show that daily cigarette smoking was substantially lower than any smoking during the past 30 days. Similarly, the 2002 DoD Health Survey distinguished a subcategory of “heavy smoking.” The rate of heavy smoking in the military was 13 percent in 2002, which is virtually the same as the rate of heavy smoking in 1998 (no comparisons with the civilian population were offered). There were few important differences across the Services, with the exception of the Air Force, in which heavy smoking was 10 percent. The rate of Navy heavy smoking in the DoD survey is similar to its rate of heavy drinking in the Navy study reported in a later section.

Cigarette Smoking and Military Performance

The fact that younger military and civilian populations have similar rates of smoking says nothing about whether smoking has adverse effects on military performance. It is well-documented in medical research that smoking leads to a higher risk of certain diseases, particularly emphysema, cancer, and heart disease. However, most of these diseases do not usually manifest themselves until a person is older, and therefore smoking may not create significant health care costs during the first term of enlistment. Smoking does, however, have adverse affects on physical fitness and on attrition. The following sections treat these in turn.

Injury Risk

In 2000, Jones et al. identified smoking as an injury risk factor that should be addressed in implementing a comprehensive injury prevention program for the military. In a cohort study of nearly 2,000 Army recruits, Altarac and colleagues (2000) identified smoking as a risk factor for injury during basic training. Using a multivariate analyses and controlling for age, education, race, body mass index, and physical fitness, he found that the risk of any injury during basic training was 1.5 times higher in smokers than nonsmokers for men (95 percent confidence interval, CI: 1.1, 2.0) and 1.6 times higher for women (95 percent confidence interval, CI: 1.2, 2.2). The results also showed a modest dose-response relationship between the number of cigarettes smoked in the month prior to basic training and the risk of injury. Similar relationships between smoking and injury in military training have been found in the Army and the Marine Corps (Jones, 1993b; Jones, Shaffer, and Snedecor, 1999) and among Norwegian conscripts (Heir and Eide, 1997). The latter study showed that smokeless tobacco was also related to injury.

A number of recent observational studies have noted that smoking is associated with musculoskeletal disorders and disabilities in the military (Lincoln et al., 2003; Dunn et al., 2003) and civilian workforces (Khatun,

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