rose to $150 when nonmedical costs, such as lost productivity, were included (Dall et al., 2007).

Lost Productivity and Training Costs

As discussed previously, the total cost to DoD extends beyond that associated with medical treatment for tobacco-related disease and direct costs of treatment for tobacco use (medications and counseling). It also includes time lost to smoking breaks, increased absenteeism due to illness, presenteeism, and reduced productivity at work.

Helyer et al. (1998) estimated that in 1995, the cost of lost productivity of active-duty US military personnel due to smoking breaks (30 min/day for 220 workdays/year) was over $345 million. Those smoking breaks were considered to be in excess of the regular breaks that most workers take each day and amounted to 14,900 person-years (based on an 8-hour day) (Helyer et al., 1998). CDC (2000) estimated that in 1997 workday losses attributable to smoking by active-duty Air Force personnel (about 25% of the men and 27% of the women were smokers) amounted to 893,128 days on the basis of 250 workdays/year, or the equivalent of 3,573 full-time employees (FTEs); these workdays represented about $87 million in lost productivity. One study (Zadoo et al., 1993), however, found that in 1990 smoking was not associated with an increased number of sick calls or time off from duty among soldiers (enlisted, noncommissioned, and officers).

Dall et al. (2007) calculated that moderate to heavy smoking was associated with greater absenteeism in the DoD TRICARE Prime enrolled population—356,000 FTE days were lost per year—and 30,000 FTE days were lost as a result of below-normal work performance. That amounted to $54 million in productivity lost to DoD. Smokers also indicated greater intent to leave military service, but this could not be statistically correlated with tobacco use.

Tobacco use also affects and increases training costs for new recruits; failure to complete basic training costs the government about $16,000 per recruit (at the time of the study) (Snoddy and Henderson, 1994). During a 13-week training cycle, which included over 649 recruits at the US Army Infantry Training Center, there were 1,023 visits to medical facilities. One-third of the trainees had no medical visits, but overall there were 1.58 visits/trainee and a mean of 4.53 (± 8.49) days/person lost or with reduced training time. A history of tobacco use was the only predictor of an increased number of medical visits (p = 0.006) and of time lost for medical problems (p = 0.036) during training; both previous injury and cigarette-smoking were correlated with a

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