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Combating Tobacco Use in Military and Veteran Populations 2 SCOPE OF THE PROBLEM In this chapter, the committee describes why tobacco use is of concern to both the Department of Defense (DoD) and the Department of Veterans Affairs (VA). Specifically with respect to the military, tobacco use impairs readiness, decreases performance, and reduces productivity of active-duty and civilian personnel. In veteran populations, it exacerbates pre-existing health problems and leads to new ones, and it results in increased absenteeism and decreased productivity. Military personnel who use tobacco may eventually enter the VA health system; this means more and sicker veterans who require medical care and, consequently, increases in health-care costs. Tobacco use is also associated with short- and long-term health problems in all users and in those exposed to secondhand smoke. Although the adverse effects of tobacco use may be reduced by improving smoking-cessation services, the issues surrounding tobacco use extend beyond helping people to quit. They include keeping people who do not use tobacco from doing so in the future and helping those who have quit from starting to use again. TOBACCO USE IN MILITARY AND VETERAN POPULATIONS This report considers the impact of tobacco use on the three military branches in the DoD—the Army, the Air Force, and the Navy. The Marine Corps is a second armed service in the Department of the Navy, but it has a different culture, demographic, and mission and is therefore generally considered a separate entity in the report. The Coast Guard, which has been moved from the Department of Defense to the Department of Homeland Security, is not considered in this report. Demographics of the Military Population The total US military population consists of nearly 3.5 million people in all branches, including 800,000 civilian personnel. The military is volunteer-based, and all services are more ethnically diverse today than before 1973 (see Table 2-1) (DoD, 2006a). As of March 2008, over
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Combating Tobacco Use in Military and Veteran Populations 1.1 million US troops have served in Iraq and Afghanistan: 806,964 Army personnel (including 146,655 in the Army National Guard and 74,461 in the Army Reserve), 194,401 Marine Corps personnel, 30,868 Navy personnel (including 7,028 reservists), and 70,136 Air Force personnel (Stars and Stripes, 2008). Tables 2-1 and 2-2 summarize the demographics of the US military population, including reservists1 and family members. TABLE 2-1 Demographic Profile of the Military Population Army Navy Marine Corps Air Force Active duty 502,790 345,098 180,252 344,529 Reservea 189,975 70,500 39,489 74,075 Guarda 346,288 — — 105,658 Total 1,039,053 415,598 219,741 524,262 Dependents About 1,400,000 About 580,000 About 200,000 About 760,000 Female Personnel (% of total service) Active duty 14.0 14.5 6.2 19.7 Reservea 23.3 20.3 4.7 23.9 Guarda 13.5 — — 18.0 Total 15.5 15.5 5.9 19.9 Minority-Group Personnel (% of total service) Black 18.6 17.3 9.9 13.4 Hispanic 9.8 12.4 13.0 5.7 Asian 3.2 6.4 3.2 3.6 American Indian 0.9 3.7 1.8 0.8 White 67.4 60.1 72.1 76.4 1 Ready reserve only; for the purposes of this report, the standby and retired reserve components of all military branches have been excluded. All demographics for reserve and National Guard members are reported only for the selected reserve, that is, those members of the ready reserve who train throughout the year and participate in annual active-duty training exercises. Demographic profiles of the individual ready reserve and the inactive National Guard—the other two components of the ready reserve—were not available.
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Combating Tobacco Use in Military and Veteran Populations Army Navy Marine Corps Air Force Married Personnel (% of total service) Active duty 54.7 55.0 45.2 60.6 Reservea 47.5 61.9 30.6 59.1 Guarda 46.5 — — 57.0 Total force 50.7 56.2 42.6 59.7 Personnel With Children (% of total service) Active duty 46.2 42.4 30.1 45.8 Reservea 40.2 51.8 20.7 50.4 Guarda 40.2 — — 48.7 Total force 43.1 44.0 28.4 47.0 Single Parent Personnel (% of total service) Active duty 6.5 5.1 2.7 4.8 Reservea 8.5 9.6 2.9 9.5 Guarda 8.2 — — 8.5 Total force 7.4 5.9 2.7 6.2 aIncludes only members of the selected reserve. SOURCE: Adapted from DoD (2006a). TABLE 2-2 Age of the Military Population (years) Army Navy Marine Corps Air Force Active-Duty Officers (%) 25 and under 14.3 12.3 15.3 13.9 26–30 20.9 20.7 23.3 22.1 31–35 21.4 20.0 24.3 21.0 36–40 19.6 20.0 20.6 19.6 41 and over 23.8 27.1 16.4 23.4 Active-Duty Enlisted (%) 25 and under 52.1 50.1 72.4 45.5 26–30 19.9 20.1 14.2 21.0 31–35 13.0 13.4 7.1 13.1 36–40 9.7 10.5 4.2 11.9
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Combating Tobacco Use in Military and Veteran Populations Army Navy Marine Corps Air Force 41 and over 5.3 5.9 2.1 8.4 Guard and Reserve Officers (%)a 25 and under 5.5 0.6 0.7 1.2 26–30 9.2 4.6 4.9 7.4 31–35 14.8 2.8 17.1 14.3 36–40 23.3 31.5 31.1 23.8 41 and over 47.3 60.6 46.2 53.5 Guard and Reserve Enlisted Members (%)a 25 and under 43.4 17.9 72.8 23.0 26–30 16.0 15.1 15.0 14.8 31–35 9.5 18.9 6.0 13.3 36–40 12.2 24.2 3.7 16.4 41 and over 18.8 23.8 2.5 32.5 Retireesb Retired with 20+ years of active service 438,590 Retired with 20+ years reserve service 260,737 Total 778,682 aIncludes only members of the selected reserve. b Includes active duty and reserve retirees, does not include disabled retirees. SOURCE: Adapted from DoD (2006a); retiree information from Army (2006). Demographics of the Veteran Population In 2008, there were an estimated 26.5 million US veterans, 7.8 million of whom were enrolled in the VA health-care system. Of the 7.8 million, 45.1% are at least 65 years old, 41.0% are 45–64 years old, and 13.9% (fewer than 1 million) are under 45 years old. In 2000, about 7.5% (1.6 million) of the veterans enrolled in the VA health-care system were women. The largest group of veterans using the VA health-care system (36%) consists of those who served during the Vietnam era (1965–1974), followed by those who served between the Korean and Vietnam wars (1955–1964) (29%), military personnel who served between Vietnam and the 1990–1991 Gulf War (23%), and those who served in World War
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Combating Tobacco Use in Military and Veteran Populations II (19%), Korea (18%), and during the Gulf War era (1991-2001) (13%). Of those using the VA health-care system, 60% have no private or Medigap insurance; and two-thirds of veterans enrolled in the VA healthcare system have an annual income of less than $20,000/year. Of enrolled veterans, 84% are white, 10% are black, 4.6% are American Indian or Alaskan Native, 0.7% are Asian, and 0.5% are native Hawaiian and other Pacific Islander (VA, 2006a). In 2004 (the most recent year for which data are available), the national unemployment rate of VA enrollees was estimated to be 15.6%, which is substantially higher than the average annual unemployment rate of 5.5% in the general population. VA attributes that high rate to higher rates of disability. A 2007 survey of recently separated veterans, most of whom had served in Iraq or Afghanistan, found that 18% were unemployed; of those who were employed, 25% earned less than $22,000/year (VA, 2008a). In 2005, nearly 67% of the veteran enrollees in the VA health-care system were married, 15% were divorced, 9% had never been married, 7% were widowed, and 2% were separated from their spouses (VA, 2006a). Tobacco Use in Military Populations Centers for Disease Control and Prevention estimates of smoking prevalence in the general population show that 19.8% of adults in the United States were smokers in 2007, a slight decline from 20.8% in 2006 (CDC, 2008a). Smoking prevalence was higher among men (22.3%) than among women (17.4%) (CDC, 2008a). Although tobacco use has declined since World War II among military personnel, it remains an important issue for DoD and VA. A series of surveys of health-related behaviors in active-duty military personnel showed that tobacco use within the 30 days before a survey decreased from 51.0% in 1980 to 32.2% in 2005 (see Figure 2-1); this trend was observed consistently among all the services (DoD, 2006b). Smoking rates in 2005 among 18–25 year old military men (42.4%) and women (29.2%) (overall rate, 40.0%) were higher than the overall rate among their civilian counterparts (35.4%) (DoD, 2006b). Despite the decline, there had recently been an increase (within the preceding 30 days) from 1998 (29.9%) to 2005 (32.2%) among the services (DoD, 2006b).
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Combating Tobacco Use in Military and Veteran Populations FIGURE 2-1 Cigarette use in preceding 30 days, by service (1980–2005). SOURCE: DoD (2006b). In the general population, lower levels of education and living below the poverty line are associated with a higher prevalence of smoking in all age groups (Agrawal et al., 2008; Barbeau et al., 2004). The Institute of Medicine noted that in the general population the most vulnerable subpopulations for long-term smoking are young people who start smoking early, people who have low socioeconomic status (SES) or are less well educated, and some racial and ethnic minorities (IOM, 2007). Associations in the military parallel those in the general population as tobacco use is more prevalent among military personnel who are younger, less well educated, and of lower SES. Current cigarette use in the military is more likely among men, those who are white, have less than a college education, are younger than 34 years old, and are enlisted versus officers (Bray and Hourani, 2007; DoD, 2006b; Haddock et al., 1998). The age at which daily smoking begins is typically in the few years prior to age of entry into the military—that is, prior to 20 years of age (see Figure 2-2). A 1998 survey of 2,002 Naval recruits, half of whom were 18 years of age, found that 51% of all the recruits had used tobacco in the 30 days prior to enlistment, primarily cigarettes (38%) or cigars and pipes (27%), with less smokeless tobacco use (12%); most cigarette smokers averaged about 0.5 packs per day (Ames et al., 2002). A 2003 survey of 15,556 male Marine Corps recruits (mean age 19.5 years) completing basic training found that 40.4% were users of a
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Combating Tobacco Use in Military and Veteran Populations tobacco product in the 30 days prior to entering the military, primarily cigarettes; 7.6% used only smokeless tobacco and 18.4% used both smokeless tobacco and cigarettes (Trent et al., 2007). Careerists in the enlisted ranks were significantly more likely to be current smokers and heavy smokers compared with careerist officers (Cunradi et al., 2008). In a study of military retirees (1,371 men and 1,095 women) only 131 men and 75 women were current smokers, although 418 of the women and 928 of the men were ex-smokers (Talcott et al., 1998). In a survey of 589 Air National Guard members, the overall smoking prevalence was 19%, with the heaviest smokers (one or more packs per day) being enlisted personnel in the middle and highest pay grades; there was no smoking reported among the junior officers (Messecar and Sullivan, 2001). Tobacco use varies greatly among the services (see Table 2-3) (Conway, 1998). Army personnel (37.3%) and Marine Corps personnel (35.7%) had a significantly higher prevalence of cigarette-smoking than DoD civilians (28.9%); the Air Force, however, had a significantly lower prevalence (23.2%) than civilians. Rates of heavy smoking (one pack a day or more) were also higher in the Army, Navy, and Marine Corps (9.9–15.3%) than in the Air Force (7%). Smoking initiation after entering the military was highest in the Marine Corps (21.6%), followed by the Army (20.5%) and the Navy (18.7%), and lowest in the Air Force FIGURE 2-2 The age (in years) at initiation of daily smoking by people who reported ever smoking for 30 consecutive days. SOURCE: Adapted from SAMHSA (2008).
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Combating Tobacco Use in Military and Veteran Populations TABLE 2-3 Tobacco Use in the Military (%) Army Navy Marine Corps Air Force Cigarette use and nicotine dependencea in preceding 30 days Any smoking 38.2 32.4 36.3 23.3 Heavy smokingb 15.3 9.9 11.1 7.0 Nicotine dependence 10.8 6.4 9.5 4.8 Prevalence of cigarette-smoking in preceding 30 days by sex and age Men 18–25 years old 49.0 37.8 42.8 37.0 26–55 years old 31.4 25.9 24.8 16.2 All ages 39.4 29.8 36.3 23.3 Women 18–25 years old 31.7 27.0 29.1 28.1 26–55 years old 19.2 18.6 19.7 18.3 All ages 26.0 22.2 26.6 22.8 Cigarette-smoking initiation in the militaryc Mend 21.6 19.1 21.7 14.9 Womend 13.5 16.0 20.4 12.8 Totald 20.5 18.7 21.6 14.5 Men (current smokers)e 36.7 36.1 40.5 40.3 Women (current smokers)e 34.6 38.1 39.7 33.7 Total (current smokers)e 36.5 36.3 40.5 39.0 Smokeless-tobacco initiation in the military among menf 18–25 years old 22.9 12.5 11.1 17.5 26–55 years old 14.2 8.4 6.9 10.3 Total 18.7 10.2 8.5 13.7 Smokeless-tobacco use Any smokeless-tobacco use in preceding 12 months 27.7 16.7 33.0 14.5 Any smokeless-tobacco use in preceding 30 days 18.8 11.1 22.3 9.2
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Combating Tobacco Use in Military and Veteran Populations Army Navy Marine Corps Air Force Cigar or pipe use Any cigar or pipe use in preceding 12 months 30.0 24.5 36.7 21.5 aNicotine dependence defined as score of 5 or more on Fagerstrom Nicotine Dependency Assessment. bHeavy smoking defined as smoking one or more packs per day. cPersons who started smoking after joining military. dAs a percentage of the total DoD population, whether current smokers or not. eAs a percentage of those who identified themselves as current smokers at the time of the survey. fPersons who started using smokeless tobacco after joining the military. SOURCE: Adapted from DoD (2006b). (14.5%). The highest rates of cigar and pipe use reported during the preceding 12 months were in the Marine Corps (36.7%) and the Army (30.0%) (DoD, 2006b). According to the 2005 DoD Survey of Health Related Behaviors among Active Duty Military Personnel (DoD, 2006b), from 1995 to 2005, the prevalence of smokeless-tobacco use (snuff and chewing tobacco) increased from 13.2% to 14.5%. In 2005, the Marine Corps (22.3%) and the Army (18.8%) reported the highest rates of smokeless-tobacco use (during the preceding 30 days), and the Navy (11.1%) and Air Force (9.2%) the lowest. Most users of smokeless tobacco are men 18–24 years old (DoD, 2006b; Ebbert et al., 2006). A recent study published by Vander Weg et al. (2008) assessed the prevalence of use of alternative forms of tobacco—including bidis, cigars, kreteks (clove cigarettes), pipes, and smokeless tobacco—in a population of Air Force recruits. The authors found that 18.5% of the study population was using an alternative form of tobacco before basic training, including 6.7% who used smokeless tobacco. Men were more likely than women to use smokeless tobacco before basic training, as were whites compared with Asians, Pacific Islanders, blacks, or Hispanics. Higher income was significantly correlated with smokeless-tobacco use in the study population. Participants who had some education beyond high school were less likely to use smokeless tobacco than those with only a high-school education (Vander Weg et al., 2008). Tobacco Use in Veteran Populations In a 2005 survey of the VA enrollee population, 71.2% reported that they smoked at least 100 cigarettes during their lifetime; 22.2% were current smokers, a slightly higher proportion than the 19.8% of the
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Combating Tobacco Use in Military and Veteran Populations general population (VA, 2006a); and 28.1% said that they had never smoked. Most current veteran smokers are 45–64 years old, and most make less than $36,000 a year (VA, 2006a). Higher rates of disability and psychiatric disorders in the veteran population may contribute to higher tobacco use and its health effects. Klevens et al. (1995) noted that the prevalence of ever smoking was 74.2% in veterans and 48.4% in nonveterans. Of those who had not started smoking before the age of 18 years, veterans were more likely than nonveterans to report ever and current smoking (Klevens et al., 1995). Of veterans with access only to the Veterans Health Administration, 25.7% are smokers, compared with 10.8–13.8% of those with access to at least one type of Medicare (fee for service or a health-maintenance organization) (Keyhani et al., 2007). HEALTH EFFECTS OF TOBACCO USE In 1964, the US Surgeon General published a landmark report Smoking and Health that implicated smoking as the cause of a variety of health effects (US Surgeon General, 1964). Since then, other reports on smoking from the surgeon general (2004, 2006) and numerous studies have confirmed that smoking causes a multitude of short- and long-term health effects in people of all ages. The surgeon general has also issued reports on the effects of smoking in women (2001) and on the effects of secondhand smoke on children (2007). Table 2-4 summarizes some of the health hazards associated with tobacco use, many of which are discussed in this chapter. TABLE 2-4 Health Hazards Posed by Tobacco Use Health Hazards Cancer (see Table 2-6) Cardiovascular disease Sudden death Acute myocardial infarction Unstable angina Stroke Peripheral arterial occlusive disease (including thromboangiitis obliterans) Aortic aneurysm Pulmonary disease Lung cancer Chronic bronchitis Emphysema Asthma Increased susceptibility to pneumonia and to pulmonary tuberculosis Increased susceptibility to desquamative interstitial pneumonitis Increased susceptibility to and morbidity from viral respiratory infection
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Combating Tobacco Use in Military and Veteran Populations Health Hazards Gastrointestinal disease Peptic ulcer Esophageal reflux Reproductive disturbances Reduced fertility Premature birth Low birth weight Spontaneous abortion Abruptio placentae Premature rupture of membranes Increased perinatal mortality Oral disease (smokeless tobacco) Oral cancer Leukoplakia Gingivitis Gingival recession Tooth staining Other Non-insulin-dependent diabetes mellitus Impaired wound healing Osteoporosis Cataract Amblyopia (loss of vision) Age-related macular degeneration Premature skin wrinkling Aggravation of hypothyroidism Altered drug metabolism or effects SOURCE: Adapted from US Surgeon General (2004). Short-Term Effects of Tobacco Use In addition to the widely acknowledged long-term health consequences of tobacco use such as cancer and cardiovascular disease, tobacco use also adversely affects performance and health on a much shorter time scale. Being tobacco-free is an essential component of physical fitness and provides myriad advantages to military personnel in terms of readiness and performance. In the sections below, the committee considers the performance and short-term health consequences of tobacco use that are of most importance for active-duty military personnel. Box 2-1 at the end of the section summarizes the effects of tobacco use on military readiness and short-term health.
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Combating Tobacco Use in Military and Veteran Populations Dall, T. M., Y. Zhang, Y. J. Chen, R. C. Wagner, P. F. Hogan, N. K. Fagan, S. T. Olaiya, and D. N. Tornberg. 2007. Cost associated with being overweight and with obesity, high alcohol consumption, and tobacco use within the military health system’s TRICARE prime-enrolled population. American Journal of Health Promotion 22(2):120-139. Demars, S. M., W. J. Harsha, and J. V. Crawford. 2008. The effects of smoking on the rate of postoperative hemorrhage after tonsillectomy and uvulopalatopharyngoplasty. Archives of Otolaryngology—Head and Neck Surgery. 134(8):811-814. Dembert, M. L., G. J. Beck, J. F. Jekel, and L. W. Mooney. 1984. Relations of smoking and diving experience to pulmonary function among US Navy divers. . Undersea Biomedical Research 11(3): 299-304. DoD (Department of Defense). 2006a. Profile of the Military Community: DoD 2006 Demographics Report. Washington, DC: Office of the Deputy Under Secretary of Defense for Military Community and Family Policy. DoD. 2006b. 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Research Triangle Park, NC: RTI International. DoD. 2008. Department of Defense Anti-Tobacco Campaign Invades Military Markets. TRICARE News Release 08-23. http://www.tricare.mil/pressroom/news.aspx?fid=379 (accessed April 3, 2009). Durazzini, G., F. Zazo, and G. Bertoni. 1975. The importance of the dosage of thiocyanates in urine and blood of flying personnel for the prevention of diseases of visual function. In Medical Requirements and Examination Procedures in Relation to the Tasks of Today's Aircrew, edited by G. Perdriel. London, UK: NATO Advisory Group for Aerospace Research and Development. Dyer, F. N. 1986. Smoking and Soldier Performance: A Literature Review. US Army Aeromedical Research Laboratory, Report No. 86-13. Columbus, GA: Research Solutions, Inc. Ebbert, J. O., C. K. Haddock, M. Vander Weg, R. C. Klesges, W. S. Poston, and M. DeBon. 2006. Predictors of smokeless tobacco initiation in a young adult military cohort. American Journal of Health Behaviors 30(1):103-112.
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Combating Tobacco Use in Military and Veteran Populations Fiore, M., F. Shi, S. Heishman, and J. Henningfield. 1994. The Effects of Smoking and Smoking Withdrawal on Flight Performance: A 1994 Update. Rockville, MD: CDC, Office on Smoking and Health. Fisher, M. A., G. W. Taylor, and K. R. Tilashalski. 2005. Smokeless tobacco and severe active periodontal disease, NHANES III. Journal of Dental Research 84(8):705-710. Frankenhaeuser, M., A. Myrsten, B. Post, and G. Johansson. 1971. Behavioural and physiological effects of cigarette smoking in a monotonous situation. Psychopharmacologia 22(1):1-7. Frayser, R. 1974. The effect of repetitive exercise on ventilatory function in smokers and nonsmokers. Southern Medical Journal 67(8): 926-929. Giannakoulas, G., A. Katramados, N. Melas, I. Diamantopoulos, and E. Chimonas. 2003. Acute effects of nicotine withdrawal syndrome in pilots during flight. Aviation Space and Environmental Medicine 74(3):247-251. Gordon, D. J., A. S. Leon, and L. G. Ekelund. 1987. Smoking, physical activity, and other predictors of endurance and heart rate response to exercise in asymptomatic hypercholesterolemic men: The Lipid Research Clinics Coronary Primary Prevention Trial. American Journal of Epidemiology 125(4):587-600. Gramberg-Danielsen, B., N. Puls, and G. Tolksdorf, G. 1974. Ist das mesopische sehen kurzfristig beeinflussbar? Medizinische Monatsschrift 28:285-289. Grout, P., K. Cliff, M. Harman, and D. Machin. 1983. Cigarette smoking, road traffic accidents and seat belt usage. Public Health, London 97:95-101. Haddock, C. K., R. C. Klesges, G. W. Talcott, H. Lando, and R. J. Stein. 1998. Smoking prevalence and risk factors for smoking in a population of United States Air Force basic trainees. Tobacco Control 7(3):232-235. Halpern, M. T., R. Shikiar, A. M. Rentz, and Z. M. Khan. 2001. Impact of smoking status on workplace absenteeism and productivity. Tobacco Control 10(3):233-238. Hartling, O. 1975. The effect of the first three months of military service on the physical work capacity of conscripts. Forsvarsmedicin 11(4):213-218. Hecht, S. S. 1998. Biochemistry, biology, and carcinogenicity of tobacco-specific N-nitrosamines. Chemical Research in Toxicology 11(6):559-603.
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