7
SUMMARY AND RECOMMENDATIONS

The health and economic costs of tobacco use in military and veteran populations are high. In the military, the proportion of smokers, more than 30%, is half again as high as in the civilian population (19.8%) (CDC, 2008), and more military personnel use smokeless-tobacco products than a comparable civilian population (DoD, 2006). The cost of treating people for tobacco-related diseases in the Department of Defense (DoD) is estimated to be over $500 million per year for medical care and $346 million in lost productivity. The veteran population served by the Department of Veteran Affairs (VA) also has a higher smoking rate, 22% (VA, 2006), than the general population. VA costs to treat people with such diseases as chronic obstructive pulmonary disease (COPD) and arteriosclerosis, both of which are strongly associated with tobacco use, in an older and less healthy population, exceeded $5 billion and $1.3 billion, respectively, in 2008.

There are many proven methods for reducing tobacco consumption in the US population, as discussed in Chapter 4. They include legal and regulatory approaches, such as restricting advertising of tobacco products and limiting where tobacco products can be used; economic approaches, such as raising the price of cigarettes; behavioral approaches, such as public-education campaigns to deglamorize tobacco use; and therapeutic interventions, such as counseling and medications to help tobacco users quit. The ultimate goals are to prevent people from starting to use tobacco products and to help those who use tobacco products to stop.

As seen in the preceding chapters, although DoD and VA both serve military populations in their health-care systems, the similarity ends there and the many differences begin. The differences include the age and demographics of the populations that each organization serves; the resources that they can bring to an issue; their authority over their populations and activities, including their health-care practitioners; and their missions and cultures. Those differences have an effect on the ability to change social norms around tobacco use and ultimately on



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7 SUMMARY AND RECOMMENDATIONS The health and economic costs of tobacco use in military and veteran populations are high. In the military, the proportion of smokers, more than 30%, is half again as high as in the civilian population (19.8%) (CDC, 2008), and more military personnel use smokeless- tobacco products than a comparable civilian population (DoD, 2006). The cost of treating people for tobacco-related diseases in the Department of Defense (DoD) is estimated to be over $500 million per year for medical care and $346 million in lost productivity. The veteran population served by the Department of Veteran Affairs (VA) also has a higher smoking rate, 22% (VA, 2006), than the general population. VA costs to treat people with such diseases as chronic obstructive pulmonary disease (COPD) and arteriosclerosis, both of which are strongly associated with tobacco use, in an older and less healthy population, exceeded $5 billion and $1.3 billion, respectively, in 2008. There are many proven methods for reducing tobacco consumption in the US population, as discussed in Chapter 4. They include legal and regulatory approaches, such as restricting advertising of tobacco products and limiting where tobacco products can be used; economic approaches, such as raising the price of cigarettes; behavioral approaches, such as public-education campaigns to deglamorize tobacco use; and therapeutic interventions, such as counseling and medications to help tobacco users quit. The ultimate goals are to prevent people from starting to use tobacco products and to help those who use tobacco products to stop. As seen in the preceding chapters, although DoD and VA both serve military populations in their health-care systems, the similarity ends there and the many differences begin. The differences include the age and demographics of the populations that each organization serves; the resources that they can bring to an issue; their authority over their populations and activities, including their health-care practitioners; and their missions and cultures. Those differences have an effect on the ability to change social norms around tobacco use and ultimately on 307

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308 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS prevention of tobacco use in military personnel and veterans as well as on whether and how tobacco users are supported in their cessation efforts. The committee summarizes its observations on those issues below and then looks at synergies between DoD and VA that can be used to enhance tobacco-control activities in both organizations. TOWARD A TOBACCO-FREE MILITARY POPULATION The idea of establishing a tobacco-free military is not novel. There are numerous reasons why the military would support the goal of becoming tobacco-free, such as improved military readiness, better health of the force, and decreased health-care costs. The US military has set goals to become tobacco-free several times (Arvey and Malone, 2008). Those goals were not reached, but the efforts highlight the military’s interest in achieving a tobacco-free force. The committee finds that a comprehensive tobacco-control program that combines prevention efforts with restrictions on tobacco use and sales, increases tobacco prices, incorporates a counteradvertising campaign to change social norms around tobacco use, and provides easy access to tobacco-cessation interventions based on best practices would be the most effective approach for helping DoD to achieve a healthier, tobacco-free military. The committee believes that the most realistic plan for reaching the long-term goal of a tobacco-free military is a phased approach that requires policy changes to close the pipeline of new tobacco users entering the military. As people enter active-duty military service through basic training and officer-commissioning programs, they become part of a pipeline of service members who will then enter advanced military training and technical-school training and eventually meet a projected personnel need. Over 300,000 enlisted personnel are recruited into the military each year. The committee encourages each armed service, and DoD as a whole, to establish a timeline to end tobacco use in new officer and enlisted accessions into the military. The armed services are encouraged to be as creative as possible to reach that goal. A variety of approaches could be used, some of which might be based on the success achieved and lessons learned from each service’s initiation of a tobacco ban during basic training. Different groups of new accessions could be targeted over a timeline specified by each armed service. Military officers might be one of the easiest groups to initially target inasmuch as they are held as role models for the enlisted force and their tobacco use is already the lowest among military groups (see Chapter 2). Among new officer accessions, people attending the US military service academies would be the easiest to target initially. For example, the Air Force Academy could establish a date when entering freshmen would be informed that tobacco use would be

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309 SUMMARY AND RECOMMENDATIONS forbidden while they are at the Academy and later in the Air Force and that their graduating class would be the first to be commissioned with the expectation that they remain tobacco-free during their military careers. People who are accepted into the US military academies already constitute an elite group of high-school seniors. Selection for each service academy is extremely competitive, and the committee believes that adding the expectation of a tobacco-free lifestyle is unlikely to be seen as too severe a challenge. A similar approach could be used for other officer-commissioning programs, such as the Reserve Officers’ Training Corps (ROTC). Before entry into these training programs, all officer candidates would be informed that the military policy for officers is that they not use any tobacco products during their active-duty military careers. Shortly after or simultaneously with the institution of the tobacco-free policy for new officer accessions, a similar plan could be established for new enlistees. Establishing a tobacco-free policy for military personnel that continues after the completion of initial basic training and into the advanced and technical training schools might be relatively easy. The committee finds that an extended period of nonuse of tobacco during advanced and technical training should make it easier for enlisted personnel to remain tobacco-free. The ban on tobacco use could eventually be extended to all new enlistees, who would be informed during recruitment that tobacco use would be prohibited during active- duty military service, and that new military service members would be expected to remain tobacco-free during their entire military careers. Recruits and trainees would be given all necessary assistance to remain tobacco-free. If such a ban is in place within a year of the release of this report, the military might be virtually tobacco-free within 20 years although the committee expects that, except for a few highly addicted smokers, the goal could be reached sooner. In preparing this report, the committee was struck by a contradiction: DoD and the four armed services acknowledge that tobacco use impairs the readiness of military personnel and results in enormous costs to service members, but DoD still sells tobacco products at a discount, permits tobacco use in some areas of military installations (including the military service academies), and has given tobacco use less attention than alcohol abuse, physical fitness, and weight management. In the future, tobacco use in the military should be treated in the same way as these other health-related behaviors. Current policies mandate that service members who do not pass their annual physical fitness examinations engage in extra physical-conditioning programs, those who are overweight are often required to attend weight- management programs, and those identified as having had alcohol-

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310 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS related incidents are required to attend alcohol-awareness and education programs. Those that cannot meet the requirements may be subject to sanctions. Tobacco use could be monitored in new accessions after a tobacco-free policy has been implemented. People identified as tobacco users during established screening procedures would be required to attend a tobacco-cessation program to help them to quit. To monitor illicit drug use by service members, the military has established a mandatory drug-screening program. Every new accession is screened with a urinary drug test; and every service member is subjected to random drug screening at least once per year. The committee suggests that screening for urinary cotinine (a metabolite of nicotine that is widely used as a biomarker of tobacco use) or a similar screening test be added to the current random drug-testing program that already exists in all of the armed services. The comprehensive tobacco-control programs discussed in Chapter 4 all addressed restrictions on where tobacco products could be used and how much they cost. DoD should exercise similar regulatory restrictions. DoD and the armed services have established regulations that restrict tobacco use on military installations and in some cases have gone entirely tobacco-free, particularly at medical-treatment facilities. The committee emphasizes that such restrictions should be strictly enforced. The committee recommends that DoD establish a timeline to eliminate all tobacco use on military installations—including service academies, ships, and submarines—in the interest of protecting the health of all military personnel, civilian employees, family members, and visitors. The committee finds it unfortunate that DoD and Congress continue to allow the sale of tobacco products on military installations. Profits from the sales of tobacco products benefit the morale, welfare, and recreation programs on military installations, but the committee believes that DoD should not be selling products that are known to impair military readiness and health, and it recommends that these sales be eliminated on all military installations. Again, a phased approach may be most effective. The committee recommends that, at the very least, tobacco sales be eliminated in Army and Air Force commissaries (as they are currently in Navy and Marine Corps commissaries) and, if tobacco products are to be sold in military exchanges, that they be sold at prices commensurate with local civilian retail prices (inclusive of sales taxes). Discounting the price of tobacco products sends the message that they are acceptable and even encouraged. Evidence from state tobacco- control programs shows that increasing the price of tobacco products is an effective mechanism for reducing consumption, preventing initiation,

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311 SUMMARY AND RECOMMENDATIONS and increasing cessation. The committee recommends that there be no legislative barriers to DoD’s increasing the prices of tobacco products or discontinuing their sale in commissaries and exchanges. Prevention is only one goal of tobacco control in DoD, although it is perhaps the easiest to achieve in the long term. A second goal is to expand and enhance established programs to encourage voluntary tobacco cessation in active-duty personnel, retirees, and families. The committee understands that, with the great demands placed upon the US military since 2001 as a result of the conflict in the Middle East, tobacco control policy, practice, and program evaluation has not been a high priority within the DoD. The committee recognizes that DoD does not wish to apply undue pressure on active-duty military personnel to quit tobacco use during a time of war or intense military conflict but notes that even during this stressful time, some personnel desire to quit tobacco use and should be encouraged to do so. The committee notes that even among deployed troops, the majority of them do not use tobacco. For current tobacco users, military leaders should encourage tobacco cessation and support the idea that tobacco use is incompatible with a fit fighting force. The committee has heard from service members that military leaders, although recognizing that tobacco use is detrimental to military readiness, also believe that when military members are engaged in conflict it is not fair to restrain any legal activities that they enjoy while deployed. The committee acknowledges that military members may find tobacco use to be a respite during deployment, but it does not believe that military leaders should abdicate their responsibility to encourage tobacco cessation even during deployment. The committee is concerned that, although each of the services has stated goals of being tobacco-free (see Chapter 5), installation commanders have considerable autonomy with regard to implementation and enforcement of tobacco- control measures and that enforcement of tobacco-control policies is not a priority or a performance measure for installation commanders. Strong leadership and enforcement of tobacco-control policies, with appropriate performance measures, is required to motivate military tobacco users to quit. Military health-care providers, through health promotion, should provide a variety of tobacco-cessation interventions, including counteradvertising campaigns, telephone cessation programs, online intervention programs, brief interventions in primary-care settings, and intensive tobacco-cessation programs. Counteradvertising campaigns, possibly building on the DoD “Quit Tobacco. Make Everyone Proud” program, must be targeted to a military audience, particularly young men who have the highest tobacco-use rates. Tailoring the messages to the missions, culture, and social norms of each armed service is also

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312 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS important. These campaigns should also include smokeless-tobacco use which is on the rise. The lack of publicly available evaluations of the tobacco- cessation programs offered by the armed services makes it difficult for the committee to recommend specific programmatic changes. However, the committee endorses the use of the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use (VA/DoD, 2004) and the Public Health Service’s clinical-practice guideline Treating Tobacco Use and Dependence: 2008 Update (Fiore et al., 2008) by military health- care providers. Easy access to tobacco-cessation medications and counseling sessions are important to ensure that tobacco-cessation treatment is as easy to access as are tobacco products on military installations. Given the peripatetic nature of military service, the committee recommends that DoD establish a dedicated quitline for military personnel that is accessible by all military personnel, retirees, and their families regardless of where they are stationed (with the possible exception of those deployed to war zones with limited telephone access) and how frequently they move. The counselors for the quitline should be trained to deal with issues that are peculiar to military personnel, such as deployment stress, frequent moves, and military culture. The committee recognizes that DoD has already made commendable strides in that direction with the initiation of the “Quit Tobacco. Make Everyone Proud” campaign. However, the effort would be enhanced by enabling users to call a trained counselor immediately and to receive free tobacco-cessation medications, particularly those sold over the counter in the civilian sector, and also by adding a follow-up to each call to evaluate the reach and effectiveness of the program and its modifications. Many service members, retirees, and family members will have their tobacco-cessation needs met by the treatments outlined in the VA/DoD clinical-practice guideline, but some DoD populations, especially deployed personnel, may need special accommodations or treatments, as described in Chapter 5. The committee finds that the evidence supports providing deployed personnel with tobacco-cessation programs comparable with those available to nondeployed personnel. Indeed, given the nature of the current deployments, which present extreme stress and boredom, both of which are conducive to tobacco use, the committee argues that such programs are even more important. Personnel must be trained to offer programs, which should be conducted at times and places and in formats that make it easy for personnel to attend. Group sessions, which may provide needed support for some deployed service members, do not meet the needs of all members and may be perceived by some as encroaching unnecessarily on much-

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313 SUMMARY AND RECOMMENDATIONS needed relaxation time. Programs tailored specifically to both deployed and nondeployed personnel are needed. Given the command-and-control structure of DoD, it is not surprising that surveillance data on personnel health status are available. Some performance metrics have been developed by individual services to assess short-term tobacco-cessation rates and the number of personnel who attend counseling sessions or receive medications, but the impact of the metrics on improving tobacco-cessation rates and services is unclear, and the information is not publicly available. Furthermore, more information should be gathered on the long-term success rates of tobacco-cessation programs so that human and financial resources and treatments can be adjusted to increase their effectiveness. For example, the committee was frustrated in its attempts to obtain a report that evaluated tobacco-cessation programs across the armed services, although a fact sheet on the evaluation was eventually published (DoD, 2008). This does not inspire confidence that the programs are meeting the needs of military personnel, and it prevents contributions by outside experts on how the programs might be improved. TOWARD A TOBACCO-FREE VETERAN POPULATION The tobacco-cessation programs used by VA are similar to those of DoD, but VA’s organizational structure and population being served are considerably different. Unlike DoD, VA (with a few exceptions) provides health care only to veterans and does not provide health care to their families or dependents. VA is a health leader in many fields, such as electronic medical records and mental-health research, and its medical-research advances are widely recognized. VA has a long history of attempting to reduce tobacco use by veterans and has been responsible for numerous scientific advances regarding health effects of smoking. In addition, its organizational structure provides for considerable autonomy for medical facilities to address the needs of its patient populations. The committee finds that this autonomy has advantages in allowing the tobacco-cessation lead clinician in each VA medical center to modify programs to meet specific patient needs. However, the lack of systematic information on tobacco-control programs offered in outpatient clinics, including community-based outpatient clinics, needs to be addressed. Evaluative data are spotty, and there is no information on whether clients at VA Veterans Centers have much interest in such programs. Given the older patient population in the VA health-care system, the need for prevention of tobacco-use initiation is less than that in DoD; there is, however, a great need for prevention of tobacco-use relapse. The committee believes that the growing number of veterans returning from deployment with mental-health disorders, especially posttraumatic stress

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314 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS disorder (PTSD) and depression, may increase the demand for tobacco- relapse prevention services. People with mental-health disorders use tobacco at far higher rates than those without such disorders. The committee advocates the use of tobacco-cessation therapy in conjunction with therapy for mental-health disorders for patients interested in quitting tobacco use. The evidence indicates that treatment for tobacco use does not adversely affect treatment for mental-health disorders. The VA patient population is not only older than that served by the DoD Military Health System, but it has a higher incidence of tobacco-related morbidity—such as cardiovascular disease, COPD, and lung cancer—than the DoD active-duty population. The prevalence of smoking in veterans is not substantially higher than the general population (22% vs. 20%), so veterans must be quitting smoking after they leave the military or have died as a result of their tobacco use. VA, with its electronic medical records for all patients, should be able to track when patients stop smoking and whether they do so in response to treatment received through VA or from another source. That information will prove to be valuable in tailoring tobacco-cessation programs to veterans. The committee concurs with the VA/DoD clinical-practice guideline that tobacco-cessation services should be offered to all patients, including hospitalized patients and those in primary-care clinics for other reasons. The committee believes that having a dedicated smoking and tobacco-use cessation lead clinician in each VA medical facility is a good start toward ensuring that VA staff are familiar with the most effective tobacco-cessation treatments and also have a point of contact for more information. Like DoD, VA does not have a dedicated national quitline. The committee believes that such a quitline, available toll-free to all veterans and their dependents, would provide a valuable and cost-effective service for veterans. Veterans, like active-duty and retired military, have concerns about tobacco cessation that should be addressed by counselors who are trained to deal with these issues. Although veterans may move less frequently than military personnel, continuity of service would be enhanced by a nationwide quitline. The committee also recommends that quitline counselors be able to provide nicotine-replacement therapy (NRT) to veterans who are participating in telephone counseling and, with proper training, prescription tobacco-cessation medications as well. If the latter is not feasible, the committee recommends that counselors at least be able to refer patients to an appropriate health-care provider in their areas to provide prescriptions or payment vouchers for NRTs at local pharmacies. In essence, the committee believes that VA should act to make tobacco-cessation medications easily accessible for veterans

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315 SUMMARY AND RECOMMENDATIONS whether or not they see a primary-care physician about quitting tobacco use or attend a tobacco-cessation program. It should also put into place systems of continuing evaluation and oversight to measure the effectiveness of its tobacco-cessation programs. VA does not provide health-care services to dependents of veterans, with a few exceptions. The evidence shows that smokers whose partners smoke are less likely to quit and more likely to relapse. Some VA medical facilities permit partners of smokers to attend counseling sessions but cannot cover the costs of their tobacco-cessation medications. Inclusion of partners is at the discretion of the clinicians conducting the sessions. The committee recommends that partners of smokers be allowed access to treatment. The committee also recommends that VA explore the additional costs that might be incurred by providing tobacco medications to partners, either free or at reduced cost. VA has been in the forefront of the use of electronic medical records. The records might be used to enable primary-care providers and other appropriately trained health-care personnel to indicate that tobacco- cessation medications (especially NRTs) are to be mailed to interested patients without going to pharmacies and without the need for health- care providers who lack prescription privileges to obtain them from providers who do. Each of these steps would make it more likely that a motivated patient will use the medications and thus increase the chances of quitting tobacco use. Unlike DoD, VA does not have to respond to the sale of tobacco products, having discontinued such sales several years ago. However, it does have a congressional mandate to maintain smoking areas for patients. The committee finds that this congressional requirement is in conflict with current understanding of the harm caused by exposure to tobacco smoke. The committee also finds that maintaining such smoking areas is not in compliance with the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) tobacco- control standard that bans smoking in hospital buildings. In light of VA’s leadership in numerous health-care fields, and its repeated attempts to make its facilities entirely tobacco-free (both indoor and outdoor), the committee finds it lamentable that Congress continues to require that VA maintain smoking shelters at its health-care facilities. VA has been in the forefront of the development and implementation of performance measures to ensure that health-care providers ask patients about tobacco use, advise them to quit, and assist patients who are willing to quit in obtaining tobacco-cessation treatment. Although compliance with the performance measures is extremely high—almost 100% in some VA facilities—there is little documentation

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316 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS on whether such measures have translated into higher abstinence rates and which programs have greater success. Without such information, one cannot know whether asking patients about tobacco use ensures that the treatment they receive is helpful and improves patient care and outcomes. TOBACCO-CONTROL COMMONALITIES In the sections above, the committee considered DoD and VA as separate entities in dealing with tobacco control. In spite of their differences, those organizations have many issues in common, and the committee believes that there are policies and programs that are applicable to both organizations. Because all veterans were at one time in the military, there is a continuum of health-care needs that may best be addressed by a comprehensive tobacco-control program that spans both DoD and VA. An integrated approach will ensure that military personnel know what to expect regarding tobacco-cessation services as they move from the Military Health System to the VA health-care system. DoD and VA have worked together on several other health-care goals. For example, they are exploring ways to ensure that DoD medical records can be used by VA health-care providers. Of particular relevance to the present study is the joint DoD and VA Management of Tobacco Use Working Group that produced the 2004 clinical-practice guideline. That guideline gives health-care providers in both organizations recommendations on how to assess, treat, and prevent tobacco use in military and veteran populations. It has sections on dealing with special populations that may of greater use to DoD health-care providers as well as sections that may be of greater use to VA health-care providers. The committee commends the joint effort and believes that it can be expanded to other aspects of tobacco control. Both VA and DoD permit civilian employees to attend tobacco- cessation counseling sessions as space permits, but neither organization provides tobacco-cessation medications for them. The committee believes this may pose a barrier to employees’ quitting tobacco use. DoD and VA should conduct analyses to determine whether providing such medications would increase employee participation in tobacco-cessation programs, what the costs of such medications might be, and whether the costs might be recouped by the employees’ health-insurance plans. VA requires that each VA medical facility have a smoking and tobacco-use cessation lead clinician who serves as a tobacco-control advocate in the facility and as a point of contact for information. The committee endorses the designation of such persons and recommends that all VA medical clinics, not just medical centers, identify and train

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317 SUMMARY AND RECOMMENDATIONS them. DoD should also require that each military installation designate such persons and give them appropriate training. DoD and VA are both adept at outreach and public-education campaigns and have used their expertise in the past for alcohol-abuse and weight-management programs. The committee believes that such public- education expertise, along with counteradvertising campaigns to change social norms around tobacco use, can be applied to tobacco cessation. Engaging such groups as veteran service organizations, the United Service Organizations, VA volunteer services, and military family organizations can raise the profile of tobacco-control issues and stimulate support and services for military members and veterans who are trying to quit. Local military installations and VA outpatient clinics can establish relationships with local chapters of such groups as the American Cancer Society and the American Lung Associations. Such relationships can help health professionals access patient-education materials, provide advice to their patients on support groups, and keep abreast of new developments in tobacco-control research. Both the VA/DoD guideline and the 2008 Public Health Service (PHS) guideline advocate the use of the 5 A’s for each patient seen by a health-care provider. Although many of the health-care facilities in each organization follow the guidelines and virtually all patients are asked about tobacco use, advised to quit, and given assistance in the form of a referral to tobacco-cessation programs, many do not assess the likelihood that patients are willing to quit and do not arrange for follow-up with easily accessed treatment. The committee recommends that all health- care providers be trained in the 5 A’s and in the use of the tobacco- cessation approaches in the guidelines. All of these efforts will help to reduce barriers to accessing tobacco-cessation services for military personnel, their families, and veterans. The committee is aware that surveillance of tobacco use and cessation is time-consuming and that VA and DoD may not have enough personnel to accomplish this task. The committee recommends that VA and DoD evaluate their personnel needs for tobacco surveillance, prevention, and cessation and make appropriate requests for additional staff through regular channels. In reviewing the comprehensive tobacco-control programs used by states and other organizations, the committee was struck by one component that served as a driver for developing and implementing each program: strong, committed, and dynamic leadership. VA and DoD are top-down organizations, and leadership initiatives are most likely to result in organizational change. This has been seen in the reorganization of the Veterans Health Administration from an inpatient-based system to an outpatient-based system under the auspices of the under secretary for

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318 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS health in the middle 1990s. Similarly, the potential influence of military leadership on programs, plans, and policies is enormous. The committee believes that without the enthusiastic support of involved leaders, tobacco control will not have a high priority in either DoD or VA. Considering the staggering toll of tobacco use on military readiness, lost productivity, adverse health effects, exposure to secondhand smoke, cost of tobacco products, and health-care expenditures, DoD and VA should develop, implement, and evaluate outcomes of continuing broad and systematic tobacco-control programs as major components of their health-care systems. Preventing tobacco use and reducing the number of tobacco users will result in great benefits to both organizations and improve the quality of life of military personnel, veterans, and their families for years to come. SUMMARY OF FINDINGS AND RECOMMENDATIONS In Table 7-1, the committee lists its major findings and recommendations. Findings and recommendations that refer specifically to DoD and VA are in Chapters 5 and 6, respectively. TABLE 7-1 The Committee’s Findings and Recommendations for the Department of Defense and the Department of Veterans Affairs Findings Recommendations Tobacco use in the US military and veteran populations exceeds that in the general population. Tobacco use • impairs military operational readiness; • is a cause of increased morbidity and mortality in active-duty military personnel, retirees, veterans, and family members; • results in increased health-care costs for tobacco users and their families; and DoD, VA, and the general public; and • creates a patient pipeline from DoD to VA. DoD and the armed services have The goal of a tobacco-free military stated goals of being tobacco-free service may be achieved incrementally. but have not achieved these goals. DoD and the armed services can use

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319 SUMMARY AND RECOMMENDATIONS Findings Recommendations several mechanisms to intensify their efforts to reach the goal: • Set a specific date by which the military will be tobacco-free and make compliance in all the armed services mandatory. Require each service to develop and enforce a timeline for achieving tobacco-free status. • The military academies, officer- candidate training programs, and university-based reserve officer training corps programs should become tobacco-free first, followed by new enlisted accessions, and then by all other active-duty personnel. Tobacco control does not have a DoD, the armed services, and VA should high priority in DoD or VA. raise the priority given to tobacco control Neither department has instituted a throughout their organizations. comprehensive tobacco-control program. Existing programs are not DoD, the armed services, and VA should comprehensive, standardized, or develop comprehensive, integrated consistently enforced. tobacco-control programs with timelines for benchmarks and strategies for achieving them. The departmentwide plans should encompass tobacco-use restrictions, sales restrictions (in DoD only), communication interventions, treatment interventions (including those for special populations), treatment delivery (such as clinical settings and quitlines), surveillance mechanisms, and periodic program evaluations. Tobacco use by military personnel DoD and VA should take the following and veterans is not denormalized. actions to denormalize tobacco use: • Eliminate tobacco use on military installations and in VA medical facilities using evidence-based practices and, for the DoD, a phased- in approach. • Eliminate the sale of tobacco products

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320 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Findings Recommendations on all military installations. At the very least, prohibit the sale of tobacco products in Army and Air Force commissaries. (Navy and Marine Corps commissaries do not sell tobacco products.) • Should tobacco products be sold at military installations (exchanges and package stores), they should be priced at least on par with local civilian retail prices and preferably higher than the average prices in the community. Funds generated by the differential pricing should be used for tobacco- control activities. • Enforce equal work breaks for all employees. DoD and VA have many As part of a comprehensive tobacco- components of a comprehensive control program, DoD and VA should do tobacco-control programs in place, the following: • Place the authority for developing but they lack • effective, committed, and tobacco-control policies and supportive leadership at the strategies in a single high-level entity highest levels of the in DoD. In VA, the secretary and the departments; under secretary for health should • a chain of accountability for actively promote tobacco cessation. • Ensure that the surgeon general of program execution; • engaged and properly trained each armed service and the individual installation commanders are staff in all health-care and accountable for DoD program health-promotion facilities; implementation and enforcement and • adequate resources, including that veterans integrated service infrastructure and funding of all network directors are accountable for facilities; and VA program implementation and • sufficient performance metrics to enforcement. drive program improvement. • Educate all DoD and VA health-care and health-promotion staff in tobacco-control practices and train health-care providers in the 5 A’s. • Provide all DoD and VA staff and patients with barrier-free access to tobacco-cessation services.

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321 SUMMARY AND RECOMMENDATIONS Findings Recommendations • Ensure that there are adequate resources, including infrastructure and funding, at all facilities. • Inventory tobacco-cessation programs at each military installation and DoD and VA medical facility, and ensure that a trained tobacco- cessation counselor is available in each facility. • All DoD and VA health-care providers, including counselors, should be able to provide brief counseling and nicotine-replacement therapy to patients. • Report publicly and regularly on the performance of their tobacco-control programs, adherence to clinical- practice guidelines, and tobacco- cessation rates. DoD and VA have established The VA/DoD Clinical Practice many best practices in tobacco Guideline for the Management of cessation. Widespread adoption of Tobacco Use should be updated and the practices is essential for harmonized with the PHS clinical- predictable and consistent tobacco- practice guideline on tobacco cessation services in DoD and VA. management. DoD and VA should develop and implement standards for the content and evaluation of tobacco-cessation counseling. There is a strong association DoD and VA should follow the VA/DoD between tobacco addiction and and PHS guidelines for treating tobacco mental-health problems, including use in patients who have mental-health anxiety disorders (such as PTSD), disorders. mood disorders (such as depression and bipolar disorder), Mental-health professionals should schizophrenia, and substance abuse receive training in tobacco-cessation (alcohol and illicit drugs). treatment and provide assistance to any patients who are willing to try to quit.

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322 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Findings Recommendations Legislative support is essential for Congress should do the following: • Repeal the Veterans Health Care Act a comprehensive tobacco-control program in DoD and VA. of 1992 (Public Law 102-585, §526) to allow VA health-care facilities to become completely tobacco-free. • Expand the 2009 National Defense Authorization Act Section 713, “Smoking Cessation Program Under TRICARE,” to include smokeless- tobacco cessation treatment. • Direct DoD to sell tobacco products at prices at least equal to and preferably greater than local civilian retail prices. DoD and VA research contributes DoD and VA should develop and fund a to identifying effective tobacco- joint comprehensive research plan on control programs, particularly for tobacco control in military and veteran special populations, such as those populations. with mental-health and substance- abuse problems. RESEARCH AGENDA Much research has been done on tobacco control by public entities and by DoD and VA. For example, VA has supported considerable research on tobacco use in veterans who have mental-health disorders, on new tobacco-cessation medications, and on the role of health-care providers in delivering tobacco-cessation services. DoD has funded studies on the initiation of tobacco use by new recruits and on relapse of tobacco use after basic training. But the committee was struck by several gaps in knowledge that should be filled through research. There is a dearth of information in both organizations about the success of their tobacco-cessation programs, particularly long-term abstinence rates. Some of that information should be generated by the program evaluation necessary for efficient operation, which needs to be enhanced. Beyond operational data, there is a need for research on changing demographics, behavioral and cultural inducers, and improved or innovative program design. Without such information, it is difficult to assess what programs are working for military personnel, retirees, their families, and veterans. It is possible that some programs work better for

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323 SUMMARY AND RECOMMENDATIONS one population than for another. Data on long-term abstinence rates in people who leave military service might be more difficult for DoD to capture, but such follow-up is important for careerists and those who remain in the military for several years. VA acknowledges that most veterans who enter its health-care system stay in it for life. Therefore, obtaining long-term follow-up data on these veterans would probably not be difficult. For example, given that a smaller proportion of veterans use tobacco than do active-duty military personnel, veterans who no longer use tobacco could be evaluated to determine when and how they quit. The issue of tobacco use in select populations should be of continuing concern for DoD and VA. DoD has a higher rate of tobacco initiation than the general population, and further research should be conducted to identify why that is the case and what may be done to change it. In addition, the DoD should conduct research on whether policies to ban tobacco use during technical and advanced training are effective in preventing relapse after such training. Deployed personnel also use tobacco more than nondeployed personnel, and research should focus on identifying healthy substitutes for tobacco as a stress and boredom reliever during deployment. Deployed personnel also use more smokeless tobacco; DoD should fund research on the long-term health effects of smokeless tobacco and effective cessation interventions. Given the number of veterans and military retirees who have comorbid medical and psychiatric conditions, the committee recommends that DoD and VA consider jointly funding research on the effects of tobacco use on these conditions and on effective tobacco- cessation interventions for these populations. Tobacco use in people with comorbid mental-health disorders should be monitored, and research should be conducted to develop more effective tobacco-cessation programs for such VA populations as those with alcohol abuse or PTSD. VA has conducted considerable research in that field, but further work needs to be done, particularly with regard to the timing of interventions and the use and possible interactions of tobacco-cessation medications and psychiatric medications. It may also want to consider jointly funding such efforts with DoD, given the large population of military personnel returning from the conflicts in Iraq and Afghanistan with mental-health disorders. DoD and VA may consider research to assess the use and effectiveness of tobacco-cessation treatments provided in various medical-care facilities in both organizations. Can military personnel who are stationed at smaller installations and veterans who receive care at community-based outpatient clinics access the same level of care as military personnel and veterans at large medical facilities? Stemming from the issue of access to care is the need to assess the role of quitlines

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324 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS in providing assistance to military and veteran populations. Demonstration projects could be funded to determine the use and effectiveness of national quitlines for both DoD and VA with counselors trained to deal with issues peculiar to military and veteran life. Evidence has shown that having a partner who smokes makes it more difficult for a person to quit smoking. VA does not provide tobacco-cessation medications for partners of veterans who use tobacco, although many VA tobacco-cessation counseling programs allow partners to attend the sessions. VA might explore the costs and long-term benefits that might accrue if partners were provided with cost-free or discounted tobacco-cessation medications. Finally, there is the issue of resources to pay for services and to address the committee’s recommendations. The committee acknowledges that the DoD morale, welfare, and recreation programs receives a substantial portion of its budget from the sales of tobacco. DoD should undertake a study of finding alternative funding streams. It should examine what effect raising the prices of tobacco products would have on consumption and revenue. The committee concludes that although DoD and VA have demonstrated a continuing commitment to the health of military personnel and veterans, respectively, particularly with respect to tobacco- use cessation, much remains to be done. Given the effect of tobacco use on military readiness and on the health of military personnel, retirees, families, and veterans, the time has come for DoD and VA to assign high priority to tobacco control. REFERENCES Arvey, S. R., and R. E. Malone. 2008. Advance and retreat: Tobacco control policy in the US military. Military Medicine 173(10):985-991. CDC (Centers for Disease Control and Prevention). 2008. Cigarette smoking among adults—United States, 2007. Morbidity and Mortality Weekly Report 57(45):1221-1226. DoD (Department of Defense). 2006. 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Research Triangle Park, NC: RTI International. DoD. 2008. Evaluation of Tobacco Use Cessation Programs in the Military Health System. Washington, DC: DoD Military Health System Clinical Quality Management. Fiore, M. C., C. R. Jaen, T. B. Baker, et al. 2008. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update. Washington, DC: Department of Health and Human Services, Public Health Service.

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325 SUMMARY AND RECOMMENDATIONS VA (Department of Veterans Affairs). 2006. 2005 Survey of Veteran Enrollees’ Health and Reliance upon VA with Selected Comparisons to the 1999–2003 Surveys. Washington, DC: Veterans Health Administration. VA/DoD. 2004. VA/DoD Clinical Practice Guideline for the Management of Tobacco Use. Washington, DC: VA/DoD.

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