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2 SCOPE OF THE PROBLEM In this chapter, the committee describes why tobacco use is of concern to both the Department of Defense (DoD) and the Department of Veterans Affairs (VA). Specifically with respect to the military, tobacco use impairs readiness, decreases performance, and reduces productivity of active-duty and civilian personnel. In veteran populations, it exacerbates pre-existing health problems and leads to new ones, and it results in increased absenteeism and decreased productivity. Military personnel who use tobacco may eventually enter the VA health system; this means more and sicker veterans who require medical care and, consequently, increases in health-care costs. Tobacco use is also associated with short- and long-term health problems in all users and in those exposed to secondhand smoke. Although the adverse effects of tobacco use may be reduced by improving smoking-cessation services, the issues surrounding tobacco use extend beyond helping people to quit. They include keeping people who do not use tobacco from doing so in the future and helping those who have quit from starting to use again. TOBACCO USE IN MILITARY AND VETERAN POPULATIONS This report considers the impact of tobacco use on the three military branches in the DoDâthe Army, the Air Force, and the Navy. The Marine Corps is a second armed service in the Department of the Navy, but it has a different culture, demographic, and mission and is therefore generally considered a separate entity in the report. The Coast Guard, which has been moved from the Department of Defense to the Department of Homeland Security, is not considered in this report. Demographics of the Military Population The total US military population consists of nearly 3.5 million people in all branches, including 800,000 civilian personnel. The military is volunteer-based, and all services are more ethnically diverse today than before 1973 (see Table 2-1) (DoD, 2006a). As of March 2008, over 31
32 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS 1.1 million US troops have served in Iraq and Afghanistan: 806,964 Army personnel (including 146,655 in the Army National Guard and 74,461 in the Army Reserve), 194,401 Marine Corps personnel, 30,868 Navy personnel (including 7,028 reservists), and 70,136 Air Force personnel (Stars and Stripes, 2008). Tables 2-1 and 2-2 summarize the demographics of the US military population, including reservists1 and family members. TABLE 2-1 Demographic Profile of the Military Population Marine Army Navy Corps Air Force Active duty 502,790 345,098 180,252 344,529 Reservea 189,975 70,500 39,489 74,075 a Guard 346,288 â â 105,658 Total 1,039,053 415,598 219,741 524,262 Dependents About About About About 1,400,000 580,000 200,000 760,000 Female Personnel (% of total service) Active duty 14.0 14.5 6.2 19.7 a Reserve 23.3 20.3 4.7 23.9 a Guard 13.5 â â 18.0 Total 15.5 15.5 5.9 19.9 Minority-Group Personnel (% of total service) Black 18.6 17.3 9.9 13.4 Hispanic 9.8 12.4 13.0 5.7 Asian 3.2 6.4 3.2 3.6 American Indian 0.9 3.7 1.8 0.8 White 67.4 60.1 72.1 76.4 1 Ready reserve only; for the purposes of this report, the standby and retired reserve components of all military branches have been excluded. All demographics for reserve and National Guard members are reported only for the selected reserve, that is, those members of the ready reserve who train throughout the year and participate in annual active-duty training exercises. Demographic profiles of the individual ready reserve and the inactive National Guardâthe other two components of the ready reserveâwere not available.
SCOPE OF THE PROBLEM 33 Marine Army Navy Corps Air Force Married Personnel (% of total service) Active duty 54.7 55.0 45.2 60.6 a Reserve 47.5 61.9 30.6 59.1 a Guard 46.5 â â 57.0 Total force 50.7 56.2 42.6 59.7 Personnel With Children (% of total service) Active duty 46.2 42.4 30.1 45.8 a Reserve 40.2 51.8 20.7 50.4 a Guard 40.2 â â 48.7 Total force 43.1 44.0 28.4 47.0 Single Parent Personnel (% of total service) Active duty 6.5 5.1 2.7 4.8 a Reserve 8.5 9.6 2.9 9.5 a Guard 8.2 â â 8.5 Total force 7.4 5.9 2.7 6.2 a Includes only members of the selected reserve. SOURCE: Adapted from DoD (2006a). TABLE 2-2 Age of the Military Population (years) Marine Army Navy Corps Air Force Active-Duty Officers (%) 25 and under 14.3 12.3 15.3 13.9 26â30 20.9 20.7 23.3 22.1 31â35 21.4 20.0 24.3 21.0 36â40 19.6 20.0 20.6 19.6 41 and over 23.8 27.1 16.4 23.4 Active-Duty Enlisted (%) 25 and under 52.1 50.1 72.4 45.5 26â30 19.9 20.1 14.2 21.0 31â35 13.0 13.4 7.1 13.1 36â40 9.7 10.5 4.2 11.9
34 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Marine Army Navy Corps Air Force 41 and over 5.3 5.9 2.1 8.4 Guard and Reserve Officers (%)a 25 and under 5.5 0.6 0.7 1.2 26â30 9.2 4.6 4.9 7.4 31â35 14.8 2.8 17.1 14.3 36â40 23.3 31.5 31.1 23.8 41 and over 47.3 60.6 46.2 53.5 a Guard and Reserve Enlisted Members (%) 25 and under 43.4 17.9 72.8 23.0 26â30 16.0 15.1 15.0 14.8 31â35 9.5 18.9 6.0 13.3 36â40 12.2 24.2 3.7 16.4 41 and over 18.8 23.8 2.5 32.5 b Retirees Retired with 20+ years of active 438,590 service Retired with 20+ years reserve 260,737 service Total 778,682 a Includes only members of the selected reserve. b Includes active duty and reserve retirees, does not include disabled retirees. SOURCE: Adapted from DoD (2006a); retiree information from Army (2006). Demographics of the Veteran Population In 2008, there were an estimated 26.5 million US veterans, 7.8 million of whom were enrolled in the VA health-care system. Of the 7.8 million, 45.1% are at least 65 years old, 41.0% are 45â64 years old, and 13.9% (fewer than 1 million) are under 45 years old. In 2000, about 7.5% (1.6 million) of the veterans enrolled in the VA health-care system were women. The largest group of veterans using the VA health-care system (36%) consists of those who served during the Vietnam era (1965â1974), followed by those who served between the Korean and Vietnam wars (1955â1964) (29%), military personnel who served between Vietnam and the 1990â1991 Gulf War (23%), and those who served in World War
SCOPE OF THE PROBLEM 35 II (19%), Korea (18%), and during the Gulf War era (1991-2001) (13%). Of those using the VA health-care system, 60% have no private or Medigap insurance; and two-thirds of veterans enrolled in the VA health- care system have an annual income of less than $20,000/year. Of enrolled veterans, 84% are white, 10% are black, 4.6% are American Indian or Alaskan Native, 0.7% are Asian, and 0.5% are native Hawaiian and other Pacific Islander (VA, 2006a). In 2004 (the most recent year for which data are available), the national unemployment rate of VA enrollees was estimated to be 15.6%, which is substantially higher than the average annual unemployment rate of 5.5% in the general population. VA attributes that high rate to higher rates of disability. A 2007 survey of recently separated veterans, most of whom had served in Iraq or Afghanistan, found that 18% were unemployed; of those who were employed, 25% earned less than $22,000/year (VA, 2008a). In 2005, nearly 67% of the veteran enrollees in the VA health-care system were married, 15% were divorced, 9% had never been married, 7% were widowed, and 2% were separated from their spouses (VA, 2006a). Tobacco Use in Military Populations Centers for Disease Control and Prevention estimates of smoking prevalence in the general population show that 19.8% of adults in the United States were smokers in 2007, a slight decline from 20.8% in 2006 (CDC, 2008a). Smoking prevalence was higher among men (22.3%) than among women (17.4%) (CDC, 2008a). Although tobacco use has declined since World War II among military personnel, it remains an important issue for DoD and VA. A series of surveys of health-related behaviors in active-duty military personnel showed that tobacco use within the 30 days before a survey decreased from 51.0% in 1980 to 32.2% in 2005 (see Figure 2-1); this trend was observed consistently among all the services (DoD, 2006b). Smoking rates in 2005 among 18â25 year old military men (42.4%) and women (29.2%) (overall rate, 40.0%) were higher than the overall rate among their civilian counterparts (35.4%) (DoD, 2006b). Despite the decline, there had recently been an increase (within the preceding 30 days) from 1998 (29.9%) to 2005 (32.2%) among the services (DoD, 2006b).
36 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS 60 50 40 Army Percent 30 Marine Corps Navy 20 Air Force 10 0 1980 1982 1985 1988 1992 1995 1998 2002 2005 Year FIGURE 2-1 Cigarette use in preceding 30 days, by service (1980â2005). SOURCE: DoD (2006b). In the general population, lower levels of education and living below the poverty line are associated with a higher prevalence of smoking in all age groups (Agrawal et al., 2008; Barbeau et al., 2004). The Institute of Medicine noted that in the general population the most vulnerable subpopulations for long-term smoking are young people who start smoking early, people who have low socioeconomic status (SES) or are less well educated, and some racial and ethnic minorities (IOM, 2007). Associations in the military parallel those in the general population as tobacco use is more prevalent among military personnel who are younger, less well educated, and of lower SES. Current cigarette use in the military is more likely among men, those who are white, have less than a college education, are younger than 34 years old, and are enlisted versus officers (Bray and Hourani, 2007; DoD, 2006b; Haddock et al., 1998). The age at which daily smoking begins is typically in the few years prior to age of entry into the militaryâthat is, prior to 20 years of age (see Figure 2-2). A 1998 survey of 2,002 Naval recruits, half of whom were 18 years of age, found that 51% of all the recruits had used tobacco in the 30 days prior to enlistment, primarily cigarettes (38%) or cigars and pipes (27%), with less smokeless tobacco use (12%); most cigarette smokers averaged about 0.5 packs per day (Ames et al., 2002). A 2003 survey of 15,556 male Marine Corps recruits (mean age 19.5 years) completing basic training found that 40.4% were users of a
SCOPE OF THE PROBLEM 37 tobacco product in the 30 days prior to entering the military, primarily cigarettes; 7.6% used only smokeless tobacco and 18.4% used both smokeless tobacco and cigarettes (Trent et al., 2007). Careerists in the enlisted ranks were significantly more likely to be current smokers and heavy smokers compared with careerist officers (Cunradi et al., 2008). In a study of military retirees (1,371 men and 1,095 women) only 131 men and 75 women were current smokers, although 418 of the women and 928 of the men were ex-smokers (Talcott et al., 1998). In a survey of 589 Air National Guard members, the overall smoking prevalence was 19%, with the heaviest smokers (one or more packs per day) being enlisted personnel in the middle and highest pay grades; there was no smoking reported among the junior officers (Messecar and Sullivan, 2001). Tobacco use varies greatly among the services (see Table 2-3) (Conway, 1998). Army personnel (37.3%) and Marine Corps personnel (35.7%) had a significantly higher prevalence of cigarette-smoking than DoD civilians (28.9%); the Air Force, however, had a significantly lower prevalence (23.2%) than civilians. Rates of heavy smoking (one pack a day or more) were also higher in the Army, Navy, and Marine Corps (9.9â15.3%) than in the Air Force (7%). Smoking initiation after entering the military was highest in the Marine Corps (21.6%), followed by the Army (20.5%) and the Navy (18.7%), and lowest in the Air Force 25 20 Percent 15 10 5 0 Under 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30+ 14 Age (years) Military Other FIGURE 2-2 The age (in years) at initiation of daily smoking by people who reported ever smoking for 30 consecutive days. SOURCE: Adapted from SAMHSA (2008).
38 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS TABLE 2-3 Tobacco Use in the Military (%) Army Navy Marine Corps Air Force Cigarette use and nicotine dependencea in preceding 30 days Any smoking 38.2 32.4 36.3 23.3 Heavy smokingb 15.3 9.9 11.1 7.0 Nicotine dependence 10.8 6.4 9.5 4.8 Prevalence of cigarette-smoking in preceding 30 days by sex and age Men 18â25 years old 49.0 37.8 42.8 37.0 26â55 years old 31.4 25.9 24.8 16.2 All ages 39.4 29.8 36.3 23.3 Women 18â25 years old 31.7 27.0 29.1 28.1 26â55 years old 19.2 18.6 19.7 18.3 All ages 26.0 22.2 26.6 22.8 c Cigarette-smoking initiation in the military Mend 21.6 19.1 21.7 14.9 Womend 13.5 16.0 20.4 12.8 d Total 20.5 18.7 21.6 14.5 Men (current 36.7 36.1 40.5 40.3 smokers)e Women (current 34.6 38.1 39.7 33.7 smokers)e Total (current 36.5 36.3 40.5 39.0 smokers)e Smokeless-tobacco initiation in the military among menf 18â25 years old 22.9 12.5 11.1 17.5 26â55 years old 14.2 8.4 6.9 10.3 Total 18.7 10.2 8.5 13.7 Smokeless-tobacco use Any smokeless- 27.7 16.7 33.0 14.5 tobacco use in preceding 12 months Any smokeless- 18.8 11.1 22.3 9.2 tobacco use in preceding 30 days
SCOPE OF THE PROBLEM 39 Army Navy Marine Corps Air Force Cigar or pipe use Any cigar or pipe 30.0 24.5 36.7 21.5 use in preceding 12 months a Nicotine dependence defined as score of 5 or more on Fagerstrom Nicotine Dependency Assessment. b Heavy smoking defined as smoking one or more packs per day. c Persons who started smoking after joining military. d As a percentage of the total DoD population, whether current smokers or not. e As a percentage of those who identified themselves as current smokers at the time of the survey. f Persons who started using smokeless tobacco after joining the military. SOURCE: Adapted from DoD (2006b). (14.5%). The highest rates of cigar and pipe use reported during the preceding 12 months were in the Marine Corps (36.7%) and the Army (30.0%) (DoD, 2006b). According to the 2005 DoD Survey of Health Related Behaviors among Active Duty Military Personnel (DoD, 2006b), from 1995 to 2005, the prevalence of smokeless-tobacco use (snuff and chewing tobacco) increased from 13.2% to 14.5%. In 2005, the Marine Corps (22.3%) and the Army (18.8%) reported the highest rates of smokeless- tobacco use (during the preceding 30 days), and the Navy (11.1%) and Air Force (9.2%) the lowest. Most users of smokeless tobacco are men 18â24 years old (DoD, 2006b; Ebbert et al., 2006). A recent study published by Vander Weg et al. (2008) assessed the prevalence of use of alternative forms of tobaccoâincluding bidis, cigars, kreteks (clove cigarettes), pipes, and smokeless tobaccoâin a population of Air Force recruits. The authors found that 18.5% of the study population was using an alternative form of tobacco before basic training, including 6.7% who used smokeless tobacco. Men were more likely than women to use smokeless tobacco before basic training, as were whites compared with Asians, Pacific Islanders, blacks, or Hispanics. Higher income was significantly correlated with smokeless-tobacco use in the study population. Participants who had some education beyond high school were less likely to use smokeless tobacco than those with only a high- school education (Vander Weg et al., 2008). Tobacco Use in Veteran Populations In a 2005 survey of the VA enrollee population, 71.2% reported that they smoked at least 100 cigarettes during their lifetime; 22.2% were current smokers, a slightly higher proportion than the 19.8% of the
40 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS general population (VA, 2006a); and 28.1% said that they had never smoked. Most current veteran smokers are 45â64 years old, and most make less than $36,000 a year (VA, 2006a). Higher rates of disability and psychiatric disorders in the veteran population may contribute to higher tobacco use and its health effects. Klevens et al. (1995) noted that the prevalence of ever smoking was 74.2% in veterans and 48.4% in nonveterans. Of those who had not started smoking before the age of 18 years, veterans were more likely than nonveterans to report ever and current smoking (Klevens et al., 1995). Of veterans with access only to the Veterans Health Administration, 25.7% are smokers, compared with 10.8â13.8% of those with access to at least one type of Medicare (fee for service or a health-maintenance organization) (Keyhani et al., 2007). HEALTH EFFECTS OF TOBACCO USE In 1964, the US Surgeon General published a landmark report Smoking and Health that implicated smoking as the cause of a variety of health effects (US Surgeon General, 1964). Since then, other reports on smoking from the surgeon general (2004, 2006) and numerous studies have confirmed that smoking causes a multitude of short- and long-term health effects in people of all ages. The surgeon general has also issued reports on the effects of smoking in women (2001) and on the effects of secondhand smoke on children (2007). Table 2-4 summarizes some of the health hazards associated with tobacco use, many of which are discussed in this chapter. TABLE 2-4 Health Hazards Posed by Tobacco Use Health Hazards Cancer (see Table 2-6) Cardiovascular disease Sudden death Acute myocardial infarction Unstable angina Stroke Peripheral arterial occlusive disease (including thromboangiitis obliterans) Aortic aneurysm Pulmonary disease Lung cancer Chronic bronchitis Emphysema Asthma Increased susceptibility to pneumonia and to pulmonary tuberculosis Increased susceptibility to desquamative interstitial pneumonitis Increased susceptibility to and morbidity from viral respiratory infection
SCOPE OF THE PROBLEM 41 Health Hazards Gastrointestinal disease Peptic ulcer Esophageal reflux Reproductive disturbances Reduced fertility Premature birth Low birth weight Spontaneous abortion Abruptio placentae Premature rupture of membranes Increased perinatal mortality Oral disease (smokeless tobacco) Oral cancer Leukoplakia Gingivitis Gingival recession Tooth staining Other Non-insulin-dependent diabetes mellitus Impaired wound healing Osteoporosis Cataract Amblyopia (loss of vision) Age-related macular degeneration Premature skin wrinkling Aggravation of hypothyroidism Altered drug metabolism or effects SOURCE: Adapted from US Surgeon General (2004). Short-Term Effects of Tobacco Use In addition to the widely acknowledged long-term health consequences of tobacco use such as cancer and cardiovascular disease, tobacco use also adversely affects performance and health on a much shorter time scale. Being tobacco-free is an essential component of physical fitness and provides myriad advantages to military personnel in terms of readiness and performance. In the sections below, the committee considers the performance and short-term health consequences of tobacco use that are of most importance for active-duty military personnel. Box 2-1 at the end of the section summarizes the effects of tobacco use on military readiness and short-term health.
42 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Effects on Military Readiness and Performance The effects of smoking on military readiness was extensively reviewed in a 1986 report from the US Army Aeromedical Research Laboratory (Dyer, 1986); the sections below summarize that reportâs major findings and update the literature with additional information from the few new studies available on the subject. The committee was surprised and dismayed by the lack of recent research on the effects of tobacco use on military readiness, given the number of tobacco users in the military and the need for military readiness during the last decade. Nicotine Withdrawal Smoking may impair performance both through direct exposures to nicotine, carbon monoxide (CO), and other tobacco-smoke toxicants and through nicotine withdrawal. Nicotine withdrawal refers to the effects of being unable to take in nicotine when a smoker would usually do so because of lack of tobacco or restrictions on its use. Regular intake of nicotine produces changes in brain chemistry and function, as described in detail in Chapter 3, causing the brain to become dependent on nicotine for normal functioning. In the absence of nicotine, brain function becomes abnormal, leading to withdrawal symptoms, which may include irritability; restlessness; anger; difficulty in concentrating; anxiety; depressed mood; and impaired performance in a variety of attentional, reaction-time, and other cognitive tasks (Sommese and Patterson, 1995). The potential adverse consequences of nicotine withdrawal on military performance, specifically cognitive functions and activities, is discussed below. Although most research indicates that nicotine acts as a stimulant to improve or maintain performance in simple perceptual and reaction-time tasks, there is evidence that smoking results in short-term impairment of performance in complex information- processing tasks (Spilich et al., 1992). Physical-Work Capacity and Endurance Smoking impairs strength and physical endurance in part by exposing the smoker to CO, which reduces the oxygen-carrying capacity of blood. Smoking also causes chronic pulmonary inflammation and impairs blood-vessel endothelial function, reducing the vascular dilation associated with physical activity. In most studies, maximal oxygen consumption, reflecting aerobic capacity, is generally similar in young (18â24 years old) smokers and nonsmokers (Chevalier et al., 1963; Knapik et al., 2001; Krumholz et al., 1965; Maksud and Baron, 1980; Montoye et al., 1980). Older smokers have lower aerobic capacity than older nonsmokers (Raven et al., 1974). Among younger smokers, the immediate effects of smoking are reduced maximal oxygen consumption
SCOPE OF THE PROBLEM 43 and exercise duration compared with performance in the same person when he or she has not been smoking (Hirsch et al., 1985). Reductions of 5â10% in maximal aerobic power and endurance have been estimated in young male smokers compared with nonsmokers (Astrand and Rodahl, 1970). Smokers have lower physical-performance capacity than nonsmokers as assessed by scores on the Army physical-training test (running, pushups, and situps) (Zadoo et al. 1993), the Navy physical- readiness test (Conway and Cronan, 1992), and other physical tests (Cooper et al., 1968; Gordon et al., 1987; Hartling, 1975; Jensen, 1986; Marti et al., 1988). In some studies, smokers respond less well to physical training, with a smaller increase in endurance over the course of the training program compared with nonsmokers (Blair et al., 1984; Cooper et al., 1968; Frayser, 1974; Hoad and Clay, 1992). Night Vision and Hearing Most studies indicate that smokers have slower dark adaptation and lower visual acuity in dim lighting after smoking than nonsmokers (McFarland, 1970); one study, however, showed that night vision improves in smokers immediately after smoking although those smokers were not compared with nonsmokers (Gramberg-Danielsen et al., 1974, cited in Dyer, 1986). Poorer night vision in pilots who were smokers than in nonsmokers has been reported (Durazzini et al., 1975). One study found that visual sensitivity improved in smokers after several hours of nonsmoking (Luria and McKay, 1979). Smoking has been strongly associated with accelerated hearing loss during aging. In a cross-sectional US population study (Cruickshanks et al., 1998), smoking was associated with a 70% increase in hearing loss compared with that in nonsmokers; the magnitude of the hearing loss appears to be dose-related in middle-aged men (Uchida et al., 2005). A meta-analysis indicated that smoking increases the risk ratio for hearing loss to 1.33 in cross-sectional studies, 1.7 in cohort studies, and 2.39 in case-control reports (Nomura et al., 2005). Smoking also appears to interact with noise in further inducing hearing loss (Pouryaghoub et al., 2007). Smoking causes hearing loss predominantly in middle-aged and older people, but the risk of hearing loss is also strongly increased by smoking in people under 35 years old (Sharabi et al., 2002). Thus, smoking, particularly in combination with noise, which is common in the military, can result in hearing impairment in active- duty personnel. In summary, there is some evidence that smokers perform more poorly than nonsmokers in low-light conditions. It is not known whether that impairment is related to smoking or to nicotine withdrawal. In either
44 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS case, the visual performance of soldiers in combat could be impaired in low illumination situations. There is strong evidence that smoking accelerates hearing loss associated with aging and interacts with ambient noise to increase this risk. Vigilance and Cognitive Function Visual and auditory vigilance is important in military performance, particularly during tedious tasks in which detection of infrequent events is critical, such as watch duty. In general, nicotine appears to enhance vigilance in repetitive tasks acutely, and deprivation of nicotine is associated with substantial decrements in vigilance and cognitive function (Hirshman et al., 2004; Mancuso et al., 2001). Thus, in deployment circumstances in which military personnel are unable to smoke, nicotine withdrawal may impair performance. Motor-vehicle driving simulation studies show that deprived smokers have longer reaction times and more driving errors than nonsmokers and nondeprived smokers (Heimstra et al., 1967). Similar findings have been observed in various reaction-time tasks (Frankenhaeuser et al., 1971; Myrsten et al., 1972). Smoking allows better performance in the later stages of vigilance tasks (Wesnes and Warburton, 1978). Nonsmokers outperform nicotine-deprived smokers in rapid information-processing tasks (Taylor and Blezard, 1979). Hill et al. (2003) reported that subjects who had never smoked cigarettes outperformed current smokers significantly in two cognitively demanding tasks: block design and free recall. Poorer performance was correlated with higher frequency and longer duration of cigarette- smoking. Performance in less demanding tasks, such as general knowledge and word comprehension, was not significantly different between the two groups. Nonsmoking university students were better able than nonsmokers to detect signals in an auditor-vigilance task (Tong et al., 1977). Aviation Performance Pilots require a high level of cognitive function, vigilance, short reaction time, and rapid decision-making for optimal flight safety. Pilots who are regular smokers may experience withdrawal effects during flight that may impair performance and threaten safety (Sommese and Patterson, 1995). Mertens et al. (1983) examined the effects of not smoking for 4 hours on 17 habitual smokers who were taking the Civil Aeromedical Institute multiple-task performance battery at a simulated cabin altitude of 6,500 ft. Not smoking impaired performance, particularly tracking performance, which is a function that is thought to be important in flying (Mertens et al., 1983). Giannokoulas et al. (2003) studied 20 experienced pilots in the Greek Air Force who smoked an
SCOPE OF THE PROBLEM 45 average of 21 cigarettes per day. Pilots were given computerized mental- arithmetic, visual-vigilance, and image-recall tasks in conditions of ad libitum smoking and after 12 hours of tobacco abstinence on separate days. Cigarette abstinence was associated with impaired performance in all tasks; there were significant decrements in the mental-arithmetic and image-recall tasks. Given that pilots need to retain and evaluate multiple conditions and make quick decisions, the authors of the study concluded that abrupt cessation of smoking is likely to be detrimental to flight safety (Giannakoulas et al., 2003). A 1994 CDC report found that performance disruption would not be a significant impairment for most flight personnel for 4 hours following the last cigarette and that nicotine replacement medications could alleviate withdrawal symptoms associated with longer periods of deprivation (Fiore et al., 1994). Diving Military diving is highly demanding with respect to both general physical endurance and respiratory function. Longitudinal and cross- sectional studies have found decreased pulmonary function, as measured by forced expiratory volume in 1 second as well as other pulmonary- function tests, in divers who smoke compared with divers who do not smoke (Dembert et al., 1984; Tetzlaff et al., 2006). Obstructive airways disease secondary to smoking would be expected to be hazardous during diving in general. Diving-related symptoms of decompression illness are more severe in smokers. Severe decompression illness may include alteration in consciousness and balance, bladder- or bowel-control problems, motor weakness, visual symptoms, or convulsions. There is a dose-response relationship between intensity of smoking and severity of decompression symptoms. Thus, divers who smoke are at increased risk for both aggravation of acute obstructive lung changes and decompression illness (Buch et al., 2003). Accidents and Injuries Smoking has been associated with an increased risk of motor- vehicle collisions in a number of studies (Hutchens et al., 2008; McGuire, 1972). The incidents may be the result of slower reaction times in smokers who are deprived of nicotine (Heimstra et al., 1967). Smokers are more likely than nonsmokers to have motor-vehicle collisions at night and are less likely to wear seatbelts (Grout et al., 1983). Lighting or manipulating cigarettes, or dealing with falling ashes could divert a smokerâs attention from driving. However, one study found that smoking improves the driving performance of habitual smokers; there may be an optimal nicotine dose for the enhancement of cognitive and psychomotor function (Sherwood, 1995).
46 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS 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], 0.82â1.95) for men who smoked 0.5â1 pack of cigarettes per day and 1.96 (95% CI, 1.27â3.03) for women compared with nonsmokers; men and women who smoked more than a pack per day had injury ORs of 2.03 (95% CI, 1.22â3.38) and 1.28 (95% CI, 0.63â2.59), 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, 1.0â5.4) 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 âaffective distressâ (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
SCOPE OF THE PROBLEM 47 that the risk of being hospitalized for causes other than injury or pregnancy was 30% and 25% higher in men and women who smoked, respectively, than in nonsmokers; 7.5% of the hospitalizations for men and 5.0% of the hospitalizations for women were attributed to smoking (Robbins et al., 2000). Smokers were more likely to receive a diagnosis of alcohol dependence, chest pain, or lumbar intervertebral disk disease than nonsmokers. There was a 60% (men) and 15% (women) greater risk of lost workdays due to hospitalization and a 7% and 54% greater risk, respectively, of lost workdays related to injuries in those who smoked than in nonsmokers. The authors estimated that if the entire male US Army population became nonsmokers, the number of days of lost duty not related to injury would decrease by 18.3% after 2.5 years. Studies have also linked presenteeismâdecrease in on-the-job performance due to health problemsâto tobacco use. A survey of 28,902 US workers found that loss of productive time because of health was twice as high in smokers as in nonsmokers. The adjusted loss of productive time in people who smoked at least one pack of cigarettes per day was about 75% higher than in nonsmokers (Stewart et al., 2003). Bunn et al. (2006), in a study of smoking effects on productivity in a large sample of US employees, found that current smokers missed more work and reported more unproductive time at work than former smokers and nonsmokers; current smokers lost a mean of 76.5 hours/year, nonsmokers, 42.8 hours/year, and former smokers, 56 hours/year. Halpern et al. (2001) evaluated work productivity in 96 airline employees. The employees were categorized as never smokers, former smokers, and current smokers. Absenteeism was significantly (p = 0.03) higher in current smokers than in former smokers. Although objective measures of productivity did not differ significantly between the groups, productivity perceived by others was lowest for current smokers, highest for never smokers, and in between for former smokers; the productivity of former smokers increased with duration of abstinence. The specific economic burdens placed on DoD by abseentism and productivity loss are discussed later in this chapter. Effects on Health The 2004 US Surgeon Generalâs report The Health Consequences of Smoking found a causal relationship between smoking and several short-term health effects. The health effects included increased risk of infectious disease, poor asthma control, periodontitis, peptic ulcer disease, and adverse surgical outcomes. Those and other health effects associated with tobacco use are briefly considered in the following sections.
48 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Infection Smoking is a major risk factor for acute respiratory tract and other systemic infections (see Table 2-5); active and passive smoke exposure increases the risk of infection (Arcavi and Benowitz, 2004). The mechanisms by which smoking increases risk are multifactorial and include structural and immunologic alterations (US Surgeon General, 2004). Smoking suppresses immune responses and impairs host defenses, such as removal of contaminants from the respiratory tract (Mehta et al., 2008). It also produces a chronic inflammatory state, including chronic bronchitis and aggravation of asthma. Smokers are more likely to become ill with and die from influenza and bacterial pneumonia (US Surgeon General, 2004); those who become ill have more serious illnesses, are more likely to be hospitalized, and lose more workdays. Smoking has been associated with increased risk of Legionnaireâs disease, meningococcal meningitis, tuberculosis, and other infectious diseases (Arcavi and Benowitz, 2004). Smoking is a substantial risk factor for pneumococcal pneumonia, especially in patients with chronic obstructive pulmonary disease (COPD). Smoking is strongly associated with invasive pneumococcal disease in otherwise healthy adults and with a nearly twofold increased risk of community- acquired pneumonia, with 32% of the risk attributable to smoking (US Surgeon General, 2004). The risk of developing and the severity of viral infections including the common cold, influenza, and varicella pneumonia are also increased in smokers. Influenza infections are more severe with more coughing, acute and chronic phlegm production, shortness of breath and wheezing in smokers. Influenza infections produce more work-loss days in smokers compared to nonsmokers. Smokers are at greater risk of TABLE 2-5 Smoking and Infection Type of Infection OR (95% CI) Pneumococcal pneumonia 2.6 (1.9â3.5) Legionnaireâs disease 3.5 (2.1â5.8) Meningococcal disease 2.4 (0.9â6.6) Periodontal disease 2.8 (1.9â4.1) Common cold 1.5 (1.1â1.8) Influenza 2.4 (1.5â3.8) HIV infection 3.4 (1.6â7.5) Tuberculosis 4.5 (4.0â5.0) SOURCE: Adapted from Arcavi and Benowitz (2004).
SCOPE OF THE PROBLEM 49 developing varicella pneumonitis compared with nonsmokers (US Surgeon General, 2004). Smokers are also at greater risk for developing and dying of tuberculosis than nonsmokers (Lin et al., 2007). Impaired Wound Healing Smoking is causally associated with adverse postoperative effects and delayed wound healing. In particular, nicotine impairs skin- flap survival and increases wound complications after surgical procedures by constricting blood vessels in the skin (Siana et al., 1989). Potential mechanisms include impairment of epithelialization, decrease in oxygen delivery, microvascular injury, and effects on inflammatory cells and thrombotic mechanisms. Impairment of clearance of secretions, alteration in immune function and collagen synthesis, and underlying tobacco-related diseasesâsuch as COPD and altered cardiovascular functionâalso contribute to postoperative complications. Smokers who underwent elective hip or knee surgery and who received a smoking-cessation intervention had a substantially lower rate of wound complications and cardiovascular complications than surgical patients who smoked and received usual care (LindstrÃ¶m et al., 2008; MÃ¸ller et al., 2002). Some studies have shown that smokers undergoing ambulatory surgery have significantly higher rates of respiratory complications and wound infections than nonsmokers (Myles et al., 2002). Smokers also have higher rates of complication after lung surgery and after hepatic and renal transplantation (Pungpapong et al., 2002; Slama et al., 2007). Smoking was associated with an increased risk of postoperative hemorrhage in adults treated in a US military hospital. Bleeding episodes after uvulopalatopharyngoplasty occurred in 10.9% of smokers and 3.3% of nonsmokers (p = 0.006), possibly as a result of general poor wound healing complicated by the drying and irritating effects of smoking (Demars et al., 2008). Peptic Ulcer Disease Smoking can cause acute peptic ulcer disease because it impairs the protective barrier in the stomach (US Surgeon General, 2004). Smoking may also increase the likelihood of gastric Helicobacter pylori infection, which is involved in the pathogenesis of peptic ulcer disease (Maity et al., 2003). Periodontal Disease Smoking and the use of smokeless tobacco both cause periodontal disease (BergstrÃ¶m, 2004) (smokeless tobacco is discussed later in this chapter). The mechanisms include immune suppression, reduction of local blood flow, and the local toxic effects of tobacco
50 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS smoke in the mouth. According to the National Health and Nutrition Examination Survey III, after adjustments for age, race, income, and education level, current smokers were 4 times more likely than nonsmokers to have periodontitis (Johnson and Guthmiller, 2007). One study found that two-thirds of new cases of periodontal attachment loss could be attributed to smoking (Thomson et al., 2007). Periodontal disease showed a dose-response relationship with smoking in young Israelis leaving military service (Vered et al., 2008). Acute Eosinophilic Pneumonia Acute eosinophilic pneumonia (AEP) is a rare, often life- threatening form of pneumonia believed to be an allergic response to an environmental exposure (Janz et al., 2009). Smoking is known to be a risk factor for AEP (Vassallo and Ryu, 2008). Shorr et al. (2004) identified 18 cases of AEP, two of which were fatal, in the 183,000 soldiers deployed in Iraq during March 2003âMarch 2004. All 18 patients smoked tobacco, and 14 of them had started smoking only recently. The Stars and Stripes military newspaper reported that at least 36 troops deployed in or near Iraq developed AEP from 2003 to 2008; 27 of them had begun smoking shortly before developing AEP (Mraz, 2008). It is hypothesized that the effects of smoking on pulmonary defenses or immune responses interact with such environmental exposures as windborne dust to trigger AEP (Shorr et al., 2004). BOX 2-1 Effects of Smoking on Military Readiness and Performance Tobacco use affects military readiness by â¢ impairing physical endurance and performance capacity; â¢ impairing visual performance, dark adaptation, and night vision; â¢ accelerating age-related hearing loss and potentially interacting with noise-induced hearing loss; â¢ impairing vigilance and cognitive function (nicotine withdrawal); â¢ increasing the risk of motor-vehicle collisions and other accidents; â¢ increasing work absenteeism (due to illness, accidents, and alcohol and substance abuse); â¢ increasing the risk of lower respiratory tract infections; â¢ increasing the risk of peptic ulcer disease; â¢ impairing wound healing; â¢ increasing postoperative complications; â¢ increasing the risk of periodontal disease; and â¢ possibly increasing the risk of AEP.
SCOPE OF THE PROBLEM 51 Long-Term Health Effects Since the publication of the surgeon generalâs seminal 1964 report on smoking, research has confirmed that smoking causes cancers of the esophagus, larynx, oral cavity and pharynx, stomach, pancreas, lung, cervix, kidney, and bladder and causes acute myeloid leukemia (IOM, 2007). It also causes a variety of other diseases, including stroke, atherosclerosis, cardiovascular disease, COPD, and such infectious diseases as influenza, and it increases the risk of infection (US Surgeon General, 2007). In short, a lifelong smoker has a 1-in-2 chance of dying prematurely from a complication of smoking. As a result of the 1964 report and later reports from the surgeon general and public-health campaigns, there has been a substantial decline in the use of tobacco in the US population. Smoking rates dropped from more than 42% before 1964 (CDC, 2009) to less than 20% today. Nevertheless, tobacco use continues to be the number one cause of preventable death in the United States and is a major cause of chronic disease, disability, and death in military veterans (IOM, 2007). This section briefly reviews long-term health consequences of smoking (see Table 2-4); for a detailed review, the reader is referred to the surgeon generalâs recent reports on smoking and health (US Surgeon General, 2004, 2007). Cancer Smoking is the greatest preventable cause of cancer and is responsible for 30% of cancer deaths (ACS, 2008). Lung cancer is the leading cause of cancer mortality in the United States; 90% of lung- cancer cases in men and 80% in women are attributable to smoking (US Surgeon General, 2004). The risk of lung cancer and other cancers is proportional to the number of cigarettes smoked per day and the duration of smoking (US Surgeon General, 2004). However, even quitting smoking at the age of 50 years can reduce the lifelong risk of lung cancer by half. Workplace exposure to asbestos, as may occur in military construction and maintenance workers and mechanics, synergistically increases the risk of lung cancer posed by smoking. Alcohol use also acts synergistically with smoking to cause oral laryngeal and esophageal cancer (see Table 2-6). Cervical cancer is more common in women who smoke. Smoking is responsible for 20â30% of leukemia cases in adults, including lymphoid and myeloid leukemia (CDC, 1989). Smoking was associated with an increase in risk of colorectal cancer in men and women in a meta-analysis of 36 studies (Kenfield et al., 2008). Exposure to such industrial solvents as benzene, with which military personnel may work, presumably adds to the effect of the benzene in tobacco smoke in causing leukemia (US Surgeon General, 2004).
52 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS TABLE 2-6 Smoking and Cancer Riska Population-Attributable Risk (%)b Average Relative Cancer Men Women Risk Lung 87 70 15.0â30.0 Urinary tract 46 27 3.0 Oral cavity 73 46 4.0â5.0 Oropharynx, hypopharynx â â 4.0â5.0c Esophagus 72 56 1.5â5.0 Larynx 82 72 10.0c Pancreas 21 23 2.0â4.0 Nasal cavity, sinuses, â â 1.5â2.5 nasopharynx Stomach 27 12 1.5â2.0 Liver â â 1.5â2.5 Kidney 38 5 1.5â2.0 Uterine cervix â 12 1.5â2.5 Myeloid leukemia 22 11 1.5â2.0 a Adapted with permission from IARC (2004); Vineis et al. (2004). b Data from CDC (2008b). c Synergistic interaction with alcohol use. Cardiovascular Disease About one-third of smoking-related deaths in the United States result from cardiovascular disease (CDC, 2008b). Smoking causes 20% of cardiovascular deaths in the United States; it increases the risk of coronary heart disease, including acute myocardial infarction; sudden death; stroke; and peripheral vascular disease, including abdominal aortic aneurysm (Burns, 2003). Smoking accelerates atherosclerosis, causes endothelial injury and dysfunction, and increases blood coagulation, thereby promoting acute ischemic events (US Surgeon General, 2004). Smoking delivers CO to the blood, which reduces the amount of oxygen carried by the hemoglobin and impairs the release of oxygen from hemoglobin to body tissues; this results in functional anemia. Concentrations of carboxyhemoglobin, which binds to red blood cells and competes with oxygen, are typically 5â10% in smokers and 1% in nonsmokers. Reduction in oxygen delivery secondary to CO exposure reduces the maximal exercise capacity in otherwise healthy smokers and the exercise capacity is reduced even further in people who have
SCOPE OF THE PROBLEM 53 impaired exercise capacity because of angina pectoris, intermittent claudication, or COPD (US Surgeon General, 2004). Smoking also interacts with other cardiac risk factors to increase the risk of cardiovascular disease. It increases heart rate, transiently increases blood pressure, and increases the complications of hypertension, including coronary heart disease and chronic renal disease. It also produces insulin resistance and increases the risk of non-insulin- dependent diabetes, which is another risk factor for coronary heart disease and chronic renal disease. Smoking is associated with an atherogenic lipid profile (higher low-density lipoprotein and lower high- density lipoprotein concentrations with more oxidized low-density lipoprotein), which aggravates the adverse effects of genetic factors, diet, or diabetes on blood lipids. Women who use oral contraceptives and smoke have a substantially increased risk of myocardial infarction and stroke, particularly if they are over 35 years old (US Surgeon General, 2004). After acute myocardial infarction, the risk of recurrent myocardial infarction or death is much higher in current smokers than in former smokers. Smoking increases morbidity and mortality in patients with heart failure. Smoking cessation reduces mortality at least as much as does taking medications for heart failure (US Surgeon General, 2004). Chronic Lung Disease More than 80% of cases of COPD in the United States are attributed to smoking. Smoking also increases the risk of respiratory infection, including pneumonia, and results in greater disability from viral respiratory tract infection. Pulmonary disease caused by smoking includes the overlapping syndromes of chronic bronchitis, emphysema, and airway obstruction (US Surgeon General, 2004). Smoking also causes premature onset of decline in lung function and accelerates the age-related decline. Sustained smoking abstinence results in a return of the rate of lung-function decline to that of a never smoker (US Surgeon General, 2004). Smoking may contribute to the development of asthma, but this potential link is confounded by the increased rate of pulmonary infections in smokers. Among asthmatics, current smokers experience more severe asthma, that is, more frequent symptoms and attacks. Exposure to secondhand smoke has been associated with increased risk of asthma in nonsmoking adults. Smoking is associated with other pulmonary disorders, including respiratory bronchiolitis and desquamative interstitial pneumonia (Craig et al., 2004), interstitial lung disease (US Surgeon General, 2004),
54 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Langerhans cell histiocytosis (Ryu et al., 2001), and cryptogenic fibrosing alveolitis (Hubbard et al., 2000). Other Health Effects of Tobacco Use Numerous other health effects that may affect military personnel health and readiness are caused by or have been associated with smoking (US Surgeon General, 2004). As mentioned previously, smoking causes duodenal and gastric ulcers, is associated with esophageal reflux symptoms, delays the rate of ulcer healing, and increases the risk of relapse after ulcer treatment. It increases the risk of osteoporosis and causes a reduction in the peak bone mass attained in early adulthood, and it increases the rate of bone loss in later adulthood. Smoking antagonizes the protective effect of estrogen-replacement therapy on the risk of osteoporosis in postmenopausal women. It can cause cataracts and increases the risk of macular degeneration. Smoking reduces the secretion of thyroid hormone and may increase the severity of clinical symptoms of hypothyroidism. It also interacts with a variety of drugsâ such as insulin, antihypertensive drugs, a number of psychiatric drugs, and some cancer chemotherapeutic agentsâby accelerating drug metabolism or by the pharmacologic interactions of nicotine and other constituents of tobacco with other drugs (US Surgeon General, 2004). Smoking is also associated with poor reproductive outcomes in women, including reduced fertility and babies with low birth weight (US Surgeon General, 2004). Health Effects of Secondhand Smoke Exposure to secondhand smoke is a well-established cause of death, illness, and annoyance in nonsmokers (US Surgeon General, 2007). Secondhand smoke contains the same toxic constituents as mainstream smoke, some of which are present in higher concentrations than in mainstream smoke. Some constituents of secondhand smoke persist at high concentrations for many hours after smoking has ceased (Singer et al., 2002, 2003). In nonsmoking adults, secondhand-smoke exposure is associated with an increased risk of lung cancer and acute myocardial infarction (MI) and a 20â30% excess risk of coronary heart disease (Chen and Boreham, 2002). Meta-analyses showed that secondhand smoke increases the risk of acute MI by 31% (Barnoya and Glantz, 2005) and the risk of lung cancer by up to 20% (IARC, 2004). Several recent studies have found that implementation of smoke-free indoor-air regulations results in a rapid decline in the risk of acute MI and other acute cardiovascular events (Pell et al., 2008). Secondhand smoke also increases the severity of some infectious diseases, such as influenza, and
SCOPE OF THE PROBLEM 55 increases the risk of invasive pneumococcal disease. Secondhand smoke is associated with aggravation of allergies and asthma and with reduction in pulmonary function. Parental smoking can cause pneumonia and bronchitis in young children. Exposure appears to interact with acute respiratory infection in the first year of life and increases the incidence of childhood asthma and middle ear infection. It also increases the risk of sudden infant death syndrome (US Surgeon General, 2007). Children born to mothers who smoke or who are exposed to secondhand smoke have reduced lung volumes compared with nonexposed (US Surgeon General, 2007). Health Effects of Smokeless-Tobacco Use The most widely used smokeless-tobacco products in the United States are moist snuff and chewing tobacco. Moist snuff is available both as loose tobacco and in small packets (sachets) that are placed between the lip and the gum. Smokeless tobacco delivers as much nicotine to the user as does smoking but does not expose the user to all the toxicants generated by the combustion of tobacco (Wennmalm et al., 1991). About 3% of American adults use smokeless tobacco; the prevalence is much higher in men (6%) than in women (0.4%) (CDC, 2007). Smokeless tobacco poses two types of health risks: its constituents directly affect health, and, perhaps more important with respect to disease risk, its use maintains nicotine addiction and promotes continued smoking. For example, some smokers use smokeless tobacco to satisfy their need for nicotine when smoking is restricted but continue to smoke when smoking is permitted. The direct harm caused by use of smokeless tobacco must be viewed in relation to specific products, which differ markedly in the composition and content of carcinogens and other toxicants. All smokeless tobacco delivers carcinogens, such as tobacco-specific nitrosamines, which are formed from nicotine in the curing process (Hecht, 1998). IARC (2007) finds that there is sufficient evidence that smokeless-tobacco use causes cancers of the oral cavity and pancreas. One study of Swedish men compared those who used snus (moist snuff) with those who had never used any tobacco; snus users had a higher rate of pancreatic cancer (relative risk [RR], 2.0; 95% CI, 1.2â3.3) but not of oral cancer (RR, 0.8; 95% CI, 0.4â1.7) or lung cancer (RR, 0.8; 95% CI, 0.5â1.3) (Luo et al., 2007). A recent systematic review of 11 studies, however, found that smokeless tobacco use was not associated with an increased risk of pancreatic cancer (RR, 1.03; 95% CI, 0.71â1.49) (Sponsiello-Wang et al., 2008). Smokeless tobacco is associated with dental problems, including caries. Smokeless tobacco users are twice as
56 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS likely as nonusers to have severe active periodontal disease (Fisher et al., 2005). Two studies of Swedish smokeless-tobacco users found no increased risk of cardiovascular disease, stroke, or sudden death compared with nonusers (Hergens et al., 2005; Huhtasaari et al., 1999), although other studies have shown an increased risk of cardiovascular disease, including hypertension and myocardial infarction, particularly in those who combine smokeless tobacco with tobacco-smoking (Bolinder et al., 1994; Johansson et al., 2005). The reason for the discrepancy is unclear. In summary, smokeless-tobacco use poses a health risk to military personnel and veterans in that it causes oral and pancreatic cancer and periodontal disease, maintains tobacco use, and may increase the risk of cardiovascular disease. ECONOMIC IMPACTS The societal costs of tobacco use in the military and veteran populations are expansive. They include the costs of treating military and veteran tobacco users for tobacco-related illnesses, health-care costs for those exposed to secondhand smoke, and the costs associated with lost productivity of military and veteran tobacco users. The economic impacts of tobacco use also include revenues to DoD from tobacco- product retail sales on installations, which are used to partially fund morale, welfare, and recreation (MWR) activities for military personnel and their families. MWR activities are support and leisure services designed to enhance the lives of military personnel, retirees, family members, and civilian employees; programs include child care, recreational activities, sports, and travel. Impacts on the Department of Defense In 2008, the DoD assistant secretary for health affairs stated, âEvery year, tobacco use leads to unnecessary compromises in the readiness of our troops and costs the Department of Defense millions of dollars in preventable health care costs.â Furthermore, DoD spends over $1.6 billion a year on tobacco-related medical care, increased hospitalization, and lost days of work (DoD, 2008). Tobacco use by military personnel has two major economic effects on DoD: the cost of health care for military personnelâactive-duty, retired, and dependentsâand the cost of lost productivity.
SCOPE OF THE PROBLEM 57 Health-Care Costs Helyer et al. (1998) estimated the direct health-care costs for prevention, diagnosis of, and treatment for tobacco-related diseases in US military personnel in 1995 to be $584 millionâmostly for hospitalization (77%) and physician fees (18%). Over 9,200 hospital-bed days for active-duty personnel were attributed to tobacco-related diseases, or about 10% of the total DoD hospital-bed days and 1.5% of all active-duty hospital-bed days (Helyer et al., 1998). Tobacco-related medical costs amounted to $20 million in a 1997 CDC study of smoking in active-duty Air Force personnel, or 6% of total Air Force medical- system expenditures (CDC, 2000); the study was based on a health- assessment survey of 5,164 active-duty Air Force TRICARE Prime enrollees who were 17â64 years old in 1997, and about 26% of the men and 27% of the women smoked. In 2006, about 4.3 million people were enrolled in the DoD Military Health System TRICARE Prime program (active-duty personnel and their dependents as well as military retirees under 65 years old and their dependents). The annual cost of health care for those enrollees is $12.8 billion. Dall et al. (2007) conducted a financial analysis to determine the costs to TRICARE Prime for treating health problems associated with being overweight and obese, with high alcohol consumption, and with tobacco use in this population. About 1.4 million (47%) of all TRICARE Prime adult enrollees (17â64 years old) were current or former smokers, 19% were former smokers (no cigarettes in the preceding 30 days and at least 100 cigarettes in their lifetime), 17% were light smokers (1â14 cigarettes/day), 7% were moderate smokers (15â24 cigarettes/day), and 3% were heavy smokers (at least 25 cigarettes/day). An estimated 179,000 enrollees (mostly young men) were smokeless tobacco users; the prevalence of pipe and cigar smokers was low. The annual medical cost to TRICARE Prime to treat comorbidities associated with tobacco use was $564 million or 4% of the total expenditures; the greatest expenditures were due to 61,367 cases of cardiovascular disease ($255 million) and 94,419 cases of respiratory problems ($150 million). Other major costs were associated with 4,808 cases of cancer ($81 million), 11,686 cases of cerebrovascular disease ($72 million), and 150 cases of newborn health conditions ($2 million). In 2006, direct treatment for tobacco use amounted to $4.3 million for 18,869 tobacco users, or about $228 per tobacco user per year. When the costs of treating all medical conditions associated with tobacco use were averaged, retirees and dependents incurred greater medical costs due to tobacco use ($321) than did active-duty enrollees ($104) or their dependents ($106). However, the total average for active-duty personnel
58 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS 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 populationâ356,000 FTE days were lost per yearâand 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 (Â± 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
SCOPE OF THE PROBLEM 59 greater likelihood of not completing the training course (p = 0.023) (Snoddy and Henderson, 1994). Klesges et al. (2001) reported that tobacco use was associated with early discharge from the Air Force. In a study of 29,044 Air Force recruits in 1995â1996 who were followed for 12 months, 19.4% of smokers and 11.8% of nonsmokers were prematurely discharged (RR, 1.795; 95% CI, 1.676â1.923). The premature discharges resulted in $18 million in excess training costs for the Air Force and over $130 million for all four services (Klesges et al., 2001). Conway et al. (2007) found that women who were daily smokers before entering the Navy had poorer job performance than nonsmokers as demonstrated by early attrition before serving a full-term enlistment, were more likely to have a less-than-honorable discharge, had more demotions and desertions, achieved a lower paygrade, and were less likely to re-enlist. Early discharge from the military has also been associated with smoking in other countries, such as Sweden (Larsson et al., 2009). Tobacco Sales on Military Installations DoD, through its exchanges and commissaries, provides active- duty and retired armed service members and their families with access to a wide array of consumer goods at reduced prices relative to the private market. Military exchanges are the primary venues for the sale of nonfood merchandise, including tobacco products. According to DoD Instruction 1330.09 (December 7, 2007), exchanges have the dual mission of providing merchandise and services and of generating earnings that help to fund military MWR programs, including child care for dependents of military personnel. Exchanges are supported solely by nonappropriated funds, which are derived from the sale of goods and services to DoD military and civilian personnel and their family members. The nonappropriated funds are used to support MWR programs.2 As authorized by Congress (10 United States Code [USC] Section 2486 [a]), military commissaries are equivalent to commercial grocery stores and sell similar merchandise. Unlike military exchanges, commissaries are supported by congressionally appropriated funds and sell goods at actual product cost to the military plus a 5% surcharge (10 USC Section 2484 [d][e]). Commissaries have the authority to sell 2 According to written testimony to the House Armed Services Committee by Alphonso Maldon, Jr., assistant secretary of defense (force management policy), on March 15, 2000, exchanges designate about 70% of their profits to MWR programs.
60 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS tobacco products under 10 USC Section 2484 (b)(8). Since 1996, tobacco products have been sold at commissaries on consignment from exchanges;3 under 10 USC 2484(3)(a), exchanges are the vendors for tobacco products in commissaries. On most installations, commissaries and exchanges are independent entities and can price their products independently. Table 2-7 shows an example of the variety of pricing of tobacco products at an Army exchange and commissary as well as at nearby civilian tobacco retailers. In a few cases in which a substantial number of active-duty members and their families do not live on the military installation, the commissary and the exchange are combined into a hybrid store. Many installations also have small stores, akin to civilian convenience stores, that are run by the exchanges and that sell tobacco, TABLE 2-7 Price List ($) for Cigarettes and Smokeless Tobacco at and Near an Army Installation Retail Store A (outside Retail Store B Exchange Commissary installation (several miles Tobacco Type Price Price gates) from gates) Cigarettes A, 5.91 Sells cartons 6.48 5.54 1 pack only Cigarettes A, 52.88 47.03 Sells packs only 50.99 carton (10 packs) Cigarettes B, 6.62 Sells cartons 7.13 6.09 1 pack only Cigarettes B, 56.48 50.46 Sells packs only 52.09 carton Chewing 4.50 Sells rolls only 5.59 6.19 tobacco, 1 can Chewing 22.50 21.43 Sells cans only Sells cans only tobacco, 1 roll (5 cans) SOURCE: Cynthia Hawthorne, US Army, personal communication, May 6, 2009. 3 According to Defense Commissary Agency Directive 40-5 (June 26, 1992â Administrative Reissuance Incorporating Changes Through Change 4, August 1, 2000), this policy became effective on November 1, 1996. The reason for the decision was âto support DoD efforts to enhance military readiness by discouraging smoking and promoting healthier lifestylesâ (DeCA Directive 40- 5, Chapter 6, Tobacco Products, 6-1[a]).
SCOPE OF THE PROBLEM 61 alcohol, and snacks. Tobacco is not sold in commissaries on Marine Corps installations and is sold in only two commissaries on Navy installations. DoD, which sells products to both military personnel and veterans at armed services exchanges and commissaries, had tobacco revenue in excess of $611 million in 2005. About 70% of the profits go to MWR activities and in 2005 amounted to over $83 million (see Table 2-8). Individual Costs Pyle et al. (2007) assessed the cost of buying tobacco for active- duty junior enlisted military personnel who responded to the 2002 DoD Survey of Health Related Behaviors Among Active-Duty Military Personnel. Tobacco use may consume as much as 10% of an enlisted personâs base pay. Tobacco users experienced more financial strain and stress than nonusers (OR, 1.89; 95% CI, 1.18â3.03); those who smoked two or more packs per day experienced the greatest stress as a result of money problems in the preceding year (OR, 7.49; 95% CI, 3.51â15.97) (Pyle et al., 2007). The money problems may be of particular concern to young military families. Armour et al. (2007) found that food insecurity (that is, inability to afford enough food for a healthy lifestyle) was more TABLE 2-8 2005 Tobacco Sales Revenue ($) for DoD Source AAFESa NEXCOMb MCXc Total Exchanges 344,566,620 127,216,525 40,150,000 511,933,145 (including package stores) Commissariesd 154,132,028 3,097,445 0 157,229,473 Total tobacco sales 498,698,648 130,313,970 40,150,000 669,162,618 Revenue to MWR 66,548,746 15,511,476 1,300,000 83,360,222 programse a AAFES = Army and Air Force Exchange Service. b NEXCOM = Navy Exchange Service Command. c MCX = Marine Corps exchange. d All tobacco sales in commissaries are exchange consignment sales. e Sales and revenue to MWR programs are for exchange retail fiscal year February 1, 2005âJanuary 31, 2006. SOURCE: Office of the Deputy Under Secretary of Defense for Military Community and Family Policy (September 11, 2008).
62 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS pronounced in low-income families of tobacco users than in low-income families that did not use tobacco; the former spent a large share of their income on tobacco products (Armour et al., 2007). Impacts on the Department of Veterans Affairs The cost of tobacco use for VA is primarily for the health care of veterans with tobacco-related diseases (with a few exceptions, health- care costs for dependents are not covered by the VA health-care system). Those costs can include the cost of tobacco-cessation medications approved by the Food and Drug Administration, costs for staff to lead programs and conduct counseling, and costs for staff training. According to the Congressional Budget Office, 7.4 million veterans were enrolled in the VA health-care system in 2004, or about 30% of the total population of veterans (Congressional Budget Office, 2005). In 2005, VA medical funding exceeded $28.2 billion. According to a 2006 Congressional Research Service report, the VA budget for medical services in fiscal year 2007 was $22.44 billion in the Military Quality of Life and Veterans Affairs Appropriations Act, 2006 (Public Law 109-114) (Panangala, 2006). Veterans in priority group 5 make up the largest population of veterans receiving care through VA (about 35%); their medical costs are about 40% of the VA budget. Veterans in priority group 1 are less than 10% of the enrollees but cost almost 20% of the budget. The most expensive veterans are in priority group 4 (housebound), which makes up only 3% of the population but requires almost 15% of the budget (see Table 2-9 for definitions of VA priority groups) (Congressional Budget Office, 2005). Disease-specific costs attributable to tobacco use are high; for example, VA spent about $5.2 billion in 2008 on health care for veterans with COPD (see Table 2-10 for additional disease-related costs) (Kim Hamlett-Barry, VA, personal communication, February 26, 2009). An economic analysis conducted by VA indicated that as of 2003, âthe percentage of total health-care costs associated with smoking in the VA health-care system could range from 8.31-23.81%.â When VA was considering a waiver for the co-pay required for smoking-cessation treatment, the analysis found that the time to recoup the costs associated with the waiver (that is, lost revenues from copays) was about 2 to 5 years (VA, 2006b). Over the next 10 years, the net present value (NPV) of preventable smoking-attributable health-care expenditures is $19.685 billion for the entire VA populationâan average of $21,444 per current
SCOPE OF THE PROBLEM 63 TABLE 2-9 Health-Care Priority Groups Priority Group Description 1 Veterans with service-connected disabilities (SCDs) rated 50% or more disabling 2 Veterans with SCDs rated 30% or 40% disabling 3 Veterans who are former prisoners of war, were awarded the Purple Heart, were discharged for an SCD, have SCDs rated 10% or 20% disabling, or were disabled by treatment or vocational rehabilitation 4 Veterans who are receiving aid and attendance benefits or are housebound, and veterans who have been determined by the Department of Veterans Affairs (VA) to be catastrophically disabled 5 Veterans without SCDs or with noncompensable SCDs rated 0% disabling living below established VA means test thresholds; veterans who are receiving VA pension benefits; and veterans who are eligible for Medicaid benefits 6 Veterans of either World War I or the Mexican Border War; veterans seeking care solely for disorders associated with exposure to chemical, nuclear, or biological agents in the line of duty (including, for example, Agent Orange, atmospheric testing, and Project 112/ Shipboard Hazard and Defense [SHAD]; and veterans with compensable SCDs rated 0% disabling 7 Veterans with net worth above the VA means test threshold and below a geographic index defined by the Department of Housing and Urban Development (HUD) 8 Veterans with net worth above both the VA means test threshold and the HUD geographic index SOURCE: Adapted from VA (2008b). VA smoker. Over the next 15 years, those numbers jump to $30.909 billion and $33,670 per tobacco user. Lee and Volpp (2004) report that âsensitivity analyses varied the ratio of health costs incurred by ex- smokers relative to those of current smokers. A ratio of 0.8 yielded a total 10 year NPV of $15.643 billion ($17,040 per current VA smoker); a ratio of 0.2 yielded $26.544 billion ($28,915 per current VA smoker).â Within the next 10â15 years, substantial funds could be directed toward tobacco-cessation programs, which could reduce tobacco use without increasing net expenditures (Lee and Volpp, 2004). To assess the cost to VA of smoking-cessation aids (SCA), Jonk et al. (2005) determined the pharmacy costs for SCAs from 1998 to 2002. They estimated that during that time about 30% of the veterans in the VA were smokers and that 7% of them were receiving prescriptions
64 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS TABLE 2-10 Cost ($) of Tobacco-Related Illness to VA in 2008 Disease VA Health Care Costs Attributable to Smokinga COPD 5,202,546,555 Arteriosclerosis 1,313,707,302 Heart failure 819,735,182 Cancers of lung, trachea, 732,264,868 bronchus Aortic aneurysm 394,811,894 Oral cancers 265,517,063 Stroke 95,736,078 Atherosclerosis 41,132,033 a Numbers reported here include all VA health-care costs for people with these conditions and are therefore not mutually exclusive in that some may have multiple conditions. Assigned on basis of annual spending for persons with the condition multiplied by the share of smoking-attributable mortality from that condition, according to p. 860 of surgeon generalâs 2004 report, The Health Consequences of Smoking. SOURCE: The disease categories were adapted from US Surgeon General (2004); the cost data were supplied by VA (James Schaeffer, VA, personal communication, February 26, 2009). for SCAsâprimarily nicotine patches. Eighteen sites were included in the study, of which eight restricted SCAs to veterans who were participating in smoking-cessation programs and 10 had no restriction on who might receive prescriptions. Sites that restricted prescriptions for SCAs to those enrolled in smoking-cessation programs provided SCAs to only about half as many veterans as did unrestricted sites (5.4% vs. 9.6%) and spent about one-half to two-thirds as much per smoker. Specifically, in 2002 the restricted sites spent about $19,500 per 10,000 veterans for SCAs, and the unrestricted sites $56,000 per 10,000 veterans. Outpatient pharmacy expenditures increased from $1.8 billion in 1999 to $2.3 billion in 2002; the costs of the SCAs decreased from about 0.56% of the pharmacy costs in 1999 to 0.37% in 2002 (or from about $160/patient in 1999 to $112/patient in 2002). In short, the costs are considerably less burdensome than those needed to cover the many health issues related to tobacco use (Jonk et al., 2005). In 2007, VA outpatient drug expenditures were about $3.3 billion for 122 million outpatient prescriptions. The number of unique VA patients receiving tobacco-cessation medications in 2007 was 4â8% of the total population
SCOPE OF THE PROBLEM 65 served by each Veteran Integrated Service Network (Michael Valentino, VA, presentation to the committee, June 2, 2008). REFERENCES ACS (American Cancer Society). 2008. Cancer Facts and Figures. Atlanta, GA: ACS. Agrawal, A., C. Sartor, M. L. Pergadia, A. C. Huizink, and M. T. Linskey. 2008. Correlates of smoking cessation in a nationally representative sample of US adults. Addictive Behaviors 33(9):1223- 1226. Altarac, M., J. W. Gardner, R. M. Popovich, R. Potter, J. J. Knapik, and B. H. Jones. 2000. Cigarette smoking and exercise-related injuries among young men and women. American Journal of Preventive Medicine 18(3 Suppl 1):96-102. Ames, G. M., C. B. Cunradi, and R. S. Moore. 2002. Alcohol, tobacco, and drug use among young adults prior to entering the military. Prevention Science 3(2):135-144. Arcavi, L., and N. L. Benowitz. 2004. Cigarette smoking and infection. Archives of Internal Medicine 164(20):2206-2216. Armour, B. S., M. M. Pitts, and C.-W. Lee. 2007. Cigarette Smoking and Food Insecurity Among Low-Income Families in the United States, 2001. Working Paper 2007-19. Atlanta, GA: Federal Reserve Bank of Atlanta. Army. 2006. Army Demographics: FY06 Army Profile. Washington, DC: Department of the Army Headquarters. Associated Press. 2008. âNavy cites smoking as likely cause of carrier fire.â USA Today, July 31, 2008. Astrand, P., and K. Rodahl. 1970. Textbook of Work Physiology. New York: McGraw-Hill. Athanasou, J. A. 1979. Smoking and absenteeism. Medical Journal of Australia 1(6):234-236. Barbeau, E. M., D. McLellan, C. Levenstein, G. F. DeLaurier, G. Kelder, and G. Sorensen. 2004. Reducing occupation-based disparities related to tobacco: Roles for occupational health and organized labor. American Journal of Industrial Medicine 46(2):170-179. Barnoya, J., and S. A. Glantz. 2005. Cardiovascular effects of secondhand smoke: Nearly as large as smoking. Circulation 111(20):2684-2698.
66 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS BergstrÃ¶m, J. 2004. Tobacco smoking and chronic destructive periodontal disease. Odontology/The Society of the Nippon Dental University 92(1):1-8. Blair, S. N., N. N. Goodyear, K. L. Wynne, and R. P. Saunders. 1984. Comparison of dietary and smoking habit changes in physical fitness improvers and nonimprovers. Preventive Medicine 13(4):411-420. Bolinder, G., L. Alfredsson, A. Englund, and U. De Faire. 1994. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. American Journal of Public Health 84(3):399-404. Bray, R. M., and L. L. Hourani. 2007. Substance use trends among active duty military personnel: Findings from the United States Department of Defense Health Related Behavior Surveys, 1980-2005. Addiction 102(7):1092-1101. Buch, D. A., H. El Moalem, J. A. Dovenbarger, D. M. Uguccioni, and R. E. Moon. 2003. Cigarette smoking and decompression illness severity: A retrospective study in recreational divers. Aviation Space and Environmental Medicine 74(12):1271-1274. Bunn, W. B., 3rd, G. M. Stave, K. E. Downs, J. M. Alvir, and R. Dirani. 2006. Effect of smoking status on productivity loss. Journal of Occupational and Environmental Medicine 48(10):1099-1108. Burns, D. M. 2003. Epidemiology of smoking-induced cardiovascular disease. Progress in Cardiovascular Diseases 46(1):11-29. CDC (Centers for Disease Control and Prevention). 1989. Progress in chronic disease prevention chronic disease reports: Deaths from cervical cancerâUnited States, 1984â1986. Morbidity Mortality Weekly Report 38(16):273-274. CDC. 2000. Costs of smoking among active duty US Air Force personnelâUnited States, 1997. MMWR CDC Surveillance Summary 49(20):441-445. CDC. 2007. Fact Sheet: Smokeless Tobacco. http://www.cdc.gov/ tobacco/data_statistics/fact_sheets/smokeless/smokeless_tobacco.htm (accessed April 3, 2009). CDC. 2008a. Cigarette smoking among adultsâUnited States, 2007. Morbidity Mortality Weekly Report 57(45):1221-1226. CDC. 2008b. Annual smoking-attributable mortality, years of potential life lost, and productivity lossesâUnited States, 2000-2004. Morbidity Mortality Weekly Report 57(45):1226-1228.
SCOPE OF THE PROBLEM 67 CDC. 2009. Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965â2007. http://www.cdc.gov/ tobacco/data_statistics/tables/trends/cig_smoking/index.htm (accessed April 3, 2009). Chen, Z., and J. Boreham. 2002. Smoking and cardiovascular disease. Seminars in Vascular Medicine 2(3):243-252. Chevalier, R., J. Bowers, S. Bondurant, and J. Ross. 1963. Circulatory and ventilatory effects of exercise in smokers and nonsmokers. Journal of Applied Physiology 18:357-360. Congressional Budget Office. 2005. The Potential Cost of Meeting Demand for Veteransâ Health Care. Washington, DC: Congress of the United States. Conway, T. L. 1998. Tobacco use and the United States military: A longstanding problem. Tobacco Control 7(3):219-221. Conway, T. L., and T. A. Cronan. 1992. Smoking, exercise and physical fitness. Preventive Medicine 21(6):723-734. Conway, T. L., S. I. Woodruff, and L. K. Hervig. 2007. Womensâ smoking history prior to entering the US Navy: A prospective predictor of performance. Tobacco Control 16(2):79-84. Cooper, K. H., G. O. Gey, and R. A. Bottenberg. 1968. Effects of cigarette smoking on endurance performance. Journal of the American Medical Association 203(3):189-192. Craig, P. J., A. U. Wells, S. Doffman, D. Rassl, T. V. Colby, D. M. Hansell, R. M. Du Bois, and A. G. Nicholson. 2004. Desquamative interstitial pneumonia, respiratory bronchiolitis and their relationship to smoking. Histopathology 45(3):275-282. Crowdy, J. P., and R. R. Sowden. 1975. Cigarette smoking and respiratory ill health in the British Army. Lancet 1(7918):1232-1234. Cruickshanks, K. J., R. Klein, B. E. Klein, T. L. Wiley, D. M. Nondahl, and T. S. Tweed. 1998. Cigarette smoking and hearing loss: The epidemiology of hearing loss study. Journal of the American Medical Association 279(21):1715-1719. Cunradi, C. B., R. S. Moore, and G. Ames. 2008. Contribution of occupational factors to current smoking among active-duty US Navy careerists. Nicotine and Tobacco Research 10(3):429-437.
68 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Dall, T. M., Y. Zhang, Y. J. Chen, R. C. Wagner, P. F. Hogan, N. K. Fagan, S. T. Olaiya, and D. N. Tornberg. 2007. Cost associated with being overweight and with obesity, high alcohol consumption, and tobacco use within the military health systemâs TRICARE prime- enrolled population. American Journal of Health Promotion 22(2):120-139. Demars, S. M., W. J. Harsha, and J. V. Crawford. 2008. The effects of smoking on the rate of postoperative hemorrhage after tonsillectomy and uvulopalatopharyngoplasty. Archives of OtolaryngologyâHead and Neck Surgery. 134(8):811-814. Dembert, M. L., G. J. Beck, J. F. Jekel, and L. W. Mooney. 1984. Relations of smoking and diving experience to pulmonary function among US Navy divers. Undersea Biomedical Research 11(3): 299-304. DoD (Department of Defense). 2006a. Profile of the Military Community: DoD 2006 Demographics Report. Washington, DC: Office of the Deputy Under Secretary of Defense for Military Community and Family Policy. DoD. 2006b. 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Research Triangle Park, NC: RTI International. DoD. 2008. Department of Defense Anti-Tobacco Campaign Invades Military Markets. TRICARE News Release 08-23. http://www.tricare.mil/pressroom/news.aspx?fid=379 (accessed April 3, 2009). Durazzini, G., F. Zazo, and G. Bertoni. 1975. The importance of the dosage of thiocyanates in urine and blood of flying personnel for the prevention of diseases of visual function. In Medical Requirements and Examination Procedures in Relation to the Tasks of Today's Aircrew, edited by G. Perdriel. London, UK: NATO Advisory Group for Aerospace Research and Development. Dyer, F. N. 1986. Smoking and Soldier Performance: A Literature Review. US Army Aeromedical Research Laboratory, Report No. 86- 13. Columbus, GA: Research Solutions, Inc. Ebbert, J. O., C. K. Haddock, M. Vander Weg, R. C. Klesges, W. S. Poston, and M. DeBon. 2006. Predictors of smokeless tobacco initiation in a young adult military cohort. American Journal of Health Behaviors 30(1):103-112.
SCOPE OF THE PROBLEM 69 Fiore, M., F. Shi, S. Heishman, and J. Henningfield. 1994. The Effects of Smoking and Smoking Withdrawal on Flight Performance: A 1994 Update. Rockville, MD: CDC, Office on Smoking and Health. Fisher, M. A., G. W. Taylor, and K. R. Tilashalski. 2005. Smokeless tobacco and severe active periodontal disease, NHANES III. Journal of Dental Research 84(8):705-710. Frankenhaeuser, M., A. Myrsten, B. Post, and G. Johansson. 1971. Behavioural and physiological effects of cigarette smoking in a monotonous situation. Psychopharmacologia 22(1):1-7. Frayser, R. 1974. The effect of repetitive exercise on ventilatory function in smokers and nonsmokers. Southern Medical Journal 67(8): 926-929. Giannakoulas, G., A. Katramados, N. Melas, I. Diamantopoulos, and E. Chimonas. 2003. Acute effects of nicotine withdrawal syndrome in pilots during flight. Aviation Space and Environmental Medicine 74(3):247-251. Gordon, D. J., A. S. Leon, and L. G. Ekelund. 1987. Smoking, physical activity, and other predictors of endurance and heart rate response to exercise in asymptomatic hypercholesterolemic men: The Lipid Research Clinics Coronary Primary Prevention Trial. American Journal of Epidemiology 125(4):587-600. Gramberg-Danielsen, B., N. Puls, and G. Tolksdorf, G. 1974. Ist das mesopische sehen kurzfristig beeinflussbar? Medizinische Monatsschrift 28:285-289. Grout, P., K. Cliff, M. Harman, and D. Machin. 1983. Cigarette smoking, road traffic accidents and seat belt usage. Public Health, London 97:95-101. Haddock, C. K., R. C. Klesges, G. W. Talcott, H. Lando, and R. J. Stein. 1998. Smoking prevalence and risk factors for smoking in a population of United States Air Force basic trainees. Tobacco Control 7(3):232-235. Halpern, M. T., R. Shikiar, A. M. Rentz, and Z. M. Khan. 2001. Impact of smoking status on workplace absenteeism and productivity. Tobacco Control 10(3):233-238. Hartling, O. 1975. The effect of the first three months of military service on the physical work capacity of conscripts. Forsvarsmedicin 11(4):213-218. Hecht, S. S. 1998. Biochemistry, biology, and carcinogenicity of tobacco-specific N-nitrosamines. Chemical Research in Toxicology 11(6):559-603.
70 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Heimstra, N., N. Bancroft, and A. DeKock. 1967. Effects of smoking upon sustained performance in a simulated driving task. Annals of the New York Academy of Sciences 142:295-307. Helyer, A. J., W. T. Brehm, and L. Perino. 1998. Economic consequences of tobacco use for the Department of Defense, 1995. Military Medicine 163(4):217-221. Hergens, M. P., A. Ahlbom, T. Andersson, and G. Pershagen. 2005. Swedish moist snuff and myocardial infarction among men. Epidemiology 16(1):12-16. Hill, R. D., L.-G. Nilsson, L. Nyberg, and L. Backman. 2003. Cigarette smoking and cognitive performance in healthy Swedish adults. Age and Ageing 32(5):548-550. Hirsch, G. L., D. Y. Sue, and K. Wasserman. 1985. Immediate effects of cigarette smoking on cardiorespiratory responses to exercise. Journal of Applied Physiology 58(6):1975-1981. Hirshman, E., P. Merritt, D. K. Rhodes, and M. Zinser. 2004. The effect of tobacco abstinence on recognition memory, digit span recall, and attentional vigilance. Experimental and Clinical Psychopharmacology 12(1):76-83. Hoad, N. A., and D. N. Clay. 1992. Smoking impairs the response to a physical training regime: A study of officer cadets. Journal of the Royal Army Medical Corps 138(3):115-117. Holcomb, H. S., III, and J. W. Meigs. 1972. Medical absenteeism among cigarette, and cigar and pipe smokers. Archives of Environmental Health 25(4):295-300. Hubbard, R., A. Venn, S. Lewis, and J. Britton. 2000. Lung cancer and cryptogenic fibrosing alveolitis: A population-based cohort study. American Journal of Respiratory and Critical Care Medicine 161(1):5-8. Huhtasaari, F., V. Lundberg, M. Eliasson, U. Janlert, and K. Asplund. 1999. Smokeless tobacco as a possible risk factor for myocardial infarction: A population-based study in middle-aged men. Journal of the American College of Cardiology 34(6):1784-1790. Hutchens, L., T. M. Senserrick, P. E. Jamieson, D. Romer, and F. K. Winston. 2008. Teen driver crash risk and associations with smoking and drowsy driving. Accident Analysis and Prevention 40(3):869-876.
SCOPE OF THE PROBLEM 71 IARC (International Agency for Research on Cancer). 2004. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Tobacco Smoking and Involuntary Smoking. Vol. 83. Lyon, France: World Health Organization, International Agency for Research on Cancer. IOM (Institute of Medicine). 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. Isachenkov, V. 2008. âInquiry probes cause of Russian sub deaths.â The Guardian, November 12, 2008. Janz, D. R., H. R. OâNeal, Jr., and E. W. Ely. 2009. Acute eosinophilic pneumonia: A case report and review of the literature. Critical Care Medicine 37(4):1470-1474. Jensen, R. G. 1986. The effect of cigarette smoking on Army Physical Readiness Test performance of enlisted Army medical department personnel. Military Medicine 151(2):83-85. Johansson, S. E., K. Sundquist, J. Qvist, and J. Sundquist. 2005. Smokeless tobacco and coronary heart disease: A 12-year follow-up study. European Journal of Cardiovascular Prevention and Rehabilitation 12(4):387-392. Johnson, G. K., and J. M. Guthmiller. 2007. The impact of cigarette smoking on periodontal disease and treatment. Periodontology 2000 44(1):178-194. Jones, B. H., and J. J. Knapik. 1999. Physical training and exercise- related injuries. Surveillance, research and injury prevention in military populations. Sports Medicine 27(2):111-125. Jonk, Y. C., S. E. Sherman, S. S. Fu, K. W. Hamlett-Berry, M. C. Geraci, and A. M. Joseph. 2005. National trends in the provision of smoking cessation aids within the Veterans Health Administration. American Journal of Managed Care 11(2):77-85. Kenfield, S. A., M. J. Stampfer, B. A. Rosner, and G. A. Colditz. 2008. Smoking and smoking cessation in relation to mortality in women. Journal of the American Medical Association 299(17):2037-2047. Keyhani, S., J. S. Ross, P. Hebert, C. Dellenbaugh, J. D. Penrod, and A. L. Siu. 2007. Use of preventive care by elderly male veterans receiving care through the Veterans Health Administration, Medicare fee-for-service, and Medicare HMO plans. American Journal of Public Health 97(12):2179-2185.
72 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Klesges, R. C., C. K. Haddock, C. F. Chang, G. W. Talcott, and H. A. Lando. 2001. The association of smoking and the cost of military training. Tobacco Control 10(1):43-47. Klevens, R. M., G. A. Giovino, J. P. Peddicord, D. E. Nelson, P. Mowery, and L. Grummer-Strawn. 1995. The association between veteran status and cigarette-smoking behaviors. American Journal Preventive Medicine 11(4):245-250. Knapik, J. J., K. Reynolds, and J. Barson. 1999. Risk factors for foot blisters during road marching: Tobacco use, ethnicity, foot type, previous illness, and other factors. Military Medicine 164(2):92-97. Knapik, J. J., M. A. Sharp, M. Canham-Chervak, K. Hauret, J. F. Patton, and B. H. Jones. 2001. Risk factors for training-related injuries among men and women in basic combat training. Medicine and Science in Sports and Exercise 33(6):946-954. Krumholz, R., R. Chevalier, and J. Ross. 1965. Changes in cardiopulmonary functions related to abstinence from smoking: Studies in young cigarette smokers at rest and exercise at 3 and 6 weeks of abstinence. Annals of Internal Medicine 62:197-207. Larsson, H., L. Broman, and K. and Harms-Ringdahl. 2009. Individual risk factors associated with premature discharge from military service. Military Medicine 174(1):9-20. Lee, B., and K. Volpp. 2004. Potential cost savings from smoking cessation in the Veterans Affairs patient population. AcademyHealth Meet 21:Abstract no. 1648. Lin, H. H., M. Ezzati, and M. Murray. 2007. Tobacco smoke, indoor air pollution and tuberculosis: A systematic review and meta-analysis. PLoS Medicine 4(1):0173-0189. LindstrÃ¶m, D., O. S. Azodi, A. Wladis, H. TÃ¸nnesen, S. Linder, H. NÃ¥sell, S. Ponzer, and J. Adami. 2008. Effects of a perioperative smoking cessation intervention on postoperative complications: A randomized trial. Annals of Surgery 248(5):739-745. Luo, J., W. Ye, K. Zendehdel, J. Adami, H. O. Adami, P. Boffetta, and O. NyrÃ©n. 2007. Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: A retrospective cohort study. Lancet 369(9578):2015-2020. Luria, S. M., and C. L. McKay. 1979. Visual processes of smokers and nonsmokers at different ages. Archives of Environmental Health 34(6):449-454.
SCOPE OF THE PROBLEM 73 Maity, P., K. Biswas, S. Roy, R. K. Banerjee, and U. Bandyopadhyay. 2003. Smoking and the pathogenesis of gastroduodenal ulcerârecent mechanistic update. Molecular and Cellular Biochemistry 253(1-2):329-338. Maksud, M., and A. Baron. 1980. Physiological responses to exercise in chronic cigarette and marijuana users. European Journal of Applied Physiology and Occupational Physiology 43(2):127-134. Mancuso, G., M. Lejeune, and M. Ansseau. 2001. Cigarette smoking and attention: Processing speed or specific effects? Psychopharmacology 155(4):372-378. Marti, B., T. Abelin, C. E. Minder, and J. P. Vader. 1988. Smoking, alcohol consumption, and endurance capacity: An analysis of 6,500 19-year-old conscripts and 4,100 joggers. Preventive Medicine 17(1):79-92. McFarland, R. A. 1970. The effects of exposure to small quantities of carbon monoxide on vision. Annals of the New York Academy of Sciences 174(1):301-312. McGuire, F. 1972. Smoking, driver education, and other correlates of accidents among young males. Journal of Safety Research 4(5-11). Mehta, H., K. Nazzal, and R. T. Sadikot. 2008. Cigarette smoking and innate immunity. Inflammation Research 57(11):497-503. Mertens, H. W., J. M. McKenzie, and E. A. Higgins. 1983. Some Effects of Smoking Withdrawal on Complex Performance and Physiological Responses. Washington, DC: Federal Aviation Administration, Office of Aviation Medicine. Messecar, D. C., and C. Sullivan. 2001. Cigarette smoking in the Oregon Air National Guard: Findings from a health promotions survey. Military Medicine 166(9):774-776. MÃ¸ller, A. M., N. Villebro, T. Pedersen, and H. TÃ¸nnesen. 2002. Effect of preoperative smoking intervention on postoperative complications: A randomised clinical trial. Lancet 359(9301):114-117. Montoye, H., R. Gayle, and M. Higgins. 1980. Smoking habits, alcohol consumption and maximal oxygen uptake. Medicine and Science in Sports and Exercise 12(5):316-321. Mraz, S. 2008. Rare type of pneumonia infecting troops. Stars and Stripes, Pacific edition, October 4, 2008. Myles, P. S., G. A. Iacono, J. O. Hunt, H. Fletcher, J. Morris, D. McIlroy, and L. Fritschi. 2002. Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: Smokers versus nonsmokers. Anesthesiology 97(4):842-847.
74 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Myrsten, A. L., B. Post, M. Frankenhaeuser, and G. Johansson. 1972. Changes in behavioral and physiological activation induced by cigarette smoking in habitual smokers. Psychopharmacologia 27(4):305-312. Nomura, K., M. Nakao, and T. Morimoto. 2005. Effect of smoking on hearing loss: Quality assessment and meta-analysis. Preventive Medicine 40(2):138-144. Panangala, S. 2006. Veteransâ Medical Care: FY2007 Appropriations, R.L. 33409. Washington, DC: Congressional Research Service, Library of Congress. Parkes, K. R. 1983. Smoking as a moderator of the relationship between affective state and absence from work. Journal of Applied Psychology 68(4):698-708. Pell, J. P., S. Haw, S. Cobbe, D. E. Newby, A. C. Pell, C. Fischbacher, A. McConnachie, S. Pringle, D. Murdoch, F. Dunn, K. Oldroyd, P. Macintyre, B. OâRourke, and W. Borland. 2008. Smoke-free legislation and hospitalizations for acute coronary syndrome. New England Journal of Medicine 359(5):482-491. Pouryaghoub, G., R. Mehrdad, and S. Mohammadi. 2007. Interaction of smoking and occupational noise exposure on hearing loss: A cross- sectional study. BMC Public Health 7(147):137. Pungpapong, S., C. Manzarbeitia, J. Ortiz, D. J. Reich, V. Araya, K. D. Rothstein, and S. J. MuÃ±oz. 2002. Cigarette smoking is associated with an increased incidence of vascular complications after liver transplantation. Liver Transplantation 8(7):582-587. Pyle, S. A., C. K. Haddock, W. S. Poston, R. M. Bray, and J. Williams. 2007. Tobacco use and perceived financial strain among junior enlisted in the US Military in 2002. Preventive Medicine 45(6): 460-463. Raven, P. B., B. L. Drinkwater, and R. O. Ruhling. 1974. Effect of carbon monoxide and peroxyacetyl nitrate on manâs maximal aerobic capacity. Journal of Applied Physiology 36(3):288-293. Robbins, A. S., V. P. Fonseca, S. Y. Chao, G. A. Coil, N. S. Bell, and P. J. Amoroso. 2000. Short term effects of cigarette smoking on hospitalisation and associated lost workdays in a young healthy population. Tobacco Control 9(4):389-396. Ryu, J. H., T. V. Colby, T. E. Hartman, and R. Vassallo. 2001. Smoking- related interstitial lung diseases: A concise review. European Respiratory Journal 17(1):122-132.
SCOPE OF THE PROBLEM 75 SAMHSA (Substance Abuse and Mental Health Services Administration). 2008. Results from the 2007 National Survey on Drug Use and Health: National Findings. NSDUH Series H-34, Rockville, MD: Office of Applied Studies. DHHS Publication No. SMA 08-4343. Schmidt, F. 1972. Rauchen und Bundeswehr. Die Medizinische Welt 23:921-924. Sharabi, Y., I. Reshef-Haran, M. Burstein, and A. Eldad. 2002. Cigarette smoking and hearing loss: Lessons from the young adult periodic examinations in Israel (YAPEIS) database. Israeli Medical Association Journal 4(12):1118-1120. Sherwood, N. 1995. Effects of cigarette smoking on performance in a simulated driving task. Neuropsychobiology 32(3):161-165. Shorr, A. F., S. L. Scoville, S. B. Cersovs.ky, G. D. Shanks, C. F. Ockenhouse, B. L. Smoak, W. W. Carr, and B. P. Petruccelli. 2004. Acute eosinophilic pneumonia among US military personnel deployed in or near Iraq. Journal of the American Medical Association 292(24):2997-3005. Siana, J. E., S. Rex, and F. Gottrup. 1989. The effect of cigarette smoking on wound healing. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 23(3):207-209. Singer, B. C., A. T. Hodgson, K. S. Guevarra, E. L. Hawley, and W. W. Nazaroff. 2002. Gas-phase organics in environmental tobacco smoke: 1. Effects of smoking rate, ventilation, and furnishing level on emission factors. Environmental Science and Technology 36(5): 846-853. Singer, B. C., A. T. Hodgson, and W. W. Nazaroff. 2003. Gas-phase organics in environmental tobacco smoke: 2. Exposure-relevant emission factors and indirect exposures from habitual smoking. Atmospheric Environment 37(39-40):5551-5561. Slama, K., C. Y. Chiang, D. A. Enarson, K. Hassmiller, A. Fanning, P. Gupta, and C. Ray. 2007. Tobacco and tuberculosis: A qualitative systematic review and meta-analysis. International Journal of Tuberculosis and Lung Disease 11(10):1049-1061. Snoddy, R. O., Jr., and J. M. Henderson. 1994. Predictors of basic infantry training success. Military Medicine 159(9):616-622. Sommese, T., and J. C. Patterson. 1995. Acute effects of cigarette smoking withdrawal: A review of the literature. Aviation Space and Environmental Medicine 66(2):164-167.
76 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Spilich, G. J., L. June, and J. Renner. 1992. Cigarette smoking and cognitive performance. British Journal of Addiction 87(9):1313-1326. Sponsiello-Wang, Z., R. Weitkunat, and P. N. Lee. 2008. Systematic review of the relation between smokeless tobacco and cancer of the pancreas in Europe and North America. BMC Cancer 8:356. Stars and Stripes. 2008. Five Years in Iraq. http://www.stripes.com/ 08/mar08/iraq5/ (accessed March 30, 2009). Stewart, W. F., J. A. Ricci, E. Chee, and D. Morganstein. 2003. Lost productive work time costs from health conditions in the United States: Results from the American Productivity Audit. Journal of Occupational and Environmental Medicine 45(12):1234-1246. Talcott, G. W., W. S. Poston, 2nd, and C. K. Haddock. 1998. Co- occurrent use of cigarettes, alcohol, and caffeine in a retired military population. Military Medicine 163(3):133-138. Taylor, D. H., and P. N. Blezard. 1979. The effects of smoking and urinary pH on a detection task. Quarterly Journal of Experimental Psychology 31(Pt 4):635-640. Tetzlaff, K., J. Theysohn, C. Stahl, S. Schlegel, A. Koch, and C. M. Muth. 2006. Decline of FEV1 in scuba divers. Chest 130(1):238-243. Thomson, W. M., J. M. Broadbent, D. Welch, J. D. Beck, and R. Poulton. 2007. Cigarette smoking and periodontal disease among 32-year-olds: A prospective study of a representative birth cohort. Journal of Clinical Periodontology 34(10):828-834. Tong, J. E., G. Leigh, J. Campbell, and D. Smith. 1977. Tobacco smoking, personality, and sex factors in auditory vigilance performance. The British Journal of Psychology 68(3):365-370. Trent, L. K., S. M. Hilton, and T. Melcer. 2007. Premilitary tobacco use by male Marine Corps recruits. Military Medicine 172(10):1077- 1083. Uchida, Y., T. Nakashima, F. Ando, N. Niino, and H. Shimokata. 2005. Is there a relevant effect of noise and smoking on hearing? A population-based aging study. International Journal of Audiology 44(2):86-91. US Surgeon General. 1964. Report on Smoking and Health. Washington, DC: Department of Health and Human Services. US Surgeon General. 2001. Women and Smoking: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services.
SCOPE OF THE PROBLEM 77 US Surgeon General. 2004. The Health Consequences of Smoking: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services. US Surgeon General. 2006. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services. US Surgeon General. 2007. Children and Secondhand Smoke ExposureâExcerpts from The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Washington, DC: Department of Health and Human Services. VA (Department of Veterans Affairs). 2006a. 2005 Survey of Veteran Enrolleesâ Health and Reliance Upon VA With Selected Comparisons to the 1999â2003 Surveys. Washington, DC: Veterans Health Administration. VA. 2006b. 2005 Smoking and Tobacco Use Cessation Report. Washington, DC: Veterans Health Administration, Office of the Assistant Deputy Under-Secretary for Health for Policy Planning. VA. 2008a. Employment Histories Report. http://www1.va.gov/vetdata/ docs/Employment_History_080324.pdf (accessed March 10, 2009). VA. 2008b. VA Health Care Eligibility and Enrollment. http://www.va.gov/healtheligibility/eligibility/PriorityGroupsAll.asp (accessed April 3, 2009). Vander Weg, M. W., A. L. Peterson, J. O. Ebbert, M. Debon, R. C. Klesges, and C. K. Haddock. 2008. Prevalence of alternative forms of tobacco use in a population of young adult military recruits. Addictive Behavior 33(1):69-82. Vassallo, R., and J. H. Ryu. 2008. Tobacco smoke-related diffuse lung diseases. Seminars in Respiratory and Critical Care Medicine 29(6):643-650. Vered, Y., A. Livny, A. Zini, and H. D. Sgan-Cohen. 2008. Periodontal health status and smoking among young adults. Journal of Clinical Periodontology 35(9):768-772. Vineis, P., M. Alavanja, P. Buffler, E. Fontham, S. Franceschi, Y. T. Gao, P. C. Gupta, A. Hackshaw, E. Matos, J. Samet, F. Sitas, J. Smith, L. Stayner, K. Straif, M. J. Thun, H. E. Wichmann, A. H. Wu, D. Zaridze, R. Peto, and R. Doll. 2004. Tobacco and cancer: Recent epidemiological evidence. Journal of the National Cancer Institute 96(2):99-106.
78 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Wennmalm, A., G. Benthin, E. F. Granstrom, L. Persson, A. S. Petersson, and S. Winell. 1991. Relation between tobacco use and urinary excretion of thromboxane A2 and prostacyclin metabolites in young men. Circulation 83(5):1698-1704. Wesnes, K., and D. Warburton. 1978. The effects of cigarette smoking and nicotine tablets upon human attention. In Smoking Behavior, edited by R. Thornton. Edinburgh, Scotland: Churchill Livingston. Wilson, R. W. 1973. Cigarette smoking, disability days and respiratory conditions. Journal of Occupational Medicine 15(3):236-240. Zadoo, V., S. Fengler, and M. Catterson. 1993. The effects of alcohol and tobacco use on troop readiness. Military Medicine 158(7): 480-484.