COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS

Committee on Smoking Cessation in Military and Veteran Populations

Board on Population Health and Public Health Practice

Stuart Bondurant and Roberta Wedge, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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Committee on Smoking Cessation in Military and Veteran Populations Board on Population Health and Public Health Practice Stuart Bondurant and Roberta Wedge, Editors

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THE THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract V101 (93) P-2136, TO 101-E85010 (14) between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-13767-6 International Standard Book Number-10: 0-309-13767-5 Additional copies of this report are available from the The National Academies Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; (800) 624- 6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2009. Combating Tobacco Use in Military and Veteran Populations. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON SMOKING CESSATION IN MILITARY AND VETERAN POPULATIONS STUART BONDURANT, (Chair), Professor of Medicine, Dean Emeritus, University of North Carolina at Chapel Hill NEAL L. BENOWITZ, Professor of Medicine, Psychiatry, and Biopharmaceutical Sciences, University of California, San Francisco SUSAN J. CURRY, Professor and Dean, College of Public Health, University of Iowa ELLEN R. GRITZ, Professor and Chair of the Department of Behavioral Science, University of Texas and M.D. Anderson Cancer Center PETER D. JACOBSON, Professor of Health Law and Policy and Director, Center for Law, Ethics, and Health, University of Michigan School of Public Health KENNETH W. KIZER, Chairman, Medsphere Systems Corporation ROBERT C. KLESGES, Professor of Preventive Medicine, University of Tennesse Health Sciences Center, and Member, St. Jude Children's Research Hospital HOWARD K. KOH, Asssociate Dean for Public Health Practice, Harvey V. Fineberg Professor of the Practice of Public Health, and Director, Division of Public Health Practice, Harvard School of Public Health (resigned March 25, 2009) WENDY K. MARINER, Professor of Health Law, Bioethics and Human Rights, Boston University School of Public Health, and Professor of Law, Boston University School of Law ANA P. MARTINEZ-DONATE, Assistant Professor of Population Health Sciences, University of Wisconsin–Madison ELLEN R. MEARA, Associate Professor of Health Care Policy, Harvard Medical School ALAN L. PETERSON, Professor, Behavioral Wellness Center for Clinical Trials, University of Texas Health Science Center at San Antonio FRANCES STILLMAN, Associate Professor of Epidemiology, Codirector, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health v

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EDWARD P. WYATT, Founder, EWyatt Consulting, LLC DOUGLAS M. ZIEDONIS, Professor and Chair of the Department of Psychiatry, University of Massachusetts Medical School Study Staff ROBERTA WEDGE, Study Director RENEE WLODARCZYK, Associate Program Officer JENNIFER SAUNDERS, Associate Program Officer PATRICK BAUR, Research Associate JOSEPH GOODMAN, Senior Program Assistant NORMAN GROSSBLATT, Senior Editor CHRISTIE BELL, Financial Officer HOPE HARE, Administrative Assistant ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice vi

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REVIEWERS This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following for their review of this report: Greg Connolly, Harvard University School of Public Health Michael Eriksen, Georgia State University Michael C. Fiore, University of Wisconsin School of Medicine and Public Health Jack Henningfield, Pinney Associates Corinne Husten, Partners for Prevention Anna M. McDaniel, Indiana University School of Nursing Robin Mermelstein, University of Illinois at Chicago Stephanie O’Malley, Yale University, Connecticut Mental Health Center Kurt M. Ribisl, University of North Carolina Barbara K. Rimer, University of North Carolina Steven A. Schroeder, University of California, San Francisco Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Robert S. Lawrence, Johns Hopkins Bloomberg School of Public Health, and Willard G. Manning, The University of Chicago. Appointed by the National Research Council, they were responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests with the author committee and the institution. vii

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PREFACE The image of the battle-weary soldier in fatigues and helmet, fighting for his country, has frequently included his lit cigarette. Even today, when almost two of three military personnel do not use tobacco, the cultural icon of a smoking soldier endures as demonstrated by the recent Time magazine cover of a soldier in Afghanistan with a cigarette in his hand. Although smoking rates have declined in the US military over the last 50 years, some surveys indicate that tobacco use is on the rise among young military members and that deployment to Iraq and Afghanistan is resulting in even higher levels of tobacco use among these troops. Thus, these troops are essentially putting their lives at risk twice: once in service to their country, and once in service to tobacco. Tobacco use is a long-term engagement—it kills slowly and insidiously. It not only causes suffering from cardiovascular and respiratory diseases and multiple cancers, but it also impairs military readiness, reducing performance and endurance. And exposure to secondhand smoke can affect the health of fellow warriors and family alike. The good news is that tobacco use can be stopped, and there are many avenues of support for those who wish to quit. Comprehensive tobacco-control programs have shown that it is possible to prevent people from starting to use tobacco and to help those who do use it to stop. These programs—which have been implemented in many states, such as California and Massachusetts—have demonstrated that raising the price of tobacco products, restricting or even eliminating areas where people can use tobacco, educating the public about the harmfulness of tobacco, and working with advocacy groups can lead to reduced tobacco consumption in all segments of the tobacco-using public. These programs affect broad swaths of society, but individual tobacco users must also be addressed. Easy access to treatment and comprehensive programs are needed to help people cope with their nicotine addiction and to provide them with tools to quit using tobacco. The tools include nicotine-replacement therapy and other cessation medications as well as behavior modification and other forms of counseling. Systematic evaluation of program processes and outcomes is also important. The Department of Veterans Affairs (VA) and the Department of Defense (DoD) have been engaged in reducing tobacco use among their respective veteran and military populations for many years, but their goal of being tobacco-free has not been met. To help them reach their goal, the VA, in cooperation with the DoD, asked the Institute of Medicine ix

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x PREFACE (IOM) to convene a committee to provide guidance on what policies should be modified or established to prevent and reduce tobacco use and how tobacco-control programs might be improved. In response to this request, the IOM established the Committee on Smoking Cessation in Military and Veteran Populations to prepare this report. The committee was impressed by the dedication of many people in VA and DoD who have been working to promote tobacco cessation in their departments. But the committee was also concerned that, given the adverse effects of tobacco use on military readiness and health, it does not have higher priority in either department and that senior leadership has not been more active in advocating a tobacco-free military and eventually a tobacco- free veteran population. The committee hopes that this report will demonstrate the need for Congress to support VA and DoD in their efforts to become tobacco-free. The committee thanks the many people who generously responded to its requests for information and its invitations to make presentations: Kim Hamlett-Berry, Lawrence Deyton, W. Clint McSherry, Timothy Carmody, Michael Valentino, Jean Beckham, Sonya Duffy, Scott Sherman, James Schaefer, and Tammy Czarnecki of VA; David Arday and Priscilla Pazzano of DoD; Brad Taft and Cynthia Hawthorne of the US Army; Mark Long of the US Navy; Kathy Green and G. Wayne Talcott of the US Air Force; Cathy Ficadenti and Lynn Pahland of the US Marine Corps; Thomas Berger of Vietnam Veterans of America; C. Keith Haddock of the HOPE Health Research Institute; Ruth Malone and Elizabeth Smith of the University of California, San Francisco; and Ali Goldstein of Kaiser Permanente. The committee appreciates the hard work of the IOM staff members who made its work possible, including Renee Wlodarczyk and Jennifer Saunders for literature searches and background research; Joe Goodman for meeting and travel arrangements; and Roberta Wedge, whose patience, tolerance, and diligence were models, whose insights and judgments were beacons, and whose initiatives were drivers of the work. Finally, the committee thanks the dedicated members of the US armed services and the veterans who have served this country. We hope that this report helps them to live long, healthy lives. Stuart Bondurant, MD University of North Carolina School of Medicine Chair, Committee on Smoking Cessation in Military and Veteran Populations

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CONTENTS SUMMARY 1 1 INTRODUCTION 19 Charge to the Committee, 21 The Committee’s Approach to Its Charge, 23 Organization of the Report, 26 References, 28 2 SCOPE OF THE PROBLEM 31 Tobacco Use in Military and Veteran Populations, 31 Health Effects of Tobacco Use, 40 Economic Impacts, 56 References, 65 3 FACTORS THAT INFLUENCE TOBACCO USE 79 A Socioecologic Analysis of Tobacco Use in Military and Veteran Populations, 81 Individual Factors, 82 Interpersonal Factors, 93 Community Factors, 95 Societal Factors, 99 Summary, 104 References, 104 4 TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 115 Comprehensive Tobacco-Control Programs, 116 Communication Interventions, 119 Tobacco-Use Restrictions, 124 Tobacco Retail Environment, 129 Tobacco-Cessation Interventions, 133 Delivery of Interventions, 138 Tobacco Cessation in Special Populations, 149 Relapse-Prevention Interventions, 164 Surveillance and Evaluation, 165 References, 168 5 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 197 xi

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xii CONTENTS Organizational Overview, 198 Tobacco-Control Programs in the Department of Defense, 202 Communication Interventions, 208 Tobacco-Use Restrictions, 214 Tobacco Retail Environment, 223 Tobacco-Cessation Interventions, 227 Delivery of Interventions, 234 Special Populations, 242 Relapse-Prevention Interventions, 250 Surveillance and Evaluation, 253 References, 256 6 DEPARTMENT OF VETERANS AFFAIRS TOBACCO- CONTROL ACTIVITIES 263 Organizational Overview, 263 Tobacco-Control Programs in the Department of Veterans Affairs, 270 Communication Interventions, 274 Tobacco-Use Restrictions, 276 Tobacco-Control Interventions, 278 Delivery of Interventions, 282 Special Populations, 293 Surveillance and Evaluation, 298 References, 301 7 SUMMARY AND RECOMMENDATIONS 307 Toward a Tobacco-Free Military Population, 308 Toward a Tobacco-Free Veteran Population, 313 Tobacco-Control Commonalities, 316 Summary of Findings and Recommendations, 318 Research Agenda, 322 References, 324 APPENDIXES A EFFECTIVE TOBACCO-CONTROL PROGRAMS 327 B DEPARTMENT OF DEFENSE TOBACCO USE PREVENTION STRATEGIC PLAN, 1999 339 INDEX 347