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INTRODUCTION

Tobacco use is the most preventable cause of death in the world (WHO, 2008). Each year, over 400,000 Americans die of tobacco-related causes, including military personnel and veterans. 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. In addition, an alarmingly high number of service members use smokeless tobacco. Because tobacco use is greatest among the youngest service members, the health effects will be greatest among older veterans as the population ages. Thus, reducing the number of tobacco users in the military will reduce the number of veterans with tobacco-related health problems.

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 retirees and other veterans, and costs our nation millions of dollars in lost productivity and increased health care. In addition to the multitude of health problems that tobacco use causes, such as cardiovascular and respiratory diseases and cancer (US Surgeon General, 2004, 2006), it has been implicated in higher dropout rates during basic training,1 poorer visual acuity, a higher rate of leaving the service during the first year, and a higher rate of absenteeism in active-duty military personnel. In 1995, about one-sixth of deaths in the DoD population (including military retirees) were attributed to smoking; cardiovascular

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Military recruits who enlist in one of the four branches of the US military begin their service by attending basic training or boot camp, which lasts for 8–12 weeks, depending on the branch of service. The specific term used to describe this training varies among the branches. For simplicity, we use the term basic training to describe entry-level training in connection with all branches of the US military.



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1 INTRODUCTION Tobacco use is the most preventable cause of death in the world (WHO, 2008). Each year, over 400,000 Americans die of tobacco-related causes, including military personnel and veterans. 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. In addition, an alarmingly high number of service members use smokeless tobacco. Because tobacco use is greatest among the youngest service members, the health effects will be greatest among older veterans as the population ages. Thus, reducing the number of tobacco users in the military will reduce the number of veterans with tobacco-related health problems. 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 retirees and other veterans, and costs our nation millions of dollars in lost productivity and increased health care. In addition to the multitude of health problems that tobacco use causes, such as cardiovascular and respiratory diseases and cancer (US Surgeon General, 2004, 2006), it has been implicated in higher dropout rates during basic training,1 poorer visual acuity, a higher rate of leaving the service during the first year, and a higher rate of absenteeism in active-duty military personnel. In 1995, about one-sixth of deaths in the DoD population (including military retirees) were attributed to smoking; cardiovascular 1 Military recruits who enlist in one of the four branches of the US military begin their service by attending basic training or boot camp, which lasts for 8– 12 weeks, depending on the branch of service. The specific term used to describe this training varies among the branches. For simplicity, we use the term basic training to describe entry-level training in connection with all branches of the US military. 19

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20 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS disease, neoplasms, and respiratory disease accounted for virtually all these deaths (Helyer et al., 1998). Since the 1960s, as the deleterious effects of tobacco have become more widely known, its use in both military and civilian populations has decreased. In 1964, almost half the US general population smoked, as did an equal proportion of military personnel; by 2005, the proportion had decreased by more than half in the general population but was still 32% in military personnel (DoD, 2006). The sharp drop in the prevalence of tobacco use was the result of numerous national and state programs tailored to schools, businesses, and health- care facilities, such as a national education campaign aimed specifically at youth who were most at risk for tobacco initiation, a public-health campaign highlighting the dangers of smoking and of secondhand smoke, advances in treatment for tobacco use, prohibition of the use of tobacco products in public and private areas by facilities and locales, explicit recognition of the rights of nonsmokers to a tobacco-free environment, and the efforts of many states to curb tobacco use through increased taxes. Many of the education campaigns and restrictions on tobacco use have been extended to DoD and VA and have resulted in a decrease in tobacco use among service members and veterans. Recently, however, possibly as a result of deployments to Iraq and Afghanistan, tobacco use has increased among soldiers and marines serving in and returning from those areas. The military and veteran populations differ in some respects from the general US population. For example, military populations are overwhelmingly male, younger, healthier, and less educated; veteran populations are predominantly male, older, of lower socioeconomic status, and are more likely to be in poorer general health than either the military population or the general population. The populations considered in this report include military retirees and, to a lesser extent, spouses and dependents; the veteran populations considered are primarily men and women eligible to receive health care through the Veterans Health Administration. This unique combination of demographic factors may require some modification of general-population tobacco-control programs to address the specific needs of military and veteran populations. Despite the obvious benefits to military readiness and to the health of service members and veterans of reducing tobacco use, there is a perceived right among deployed military personnel to use tobacco. For instance, some military and civilian decision-makers do not believe that those willing to risk their lives for their country should be told or even be encouraged to quit using tobacco, particularly while they are deployed to

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21 INTRODUCTION a war zone. In addition, as a result of congressional interest, tobacco- industry influence, and a culture that does not stigmatize tobacco use, tobacco products are readily available and sold at a discount in military commissaries and exchanges. The contradiction between health promotion and tobacco use was observed by Smith et al. (2007): “The military is unique as a tobacco retailer: it pays for the health consequences of tobacco use for many of its customers, making it perhaps the only tobacco retailer consistently losing money. Unlike most retailers, the military has a special interest in its patrons, whose fitness is necessary to the military’s mission.” Many military tobacco-users will eventually enter the VA health system or the DoD TRICARE health-care system. Those two health-care systems bear much of the burden of care; thus, each has a vested interest in assisting active-duty and retired military personnel and veterans to stop using tobacco. The use of smokeless tobacco is increasing in military populations, particularly among young men deployed to Iraq and Afghanistan; many young military personnel use both cigarettes and smokeless tobacco. Although most young people who use tobacco have begun to do so by the age of 18 years, many young people in the military initiate tobacco use, including dual use (use of both smoked and smokeless tobacco), after they complete basic training, during which time there is servicewide prohibition of tobacco use. Although overall tobacco use in DoD personnel is about 32%, it varies considerably among the armed services. In 2005, over 38% of the men and women in the Army, over 36% of Marine Corps personnel, and 32% of Navy personnel were current tobacco-users. Only the Air Force at 23.3% had a tobacco-use rate similar to that of the civilian population (DoD, 2006). Tobacco use in the veteran population is also widespread, partly because of the higher rates of disability, psychiatric disorders, and morbidities. Although the overall prevalence of smoking in veterans enrolled in the VA health system is only slightly higher than that in the general population, the prevalence of smoking in veterans with mental- health disorders is 2–3 times higher than that in the general population (VA, 2004). CHARGE TO THE COMMITTEE Although DoD and VA are promoting tobacco-free and tobacco- cessation efforts, substantial challenges in reducing the prevalence of tobacco use in their populations remain. The challenges range from the ingrained smoking habits of new recruits to congressional requirements for smoking areas at VA medical facilities. In the face of such obstacles,

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22 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS DoD and VA struggle to identify and implement the most effective approaches to reach populations at high risk of tobacco use. To overcome those challenges, DoD and VA asked the Institute of Medicine (IOM) to convene a committee to identify ways to maximize the efficacy of their current tobacco-free and smoking-cessation programs and to provide guidance on what future modifications might be most effective. DoD and VA requested that the IOM committee offer recommendations as to how the agencies could work together to improve the health of both active- duty and veteran populations with regard to the initiation and cessation of tobacco use. Specifically, the agencies asked that the committee: 1. Identify policies and practices that might by used by DoD and VA to prevent initiation of smoking and other tobacco use in the military. 2. Identify policies or potential barriers that might inhibit broader implementation of evidence-based tobacco-use cessation care in both DoD and VA. 3. Identify opportunities for increased access to evidence-based smoking and other tobacco-use cessation programs in VA and DoD. 4. Evaluate changes, including changes in policy, that could help to lower rates of smoking and other tobacco use in military and veteran populations. 5. 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. 6. Recommend research approaches for reducing initiation of tobacco use and promoting tobacco-use cessation. In response to the agencies’ request, IOM convened the Committee on Smoking Cessation in Military and Veteran Populations, which wrote this report. In reviewing the original statement of task, the committee felt it appropriate to modify the language slightly from “smoking” to “tobacco” so that all tobacco products, particularly smokeless tobacco, would be included; the statement of task above reflects the committee’s modifications. The committee did not modify the language used in the various studies cited in the report; if a published study indicated that smoking was the focus, then the committee cited the study as being about smoking, not tobacco use. The committee was not tasked with assessing the implications of tobacco use on veterans’ disability claims or compensation. And it did not review the health

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23 INTRODUCTION effects of exposure to secondhand smoke in detail or consider policies and programs to reduce exposure to it. The committee recognized, however, that reducing the use of tobacco by military personnel and veterans would inevitably reduce exposure of their dependents, colleagues, and others to secondhand smoke. THE COMMITTEE’S APPROACH TO ITS CHARGE The committee had several goals: to review current efforts by DoD and VA to reduce tobacco use and dependence; to make recommendations for a comprehensive approach to control of tobacco use that would lead to eliminating tobacco use and dependence in all military personnel and veterans in the VA or DoD system; to help DoD become tobacco-free by preventing initiation, thus improving the health and readiness of military personnel and eventually improving veteran health; to help military personnel who do use tobacco to quit and remain abstinent; and to help veterans in the VA health-care system to avoid or quit using tobacco. The committee also hoped to provide additional tobacco-cessation guidance to military personnel and veterans who have such conditions as posttraumatic stress disorder (PTSD) and other mental-health problems. The committee began its work by holding two information- gathering sessions with representatives from VA, DoD TRICARE Management Activity, the Air Force, the Navy, the Army, experts in the area of smoking cessation programs and policies, and veterans’ service organizations. In addition, literature searches were conducted, and the committee reviewed relevant documents; information was also requested and obtained directly from DoD and VA. The committee assessed current tobacco-use policies and practices in DoD, VA, and other organizations, such as Kaiser Permanente; addressed such issues as treatment, existing policies, programs, infrastructure, and special populations; and made recommendations for improving efforts. The committee was asked to focus on evidence-based tobacco-control programs and policies in its report and interpreted this to mean assessment of policies, programs, and activities that used appropriate methods and whose results were published in widely accepted and used peer-reviewed journals. 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 the evidence base that forms the best practices; in general, the evidence base consists of successful programs and approaches used in the general US population. The committee then determined whether DoD and VA were using those best practices or a similar approach. If not, the committee identified possible obstacles to

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24 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS their implementation and made recommendations on how to overcome them from both a policy perspective and a programmatic perspective, including identification of who must implement the recommendations. If the practices were in use, the committee attempted to determine whether they were being used effectively, and what possible modifications might be necessary to increase their effectiveness for particular DoD and VA populations. The committee found that there was a lack of information on whether the tobacco-control policies and regulations established by the DoD were in fact enforced on military installations and, if so, to what extent. There was also a lack of information on tobacco-cessation programs for the DoD, the armed services, and individual military installations. The committee found the presentations from the representatives of each of the armed services on current practices regarding tobacco control to be very helpful, but the committee was aware that the representatives did not provide a comprehensive assessment of what tobacco-control activities occur throughout their service and on individual military installations. The VA has conducted surveys and held forums that provide more helpful information on the tobacco-control activities at some VA health facilities and these resources are cited throughout this report. The committee considered how general tobacco-control strategies used in aiding regions, states, and even nations in decreasing tobacco use and dependence could be specifically tailored to DoD and VA. Tobacco control is a term used for a broad array of tactics that reduce tobacco use through policies and prevention and treatment interventions; efforts range from the population to the local-agency level. The strategies recognize the need for systems change and for a comprehensive plan to address the unique aspects and complexities of DoD and VA. Most tobacco-control specialists have a public-health orientation and focus on mechanisms to reduce tobacco use and its consequent health-care burden at the population level. They work to reduce or prevent tobacco use on a large scale—the national, state, or regional scale. Examples of effective population-scale policies and interventions include increasing the cost of tobacco products, bans and restrictions on tobacco use, reducing out-of-pocket costs for treatment of tobacco addiction, counteradvertising campaigns, telephone quitlines, and multicomponent smoking-cessation campaigns (VA, 2004). The focus of tobacco control is often different for health-care providers, who deal with nicotine dependence on an individual level. For example, they attempt to help soldiers or veterans who have smoked a pack of cigarettes a day for 10 years to quit. Their concerns are related to whether a person is receptive to the idea of quitting, whether the pharmacy carries the

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25 INTRODUCTION appropriate addiction therapies, and whether the person will go to the suggested counseling sessions. Tobacco-treatment specialists are also an integral component in the continuum of tobacco-control interventions. In addition to treatment, there is a need for system change at the local level to enact program changes that will increase the likelihood of health providers helping users to quit. Local program change implies culture change and requires strong leadership; clear patient, staff, and environmental goals; strategic plans that include specific objectives and tactics; and policies to promote the sustainability of the change efforts. A comprehensive tobacco-control plan in VA and DoD will require system change and should consider tobacco-control tactics at both the macro level and the micro level. In this report, the committee discusses the need for an integrated and comprehensive plan for DoD and VA to use in developing and implementing the necessary policies and programs to eventually achieve a tobacco-free military and veteran population. In addition to a comprehensive plan, there is a need to identify which programs and treatments are most beneficial for treating nicotine dependence in the various military and veteran populations; clear evidence-based practices for the general population are available. And there is a need to continue research in VA and DoD settings to improve treatments for those with co-occurring mental disorders. To achieve those goals, it will be necessary to institute changes in DoD and VA at numerous levels and in several domains. The points at which change must occur vary from the highest levels of influence (such as the secretary of defense or the secretary of veterans affairs) down to the individual military member and veteran. Effective changes require numerous functional components, such as organizational capacity, adequate human and material resources, coherent and enforceable policies, and effective and appropriate communication. The committee has attempted to provide structured guidance for DoD and VA on what must be done to identify the necessary changes at all levels; implementation of the recommendations would ideally achieve a comprehensive and integrated tobacco-control program that improves the readiness of the military and the health of military personnel, veterans, and their families. The committee acknowledges and commends the efforts of VA and DoD in working to develop and implement tobacco-control programs. Many of the programs are based on those developed by such organizations as the American Lung Association and the American Cancer Society; however, the latter programs were not tailored to military and veteran populations. The committee recognizes that it is seeing only a snapshot of the policies and programs being used by DoD

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26 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS and VA; programs vary among services, among military installations, and within each VA medical facility. Numerous national and international organizations have considered the issue of tobacco use and have developed comprehensive programs to aid in its reduction. For example, IOM, the National Quality Forum, the Public Health Service (PHS), the Agency for Healthcare Research and Quality, the National Cancer Institute (NCI), the American Cancer Society, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO) have all provided guidance on tobacco-control policies and practices. The committee found several reports to be important reference points for its deliberations, including the recent IOM report Ending the Tobacco Problem: Blueprint for the Nation (IOM, 2007), the PHS’s Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update (Fiore et al., 2008), the CDC’s Best Practices for Comprehensive Tobacco Control Programs (CDC, 2007), the NCI’s ASSIST: Shaping the Future of Tobacco Prevention and Control (NCI, 2005) and Evaluating ASSIST: A Blueprint for Understanding State-Level Tobacco Control (NCI, 2006), and the WHO’s Building Blocks for Tobacco Control: A Handbook (WHO, 2004). Although both CDC and NCI provide a framework for developing and implementing a comprehensive tobacco-control program, the committee found that many aspects of the frameworks were not applicable to DoD or VA; rather, they were intended for state or local governments. Neither department has taxing capability, both must answer to Congress for any substantial changes in operations, military and veteran populations are not representative of the general US population, and their missions differ from those of state or local governments. Furthermore, DoD and especially VA have populations with a high prevalence of comorbid health problems such as psychiatric disorders (particularly PTSD), which may make them more susceptible to tobacco addiction as well as cardiovascular, pulmonary, and other diseases that may make them more susceptible to adverse health effects of tobacco use. Therefore, although the committee discusses the use of numerous evidence-based methods for effective tobacco-cessation programs, the unique characteristics of DoD and VA make parallels difficult. In some cases in which there is no direct evidence to support specific findings and recommendations, the committee has used its expert judgment making its findings and recommendations. ORGANIZATION OF THE REPORT Chapter 2 provides background information on why tobacco use is of concern for DoD and VA. It discusses impairment of military

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27 INTRODUCTION readiness and the short- and long-term health effects of tobacco use. The short-term effects are of great importance for military personnel; the long-term effects will be evident in retired military personnel, their dependents, and veterans, especially older ones. Also highlighted is the resulting increase in health-care costs to military personnel, veterans, and US taxpayers. Chapter 3 explains the socioecologic model that the committee uses to identify the levels at which change must occur for an effective tobacco-control program to be developed and implemented. The levels are applicable to both DoD and VA and range from the individual (soldier, airman, sailor, marine, or veteran) to the societal (government departments and the civilian population); a comprehensive program will be successful if change is implemented throughout all the described levels. In Chapter 4, the committee presents the evidence that supports the need for a comprehensive program for tobacco control in DoD and VA. This chapter describes the key components of comprehensive programs developed by other organizations, such as state governments, that have proved to be successful in reducing tobacco consumption in other populations: communication interventions, such as counteradvertising and public-education campaigns; tobacco-use restrictions in the workplace, educational settings, and outdoor spaces; the tobacco retail environment; tobacco-cessation interventions, such as counseling and medication; delivery mechanisms for the interventions, such as quitlines, clinical settings, and computer-based programs; tobacco-cessation approaches for special populations, such as those with mental-health disorders and comorbid medical conditions; relapse- prevention approaches; and surveillance and evaluation. In Chapter 5, the committee looks at DoD through the lens of a comprehensive tobacco- control program and examines what policies, programs, and services the department already has in place that meet the requirements with respect to each of the key components. It also identifies barriers in and outside DoD to the development of a comprehensive program as well as current policies and practices that might be leveraged to improve the prevention of tobacco use and improve tobacco-cessation rates in military personnel who use tobacco. In Chapter 6, the committee takes the same approach to VA with an emphasis on tobacco cessation and the treatment of veterans who have mental-health disorders. Finally, Chapter 7 summarizes the policy and program changes identified in the preceding chapters. It highlights the recommendations that the committee believes will enable DoD and VA to develop and implement a comprehensive, integrated tobacco-control program to reduce tobacco use in military and veteran populations and their dependents, and it identifies future research that could ensure that the programs are effective and that the needs of special populations for tobacco-cessation treatment are met.

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28 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS REFERENCES CDC (Centers for Disease Control and Prevention). 2007. Best Practices for Comprehensive Tobacco Control Programs—2007. Atlanta, GA: CDC, Office on Smoking and Health. DoD (Department of Defense). 2006. Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Research Triangle Park, NC: RTI International. Fiore, M. C., C. R. Jaen, T. B. Baker, et al. 2008. Clinical Practice Guideline—Treating Tobacco Use and Dependence: 2008 Update. Washington, DC: Department of Health and Human Services, Public Health Service. Helyer, A. J., W. T. Brehm, and L. Perino. 1998. Economic consequences of tobacco use for the Department of Defense, 1995. Military Medicine 163(4):217-221. IOM (Institute of Medicine). 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. NCI (National Cancer Institute). 2005. ASSIST: Shaping the Future of Tobacco Prevention and Control. Monograph 16, NCI Tobacco Control Monograph Series. NIH Publication No. 05-5645. Bethesda, MD: NCI. NCI. 2006. Evaluating ASSIST: A Blueprint for Understanding State- level Tobacco Control. Monograph 17. NCI Tobacco Control Monograph Series. NIH Publication No. 05-5645. Bethesda, MD: NCI. Smith, E. A., V. S. Blackman, and R. E. Malone. 2007. Death at a discount: How the tobacco industry thwarted tobacco control policies in US military commissaries. Tobacco Control 16(1):38-46. US Surgeon General. 2004. The Health Consequences of Smoking: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services. US Surgeon General. 2006. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services. VA (Department of Veterans Affairs). 2004. VA in the Vanguard: Building on Success in Smoking Cessation. Edited by S. Isaacs, S. Schroeder, and J. Simon. San Francisco, CA: Department of Veterans Affairs.

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29 INTRODUCTION WHO (World Health Organization). 2004. Building Blocks for Tobacco Control: A Handbook. Geneva, Switzerland: WHO. WHO. 2008. WHO Report on the Global Tobacco Epidemic. Geneva, Switzerland: WHO.

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