Smoking before basic military training is a significant risk factor for exercise-related injuries for both men and women (Jones and Knapik, 1999). Altarac et al. (2000) found that during Army basic training, the odds ratio (OR) for any injury occurrence was 1.27 (95% confidence interval [CI], 0.82–1.95) for men who smoked 0.5–1 pack of cigarettes per day and 1.96 (95% CI, 1.27–3.03) for women compared with nonsmokers; men and women who smoked more than a pack per day had injury ORs of 2.03 (95% CI, 1.22–3.38) and 1.28 (95% CI, 0.63–2.59), respectively. The adjusted risk ratio for time lost during basic training was 3.1 for men and 2.0 for women who smoked compared with nonsmokers, and there was evidence of more injuries in those who smoked more cigarettes per day (Knapik et al., 2001). Daily use of smokeless tobacco, but not cigarettes, was a significant risk factor (OR, 2.3; 95% CI, 1.0–5.4) for foot blisters in cadets at the US Military Academy during a 21-km march (Knapik et al., 1999).

Smoking has been linked to accidents in military workplaces. Recent disturbing examples of accidents linked to smoking include fires. In July 2008, a fire onboard a US nuclear-powered aircraft carrier was attributed to unauthorized smoking that ignited flammable liquids and other combustible material that was improperly stored in an adjacent space; the carrier required $70 million in repairs as a result of the accident, and several sailors were injured (Associated Press, 2008). In November 2008, 20 men were killed onboard a Russian nuclear submarine when Freon gas was released after a fire alarm was triggered; it has been suggested that the fire could have been ignited by a cigarette that was lighted near a safety gauge that switched on the fire-extinguishing system (Isachenkov, 2008).

Absenteeism, Presenteeism, and Lost Productivity

Numerous studies have documented that military and civilian smokers have higher numbers of days of work loss per year than nonsmokers as a result of illnesses (primarily respiratory tract infections), alcohol and substance abuse, and accidents (Athanasou, 1979; Holcomb and Meigs, 1972; Wilson, 1973). British soldiers who smoked had a 30% higher rate of hospital admissions than nonsmokers (Crowdy and Sowden, 1975), and German soldiers who smoked had a 44% greater number of days associated with being bedridden for illness than nonsmokers (Schmidt, 1972). Smokers also have a higher prevalence of depression and other mental illnesses that has been associated with more frequent absenteeism due to “affective distress” (Parkes, 1983).

A study of 87,991 active-duty US Army men and women (26% current smokers, 16% former smokers, and 58% never smokers) found

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