased out-of-pocket costs for treatment all reduce consumption. Increasing tobacco prices is one of the most effective mechanisms both to prevent tobacco use and to fund tobacco- control efforts. However, as tobacco taxes and tobacco-free regulations have increased, tobacco manufacturers have responded with the development and promotion of new tobacco products, particularly varieties of smokeless tobacco. The advertising of those products increases their consumption. Studies show that the rate and duration of tobacco abstinence are increased when cessation interventions are used, but only about 21% of smokers who attempted to quit for at least 1 day in the preceding year used a cessation medication. Behavioral interventions shown to have some consistent effectiveness include brief advice and assistance from a health-care provider during routine health-care visits, multisession telephone counseling, and face-to-face group and individual treatment. Those interventions are most effective when combined with pharmacologic treatments approved by the Food and Drug

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7 SUMMARY Administration (FDA). Combined interventions can result in long-term abstinence rates of more than 30%. Effectiveness has a dose-response relationship: multisession intensive interventions achieve significantly higher abstinence rates than brief interventions. FDA-approved tobacco- cessation medications are primarily nicotine-replacement therapies (such as nicotine gum or patch), bupropion, and varenicline. The Public Health Service (PHS) clinical-practice guideline Treating Tobacco Use and Dependence: 2008 Update provides an evidence base for tobacco- cessation treatments. Treatment effectiveness is irrelevant if tobacco users are not aware of treatment options, cannot access them, cannot afford them, or do not use them when they are available. Tobacco-cessation interventions can be delivered in many settings and formats. Health-care providers can inform patients about the health effects of tobacco use and counsel them about treatment options during routine appointments, patients can be referred to proactive or reactive telephone quitlines for counseling and often medications, and patients can access computer- based programs that offer counseling, support, and medications. Evidence-based systems-level interventions that are particularly effective include tobacco-use identification systems, provider education, reminder systems with feedback, and dedicated staff. For patients who are willing to quit, an evidence-based algorithm known as the 5 A’s uses a decision tree to help health-care providers to do the following: 1. Ask all patients about tobacco use. 2. Advise all current users to quit. 3. Assess all smokers’ willingness to quit. 4. Assist smokers who are willing to quit by providing appropriate tobacco-dependence treatments. 5. Arrange follow-up for smokers who are making a quit attempt. That algorithm can be used by all health-care providers, including physicians, nurses, psychologists, health educators, dentists, and pharmacists. For patients who are unwilling to quit, health-care providers can use motivational interviewing to increase future cessation attempts. Motivational interviewing can follow the 5 R’s: (1) relevance (encourage patient to explain why quitting is relevant to them), (2) risks (ask patients to explain the adverse effects of tobacco use), (3) rewards (ask patients to identify the benefits of quitting), (4) roadblocks (ask patients about the barriers to their quitting), and (5) repetition (use a motivational intervention each time a patient is seen).

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8 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Many populations of tobacco users may be reluctant to quit, find it hard to quit, or be at greater risk for adverse health outcomes from tobacco use; these special populations include people who have psychiatric and medical comorbidities, deployed military personnel, and hospitalized people. Tobacco addiction is much more prevalent in people who have mental illness, including schizophrenia, major depression, posttraumatic stress disorder (PTSD), and alcohol abuse. This is of concern given the increased numbers of veterans returning from the conflicts in Iraq and Afghanistan with PTSD and the number of Vietnam veterans who have PTSD. The PHS clinical-practice guideline provides evidence-based treatment protocols for many special populations. The issue of relapse from tobacco abstinence is well known; as many as 75% or 80% of smokers who quit tobacco use will relapse within 6 months. Relapse-prevention interventions include social support, use of medications, and avoidance of smoking cues. Comprehensive tobacco-control programs also require surveillance information to help staff to modify the programs to meet changing needs or to address disparities. Surveillance can indicate whether policies are being enforced, medications are being correctly prescribed, quitlines are being used, public-education campaigns are reaching target audiences, interventions are improving health outcomes, and funds are being spent appropriately. Established performance measures should be used to monitor program improvements. Surveillance tools should be designed and operated to provide the necessary foundation for program evaluation, which should be periodic and thorough and whose results should be disseminated publicly. DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES DoD and each of the armed services have a stated goal of a tobacco-free military, but tobacco-control efforts have not been given high priority by the Office of the Assistant Secretary of Defense for Health Affairs, OASD(HA), or the individual services’ Office of the Surgeon General. There have been recent signs, however, that tobacco control is receiving more attention with the rollout of DoD’s “Quit Tobacco. Make Everyone Proud” public-education campaign. DoD policies to prevent smoking and encourage cessation are outlined in the Code of Federal Regulations, Title 32, Part 85, which charges each armed service to develop its own health-promotion plans. The service plans typically cover where military personnel may use tobacco, requirements for access to tobacco-cessation programs, and specifications about the role of commanders and staff in promoting tobacco cessation and deglamorizing tobacco use.

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9 SUMMARY In 1999, the Alcohol and Tobacco Advisory Counsel in the OASD(HA) developed a Tobacco Use Prevention Strategic Plan that outlined goals and tasks; metrics and objectives; policy, program, practice, and resource requirements; and a timeline. That plan, which is still in effect, has eight goals: 1. Reduce smoking rates by 5% per year and reduce smokeless- tobacco use to 15% by 2001. 2. Promote a tobacco-free lifestyle and culture through education and leadership. 3. Educate commanders about how to encourage healthy and tobacco-free lifestyles. 4. Promote the benefits of nonsmoking and provide tobacco counteradvertising. 5. Decrease accessibility by increasing tobacco prices and by restricting smoking areas and use. 6. Have the MHS identify users and provide targeted interventions. 7. Have the MHS provide effective cessation programs. 8. Continually assess best practices in tobacco-use prevention. The strategic plan covers many of the key components that make up a comprehensive tobacco-control plan, including the existence of a strategic plan itself, policy review and development, public-relations and education activities, the use of evidence-based tobacco-cessation interventions, and surveillance and evaluation. It also has requirements for specific policies on tobacco pricing, access, and restrictions of when and where tobacco can be used on installations. The committee found that DoD and the armed services have not been able to achieve the goal of reducing smoking rates or rates of smokeless-tobacco use. Tobacco use declined overall from 1980 to 2005, but there has recently been an increase in consumption, possibly because of increased tobacco use by deployed troops. DoD and the armed services have promoted tobacco-free lifestyles through public-education campaigns, commander training, a complete ban on tobacco use during basic military training in all the services, and prohibition of tobacco use by training instructors in the presence of students. Tobacco use is addressed in health-education programs, including those for commanding officers. The services also encourage—but do not require—that commanders lead by example with regard to tobacco use. The Air Force has been the most successful in reducing tobacco use, particularly among officers.

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10 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Tobacco counteradvertising is a complex issue in the military and is not consistent among the services. DoD’s counteradvertising campaign “Quit Tobacco. Make Everyone Proud” includes a Web site, posters, games, and educational materials tailored to young military men. DoD tobacco-cessation activities conducted by health-promotion personnel include health fairs, Web sites, and other activities that raise the profile of tobacco cessation. The committee was unable to determine whether public-affairs staff are engaged in tobacco counteradvertising, but it noted that many of the armed services’ newsletters and Web sites contain articles on tobacco-control activities. Reaching the goal of decreasing the accessibility and availability of tobacco products by pricing and tobacco-use restrictions will require actions beyond the authority of DoD. DoD does not have complete autonomy with regard to the pricing of tobacco products and is subject to congressional oversight on this issue. Tobacco products are offered at a discount in military commissaries and exchanges, and the committee believes that DoD should not subsidize an activity that adversely affects military readiness and health. The committee finds that DoD and the armed services have restricted tobacco use to designated areas on installations but believes that primary and secondary exposure to tobacco smoke could be reduced if the restrictions were extended to decrease the number of such areas, extend the tobacco ban from basic military training to technical training, and prohibit tobacco use in medical- treatment facilities. The committee commends DoD for its efforts in identifying tobacco users. All of the armed services require that the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use be used by health-care providers. The guideline, a joint effort of VA and DoD, is modeled on the 2000 PHS clinical-practice guideline Treating Tobacco Use and Dependence. It provides a military and veteran focus for tobacco-cessation interventions. All service members are to be asked about their tobacco status during their annual physical and dental examinations, and the information is to be included in the patients’ medical records. DoD’s success in providing targeted interventions to tobacco users is less clear. Although the guideline calls for health-care professionals to advise patients to quit tobacco use and at least refer them for treatment if they indicate willingness to make a quit attempt, adherence to this practice is not monitored. Targeted interventions are available and are described in the VA/DoD guideline. The treatment options used by the armed services are variable, and their long-term effect on abstinence rates in active-duty personnel or their families has not been evaluated.

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11 SUMMARY The committee believes that DoD should provide a nationwide quitline for military personnel and their families in addition to the computer-based program “Quit Tobacco. Make Everyone Proud”. A national quitline would offer consistency regardless of where service members were stationed. Quitline counselors should be trained to deal with military-specific issues, such as deployment and PTSD. Many installations make available tobacco-cessation programs that include counseling and medication, but not all do. The committee is pleased to note that the 2009 DoD appropriation bill included a provision for TRICARE, part of the MHS, to cover smoking-cessation treatment for its beneficiaries. The committee hopes that that this coverage will include treatment for smokeless-tobacco use, a growing problem in the military. DEPARTMENT OF VETERANS AFFAIRS TOBACCO- CONTROL ACTIVITIES VA has long been engaged in efforts to promote tobacco cessation in veterans. VA researchers have been at the forefront of advances in tobacco-cessation treatments. Nevertheless, veterans served by the VA health-care system continue to have higher rates of tobacco use than their general-population counterparts, although they are not as high as those of military personnel. That suggests that many veterans quit using tobacco, but with tobacco use increasing in the military, it is likely that many new veterans accessing the VA health-care system will also be tobacco users, especially those who have been deployed in Iraq and Afghanistan. Like DoD, VA has many components of a comprehensive tobacco-control plan already in place, including effective and enforceable policies, communication mechanisms, surveillance activities in the form of performance measures, and periodic evaluation of tobacco-control practices. VA has developed a National Smoking and Tobacco Use Cessation Program, and it has recently strengthened its Smoke-Free Policy for VA Health Care Facilities. But in its efforts to become entirely tobacco-free, the department has been thwarted by congressional legislation that requires VA medical facilities to have designated smoking areas for veterans and employees. The committee finds that such a requirement prevents VA from protecting its patients, employees, and visitors from possible exposure to secondhand smoke and prevents it from promoting the health of its more vulnerable patients, those who smoke. Virtually all of the VA medical centers (VAMCs) have some form of tobacco-control program, although the programs are not standardized or uniform. Each VAMC must designate a smoking and

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12 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS tobacco-use cessation lead clinician to be the point of contact for all clinical and other communications on tobacco cessation. However, the committee finds that this position is typically not full-time, and the lead clinician may have other responsibilities that take precedence. The committee also finds that the availability of tobacco-cessation services in VA community-based outpatient clinics (CBOCs), other than the required access to medications and brief counseling, is highly variable: some CBOCs have trained staff who offer group or individual counseling, and others only refer patients to outside community services. Use of the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use has been encouraged by the VA Office of Public Health Policy and Prevention, and it has been included in its National Smoking and Tobacco Use Cessation Program. The guideline highlights the effectiveness of using the 5 A’s for each patient. VA has been successful in ensuring that all patients are asked about their tobacco status, are advised to quit, and are referred to a tobacco-cessation program; these prompts are included in patients’ electronic medical records and are performance metrics for evaluating VA health-care providers. However, adherence to the guidelines beyond the minimal effort required by the prompts in the medical records is variable. VA appears to offer a broad array of tobacco-cessation counseling interventions to patients, but there is little information on the effectiveness of these interventions for veterans. The guideline does not specify particular tobacco-cessation programs to be used, and VA uses several standard programs, including those of the American Cancer Society and the American Lung Association, in addition to the procedures in the guideline. The committee does not know whether VA tailors the programs to address special needs of veterans. The VA/DoD clinical-practice guideline and the PHS guideline provide recommendations for evidence-based treatment of special populations that seek medical care at the VA. These populations include older patients, hospitalized patients, and patients who have mental-health disorders. The committee believes that the guidelines provide a good treatment framework. The committee believes that veterans would benefit from a national VA quitline for tobacco, possibly supplemented by a computer- based cessation campaign similar to the DoD “Quit Tobacco. Make Everyone Proud” Web site. A national quitline has the advantage of consistency of service regardless of where veterans are. Quitline counselors should be trained to deal with veteran-specific issues, such as PTSD. Evidence shows that people who have mental-health disorders may be willing and able to engage in tobacco cessation and should be encouraged to do so. The committee believes that VA should assess

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13 SUMMARY whether quitline counselors can provide tobacco-cessation medications to veterans as in the private sector without the need for veterans to obtain prescriptions from their health-care providers, particularly for over-the- counter medications, such as nicotine-replacement therapy. Performance measures that assess health-care providers are a good start for improving care, but the effect of that care on patient outcomes might be even more important. The committee believes that VA should evaluate the long-term effect of its tobacco-cessation programs on abstinence rates. Such information would help to show where programs could be improved or replaced. FINDINGS AND RECOMMENDATIONS DoD and VA have made many strides toward reducing tobacco use in military and veteran populations, respectively, and their efforts have generally been associated with a decrease in smoking. But tobacco use continues to impair military readiness and cause substantial morbidity and mortality in military personnel, their families, and veterans. The committee believes that although DoD and VA are actively engaged in developing, identifying, and implementing tobacco-cessation programs, they lack a comprehensive tobacco-control program. Table S-1 summarizes the committee’s findings and recommendations. TABLE S-1 The Committee’s Findings and Recommendations for the Department of Defense and the Department of Veterans Affairs Findings Recommendations Tobacco use in the US military and veteran populations exceeds that in the general population. Tobacco use • impairs military operational readiness; • is a cause of increased morbidity and mortality in active-duty military personnel, retirees, veterans, and family members; • results in increased health-care costs for tobacco users and their families; and DoD, VA, and the general public; and • creates a patient pipeline from DoD to VA.

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14 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Findings Recommendations DoD and the armed services have The goal of a tobacco-free military stated goals of being tobacco-free service may be achieved incrementally. but have not achieved these goals. DoD and the armed services can use several mechanisms to intensify their efforts to reach the goal: • Set a specific date by which the military will be tobacco-free and make compliance in all the armed services mandatory. Require each service to develop and enforce a timeline for achieving tobacco-free status. • The military academies, officer- candidate training programs, and university-based reserve officer training corps programs should become tobacco-free first, followed by new enlisted accessions, and then by all other active-duty personnel. Tobacco control does not have a DoD, the armed services, and VA should high priority in DoD or VA. raise the priority given to tobacco control Neither department has instituted a throughout their organizations. comprehensive tobacco-control program. Existing programs are not DoD, the armed services, and VA should comprehensive, standardized, or develop comprehensive, integrated consistently enforced. tobacco-control programs with timelines for benchmarks and strategies for achieving them. The departmentwide plans should encompass tobacco-use restrictions, sales restrictions (in DoD only), communication interventions, treatment interventions (including those for special populations), treatment delivery (such as clinical settings and quitlines), surveillance mechanisms, and periodic program evaluations. Tobacco use by military personnel DoD and VA should take the following and veterans is not denormalized. actions to denormalize tobacco use: • Eliminate tobacco use on military installations and in VA medical facilities using evidence-based

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15 SUMMARY Findings Recommendations practices and, for the DoD, a phased- in approach. • Eliminate the sale of tobacco products on all military installations. At the very least, prohibit the sale of tobacco products in Army and Air Force commissaries. (Navy and Marine Corps commissaries do not sell tobacco products.) • Should tobacco products be sold at military installations (exchanges and package stores), they should be priced at least on par with local civilian retail prices and preferably higher than the average prices in the community. Funds generated by the differential pricing should be used for tobacco- control activities. • Enforce equal work breaks for all employees. DoD and VA have many As part of a comprehensive tobacco- components of a comprehensive control program, DoD and VA should do tobacco-control programs in place, the following: • Place the authority for developing but they lack • effective, committed, and tobacco-control policies and supportive leadership at the strategies in a single high-level entity highest levels of the in DoD. In VA, the secretary and the departments; under secretary for health should • a chain of accountability for actively promote tobacco cessation. • Ensure that the surgeon general of program execution; • engaged and properly trained each armed service and the individual installation commanders are staff in all health-care and accountable for DoD program health-promotion facilities; implementation and enforcement and • adequate resources, including that veterans integrated service infrastructure and funding of all network directors are accountable for facilities; and VA program implementation and • sufficient performance metrics to enforcement. drive program improvement. • Educate all DoD and VA health-care and health-promotion staff in tobacco-control practices and train health-care providers in the 5 A’s.

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16 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Findings Recommendations • Provide all DoD and VA staff and patients with barrier-free access to tobacco-cessation services. • Ensure that there are adequate resources, including infrastructure and funding, at all facilities. • Inventory tobacco-cessation programs at each military installation and DoD and VA medical facility, and ensure that a trained tobacco- cessation counselor is available in each facility. • All DoD and VA health-care providers, including counselors, should be able to provide brief counseling and nicotine-replacement therapy to patients. • Report publicly and regularly on the performance of their tobacco-control programs, adherence to clinical- practice guidelines, and tobacco- cessation rates. DoD and VA have established The VA/DoD Clinical Practice many best practices in tobacco Guideline for the Management of cessation. Widespread adoption of Tobacco Use should be updated and the practices is essential for harmonized with the PHS clinical- predictable and consistent tobacco- practice guideline on tobacco cessation services in DoD and VA. management. DoD and VA should develop and implement standards for the content and evaluation of tobacco-cessation counseling. There is a strong association DoD and VA should follow the VA/DoD between tobacco addiction and and PHS guidelines for treating tobacco mental-health problems, including use in patients who have mental-health anxiety disorders (such as PTSD), disorders. mood disorders (such as depression and bipolar disorder), Mental-health professionals should schizophrenia, and substance abuse receive training in tobacco-cessation (alcohol and illicit drugs). treatment and provide assistance to any

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17 SUMMARY Findings Recommendations patients who are willing to try to quit. Legislative support is essential for Congress should do the following: • Repeal the Veterans Health Care Act a comprehensive tobacco-control program in DoD and VA. of 1992 (Public Law 102-585, §526) to allow VA health-care facilities to become completely tobacco-free. • Expand the 2009 National Defense Authorization Act Section 713, “Smoking Cessation Program Under TRICARE,” to include smokeless- tobacco cessation treatment. • Direct DoD to sell tobacco products at prices at least equal to and preferably greater than local civilian retail prices. DoD and VA research contributes DoD and VA should develop and fund a to identifying effective tobacco- joint comprehensive research plan on control programs, particularly for tobacco control in military and veteran special populations, such as those populations. with mental-health and substance- abuse problems. RESEARCH AGENDA The committee was struck by several gaps that might be filled with appropriate research by DoD and VA. Of critical importance is the lack of information in both organizations about the success of their tobacco-cessation programs, particularly long-term abstinence rates. Without such information, it is difficult to assess which programs are working for military personnel, retirees, their families, and veterans and what might be done to improve them. Research should be addressed to finding healthy substitutes for tobacco as a stress and boredom reliever during deployment. Deployed personnel use more smokeless tobacco; DoD should fund research on the determinants of smokeless tobacco use, on its long-term health effects, and on interventions to reduce its use. The VA has conducted considerable research on tobacco use by veterans who have mental-health disorders, particularly PTSD, but more work needs to be done. Research should focus on the timing of interventions and on the use and possible interactions of tobacco-

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18 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS cessation medications and psychiatric medications. Given the number of veterans and military retirees with comorbid medical and psychiatric conditions, the committee recommends that DoD and VA consider jointly funding research on the effects of tobacco use on these conditions and on tobacco-cessation interventions for these populations. The committee concludes that although DoD and VA have demonstrated a continuing commitment to the health of military personnel and their families and of veterans, respectively, particularly with respect to tobacco control, much remains to be done. Given the effects of tobacco use on military readiness and on the health of military personnel, retirees, their families, and veterans, the time has come for DoD and VA to assign high priority to tobacco control.