smokeless tobacco; the largest group of users (21.6%) is white men 18–24 years old. The Marine Corps has the greatest use (22.3%), and the Air Force the lowest (9.2%). Smokeless-tobacco use decreased from 1995 to 2002 in the armed services, but all armed services showed an increase from 2002 to 2005 (DoD, 2006). Initiation of smokeless-tobacco use was greatest in the Army and the Marine Corps (DoD, 2006). Initiation and continuation of use of smokeless tobacco may be higher in the military than in the general population for several reasons. First, the demographics (young men) place the military at higher risk for adoption and use (SAMHSA, 2007). Second, all indoor military facilities are smoke-free, and smokeless tobacco is the only form of tobacco that can be used during active-duty hours. In the Navy and Air Force, smokeless tobacco is subject to the same restrictions as smoked tobacco (SECNAV Instruction 1500.13E, 2008, and Air Force Instruction 40-102, 2002, respectively), but this may be harder to enforce for spit-less tobacco products. Third, as noted in the section “Advertising and Promotions,” smokeless tobacco is advertised in military periodicals.

Another possible reason for the increased use of smokeless tobacco is deployment to a war zone (Wilson, 2008). In a survey of 408 marines stationed in Iraq in 2007–2008, tobacco use was nearly double that of the civilian US population. The survey found that 64% of troops used some form of tobacco: 52% smoked cigarettes, 36% used smokeless tobacco, and 24% were dual users of smokeless tobacco and cigarettes. Most of the marines surveyed stated that both being in the military and being deployed increased their tobacco use, and most were also interested in quitting (Wilson, 2008).

Effective interventions for smokeless-tobacco use in the military are largely lacking, because little is known about the specific determinants of initiation and cessation of smokeless-tobacco use in this population (see Chapter 4). Some behavioral interventions, such as proactive telephone counseling and oral examinations, have been shown to be effective in increasing long-term smokeless-tobacco abstinence rates in military personnel (Cigrang et al., 2002; Klesges et al., 2006). Only one randomized clinical trial has been conducted to evaluate the efficacy of a smokeless-tobacco–cessation program in military personnel (Severson et al., 2009). Participants were 785 active-duty military personnel who were randomly assigned to receive a minimal-contact behavioral treatment (n = 392) or usual care (n = 393). The behavioral treatment included a smokeless-tobacco–cessation manual, a videotape cessation guide tailored to military personnel, and three 15-minute telephone counseling sessions that used motivational interviewing methods. Usual care consisted of standard procedures that are part of the annual dental examination, including recommendations to quit using

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