5
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES

The Department of Defense (DoD) is the largest agency in the federal government. Headed by the secretary of defense, it is responsible for over 1.3 million men and women on active duty and 684,000 civilians. Another 1.1 million serve in the National Guard and reserves. In addition to over 2 million military retirees and their family members who receive benefits, all active-duty members and their families are eligible to receive health care from DoD. National Guard and reserve members are also eligible for DoD health care while deployed.

DoD and each of the armed services have stated that tobacco use is not an acceptable activity for military personnel (see Table 5-1). Tobacco use is not the norm for the majority of military personnel: about 70% of active-duty military do not use tobacco. Nevertheless, as described in Chapter 2, tobacco-use rates by military personnel are higher than in a comparable civilian population. Many recruits enter the service as smokers, but many military personnel who did not use tobacco before they were recruited begin to use it during their military service. This trend is of concern because tobacco use impairs military readiness (Chapter 2) and leads to short- and long-term tobacco-related health problems and increased health-care costs. DoD needs to attach high priority to preventing initiation and promoting cessation of use of tobacco products to ensure the healthiest military force possible.

In this chapter, the committee examines DoD’s tobacco-control activities, discusses how they might fit into the evidence-based comprehensive tobacco-control program described in Chapter 4, and identifies institutional and programmatic barriers and opportunities in DoD that hinder or help tobacco-control efforts. The committee describes current DoD activities in all four services and provides advice on how these activities might be enhanced or integrated to reduce tobacco use by active-duty military personnel, retired military personnel, and personnel in the National Guard and reserves. Many aspects of the tobacco-control



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 197
5 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES The Department of Defense (DoD) is the largest agency in the federal government. Headed by the secretary of defense, it is responsible for over 1.3 million men and women on active duty and 684,000 civilians. Another 1.1 million serve in the National Guard and reserves. In addition to over 2 million military retirees and their family members who receive benefits, all active-duty members and their families are eligible to receive health care from DoD. National Guard and reserve members are also eligible for DoD health care while deployed. DoD and each of the armed services have stated that tobacco use is not an acceptable activity for military personnel (see Table 5-1). Tobacco use is not the norm for the majority of military personnel: about 70% of active-duty military do not use tobacco. Nevertheless, as described in Chapter 2, tobacco-use rates by military personnel are higher than in a comparable civilian population. Many recruits enter the service as smokers, but many military personnel who did not use tobacco before they were recruited begin to use it during their military service. This trend is of concern because tobacco use impairs military readiness (Chapter 2) and leads to short- and long-term tobacco-related health problems and increased health-care costs. DoD needs to attach high priority to preventing initiation and promoting cessation of use of tobacco products to ensure the healthiest military force possible. In this chapter, the committee examines DoD’s tobacco-control activities, discusses how they might fit into the evidence-based comprehensive tobacco-control program described in Chapter 4, and identifies institutional and programmatic barriers and opportunities in DoD that hinder or help tobacco-control efforts. The committee describes current DoD activities in all four services and provides advice on how these activities might be enhanced or integrated to reduce tobacco use by active-duty military personnel, retired military personnel, and personnel in the National Guard and reserves. Many aspects of the tobacco-control 197

OCR for page 197
198 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS TABLE 5-1 Tobacco Use Goals of the DoD and Armed Services DoD Army Navy Marine Corps Air Force “It is DoD “Readiness “Reduce “It is Marine “The Air policy . . . that will be tobacco use, Corps policy to Force’s goal is smoke-free enhanced by prevent discourage the a tobacco free DoD facilities promoting the tobacco use of tobacco force” (Air be established standard of a product use products. . . . Force to protect all tobacco-free initiation, The objective Instruction 40- DoD civilian environment reduce non- is to establish a 101, 2008). and military that supports users’ safe, healthy, personnel and abstinence exposure to and tobacco/ members of from and ETS smoke free the public discourages the [environmental environment visiting or use of any tobacco for all using DoD tobacco smoke] and personnel” facilities from product” residue, (Marine Corps the health (Army promote Order 5100.28, hazards caused Regulation quitting, and 1992). by exposure to 600-63, 2007). establish tobacco tobacco-free smoke” (DoD, facilities . . . Instruction Department of 1010.5, 2001). the Navy’s vision is to be tobacco free” (SECNAV Instruction 5100.13E, 2008). program may also be applicable to DoD civilian employees and contractors who work at military facilities. ORGANIZATIONAL OVERVIEW The president and the secretary of defense form the National Command Authority, which provides direction for the military. The Office of the Secretary of Defense carries out the secretary’s policies by tasking the military departments that train and equip the forces, the chairman of the Joint Chiefs of Staff plans and coordinates military deployments and operations, and the unified commands conduct military operations. The secretary of defense is advised by under secretaries for policy, finance, acquisitions, intelligence, and personnel and readiness. It is the under secretary for personnel and readiness who is responsible for the DoD Military Health System (MHS; see Figure 5-1).

OCR for page 197
199 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES SECDEF DEPSECDEF USD (P+R) CJCS Military Joint Chiefs Departments of Staff ASD (HA) CINCs Service TMA Surgeons General TRICARE Regional Offices MTFs MCSCs FIGURE 5-1 Organizational relationships for health-care activities in DoD. ASD(HA) = assistant secretary of defense for health affairs, CINCs = regional combatant commanders, CJCS = chairman of Joint Chiefs of Staff, DEPSECDEF = deputy secretary of defense, MCSCs = managed-care support contractors, MTFs = medical-treatment facilities; SECDEF = secretary of defense, TMA = TRICARE Management Activity, USD(P+R) = undersecretary of defense for personnel and readiness. The policy organization starts with the secretary of defense and runs through the under secretary for personnel and readiness to the assistant secretary of defense for health affairs, ASD(HA). The ASD(HA) has no direct-line command and control relationship with the surgeons general of the military departments. However, policy guidance issued by the secretary of defense through the ASD(HA) is binding on the military departments. Military Health System The 2007 MHS Strategic Plan1 states that its primary mission is to “provide a medically ready and protected force and medical protection for communities—we continuously monitor health status, identify medical threats and find ways to provide protection and improve health 1 MHS, DoD. 2008. The Military Health System Strategic Plan: A Roadmap for Medical Transformation. http://www.health.mil/StrategicPlan (accessed April 3, 2009).

OCR for page 197
200 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS for individuals, communities and the Nation. These surveillance activities focus our delivery of Individual Medical Readiness services to improve health and enhance human performance and make the environment safer so service members can withstand health threats in hostile settings.” Specifics on how that mission is to be achieved are not provided in the plan, nor is tobacco use identified as a readiness issue although it is acknowledged to be an unhealthy behavior. There are over 9 million beneficiaries of the MHS, including active-duty personnel and their dependents as well as retired personnel and their dependents. The MHS is charged with providing health-care services to the operating forces and managing health benefits for all beneficiaries via the TRICARE program. The MHS employs over 132,000 military and civilian medical personnel. The major components of the system include a direct-care system of 65 hospitals, 413 medical clinics, and 413 dental clinics (DoD, 2009); a series of contracts, including 3 managed-care support contracts; a retail and mail-order pharmacy program; the Uniformed Services Family Health Plan (or designated providers); dental benefits; and the TRICARE for Life program. Each component is involved in activities of preventive medicine and healthy-behaviors programs on behalf of military beneficiaries. As the program manager for all military health activities, the Office of the Assistant Secretary of Defense for Health Affairs (OASD[HA]) oversees all direct and purchased health-care activities of the DoD. The OASD(HA) was responsible for planning, programming, and budgeting to support outlays of over $39 billion in fiscal year (FY) 2008 for the direct-care system and all purchased care. The OASD(HA) manages those programs through staff at the Pentagon. TRICARE Management Activity TRICARE is a managed health-care program in DoD that provides health care for active-duty military and their dependents, including personnel in the reserves and National Guard who have been on active duty for more than 30 consecutive days, retirees and their dependents, and beneficiaries from other services, such as the Coast Guard and Public Health Service. TRICARE offers several health plans: TRICARE Prime, the health-maintenance option; TRICARE Extra, which has a larger provider network but also has a deductible; and TRICARE Standard, a fee-for-service option that allows beneficiaries other than active-duty personnel to see any TRICARE-authorized provider. There is also TRICARE Reserve Select for eligible National Guard and reserve members, who can buy into the plan with monthly

OCR for page 197
201 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES premiums; it is open to reservists who are not on active duty. TRICARE for Life is an entitlement program offered to retirees and their family members or survivors who are eligible for Medicare and for whom Medicare is the first payer. A policy gap exists between the legally authorized TRICARE benefits and the need to support tobacco-cessation programs. The FY 2009 National Defense Authorization Act (NDAA) remedies the gap at least partially: Section 713, “Smoking Cessation Program Under TRICARE,” states that not later than 180 days after enactment, the secretary of defense must establish a smoking-cessation program under TRICARE for all beneficiaries except those who are Medicare-eligible. The program must include, at a minimum, “the availability, at no cost to the beneficiary, of pharmaceuticals used for smoking cessation, with a limitation on the availability of such pharmaceuticals to the national mail-order pharmacy program under the TRICARE program if appropriate,” counseling, “access to a toll-free quitline,” and “access to printed and Internet Web-based cessation material.” The secretary of defense must “provide for involvement by officers in the chain of command of participants in the program who are on active duty.” Within 90 days after enactment, the secretary must submit a program- implementation plan to Congress; and within a year after enactment, the secretary must report to Congress on the program. The NDAA also authorizes the secretary of defense to reimburse TRICARE beneficiaries for some costs related to smoking-cessation programs. The program called for under the law is directed at smoking and not at broader tobacco-use–cessation programs. However, Congress does recognize the importance of the need to engage those in the chain of command to ensure that the program is effective. This TRICARE program will cover non–active-duty MHS beneficiaries. Active-duty service members will still rely on the direct- care component of the MHS for tobacco-cessation counseling and medication support. The committee finds that the current health- maintenance organization preventive-care benefit package as set forth in 32 Code of Federal Regulations (CFR) Article 199.18, Section (b)(2), specifies a number of preventive-care services that are available to beneficiaries under the Civilian Health and Medical Program of the Uniformed Services, now TRICARE Standard. Smoking cessation is not a listed benefit, but Section (b)(3) of the regulation states that “in addition to preventive care services [listed above], other benefit enhancements may be added and other benefit restrictions may be waived or relaxed in connection with health care services provided to include the Uniform HMO Benefit.” The ASD(HA) must approve any additions. Nonetheless, the committee believes that this would provide

OCR for page 197
202 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS considerably greater latitude to include cessation of tobacco use, not only smoking, in TRICARE’s benefit package. In 1999, the DoD Prevention, Safety, and Health Promotion Council (PSHPC) established the Alcohol Abuse and Tobacco Use Reduction Committee (AATURC), now the Alcohol and Tobacco Advisory Council (ATAC), to provide advice on policies related to the supply, responsible use of, and the demand for alcohol and tobacco products (DoD, 1999). ATAC recommendations are given to the DoD Medical Personnel Council for consideration. ATAC members represent the services’ alcohol, substance-abuse, and health-promotion programs, their medical departments, the DoD Office of Personnel and Readiness, the DoD Office of the Chief Medical Officer, and a number of other DoD offices with an interest in alcohol and tobacco policy (DoD, 2007). The committee believes that between 1999 and 2001 the ATAC had been making good progress in addressing tobacco use in DoD. However, perhaps understandably, the high interest in, and impact of, this committee seems to have diminished since the terrorist attacks on America in 2001 as the US military addressed higher priorities. Nevertheless, over the long term, tobacco use poses one of the primary risks to the health and readiness of US military forces, and a plan must be established for once again assigning high priority to tobacco use with respect to health in DoD. TOBACCO-CONTROL PROGRAMS IN THE DEPARTMENT OF DEFENSE The MHS strategic plan for 2008 cites the military tobacco-use rate as a mission element for achieving healthy and resilient personnel, families, and communities. In 1999, the ATAC developed a Tobacco Use Prevention Strategic Plan that outlined goals and tasks; metrics and objectives; requirements for policy, programs, practices, and resources; and a timeline for achieving the goals (see Appendix B for the entire 1999 strategic plan). The plan, which is still in effect but has not been updated in 10 years, has the following goals: • reducing the smoking rate by 5%/year (Goal A.1), • reducing the smokeless-tobacco-use rate by 15% by 2001 (Goal A.1), • promoting a tobacco-free lifestyle and culture through education and leadership (Goal B.1), • educating commanders on how best to encourage healthy lifestyles (Goal B.2), • promoting the benefits of nonsmoking and providing tobacco counteradvertising (Goal B.3),

OCR for page 197
203 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES • decreasing accessibility via increased pricing and restrictions on smoking areas and tobacco use (Goal C.1), • MHS identification of users and provision of targeted interventions (Goal D.1), • MHS provision of effective cessation programs (Goal D.2), and • continual assessment of best practices in tobacco-use prevention (Goal E). In Chapter 4, the committee identified the key implementation components of a comprehensive tobacco-control program: a strategic plan, dynamic leadership, essential intervention components (enforceable and enforced policies, communication interventions, and evidence-based treatments), adequate resources, surveillance and evaluation of the program’s effectiveness, and management capability to adjust the program in response to that evaluation. The ATAC strategic plan covers many of those components: the strategic plan itself, policy review and development, public-relations activities, the use of evidence-based tobacco-cessation interventions, and surveillance and evaluation mechanisms. Furthermore, the plan requires specific policies on tobacco pricing and access, and it restricts when and where tobacco can be used on installations. In the following sections, the committee examines the progress that DoD has made toward achieving the goals set forth in the 1999 Tobacco Use Prevention Strategic Plan, identifies the gaps between the plan and the key program components of an evidence-based comprehensive plan as endorsed by the committee, and discusses actions that DoD can take to eliminate the gaps. The committee based its findings and recommendations on published instructions, directives, and other regulations or documents available publicly from the DoD ASD(HA) and each armed service. Reducing Tobacco Consumption Goal A.1 of the 1999 DoD Tobacco Use Prevention Strategic Plan seeks to reduce the smoking rate by 5%/year and the rate of the use of smokeless tobacco by 15% by 2001 from 1998 baseline rates. The goal was to be accomplished by establishing the AATURC to coordinate and monitor DoD progress on the prevention plan. An annual DoD survey of tobacco-use rate by active-duty personnel, National Guard and reserve personnel, DoD civilian employees, and TRICARE Prime enrollees was called for to determine progress. Populations at high risk for tobacco initiation, such as young military personnel and adolescent beneficiaries, were also to be identified. DoD established the AATURC, now the ATAC, which continues to provide recommendations on

OCR for page 197
204 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS tobacco policies and programs to the OASD(HA) through the PSHPC. The ATAC does not appear to have conducted smaller studies of tobacco use in select DoD populations; however, the DoD Survey of Health- Related Behaviors Among Military Personnel is conducted periodically (the latest survey for which data are publicly available was conducted in 2005) and reports on tobacco use by active-duty personnel (DoD, 2006). The survey does not include National Guard or reserve personnel, civilian employees, TRICARE Prime enrollees, or high-risk groups, so it is difficult to assess the full extent of the impact of the DoD tobacco- control program on all target populations. Finding: DoD does not survey tobacco use by all beneficiaries of the MHS, including all TRICARE beneficiaries. Recommendation: DoD should undertake such a survey to help to determine the needs of military personnel and their dependents for tobacco-control interventions. Tobacco-Control Programs in the Armed Services Independent tobacco-control programs have been developed by the armed services. The Army Health Promotion Program (AHPP) includes a tobacco-control component (Army Regulation 600-63, 2007). The program states that commanders and supervisors will encourage antitobacco activities in family members and retirees; that health-care providers will ask, advise, and assist patients with cessation information (3 of the 5 A’s described in Chapter 4); and that commanders at all levels will “demonstrate positive efforts to deglamorize the use of all forms of tobacco products.” Army installations are also directed to provide tobacco-cessation programs and, if they are not available on an installation, to coordinate such programs with local community resources. The Navy and Marine Corps Tobacco Policy (SECNAV Instruction 5100.13E, July 31, 2008) also details when and where tobacco may be used by naval personnel on installations (including housing; morale, welfare, and recreation (MWR) facilities; ships; and submarines), restricts the promotion of tobacco products, and stipulates that tobacco users should have access to tobacco-cessation treatment either on their installations or through referral to community resources. The Marine Corps, which has health-promotion personnel from the Navy, has incorporated the Navy requirements into base orders for those programs. For example, Base Order 6200.2C, “Tobacco Use Prevention Program for Camp Pendleton” (November 1993), and Base Order

OCR for page 197
205 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 6200.3C, “Marine Corps Tobacco Prevention and Control Program for Camp LeJeune” (February 2006) emphasize smoke-free workplaces, restrictions on tobacco use and disposal, and commander education on tobacco control. The Air Force has issued two instructions that pertain to tobacco: Air Force Instruction 40-102, “Tobacco Use in the Air Force” (June 2002) and Air Force Instruction 40-102, Air Education and Training Command (AETC) Supplement 1, “Tobacco Use in the Air Force” (August 2002). Those complementary instructions cover tobacco- use restrictions in the workplace, dormitories, and housing facilities; the sale and advertisement of tobacco; tobacco-cessation education programs for health-promotion personnel; and application to civilian and contractor employees. Goal B.1 of the DoD Tobacco Use Prevention Strategic Plan is to promote a tobacco-free lifestyle and culture through education and leadership. Requirements to meet the goal include education programs (discussed under “Leadership Education and Training” below) and guidance on how to ensure effective leadership for tobacco control. Army Regulation 600-63 (2007) states that commanders at all levels will “demonstrate positive efforts to deglamorize the use of all forms of tobacco products.” The Navy requires that unit commanders, commanding officers, and officers in charge must ensure that tobacco use is not part of the Navy culture and must encourage a tobacco-free lifestyle and support abstinence by personal example and command climate. Although leaders are not required to be tobacco-free, they are strongly encouraged to be (SECNAV Instruction 5100.13E, July 2008). Air Force Instruction 40-101 (May 1998) states that installation commanders are to provide leadership and guidance for integrated and comprehensive health-promotion programs but does not specify that they be tobacco-free, and Instruction 40-102 (June 2002) states that given the AETC goal of not using any tobacco products, commanders and supervisors are expected to lead by example and actively identify and use resources to help tobacco users to quit. DoD Directive 1010.10 (November 2003) establishes health- promotion programs to improve and sustain military readiness as well as the health, fitness, and quality of life of military personnel, DoD personnel, and other beneficiaries. DoD policies to prevent smoking and encourage cessation are specified in the 32 CFR 85.6, and each armed service is to develop its own health-promotion plan. The plans are implemented by the offices of the surgeons general of the military departments. The AHPP (Army Regulation 600-63, May 2007) addresses program responsibilities, from the Army deputy chief of staff to installation commanders, with implementation guidance; the tobacco- control-program guidance is brief. The program includes the Army

OCR for page 197
206 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Reserve and National Guard. The Air Force has addressed tobacco use in its Health Promotion Program (Air Force Instruction 40-101, May 1998). The Navy health-promotion plan (OPNAVINST 6100.2A, March 2007) also addresses tobacco-use prevention and cessation and delineates program responsibilities; this program is also used by the Marine Corps. Each of those regulations specifies the responsibilities of military leaders for implementation. The committee notes that although the goals of the 1999 strategic plan are in harmony with many of the components required of a comprehensive tobacco-control plan, there have been obstacles to the implementation and evaluation of the plan. The obstacles include insufficient allocation of human and financial resources, lack of engaged leadership, ineffective communication, and incomplete surveillance. Program Leadership Tobacco control has not had high priority in DoD, for several possible reasons. The committee recognizes that in a time of military conflict, DoD must first allocate resources to meet the needs of deployed forces and those who support them. The effect of tobacco products, particularly of smoked tobacco, on military readiness and performance may not be immediately apparent to commanders or even to military personnel themselves. Furthermore, the direct influence of the tobacco industry on DoD and its indirect influence via Congress in maintaining easy access to tobacco products cannot be ignored and has had the effect of keeping the DoD in the business of selling tobacco products. The tobacco industry creates relationships with groups that pressure policymakers to pass or hinder industry-favorable legislation. Research has shown that heavy lobbying by the tobacco industry and veterans’ groups helped thwart previous efforts to raise tobacco prices in commissaries (Arvey and Malone, 2008). Although the OASD(HA) and the armed services have attempted to address tobacco control, the full impact of tobacco on military readiness and health is not recognized by all military leaders. Some leadership in DoD, however, has spoken out against tobacco use. For example, in August 1996, efforts by the Assistant Secretary of Defense for Force Management Policy resulted in a price increase for cigarettes sold in commissaries in 1996, although his efforts were resisted by some members of Congress (Smith et al., 2007). The committee emphasizes that until the highest strata of DoD leadership are engaged in tobacco control, military readiness will continue to be impaired by tobacco use by active-duty personnel. As a result, all military personnel and their families, civilian employees, retirees, and the general public will bear the burden of both the adverse health effects of exposure to secondhand smoke as well as increased

OCR for page 197
207 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES health-care costs. In many cases, senior military leaders have actively engaged in and been positive role models for physical fitness, for example, by leading troops in running the Marine Corps Marathon, the Army 10-Miler, or local physical-training programs. A similar approach, in which tobacco use in the military becomes a leadership issue, and not just a medical issue, has the potential to have a major effect on tobacco use in military personnel. In the sections below, the committee follows the framework given in Chapter 4 for a comprehensive tobacco-control program. Key components of a comprehensive program are examined, including communication interventions, tobacco-use restrictions, the tobacco retail environment, cessation interventions, special populations, relapse- prevention interventions, and surveillance and evaluation, as available in DoD and the armed services. Finding: DoD has developed and put into effect a Tobacco Use Prevention Strategic Plan with goals, metrics, requirements, and a timeline. The plan is a good framework for DoD and the armed services to use to build a comprehensive tobacco-control program. Finding: Tobacco use in the armed forces continues to be considered socially acceptable behavior, with higher use than in the general population. Tobacco cessation is not a clearly stated high priority for the OASD(HA). Finding: Effective, committed, and supportive leadership from the highest levels of the departments and a designated chain of accountability for program execution are needed to increase the success of tobacco-control efforts in the DoD. Finding: There is need for a consistent and comprehensive approach to tobacco-control programs in the military community. Recommendation: Authority for developing tobacco- control policies and strategies should reside in a single high-level entity in DoD.

OCR for page 197
252 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS training was so intense that they did not even recognize that they had quit smoking; sleep deprivation, intense physical conditioning, and an overall demanding training schedule left most with no time to think about tobacco use. Focus-group participants were also asked their opinions of the tobacco-free policy in basic training. The vast majority of former smokers indicated that they approved of the policy and thought it was consistent with the overall training mission. In addition, focus groups with Air Force technical-school students who had relapsed to smoking indicated that if the Air Force wanted them to remain tobacco-free, it should just extend the tobacco ban for the duration of their enlistment. Most felt that staying tobacco-free after the completion of basic training would be relatively easy if a policy prohibited the use of tobacco (Peterson et al., 2003). Preventing Initiation and Relapse After Basic Training There appears to be substantial initiation in the first year of military service in those who were not tobacco users before entering the military (Williams et al., 1996). Two studies that evaluated smoking initiation in the military (Klesges et al., 1999, 2006) found that 8–10% of trainees who reported never smoking (“not even a puff”) before basic training were smoking at a 1-year follow-up, and 26–30% of experimental smokers, defined as having had one to two cigarettes in their lifetimes, reported smoking at follow-up. Klesges et al. (2006) randomized Air Force personnel who entered basic training and reported either being nonsmokers or experimental smokers into a smoking- prevention intervention group or a control group. The prevention program had no effect on smoking initiation (Klesges et al., 2006). Similar results were found by Conway et al. (2004), who posited two possible reasons for the finding: either the prevention-intervention strategy validated on younger people did not translate to the slighter older population, or military personnel may be particularly recalcitrant to tobacco-use prevention efforts. The VA/DoD clinical-practice guideline provides a detailed discussion of tobacco-use prevention and relapse. Approaches include motivating current tobacco users to quit with such strategies as the 5 R’s (relevance, risks, rewards, repetition, and roadblocks), motivational interviewing, and encouraging continued abstinence for those who do quit. Of particular relevance to DoD is preventing the initiation of tobacco use in military personnel who had not used tobacco before entering the service. The guideline provides practical advice on assessing the likelihood that these people will start to use tobacco and encouraging them not to do so. All military personnel see a health-care provider,

OCR for page 197
253 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES which includes seeing a dentist, at least once a year; this is an ideal opportunity to provide them with strategies to resist trying tobacco. Finding: Ironically, the very environment that appears to be conducive for tobacco users to remain abstinent (the post–basic-training period) also appears to be conducive to tobacco initiation by never-users and experimental users. Recommendation: Given the high rate of eventual tobacco- use initiation, the committee believes that future research in tobacco-use prevention efforts in the military should have high priority. Finding: The committee commends the armed services for their bans on tobacco use during basic training. Recommendation: The committee recommends that DoD promptly establish a timeline to extend the tobacco ban beyond entry-level–enlisted and officer- training programs to eventually close the pipeline of new tobacco users entering military service and to eliminate tobacco use on all US military installations. SURVEILLANCE AND EVALUATION Surveillance activities—the processes of monitoring tobacco- related attitudes, behaviors, and health outcomes at regular intervals— can occur at many organizational levels and serve a variety of functions. Survey instruments are one mechanism for collecting short-, intermediate-, and long-term data on process and population outcomes and eliminating disparities. The data are evaluated to provide an indication of how tobacco-control programs are operating and whether they are meeting their goals. The 1999 strategic plan’s Goal D.1 specifies that the MHS should actively identify tobacco users and provide targeted interventions. To identify tobacco users, a systematic approach is best. The strategic plan calls on DoD to “develop and monitor a centralized, Tri-Service (Army, Navy, and Air Force) reporting and surveillance system to track tobacco use” (Requirement D.1), “develop a plan to annually conduct a health-risk appraisal that includes the assessment of tobacco-use habits and mandates participation for active-duty personnel” (Requirement D.1.3), “develop a draft policy that requires tobacco use to be documented as ‘5th vital sign’ at all medical and dental appointment”

OCR for page 197
254 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS (Requirement D.1.4), and “assess Service policies, and draft policy if necessary, to require routine screening of all beneficiaries as part of ‘Put Prevention Into Practice’ program, with providers using guidelines from the Agency for Health Care Policy and Research” (Requirement D.1.5). DoD and the armed services have made great strides in meeting those requirements. DoD conducts periodic surveys to ascertain tobacco use by active-duty military personnel. The most recent one for which data are available, the 2005 DoD Survey of Health Related Behaviors Among Active Duty Military Personnel (DoD, 2006), determined the prevalence of alcohol use, tobacco use, and illicit-drug use on the basis of self- reports by 16,146 military personnel in all four armed services. Achievement of selected Healthy People 2010 objectives and adverse outcomes were also assessed. The TMA conducts the annual congressionally mandated Health Care Survey of Department of Defense Beneficiaries to assess user satisfaction with, and access to, the MHS. The healthy-behaviors section asks participants whether they have ever smoked; if so, how much; if they quit, for how long; whether they were advised by their doctors to quit; and whether their doctors or other health-care providers discussed methods and strategies (other than medication) to assist in smoking cessation. Questions on the use of medications are not included. Composite data from both surveys are publicly available. The DoD Health Plan Analysis and Evaluation staff conduct beneficiary surveys that include information on smoking and advice to quit. DoD also maintains the Medical Data Repository, which contains information on the use of tobacco-related diagnosis and treatment codes within the MHS direct-care system. Each armed service uses a variety of self-reported metrics to assess its tobacco-cessation programs in support of its health-promotion activities. The Navy and the Air Force use metrics to track tobacco use and cessation by service personnel. The Navy Health Promotion Wellness Tobacco Program metrics are used by staff at 32 military treatment facilities, including 3 medical centers, 15 naval hospitals, and 14 health and medical clinics. Metrics are submitted semiannually and cover the number of tobacco-cessation programs offered, individual and group counseling sessions held, training of facilitators, and costs for tobacco-cessation medications (Navy, 2009). NAVHOSPGLAKES Instruction 6220.7 (July 8, 2005) on tobacco-cessation services for the Great Lakes Naval Hospital includes a tobacco-cessation form to be used when a patient inquires about quitting tobacco use. The form is used to conduct follow-up with patients and to track success rates. The Air Force, like the Navy, uses the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set

OCR for page 197
255 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES to assess compliance with standards of care. The Air Force has also developed a list of metrics to evaluate its tobacco-cessation programs. Those metrics, which track only active-duty personnel, include reporting of the number of personnel who are tobacco users, the type of product used, the number of personnel making or contemplating quit attempts, attendance at cessation classes, referrals to outside resources (such as the ALA Freedom from Smoking Web-based program), the number of installations funding quitlines, and the number of calls to the quitlines (Kathy Green, Air Force, personal communication, July 30, 2008). The Army does not appear to use any comparable metrics. Two goals in the 1999 DoD Tobacco Use Prevention Strategic Plan apply to the evaluation of tobacco-cessation programs. Goal D.2 states that tobacco-cessation programs in the MHS are to be evaluated for effectiveness. Goal E, to “continually assess best practices in the area of tobacco prevention,” is to be reached by developing plans to assess prevention and early-intervention strategies and by developing and evaluating pilot programs of best prevention practices. The committee notes that each of the goals in the strategic plan has an accompanying metric or objective that helps in addressing the requirements to meet it. For example, Goal D.1, which includes identifying tobacco users, requires the development of a “centralized, Tri-Service reporting and surveillance system to track tobacco use.” The metric for determining whether the goal is being met is the percentage of medical records that note tobacco-use status on forms DD2766 or AF 1480A (adult preventive-care and chronic-care flowsheets, which were in development when the strategic plan was developed). The Army CHPPM Web site has a document, “Evaluation of Tobacco-Use Cessation Efforts in the Military Health System (MHS) Direct-Care System,” that describes an in-depth evaluation of the tobacco-cessation efforts at installations and among the armed services. The evaluation assesses the types of programs; which health professionals conduct the programs; how quit rates are measured by program and tobacco-use type at 1, 6, and 12 months; which tobacco- cessation medications are used and whether they have an effect on quit rates; and how frequently tobacco-use and intervention ICD-9 and CPT-4 codes are used in the MHS. The committee understands that this evaluation has been undertaken by a DoD contractor and that results are available but cannot be released to the public, including this committee, for confidentiality reasons. A 3-page factsheet, based on the evaluation and available in the Spring 2009, reported that the MHS offers comprehensive programs for tobacco use and prevention with most military treatment facilities offering formal programs with some outreach (DoD, 2008). The committee believes that such data should be available

OCR for page 197
256 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS publicly so that military personnel, retirees, families, and other interested parties can independently assess the tobacco-cessation efforts that are being undertaken by DoD and the armed services, identify problems with the programs, and propose solutions to the problems. Finding: DoD and the armed services appear to track and evaluate some important tobacco-related activities, such as revenue from the sale of tobacco in commissaries and exchanges and a variety of tobacco-cessation metrics, including number of patients asked about their tobacco use and tobacco-cessation medications prescribed. However, important information gaps exist. Those gaps include rates and types of tobacco advertising in military publications, abstinence rates for various tobacco-cessation programs, the number of policy changes that have been made in response to the 1999 DoD strategic plan, and the extent to which the policies are enforced. If such information has been collected, it is not publicly available, nor is there any indication of how the OASD(HA) or the armed services’ surgeons general should use the information or how it informs policy and program changes by senior leaders. Recommendation: DoD should report regularly and publicly on the performance of its tobacco-control programs, adherence to clinical-practice guidelines for tobacco-use management, and tobacco-cessation rates. REFERENCES Army. 2006. Technical Report: Tobacco Cessation Program Comparison. Health Promotion and Prevention Initiatives Program. MCHB-TS-HPR. http://chppm-www.apgea.army.mil/dhpw/ population/Documents/HPPI_Summary_STIs.pdf (accessed November 13, 2008). Army. 2008. Memorandum: Tobacco Cessation Analysis—Camp Cropper, Iraq (July 2007). Camp Cropper, Iraq. http://chppm- www.apgea.army.mil/dhpw/Population/TobaccoCessationReportCam pCropper.pdf (accessed December 21, 2008).

OCR for page 197
257 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES Army. 2009. USACHPPM Directorate of Health Promotion and Wellness: Tobacco Control. Department of the Army, Center for Health Promotion and Preventative Medicine. http://usachppm. apgea.army.mil/dhpw/Population/TobaccoCessation.aspx (accessed April 7, 2009). Arvey, S. R., and R. E. Malone. 2008. Advance and retreat: Tobacco control policy in the U.S. military. Military Medicine 173(10): 985-991. Brill, J. B., J. Gertner, W. G. Horn, and M. A. Gregg. 2007. An Analysis of the Cost-Effectiveness and Efficacy of Tobacco Cessation Aids. Groton, CT: Naval Submarine Medical Research Laboratory. Burns, J. C., and L. N. Williams, Jr. 1995. A survey to determine the knowledge of military members about the hazards of tobacco use, and a resulting tobacco-hazard education project. Journal of Cancer Education 10(1):37-40. Bushnell, F. K., B. Forbes, J. Goffaux, M. Dietrich, and N. Wells. 1997. Smoking cessation in military personnel. Military Medicine 162(11):715-719. Carpenter, C. R. 1998. Promoting tobacco cessation in the military: An example for primary care providers. Military Medicine 163(8): 515-518. Chaffin, J. 2003. Dental population health measures: Supporting Army transformation. Military Medicine 168(3):223-226. Cigrang, J. A., H. H. Severson, and A. L. Peterson. 2002. Pilot evaluation of a population-based health intervention for reducing use of smokeless tobacco. Nicotine and Tobacco Research 4(1):127-131. Conway, T. L., S. I. Woodruff, C. C. Edwards, J. P. Elder, S. L. Hurtado, and L. K. Hervig. 2004. Operation Stay Quit: Evaluation of two smoking relapse prevention strategies for women after involuntary cessation during US Navy recruit training. Military Medicine 169(3):236-242. Covington, L. L., L. G. Breault, J. J. O’Brien, C. H. Hatfield, S. M. Vasquez, and R. W. Lutka. 2005. An innovative tobacco use cessation program for military dental clinics. Journal of Contemporary Dental Practice 6(2):151-163. Cunradi, C. B., R. S. Moore, and G. Ames. 2008. Contribution of occupational factors to current smoking among active-duty US Navy careerists. Nicotine and Tobacco Research 10(3):429-437.

OCR for page 197
258 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS DoD (Department of Defense). 1999. DoD Health Promotion and Prevention. Alcohol Abuse and Tobacco Use Reduction Committee Charter, 22 July 1999. TRICARE. http://www.tricare.mil/hpp/ aaturc_charter.html (accessed April 7, 2009). DoD. 2006. 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Research Triangle Park, NC: RTI International. DoD. 2007. A Report to Congress on the Current Organizational Structure of Alcohol and Drug Programs and Related Policies Within the Department of Defense. Washington, DC: DoD Alcohol and Drug Programs. DoD. 2008. Evaluation of Tobacco-Use–Cessation Programs in the Military Health System. Washington, DC: DoD, Military Health System Clinical Quality Management. DoD. 2009. What is TRICARE? http://tricare.mil/mybenefit/home/ overview/WhatIsTRICARE (accessed April 3, 2009). Earles, J., R. A. Folen, M. Ma, M. Kellar, R. Geralde, and C. Dydek. 2002. Clinical effectiveness of sustained-release bupropion and behavior therapy for tobacco dependence in a clinical setting. Military Medicine 167(11):923-925. 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 Behavior 30(1):103-112. Fiore, M. C., W. C. Bailey, and S. J. Cohen, et al. 2000. Treating Tobacco Use and Dependence: Clinical-Practice Guideline. Rockville, MD: Department of Health and Human Services, Public Health Service. Green, K. J., C. M. Hunter, R. M. Bray, M. Pemberton, and J. Williams. 2008. Peer and role model influences for cigarette smoking in a young adult military population. Nicotine and Tobacco Research 10(10):1533-1541. Haddock, C. K., L. C. Parker, J. E. Taylor, W. S. Poston, H. Lando, and G. W. Talcott. 2005. An analysis of messages about tobacco in military installation newspapers. American Journal of Public Health 95(8):1458-1463. Haddock, K. C., K. Hoffman, J. Taylor, L. Schwab, W. Poston, and H. Lando. 2008. An analysis of messages about tobacco in the Military Times magazines. Nicotine and Tobacco Research 10(7):1191-1197.

OCR for page 197
259 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES Helyer, A. J., W. T. Brehm, N. O. Gentry, and T. A. Pittman. 1998. Effectiveness of a worksite smoking cessation program in the military. Program evaluation. AAOHN Journal 46(5):238-245. Hepburn, M. J., and J. N. Longfield. 2001. Availability of smoking cessation resources for US Army general medical officers. Military Medicine 166(4):328-330. Hoffman, K. M., C. K. Haddock, W. S. Poston, J. E. Taylor, H. A. Lando, and S. Shelton. 2008. A formative examination of messages that discourage tobacco use among junior enlisted members of the United States military. Nicotine and Tobacco Research 10(4):653-661. Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk, D. I. Cotting, and R. L. Koffman. 2004. Combat duty in Iraq and Afghanistan: Mental health problems, and barriers to care. New England Journal of Medicine 351(1):13-22. Hoge, C. W., J. L. Auchterlonie, and C. S. Milliken. 2006. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association 295(9):1023-1032. Hurtado, S. L., S. A. Shappell, B. K. Bohnker, and J. R. Fraser. 1995. Tobacco use and smoking policy perceptions onboard an aircraft carrier. Aviation Space and Environmental Medicine 66(1):59-62. Jackman, R. P., P. N. Willette, D. White, and S. M. Krizek. 2004. Minimizing exposure to passive smoke in the enclosed environment of US submarines. Aviation Space and Environmental Medicine 75(1):60-64. Joseph, A. M., M. Muggli, K. C. Pearson, and H. Lando. 2005. The cigarette manufacturers’efforts to promote tobacco to the US military. Military Medicine 170(10):874-880. Klesges, R. C., C. K. Haddock, H. Lando, and G. W. Talcott. 1999. Efficacy of forced smoking cessation and an adjunctive behavioral treatment on long-term smoking rates. Journal of Consulting and Clinical Psychology 67(6):952-958. Klesges, R. C., M. DeBon, M. W. Vander Weg, C. K. Haddock, H. A. Lando, G. E. Relyea, A. L. Peterson, and G. W. Talcott. 2006. Efficacy of a tailored tobacco control program on long-term use in a population of US military troops. Journal of Consulting and Clinical Psychology 74(2):295-306.

OCR for page 197
260 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Klesges, R. C., L. M. Klesges, M. W. Vander Weg, M. DeBon, W. S. Poston, J. Ebbert, J. T. Hays, and C. K. Haddock. 2007. Characteristics of Air Force personnel who choose pharmacological aids for smoking cessation following an involuntary tobacco ban and tobacco control program. Health Psychology 26(5):588-597. Kuehn, B. M. 2009. Studies linking smoking-cessation drug with suicide risk spark concerns. Journal of the American Medical Association 301(10):1007-1008. Loftus, T. J. 2008. Memorandum: Guidance on Standardized Tobacco Programs (July 15). Washington, DC: Department of the Air Force, Office of the Surgeon General. Milliken, C. S., J. L. Auchterlonie, and C. W. Hoge. 2007. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association 298(18):2141-2148. Morgan, B. J. 2001. Evaluation of an educational intervention for military tobacco users. Military Medicine 166(12):1094-1098. Navy. 2008. BUMED Position Statement: Tobacco Cessation and Pregnancy. Washington, DC: Surgeon General of the Navy. Navy. 2009. Tobacco Cessation Metrics. http://www-nehc.med.navy.mil /hp/tobacco/Tobacco_metrics.htm (accessed April 8, 2009). Nelson, J. P., and L. L. Pederson. 2008. Military tobacco use: A synthesis of the literature on prevalence, factors related to use, and cessation interventions. Nicotine and Tobacco Research 10(5): 775-790. Parsons, A. C., M. Shraim, J. Inglis, P. Aveyard, and P. Hajek. 2009. Interventions for preventing weight gain after smoking cessation. Cochrane Database of Systematic Reviews 1:CD006219. Peterson, A. L., and J. Helton. 2000. Smoking cessation and weight gain in the military. Military Medicine 165(7):536-538. Peterson, A. L., G. W. Talcott, R. Eggert, G. Martin, C. Schaefer, T. McKnight, C. M. Hunter, C. K. Haddock, and W. C. Poston. 2003. Air Force Trainee Health Working Group Tobacco Initiative Subcommittee Report: Report to the Air Education and Training Command Community Action Information Board. Peterson, A. L., H. H. Severson, J. A. Andrews, S. P. Gott, J. A. Cigrang, J. S. Gordon, C. M. Hunter, and G. C. Martin. 2007. Smokeless tobacco use in military personnel. Military Medicine 172(12): 1300-1305.

OCR for page 197
261 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES Poston, W. S. C., J. E. Taylor, K. M. Hoffman, A. L. Peterson, H. A. Lando, S. Shelton, and C. K. Haddock. 2008. Smoking and deployment: Perspectives of junior-enlisted US Air Force and US Army Personnel and their supervisors. Military Medicine 173(5): 441-447. Rodu, B. 2003. Smokeless tobacco as a smoking cessation strategy. Advance for Nurse Practitioners 11(7):18. Russ, C. R., V. P. Fonseca, A. L. Peterson, L. R. Blackman, and A. S. Robbins. 2001. Weight gain as a barrier to smoking cessation among military personnel. American Journal of Health Promotion 16(2):79-84. SAMHSA (Substance Abuse and Mental Health Services Administration). 2007. The NSDUH Report: Serious Psychological Distress and Substance Use Disorder Among Veterans. Rockville, MD: SAMSHA, Office of Applied Studies. Seufert, K. T., and W. R. Kiser. 1996. End-expiratory carbon monoxide levels as an estimate of passive smoking exposure aboard a nuclear- powered submarine. Southern Medical Journal 89(12):1181-1183. Severson, H. H., A. L. Peterson, J. A. Andrews, J. S. Gordon, J. A. Cigrang, B. G. Danaher, C. M. Hunter, and M. Barckley. 2009. Smokeless tobacco cessation in military personnel: A randomized controlled trial. Nicotine and Tobacco Research 11(6):730-738. Smith, B., M. A. Ryan, D. L. Wingard, T. L. Patterson, D. J. Slymen, and C. A. Macera. 2008. Cigarette smoking and military deployment: A prospective evaluation. American Journal of Preventive Medicine 35(6):539-546. 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. VA/DoD (Department of Veterans Affairs/Department of Defense). 2004. VA/DoD Clinical Practice Guideline for the Management of Tobacco Use. Washington, DC: VA/DoD. van Geertruyden, P. H., and C. B. Soltis. 2005. Instituting preventive health programs at a level 1 aid station in a combat environment. Military Medicine 170(6):528-529.

OCR for page 197
262 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Wetter, D. W., J. B. McClure, C. De Moor, L. Cofta-Gunn, S. Cummings, P. M. Cinciripini, and E. R. Gritz. 2002. Concomitant use of cigarettes and smokeless tobacco: Prevalence, correlates, and predictors of tobacco cessation. Preventive Medicine 34(6):638-648. Williams, J. O., N. S. Bell, and P. J. Amoroso. 2002. Drinking and other risk taking behaviors of enlisted male soldiers in the US Army. Work 18(2):141-150. Williams, L., G. Gackstetter, E. Fiedler, C. Hermesch, and H. Lando. 1996. Prevalence of tobacco use among first-term Air Force personnel before and after basic military training. Military Medicine 161(6):318-323. Wilson, M. A. 2008. Prevalence of tobacco abuse in a United States Marine Corp infantry battalion forward deployed in the Haditha triad area of operations, al Anbar, Iraq. Chest 134(4):s53001.