patient prescribing, follow-up, and adjunct treatments, such as counseling. The Naval Submarine Medical Research Laboratory conducted an analysis of the cost effectiveness and efficacy of tobacco-cessation aids and concluded that bupropion was the most cost-effective medication, but was inappropriate for nuclear field–service personnel because of the risk of seizures; NRTs were found to be the least cost-effective; and varenicline was effective and safe and, with counseling, should be considered for use by submariners and nuclear field-service personnel (Brill et al., 2007). The committee considers that the Navy may have based this conclusion on a misunderstanding of the contraindications for bupropion.

The committee was unable to locate specific information on the availability of tobacco-cessation medications at MHS pharmacies; however, in a survey of Army general medical officers in 1997, 53% of 153 respondents reported that nicotine patches were in the formulary whereas only 20% reported that nicotine gum was in the formulary, and 82% reported that smoking-cessation classes were available (Hepburn and Longfield, 2001).

Combined Behavioral Interventions and Medications

In response to Requirement D.2.4 of the 1999 strategic plan, each of the armed services offers some form of a tobacco-cessation program that includes individual or group contact (generally group), recognition of the problems encountered in quitting, at least four encounters (all of the programs appear to include a minimum of four group sessions), and NRT as appropriate pharmacotherapy (prescription required but available in all programs). The tobacco-cessation programs offered by the armed services include programs that were developed by the armed services themselves (for example, those developed by the Army CHPPM and by the Air Force) and programs that are commercially available (for example, the ACS Freshstart program and the American Lung Association [ALA] Freedom from Smoking program). The requirement of a prescription for all tobacco-cessation medications, including over-the-counter NRTs, may dissuade military personnel and their dependents from obtaining these medications and thus reduce their chance of remaining abstinent.

The Army CHPPM provides materials to conduct a 6-week tobacco-cessation program with participant workbooks, slide presentations, registration forms, and medication information (http://usachppm.apgea.army.mil/dhpw/Population/TobaccoCessation.aspx). The program is based on a program given at Fort Knox, Kentucky (Army, 2009); its effectiveness does not appear to have been evaluated.



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