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FACTORS THAT INFLUENCE TOBACCO USE

The decision to use and continue to use a tobacco product depends on many factors, from personal ones such as self-image to societal ones such as easy access to cigarettes. In this chapter, the committee uses a socioecologic framework (Figure 3-1) to examine the factors that encourage and sustain tobacco use in military and veteran populations. On the basis of a socioecologic approach (Figure 3-1), the committee posits that health behaviors result from the interplay between personal attributes (such as genetic makeup, demographics, and learning history) and the health resources and constraints that exist in the environmental settings in which a person lives (Hovell et al., 2009; McLeroy et al., 1988; Sallis et al., 2008; Stokols, 1992). Those factors interact with each other to affect health behaviors (Sallis et al., 2008) and, ultimately, the health of a population. Their influence is cumulative and unfolds throughout the life course of individuals, families, and communities (Booth et al., 2001; IOM, 2001). The factors are in operation before people enter the military system and throughout different phases of their military life, including recruitment, training, active duty, deployment, and discharge or retirement. The analysis focuses specifically on the patterns and levels of tobacco use found among those populations (Lindheim and Syme, 1983) and the role of social, cultural, and institutional contexts in shaping behaviors that can result in tobacco use (Sallis et al., 2008).

On the basis of the socioecologic perspective, reducing tobacco use in military and veteran populations will require coordinated, multilevel interventions that address the numerous determinants of use. Creating a tobacco-free environment in the Department of Defense (DoD) and the Department of Veterans Affairs (VA) and addressing the broader factors that influence smoking and the use of smokeless tobacco in the military and in veterans at the population level may be more cost-effective than focusing solely on behavioral and pharmaceutical interventions at the individual level (IOM, 2001). Intervention efforts to



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3 FACTORS THAT INFLUENCE TOBACCO USE The decision to use and continue to use a tobacco product depends on many factors, from personal ones such as self-image to societal ones such as easy access to cigarettes. In this chapter, the committee uses a socioecologic framework (Figure 3-1) to examine the factors that encourage and sustain tobacco use in military and veteran populations. On the basis of a socioecologic approach (Figure 3-1), the committee posits that health behaviors result from the interplay between personal attributes (such as genetic makeup, demographics, and learning history) and the health resources and constraints that exist in the environmental settings in which a person lives (Hovell et al., 2009; McLeroy et al., 1988; Sallis et al., 2008; Stokols, 1992). Those factors interact with each other to affect health behaviors (Sallis et al., 2008) and, ultimately, the health of a population. Their influence is cumulative and unfolds throughout the life course of individuals, families, and communities (Booth et al., 2001; IOM, 2001). The factors are in operation before people enter the military system and throughout different phases of their military life, including recruitment, training, active duty, deployment, and discharge or retirement. The analysis focuses specifically on the patterns and levels of tobacco use found among those populations (Lindheim and Syme, 1983) and the role of social, cultural, and institutional contexts in shaping behaviors that can result in tobacco use (Sallis et al., 2008). On the basis of the socioecologic perspective, reducing tobacco use in military and veteran populations will require coordinated, multilevel interventions that address the numerous determinants of use. Creating a tobacco-free environment in the Department of Defense (DoD) and the Department of Veterans Affairs (VA) and addressing the broader factors that influence smoking and the use of smokeless tobacco in the military and in veterans at the population level may be more cost- effective than focusing solely on behavioral and pharmaceutical interventions at the individual level (IOM, 2001). Intervention efforts to 79

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80 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Societal Community Interpersonal Individual FIGURE 3-1 The socioecologic model of levels of influence on behavior. Individual factors include biologic characteristics and personal history. Interpersonal factors include interactions with peers, intimate partners, and family. Community factors include schools, workplaces, and other organizations where social relationships can occur. Societal factors are social and cultural norms; health, economic, educational, and social policies; and religious and cultural belief systems (CDC, 2007). prevent tobacco-use initiation and promote cessation would need to be implemented at the multiple outlined levels (IOM, 2001). Individually oriented interventions would be most effective when the environment in which people live and make choices is in synchrony with the knowledge and behaviors addressed in the programs. Environmental and policy changes will be most effective when they are combined with programs that motivate and educate people to respond to the changes (Kumanyika, 2007). Progress made in tobacco control in the general population has been based on a socioecologic understanding of health and human behavior (Hovell et al., 2009; Martinez-Donate et al., 2008). The greatest changes in smoking prevalence have resulted from populationwide interventions: economic measures to reduce access to tobacco; laws and regulations restricting tobacco use, advertising, promotion, and sales of tobacco products; and multicomponent public-education campaigns (Fisher et al., 2004; Task Force on Community Preventive Services, 2005). Lessons from tobacco control illustrate a compounding effect due to the interaction of interventions at different levels; tobacco-control interventions at the population level have proved most effective when conducted in combination with individual-level interventions. For example, smoking restrictions in workplaces and other public places can increase smokers’ motivation to seek cessation services and to restrict smoking in their homes (Borland et al., 2006), which in turn may

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81 FACTORS THAT INFLUENCE TOBACCO USE promote cessation (Pizacani et al., 2004) and reduce initiation (Farkas et al., 2000). Likewise, the effectiveness of individual-level and school- based interventions, such as home smoking bans and school-based smoking-prevention programs, is enhanced when they take place in the context of strong communitywide tobacco-control efforts that support and reinforce changes effected at these levels (Perry, 2001). The socioecologic approach has been applied to analyses of health behaviors and the design of interventions to address a variety of other public-health issues, including physical activity (Booth et al., 2001; Sallis et al., 2006), diet and eating behaviors (Glanz et al., 2005), condom use (Cohen et al., 1999), and chronic-disease self-management (Norris et al., 2002). The framework has also been used as a guide to public-health programs nationally and internationally, including Healthy People 2010 (HHS, 2000) and the World Health Organization (WHO) Framework Convention on Tobacco Control (WHO, 2003) (see Chapter 4 and Appendix A). A SOCIOECOLOGIC ANALYSIS OF TOBACCO USE IN MILITARY AND VETERAN POPULATIONS The socioecologic analysis of tobacco use includes attention to the individual, interpersonal, community, and societal factors in military and veteran populations and considers the role of the broader social, cultural, and political context in creating an environment that may increase use. That dynamic interplay may account for increasing trends of tobacco use in the military and veteran populations over the last decade. At the individual level, the physiologic processes that underlie nicotine addiction and the high rates of physical and mental comorbidity found in these populations are addressed. At the interpersonal level, the psychosocial factors that characterize life in the military—including separation from family and friends, alternation of high levels of stress with periods of boredom, peer influences, and the perceived role of tobacco use in facilitating social connectedness—and the limited opportunities to adopt alternative, healthier coping strategies are considered. Attitudes toward tobacco use in DoD and VA, their organizational structure, and their current practices and policies that may be exacerbating the tobacco epidemic and preventing the progress in tobacco control are addressed. Variable taxation of tobacco products by the federal and state governments and the role of the tobacco industry in keeping tobacco prices low contribute to the use of tobacco by adults and children. Finally, current congressional mandates, economic constraints on a national scale, and the sustained military conflicts in Iraq and Afghanistan operate to reduce the ability of DoD and VA to become tobacco-free and increase the rates of tobacco use by active-duty and

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82 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS SOCIETAL • Historical association between smoking and military COMMUNITY • No comprehensive tobacco • Congressional control program legislation INTERPERSONAL • Acceptability of smoking • Family INDIVIDUAL • Limited enforcement of influence • Genetic predisposition • Tobacco taxes restrictions • Peer • Nicotine addiction and prices influence • Designated tobacco-use areas • Sociodemographics • Comorbidities • Stress and • Easy access to tobacco boredom • Tobacco industry • Insufficient provider training involvement • Lack of easily accessible cessation programs • Deployment to war-zone FIGURE 3-2 Some of the socioecologic influences on tobacco use among the military and veteran populations. retired military personnel and veterans. Future chapters will provide specific proposals for interventions to advance tobacco control in the military and veteran populations. Figure 3-2 illustrates some of the influences that may affect a person’s decision to start or continue tobacco use in the military and veteran populations. Table 3-1 maps the levels of influence specific to military personnel and veterans. INDIVIDUAL FACTORS Individual factors, attributes that reside within the individual, are major determinants of whether one uses tobacco. They encompass demographic, biologic, and psychologic components, some of which can be modified by the individual and the environment (such as education and skills) and some of which cannot (such as age and genetic makeup). Of primary importance is the addictive nature of nicotine, a powerful determinant of continued tobacco use.

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83 FACTORS THAT INFLUENCE TOBACCO USE TABLE 3-1 Socioecologic Model and Levels of Influence for Military and Veteran Populations Level of Influence Military Population Veteran Population Individual Soldier, seaman, airman, Veteran marine Interpersonal Military unit, unit commander, Family, friends, health-care family, friends, health-care provider, co-workers provider Community Installation personnel or Employer, veteran service commander; military treatment organization; local VA facility, TRICARE health-care health-care facility, local facility community Society DoD: Army, Navy, Marine VA, Congress, state Corps, Air Force, Office of the government, tobacco Assistant Secretary of Defense industry (Health Affairs); Congress; tobacco industry Nicotine Addiction In this report, dependence and addiction are used interchangeably. They are considered equivalent because they describe similar neurochemical and behavioral processes that sustain drug use (US Surgeon General, 1988), and they indicate a loss of control over drug-taking behavior—the principal characteristic of drug addiction. Definitions of and criteria for drug dependence or addiction have been put forth by numerous health organizations and authorities. According to WHO, drug dependence is “a behavioral pattern in which the use of a given psychoactive drug is given a sharply higher priority over other behaviors which once had a significantly higher value” (No Author, 1982)—in other words, the drug has come to control behavior to an extent that is considered detrimental to the individual. Specific criteria have been defined and developed for nicotine dependence and nicotine withdrawal by the American Psychiatric Association (2000) and for tobacco dependence and tobacco withdrawal by WHO (1992). The 1988 surgeon general’s report The Health Consequences of Smoking: Nicotine Addiction also presented criteria for drug dependence (US Surgeon General, 1988). In addition to a user’s behavior being controlled by a drug, the surgeon general’s criteria require that the drug produce psychoactive effects and that there be evidence that the drug- taking behavior is reinforced by these effects. Nicotine is associated with well-known pleasurable psychoactive effects, such as arousal, relaxation,

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84 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS and improved mood. It has also been shown to act as a positive reinforcer of smoking; for example, people smoke only tobacco that contains nicotine, and regular smokers modify their smoking behavior to maintain a particular concentration of nicotine in the body (Heishman et al., 1997). Nicotine dependence has also been defined as meeting three of the seven criteria for dependence in the Diagnostic and Statistical Manual of Mental Disorders–IV during the preceding year (American Psychiatric Association, 2000). The 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that 24.9% of the US adult population currently smoked cigarettes and 12.8% of adults were nicotine-dependent; the latter group consumed 57.5% of all cigarettes smoked (Grant et al., 2004). Biology of Nicotine Reinforcement The biology of nicotine addiction is reviewed in detail elsewhere (Benowitz, 2009). A few key aspects of the biology are mentioned here. Nicotine acts on the brain by binding to nicotinic cholinergic receptors that are normally activated by endogenously released acetylcholine. Brain-imaging studies demonstrate that nicotine acutely increases activity in the prefrontal cortex, thalamus, and visual system (Brody, 2006). It results in the release of a variety of neurotransmitters of which the most important is dopamine, which appears to be critical in drug- induced reward (Dani and De Biasi, 2001; Nestler, 2005) and signaling of a pleasurable experience—this is necessary for the reinforcing effects of nicotine and other drugs of abuse (Nestler, 2005). The decrease in brain-reward function experienced during nicotine withdrawal is an essential component of nicotine addiction and a key barrier to abstinence. Psychoactive Effects of Nicotine and Nicotine Withdrawal The nicotine in tobacco induces stimulation and pleasure while reducing stress and anxiety. Smokers come to use nicotine to modulate their levels of arousal and for mood control in daily life. Smoking may also improve concentration, reaction time, and the performance of some tasks. When one stops smoking, the following nicotine-withdrawal symptoms may emerge: irritability, depressed mood, restlessness, anxiety, problems in getting along with friends and family, difficulty in concentrating, increased hunger and eating, insomnia, and craving for tobacco (Hughes and Hatsukami, 1986). Most smokers experience withdrawal symptoms when they are unable to smoke. Withdrawal in untreated smokers produces mood disturbances comparable in intensity with those seen in psychiatric outpatients (Hughes, 2006). One withdrawal symptom seen in connection with nicotine and other drugs of

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85 FACTORS THAT INFLUENCE TOBACCO USE abuse is hedonic dysregulation—the feeling that there is little pleasure in life. Activities that were once rewarding are no longer enjoyable (Koob and Le Moal, 1997). It is hypothesized that a relative deficiency in dopamine release after long-standing nicotine exposure accounts for many of the mood disorders and for the tobacco craving that may persist for long periods after quitting (Benowitz, 2009). Conditioned Behavior and Nicotine Addiction All drug-taking behavior is learned—a result of conditioning. It is reinforced by the consequences of the pharmacologic actions of the drug in question, as discussed above in relation to nicotine. At the same time, the user begins to associate specific moods, situations, or environmental factors with the rewarding effects of the drug. Respiratory-tract sensory cues associated with tobacco smoking are a type of conditioned reinforcer that has been shown to play an important role in the regulation of smoke intake, the craving to smoke, and the rewarding effects of smoking (Rose et al., 1993, 2000). The association between such cues and expected drug effects and the resulting urge to use the drug is a type of conditioning. Animal studies have found that repeated nicotine exposure increases the behavioral control of conditioned reinforcers (such as tobacco cues) contributing to the compulsivity of smoking behavior (Olausson et al., 2004). Cigarette smoking is maintained, in part, by such conditioning. People habitually smoke cigarettes in specific situations, such as after a meal, with coffee or alcoholic beverages, or in the presence of other smokers. The repeated association between smoking and particular events causes specific environmental situations to become powerful smoking cues. Likewise, aspects of the drug-taking process, such as the manipulation of smoking materials, the taste or smell of smoke, or the feeling of it in the throat, become associated with the pleasurable effects of smoking. Even unpleasant moods can become conditioned cues for smoking. For example, a smoker may learn that not having a cigarette provokes irritability (a common symptom of the nicotine-abstinence syndrome) whereas smoking a cigarette provides relief. After such repeated experiences, a smoker may come to regard irritability from any source, such as stress or frustration, as an indicator to smoke (Benowitz, 2009). Genetics of Nicotine Addiction Twin studies have indicated a high degree of heritability (at least 50%) in the prevalence of cigarette-smoking, the ability to quit smoking, the number of cigarettes smoked per day (Lessov-Schlaggar et al., 2008),

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86 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS and the nature of particular symptoms experienced when a smoker stops smoking (Pergadia et al., 2006). Numerous studies have attempted to identify genes underlying nicotine addiction (Lessov-Schlaggar et al., 2008), but studies of the genetics of nicotine dependence and smoking behavior are problematic because such complex behaviors are determined by multiple genes and by environmental factors. Recent genomewide association studies have pointed to several genes that are promising signals for genetic determinants of nicotine dependence. Bierut et al. (2007) studied a phenotype that is thought to reflect susceptibility to nicotine dependence and showed a significant association with genes that code for components of nicotinic receptors found in the brain (Saccone et al., 2007). Other genomewide association studies have identified a number of genes that affect cell adhesion and extracellular matrix molecules. The genes are common among various addictions; this is consistent with the idea that neural plasticity and learning are key determinants of individual differences in vulnerability to nicotine and other drug addictions (Kauer and Malenka, 2007; Uhl et al., 2007). Genetic studies have identified genes that encode parts of the receptors for the neurotransmitter gamma-aminobutyric acid (Grucza and Bierut, 2006). Those genes may be involved in the development of alcohol and nicotine dependence. Siblings of alcohol-dependent people had a 1.7 times higher risk of becoming habitual smokers than did siblings of nonalcoholics; if the alcohol-dependent people were habitual smokers, the siblings’ risk was a increased further by a factor of 1.8 (Bierut et al., 1998, 2000). Nicotine Addiction, Mental Illness, and Substance Abuse People who have mental illness or substance-abuse disorders have higher rates of smoking. Results of the National Comorbidity Survey (NCS) show that 41.0% of people who had a mental illness in the preceding month were current smokers, compared with 22% of those who did not, and 60% of those with a lifetime history of mental illness were smokers (Lasser et al., 2000). Moreover, people with mental illness consume over 44% of all cigarettes sold in the United States (Lasser et al., 2000). The 2001–2002 NESARC found that 12.8% of the US population was nicotine-dependent and consumed 57.5% of all cigarettes. Nicotine-dependent people who had a mental illness amounted to 7.1% of the US population but consumed 34.2% of all cigarettes (Grant et al., 2004). Specifically, smoking prevalence is higher in people who have the following diagnosed disorders than in the general population:

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87 FACTORS THAT INFLUENCE TOBACCO USE schizophrenia, major depression, bipolar disorder, anxiety disorder, panic attacks, attention deficit hyperactivity disorder, posttraumatic stress disorder (PTSD), alcohol abuse, and illicit drug abuse (see Table 3-2 for details) (Lasser et al., 2000; Ziedonis et al., 2008). Results from the NESARC showed that 12-month prevalence of nicotine dependence was 52.4% in those who had any drug disorder, 34.5% in people who had any alcohol-use disorder, 29.2% in those who had any mood disorder, 27.3% in those who had any personality disorder, and 25.3% in those who had any anxiety disorder (Grant et al., 2004). Kotov et al. (2008) found that current smoking rates ranged from 67% to 73% in people who had bipolar, major depressive, or schizophrenia spectrum or other psychotic disorders. Patients who have more severe psychiatric symptoms are more likely to be smokers (Kalman et al., 2005); specifically, those in clinical mental-health treatment centers (outpatient, inpatient, residential, or state mental hospitals) have higher rates of tobacco dependence (American Psychiatric Association, 2006). Smoking is also associated with suicide, although smoking cessation does not appear to be (Hughes, 2008). TABLE 3-2 Tobacco-Smoking Status and Quit Rates According to Lifetime Presence of Psychiatric Disorder in the United States (%) US Current Lifetime Smoking Population Smokers Smokers Quit Ratesa Lifetime Diagnosis No psychiatric disorder 50.7 22.5 39.1 42.5 Anxiety disorders: Social phobia 12.5 35.9 54.0 33.4 Posttraumatic stress disorder 6.4 45.3 63.3 28.4 Agoraphobia 5.4 38.4 58.9 34.5 Generalized anxiety disorder 4.8 46.0 68.4 32.7 Panic disorder 3.4 35.9 61.3 41.4 Mood disorders: Major depression 16.9 36.6 59.0 38.1 Dysthymia 6.8 37.8 60.0 37.0 Bipolar disorder 1.6 68.8 82.5 16.6 Psychotic disorder 0.6 49.4 67.9 27.2 (nonaffective) a Smoking quit rate defined as proportion of lifetime smokers who were not current smokers (no significant difference in rates when quit rate was defined as not having smoked for more than preceding year). SOURCE: Adapted with permission from Lasser et al. (2000) and based on National Comorbidity Survey data.

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88 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Several mechanisms are believed to underlie the phenomenon of nicotine addiction and mental-health disorders as comorbidities. One is the ability of nicotine to reduce the severity of some psychiatric symptoms. For example, the release of serotonin and norepinephrine in the brain by nicotine is similar to the neurochemical effects of some antidepressant medications. Nicotine may improve sensory gating (the process by which the brain responds to stimuli), which is abnormal in schizophrenics. Improvement in sensory gating secondary to nicotine intake might be expected to enhance the ability to sort out extraneous stimuli and therefore improve attention (Martin and Freedman, 2007). In addition, cigarette smoking inhibits monoamine oxidase A and B (Lewis et al., 2007); such inhibition is used to treat depression, therefore cigarette smoking might benefit depressed patients in the same manner. Finally, nicotine, through its stimulant effects, may reduce unpleasant sedative side effects of psychiatric medications and reduce the sedation caused by alcohol. Tobacco Use and Alcohol Abuse There is a substantial link and possible shared genetic susceptibility between alcohol abuse and cigarette smoking (Le et al., 2006; Madden and Heath, 2002; Wilhelmsen et al., 2005). The 2001– 2002 NESARC found the 12-month prevalence of nicotine dependence to be 45.4% in people who were alcohol-dependent (Grant et al., 2004). Alcohol abusers are more likely to die from smoking-related causes than from alcohol (Burling and Ziff, 1988; Hurt et al., 1996). In a study of 499 smokers who were receiving intensive treatment for alcohol dependence, 95% considered themselves to be physically addicted to nicotine, and they smoked a mean of 25.5 cigarettes/day. Over 45% of the participants lived with another smoker, 39% had attempted to quit in the preceding year, 46% indicated that they were taking action to quit, and 33% were starting to think about quitting. 16.7% thought they should quit but were not ready. Only 8% had been told by an alcohol counselor to quit smoking and alcohol concurrently, 32% had been counseled to quit smoking in the future, and 24% had been advised to not quit by their alcohol counselor (Joseph et al., 2003). In a review of 24 smoking- cessation studies of people in treatment for substance abuse or dependence, Sussman (2002) found that quit rates increased with length of abstinence from substance use. Although some substance abusers may not benefit from or may even be harmed by concurrent treatment, for most “attempting to quit smoking does not seem to interfere with recovery from other substances . . . and concurrent exposure to smoking cessation treatment will assist with recovery.” Sussman noted that substance users who smoke differ from nonusers who smoke in several

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89 FACTORS THAT INFLUENCE TOBACCO USE ways: they started smoking at an earlier age, smoke more cigarettes per day, have more cognitive deficits, have more comorbid psychiatric disorders, have more medical problems, and have lower levels of smoking-cessation self-efficacy. Tobacco Use and Anxiety Disorders Anxiety disorders affect 25% of people (more women than men) during their lifetime and thus make up the largest entity of psychiatric disorders in the United States (Breslau et al., 1991). Anxiety disorders defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders include generalized anxiety disorder (GAD), PTSD, agoraphobia, panic disorder, simple phobia, and social phobia (American Psychiatric Association, 2000). According to data from the 2001–2002 NCS, the prevalence of nicotine dependence in those with any anxiety disorder is higher than that in the general population. Although the percentage of current smokers differs among disorders, from 31.5% for social phobia, to 44.6% for PTSD, to 54.6% for GAD, all of the rates are significantly higher than the 22.5% of current smokers who had no past or current psychiatric disorder (Lasser et al., 2000). It has been suggested that nicotine dependence increases the risk of PTSD. Koenen et al. (2005) in a study of over 6,744 Vietnam veteran twins found that nicotine dependence almost doubled the risk of developing PTSD in men exposed to trauma compared with the risk in nonsmokers. The prevalence of nicotine dependence was 71.2% in veterans who had PTSD compared with 40% in those who did not. Shared genetic effects accounted for about 63% of the association. Trauma alone and PTSD were associated significantly but less strongly than with nicotine dependence. Alterations in the function of the hypothalamic-pituitary-adrenal (HPA) axis seen in people who have PTSD may increase the risk of nicotine dependence. In a review of the neurobiologic association between smoking and PTSD, Rasmusson et al. (2006) suggested that activation of the HPA axis in response to a threat or stress releases neurohormones that can lead to arousal and anxiety. This dysfunction in areas of the brain that modulate reward, that is, the frontal lobe, hippocampus, and nucleus accumbens, is purported to promote nicotine dependence. Tobacco Use and Depression Depression is a common psychiatric disorder with a variety of subtypes and severity levels. Among patients who have depression, over 30% are daily smokers—a higher rate compared with that in the general

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104 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS As noted earlier, combat-related and non–combat-related deployment stress is associated with increased tobacco use (DoD, 2006; Smith et al., 2008). Combat-related stressors, for example, include the need for constant vigilance against enemy attack and the difficulty in distinguishing insurgents from civilians. Noncombat stressors include separation from family and friends, loss of income, and fear of deployment to a war zone (IOM, 2007). The current large-scale military conflicts have put a strain on military and veteran resources. Priority- setting among health-care services has occurred—acute medical-care needs, such as treatment for traumatic brain injury or PTSD, are now a prominent focus of military and veteran health-care resources. For those reasons and others discussed in this chapter, tobacco-use prevention and cessation efforts do not have high priority in the DoD and VA. SUMMARY Numerous factors interact and contribute to high rates of tobacco use among the military and veteran populations. Evidence-based changes—such as reducing tobacco access, restricting tobacco use through proper enforcement of existing and new policies, and expanding access to effective cessation programs—should not be difficult to attain. Long-term, sustained efforts will be required to achieve broad structural changes, such as changing social norms regarding tobacco among military and veteran populations, continuing the shift away from an association between tobacco and the military, and finding alternatives to coping with the stress and boredom of deployment. The socioecologic framework and evidence from exemplar tobacco-control programs show that factors at multiple levels of influence, from individual attributes to the social and political context, should be addressed to curb tobacco-use rates and generate a tobacco-free culture. All those efforts require leadership, strategic planning, capacity building, proper allocation of resources, and monitoring of process measures and outcomes. The following chapters provide guidance to DoD and VA on what the best approaches to tobacco control are, where DoD and VA stand with respect to the approaches, and the efforts they can undertake to leverage their resources. REFERENCES American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Publishing.

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105 FACTORS THAT INFLUENCE TOBACCO USE American Psychiatric Association. 2006. Substance Use Disorder Practice Guidelines. Washington, DC: American Psychiatric Publishing. Arvey, S. R., and R. E. Malone. 2008. Advance and retreat: Tobacco control policy in the U.S. military. Military Medicine 173(10): 985-991. Benowitz, N. L. 2009. Pharmacology of nicotine: Addiction, smoking- induced disease, and therapeutics. Annual Review of Pharmacology and Toxicology 49:57-71. Bierut, L. J., S. H. Dinwiddie, H. Beglieter, R. R. Crowe, V. Hesselbrock, J. I., Nurnberger, Jr., B. Projesz, M. A. Schuckit, and T. Reich. 1998. Familial transmission of substance dependence: Alcohol, marijuana, cocaine, and habitual smoking: A report from the Collaborative Study on the Genetics of Alcoholism. Archives of General Psychiatry 55(11):982-988. Bierut, L.J., M. A. Schuckit, V. Hesselbrock V, and T. Reich. 2000. Co- occurring risk factors for alcohol dependence and habitual smoking. Alcohol Research and Health 24(4):233-241. Bierut, L. J., P. A. Madden, N. Breslau, E. O. Johnson, D. Hatsukami, O. F. Pomerleau, G. E. Swan, J. Rutter, S. Bertelsen, L. Fox, D. Fugman, A. M. Goate, A. L. Hinrichs, K. Konvicka, N. G. Martin, G. W. Montgomery, N. L. Saccone, S. F. Saccone, J. C. Wang, G. A. Chase, J. P. Rice, and D. G. Ballinger. 2007. Novel genes identified in a high-density genome wide association study for nicotine dependence. Human Molecular Genetics 16(1):24-35. Booth, S. L., J. F. Sallis, C. Ritenbaugh, J. O. Hill, L. L. Birch, L. D. Frank, K. Glanz, D. A. Himmelgreen, M. Mudd, B. M. Popkin, K. A. Rickard, S. St Jeor, and N. P. Hays. 2001. Environmental and societal factors affect food choice and physical activity: Rationale, influences, and leverage points. Nutrition Reviews 59(3 Pt 2):S21- S39; discussion S57-S65. Borland, R., H. H. Yong, K. M. Cummings, A. Hyland, S. Anderson, and G. T. Fong. 2006. Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control 15(Suppl 3):iii42-iii50. Breslau, N., and E. O. Johnson. 2000. Predicting smoking cessation and major depression in nicotine-dependent smokers. American Journal of Public Health 90(7):1122-1127.

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