lower visual acuity, and poorer night vision than nonsmokers. Smoking is associated with hearing loss and increased risks of motor-vehicle collisions, physical injury, and hospitalization. Nicotine withdrawal can also impair performance as a result of irritability, restlessness, anger, difficulty in concentrating, anxiety, depressed mood, and decreased performance on cognitive tests.

Short-term health effects associated with smoking include respiratory infections; adverse postoperative effects, delayed wound healing, and increased risk of postoperative hemorrhage; acute peptic ulcer disease; and periodontal disease. Smokers who become ill have more serious illnesses, are more likely to be hospitalized, and have more work-loss days. The long-term adverse health effects of tobacco use are well known and affect virtually every organ system. Smoking is causally linked to cancer, particularly lung cancer, and to a variety of other diseases, including stroke, cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes, and infectious diseases. About half of all lifelong smokers will die prematurely from a complication of smoking.

Smokeless tobacco delivers as much nicotine as does cigarette-smoking, and although it does not expose the user to the toxicants in tobacco smoke, its use maintains nicotine addiction, promotes continued smoking, and causes oral and pancreatic cancer and periodontal disease.

The societal costs of tobacco use are enormous. Tobacco-related costs to the MHS were estimated to be $564 million in 2006, primarily for care of people who had cardiovascular disease or respiratory problems. Military retirees and their dependents incur greater tobacco-related health costs than do active-duty military or their dependents. Considerable costs are also associated with productivity losses due to smoke breaks and absenteeism. Tobacco use affects and increases training costs for new recruits; tobacco users are less likely to complete basic training and more likely to leave the military earlier. At the same time that tobacco results in high health-care costs and productivity losses for DoD, the department earns substantial net revenues from the sale of tobacco products in military commissaries and exchanges, and this creates an impediment to any policy that might make tobacco less accessible in those venues. In 2005, $88 million of the $611 million in tobacco sales supported military morale, welfare, and recreation activities.

In 2008, VA spent over $5 billion to treat COPD. More than 80% of COPD is attributed to smoking.

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