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3 FACTORS THAT INFLUENCE TOBACCO USE The decision to use and continue to use a tobacco product depends on many factors, from personal ones such as self-image to societal ones such as easy access to cigarettes. In this chapter, the committee uses a socioecologic framework (Figure 3-1) to examine the factors that encourage and sustain tobacco use in military and veteran populations. On the basis of a socioecologic approach (Figure 3-1), the committee posits that health behaviors result from the interplay between personal attributes (such as genetic makeup, demographics, and learning history) and the health resources and constraints that exist in the environmental settings in which a person lives (Hovell et al., 2009; McLeroy et al., 1988; Sallis et al., 2008; Stokols, 1992). Those factors interact with each other to affect health behaviors (Sallis et al., 2008) and, ultimately, the health of a population. Their influence is cumulative and unfolds throughout the life course of individuals, families, and communities (Booth et al., 2001; IOM, 2001). The factors are in operation before people enter the military system and throughout different phases of their military life, including recruitment, training, active duty, deployment, and discharge or retirement. The analysis focuses specifically on the patterns and levels of tobacco use found among those populations (Lindheim and Syme, 1983) and the role of social, cultural, and institutional contexts in shaping behaviors that can result in tobacco use (Sallis et al., 2008). On the basis of the socioecologic perspective, reducing tobacco use in military and veteran populations will require coordinated, multilevel interventions that address the numerous determinants of use. Creating a tobacco-free environment in the Department of Defense (DoD) and the Department of Veterans Affairs (VA) and addressing the broader factors that influence smoking and the use of smokeless tobacco in the military and in veterans at the population level may be more cost- effective than focusing solely on behavioral and pharmaceutical interventions at the individual level (IOM, 2001). Intervention efforts to 79
80 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Societal Community Interpersonal Individual FIGURE 3-1 The socioecologic model of levels of influence on behavior. Individual factors include biologic characteristics and personal history. Interpersonal factors include interactions with peers, intimate partners, and family. Community factors include schools, workplaces, and other organizations where social relationships can occur. Societal factors are social and cultural norms; health, economic, educational, and social policies; and religious and cultural belief systems (CDC, 2007). prevent tobacco-use initiation and promote cessation would need to be implemented at the multiple outlined levels (IOM, 2001). Individually oriented interventions would be most effective when the environment in which people live and make choices is in synchrony with the knowledge and behaviors addressed in the programs. Environmental and policy changes will be most effective when they are combined with programs that motivate and educate people to respond to the changes (Kumanyika, 2007). Progress made in tobacco control in the general population has been based on a socioecologic understanding of health and human behavior (Hovell et al., 2009; Martinez-Donate et al., 2008). The greatest changes in smoking prevalence have resulted from populationwide interventions: economic measures to reduce access to tobacco; laws and regulations restricting tobacco use, advertising, promotion, and sales of tobacco products; and multicomponent public-education campaigns (Fisher et al., 2004; Task Force on Community Preventive Services, 2005). Lessons from tobacco control illustrate a compounding effect due to the interaction of interventions at different levels; tobacco-control interventions at the population level have proved most effective when conducted in combination with individual-level interventions. For example, smoking restrictions in workplaces and other public places can increase smokersâ motivation to seek cessation services and to restrict smoking in their homes (Borland et al., 2006), which in turn may
FACTORS THAT INFLUENCE TOBACCO USE 81 promote cessation (Pizacani et al., 2004) and reduce initiation (Farkas et al., 2000). Likewise, the effectiveness of individual-level and school- based interventions, such as home smoking bans and school-based smoking-prevention programs, is enhanced when they take place in the context of strong communitywide tobacco-control efforts that support and reinforce changes effected at these levels (Perry, 2001). The socioecologic approach has been applied to analyses of health behaviors and the design of interventions to address a variety of other public-health issues, including physical activity (Booth et al., 2001; Sallis et al., 2006), diet and eating behaviors (Glanz et al., 2005), condom use (Cohen et al., 1999), and chronic-disease self-management (Norris et al., 2002). The framework has also been used as a guide to public-health programs nationally and internationally, including Healthy People 2010 (HHS, 2000) and the World Health Organization (WHO) Framework Convention on Tobacco Control (WHO, 2003) (see Chapter 4 and Appendix A). A SOCIOECOLOGIC ANALYSIS OF TOBACCO USE IN MILITARY AND VETERAN POPULATIONS The socioecologic analysis of tobacco use includes attention to the individual, interpersonal, community, and societal factors in military and veteran populations and considers the role of the broader social, cultural, and political context in creating an environment that may increase use. That dynamic interplay may account for increasing trends of tobacco use in the military and veteran populations over the last decade. At the individual level, the physiologic processes that underlie nicotine addiction and the high rates of physical and mental comorbidity found in these populations are addressed. At the interpersonal level, the psychosocial factors that characterize life in the militaryâincluding separation from family and friends, alternation of high levels of stress with periods of boredom, peer influences, and the perceived role of tobacco use in facilitating social connectednessâand the limited opportunities to adopt alternative, healthier coping strategies are considered. Attitudes toward tobacco use in DoD and VA, their organizational structure, and their current practices and policies that may be exacerbating the tobacco epidemic and preventing the progress in tobacco control are addressed. Variable taxation of tobacco products by the federal and state governments and the role of the tobacco industry in keeping tobacco prices low contribute to the use of tobacco by adults and children. Finally, current congressional mandates, economic constraints on a national scale, and the sustained military conflicts in Iraq and Afghanistan operate to reduce the ability of DoD and VA to become tobacco-free and increase the rates of tobacco use by active-duty and
82 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS SOCIETAL â¢ Historical association COMMUNITY between smoking and military â¢ No comprehensive tobacco control program â¢ Congressional INTERPERSONAL legislation â¢ Acceptability of smoking â¢ Family INDIVIDUAL influence â¢ Limited enforcement of â¢ Genetic predisposition restrictions â¢ Tobacco taxes â¢ Nicotine addiction â¢ Peer and prices â¢ Sociodemographics influence â¢ Designated tobacco-use areas â¢ Comorbidities â¢ Stress and â¢ Easy access to tobacco boredom â¢ Insufficient provider training â¢ Tobacco industry involvement â¢ Lack of easily accessible cessation programs â¢ Deployment to war-zone FIGURE 3-2 Some of the socioecologic influences on tobacco use among the military and veteran populations. retired military personnel and veterans. Future chapters will provide specific proposals for interventions to advance tobacco control in the military and veteran populations. Figure 3-2 illustrates some of the influences that may affect a personâs decision to start or continue tobacco use in the military and veteran populations. Table 3-1 maps the levels of influence specific to military personnel and veterans. INDIVIDUAL FACTORS Individual factors, attributes that reside within the individual, are major determinants of whether one uses tobacco. They encompass demographic, biologic, and psychologic components, some of which can be modified by the individual and the environment (such as education and skills) and some of which cannot (such as age and genetic makeup). Of primary importance is the addictive nature of nicotine, a powerful determinant of continued tobacco use.
FACTORS THAT INFLUENCE TOBACCO USE 83 TABLE 3-1 Socioecologic Model and Levels of Influence for Military and Veteran Populations Level of Influence Military Population Veteran Population Individual Soldier, seaman, airman, Veteran marine Interpersonal Military unit, unit commander, Family, friends, health-care family, friends, health-care provider, co-workers provider Community Installation personnel or Employer, veteran service commander; military treatment organization; local VA facility, TRICARE health-care health-care facility, local facility community Society DoD: Army, Navy, Marine VA, Congress, state Corps, Air Force, Office of the government, tobacco Assistant Secretary of Defense industry (Health Affairs); Congress; tobacco industry Nicotine Addiction In this report, dependence and addiction are used interchangeably. They are considered equivalent because they describe similar neurochemical and behavioral processes that sustain drug use (US Surgeon General, 1988), and they indicate a loss of control over drug-taking behaviorâthe principal characteristic of drug addiction. Definitions of and criteria for drug dependence or addiction have been put forth by numerous health organizations and authorities. According to WHO, drug dependence is âa behavioral pattern in which the use of a given psychoactive drug is given a sharply higher priority over other behaviors which once had a significantly higher valueâ (No Author, 1982)âin other words, the drug has come to control behavior to an extent that is considered detrimental to the individual. Specific criteria have been defined and developed for nicotine dependence and nicotine withdrawal by the American Psychiatric Association (2000) and for tobacco dependence and tobacco withdrawal by WHO (1992). The 1988 surgeon generalâs report The Health Consequences of Smoking: Nicotine Addiction also presented criteria for drug dependence (US Surgeon General, 1988). In addition to a userâs behavior being controlled by a drug, the surgeon generalâs criteria require that the drug produce psychoactive effects and that there be evidence that the drug- taking behavior is reinforced by these effects. Nicotine is associated with well-known pleasurable psychoactive effects, such as arousal, relaxation,
84 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS and improved mood. It has also been shown to act as a positive reinforcer of smoking; for example, people smoke only tobacco that contains nicotine, and regular smokers modify their smoking behavior to maintain a particular concentration of nicotine in the body (Heishman et al., 1997). Nicotine dependence has also been defined as meeting three of the seven criteria for dependence in the Diagnostic and Statistical Manual of Mental DisordersâIV during the preceding year (American Psychiatric Association, 2000). The 2001â2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that 24.9% of the US adult population currently smoked cigarettes and 12.8% of adults were nicotine-dependent; the latter group consumed 57.5% of all cigarettes smoked (Grant et al., 2004). Biology of Nicotine Reinforcement The biology of nicotine addiction is reviewed in detail elsewhere (Benowitz, 2009). A few key aspects of the biology are mentioned here. Nicotine acts on the brain by binding to nicotinic cholinergic receptors that are normally activated by endogenously released acetylcholine. Brain-imaging studies demonstrate that nicotine acutely increases activity in the prefrontal cortex, thalamus, and visual system (Brody, 2006). It results in the release of a variety of neurotransmitters of which the most important is dopamine, which appears to be critical in drug- induced reward (Dani and De Biasi, 2001; Nestler, 2005) and signaling of a pleasurable experienceâthis is necessary for the reinforcing effects of nicotine and other drugs of abuse (Nestler, 2005). The decrease in brain-reward function experienced during nicotine withdrawal is an essential component of nicotine addiction and a key barrier to abstinence. Psychoactive Effects of Nicotine and Nicotine Withdrawal The nicotine in tobacco induces stimulation and pleasure while reducing stress and anxiety. Smokers come to use nicotine to modulate their levels of arousal and for mood control in daily life. Smoking may also improve concentration, reaction time, and the performance of some tasks. When one stops smoking, the following nicotine-withdrawal symptoms may emerge: irritability, depressed mood, restlessness, anxiety, problems in getting along with friends and family, difficulty in concentrating, increased hunger and eating, insomnia, and craving for tobacco (Hughes and Hatsukami, 1986). Most smokers experience withdrawal symptoms when they are unable to smoke. Withdrawal in untreated smokers produces mood disturbances comparable in intensity with those seen in psychiatric outpatients (Hughes, 2006). One withdrawal symptom seen in connection with nicotine and other drugs of
FACTORS THAT INFLUENCE TOBACCO USE 85 abuse is hedonic dysregulationâthe feeling that there is little pleasure in life. Activities that were once rewarding are no longer enjoyable (Koob and Le Moal, 1997). It is hypothesized that a relative deficiency in dopamine release after long-standing nicotine exposure accounts for many of the mood disorders and for the tobacco craving that may persist for long periods after quitting (Benowitz, 2009). Conditioned Behavior and Nicotine Addiction All drug-taking behavior is learnedâa result of conditioning. It is reinforced by the consequences of the pharmacologic actions of the drug in question, as discussed above in relation to nicotine. At the same time, the user begins to associate specific moods, situations, or environmental factors with the rewarding effects of the drug. Respiratory-tract sensory cues associated with tobacco smoking are a type of conditioned reinforcer that has been shown to play an important role in the regulation of smoke intake, the craving to smoke, and the rewarding effects of smoking (Rose et al., 1993, 2000). The association between such cues and expected drug effects and the resulting urge to use the drug is a type of conditioning. Animal studies have found that repeated nicotine exposure increases the behavioral control of conditioned reinforcers (such as tobacco cues) contributing to the compulsivity of smoking behavior (Olausson et al., 2004). Cigarette smoking is maintained, in part, by such conditioning. People habitually smoke cigarettes in specific situations, such as after a meal, with coffee or alcoholic beverages, or in the presence of other smokers. The repeated association between smoking and particular events causes specific environmental situations to become powerful smoking cues. Likewise, aspects of the drug-taking process, such as the manipulation of smoking materials, the taste or smell of smoke, or the feeling of it in the throat, become associated with the pleasurable effects of smoking. Even unpleasant moods can become conditioned cues for smoking. For example, a smoker may learn that not having a cigarette provokes irritability (a common symptom of the nicotine-abstinence syndrome) whereas smoking a cigarette provides relief. After such repeated experiences, a smoker may come to regard irritability from any source, such as stress or frustration, as an indicator to smoke (Benowitz, 2009). Genetics of Nicotine Addiction Twin studies have indicated a high degree of heritability (at least 50%) in the prevalence of cigarette-smoking, the ability to quit smoking, the number of cigarettes smoked per day (Lessov-Schlaggar et al., 2008),
86 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS and the nature of particular symptoms experienced when a smoker stops smoking (Pergadia et al., 2006). Numerous studies have attempted to identify genes underlying nicotine addiction (Lessov-Schlaggar et al., 2008), but studies of the genetics of nicotine dependence and smoking behavior are problematic because such complex behaviors are determined by multiple genes and by environmental factors. Recent genomewide association studies have pointed to several genes that are promising signals for genetic determinants of nicotine dependence. Bierut et al. (2007) studied a phenotype that is thought to reflect susceptibility to nicotine dependence and showed a significant association with genes that code for components of nicotinic receptors found in the brain (Saccone et al., 2007). Other genomewide association studies have identified a number of genes that affect cell adhesion and extracellular matrix molecules. The genes are common among various addictions; this is consistent with the idea that neural plasticity and learning are key determinants of individual differences in vulnerability to nicotine and other drug addictions (Kauer and Malenka, 2007; Uhl et al., 2007). Genetic studies have identified genes that encode parts of the receptors for the neurotransmitter gamma-aminobutyric acid (Grucza and Bierut, 2006). Those genes may be involved in the development of alcohol and nicotine dependence. Siblings of alcohol-dependent people had a 1.7 times higher risk of becoming habitual smokers than did siblings of nonalcoholics; if the alcohol-dependent people were habitual smokers, the siblingsâ risk was a increased further by a factor of 1.8 (Bierut et al., 1998, 2000). Nicotine Addiction, Mental Illness, and Substance Abuse People who have mental illness or substance-abuse disorders have higher rates of smoking. Results of the National Comorbidity Survey (NCS) show that 41.0% of people who had a mental illness in the preceding month were current smokers, compared with 22% of those who did not, and 60% of those with a lifetime history of mental illness were smokers (Lasser et al., 2000). Moreover, people with mental illness consume over 44% of all cigarettes sold in the United States (Lasser et al., 2000). The 2001â2002 NESARC found that 12.8% of the US population was nicotine-dependent and consumed 57.5% of all cigarettes. Nicotine-dependent people who had a mental illness amounted to 7.1% of the US population but consumed 34.2% of all cigarettes (Grant et al., 2004). Specifically, smoking prevalence is higher in people who have the following diagnosed disorders than in the general population:
FACTORS THAT INFLUENCE TOBACCO USE 87 schizophrenia, major depression, bipolar disorder, anxiety disorder, panic attacks, attention deficit hyperactivity disorder, posttraumatic stress disorder (PTSD), alcohol abuse, and illicit drug abuse (see Table 3-2 for details) (Lasser et al., 2000; Ziedonis et al., 2008). Results from the NESARC showed that 12-month prevalence of nicotine dependence was 52.4% in those who had any drug disorder, 34.5% in people who had any alcohol-use disorder, 29.2% in those who had any mood disorder, 27.3% in those who had any personality disorder, and 25.3% in those who had any anxiety disorder (Grant et al., 2004). Kotov et al. (2008) found that current smoking rates ranged from 67% to 73% in people who had bipolar, major depressive, or schizophrenia spectrum or other psychotic disorders. Patients who have more severe psychiatric symptoms are more likely to be smokers (Kalman et al., 2005); specifically, those in clinical mental-health treatment centers (outpatient, inpatient, residential, or state mental hospitals) have higher rates of tobacco dependence (American Psychiatric Association, 2006). Smoking is also associated with suicide, although smoking cessation does not appear to be (Hughes, 2008). TABLE 3-2 Tobacco-Smoking Status and Quit Rates According to Lifetime Presence of Psychiatric Disorder in the United States (%) US Current Lifetime Smoking Lifetime Diagnosis Population Smokers Smokers Quit Ratesa No psychiatric disorder 50.7 22.5 39.1 42.5 Anxiety disorders: Social phobia 12.5 35.9 54.0 33.4 Posttraumatic stress disorder 6.4 45.3 63.3 28.4 Agoraphobia 5.4 38.4 58.9 34.5 Generalized anxiety disorder 4.8 46.0 68.4 32.7 Panic disorder 3.4 35.9 61.3 41.4 Mood disorders: Major depression 16.9 36.6 59.0 38.1 Dysthymia 6.8 37.8 60.0 37.0 Bipolar disorder 1.6 68.8 82.5 16.6 Psychotic disorder 0.6 49.4 67.9 27.2 (nonaffective) a Smoking quit rate defined as proportion of lifetime smokers who were not current smokers (no significant difference in rates when quit rate was defined as not having smoked for more than preceding year). SOURCE: Adapted with permission from Lasser et al. (2000) and based on National Comorbidity Survey data.
88 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Several mechanisms are believed to underlie the phenomenon of nicotine addiction and mental-health disorders as comorbidities. One is the ability of nicotine to reduce the severity of some psychiatric symptoms. For example, the release of serotonin and norepinephrine in the brain by nicotine is similar to the neurochemical effects of some antidepressant medications. Nicotine may improve sensory gating (the process by which the brain responds to stimuli), which is abnormal in schizophrenics. Improvement in sensory gating secondary to nicotine intake might be expected to enhance the ability to sort out extraneous stimuli and therefore improve attention (Martin and Freedman, 2007). In addition, cigarette smoking inhibits monoamine oxidase A and B (Lewis et al., 2007); such inhibition is used to treat depression, therefore cigarette smoking might benefit depressed patients in the same manner. Finally, nicotine, through its stimulant effects, may reduce unpleasant sedative side effects of psychiatric medications and reduce the sedation caused by alcohol. Tobacco Use and Alcohol Abuse There is a substantial link and possible shared genetic susceptibility between alcohol abuse and cigarette smoking (Le et al., 2006; Madden and Heath, 2002; Wilhelmsen et al., 2005). The 2001â 2002 NESARC found the 12-month prevalence of nicotine dependence to be 45.4% in people who were alcohol-dependent (Grant et al., 2004). Alcohol abusers are more likely to die from smoking-related causes than from alcohol (Burling and Ziff, 1988; Hurt et al., 1996). In a study of 499 smokers who were receiving intensive treatment for alcohol dependence, 95% considered themselves to be physically addicted to nicotine, and they smoked a mean of 25.5 cigarettes/day. Over 45% of the participants lived with another smoker, 39% had attempted to quit in the preceding year, 46% indicated that they were taking action to quit, and 33% were starting to think about quitting. 16.7% thought they should quit but were not ready. Only 8% had been told by an alcohol counselor to quit smoking and alcohol concurrently, 32% had been counseled to quit smoking in the future, and 24% had been advised to not quit by their alcohol counselor (Joseph et al., 2003). In a review of 24 smoking- cessation studies of people in treatment for substance abuse or dependence, Sussman (2002) found that quit rates increased with length of abstinence from substance use. Although some substance abusers may not benefit from or may even be harmed by concurrent treatment, for most âattempting to quit smoking does not seem to interfere with recovery from other substances . . . and concurrent exposure to smoking cessation treatment will assist with recovery.â Sussman noted that substance users who smoke differ from nonusers who smoke in several
FACTORS THAT INFLUENCE TOBACCO USE 89 ways: they started smoking at an earlier age, smoke more cigarettes per day, have more cognitive deficits, have more comorbid psychiatric disorders, have more medical problems, and have lower levels of smoking-cessation self-efficacy. Tobacco Use and Anxiety Disorders Anxiety disorders affect 25% of people (more women than men) during their lifetime and thus make up the largest entity of psychiatric disorders in the United States (Breslau et al., 1991). Anxiety disorders defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders include generalized anxiety disorder (GAD), PTSD, agoraphobia, panic disorder, simple phobia, and social phobia (American Psychiatric Association, 2000). According to data from the 2001â2002 NCS, the prevalence of nicotine dependence in those with any anxiety disorder is higher than that in the general population. Although the percentage of current smokers differs among disorders, from 31.5% for social phobia, to 44.6% for PTSD, to 54.6% for GAD, all of the rates are significantly higher than the 22.5% of current smokers who had no past or current psychiatric disorder (Lasser et al., 2000). It has been suggested that nicotine dependence increases the risk of PTSD. Koenen et al. (2005) in a study of over 6,744 Vietnam veteran twins found that nicotine dependence almost doubled the risk of developing PTSD in men exposed to trauma compared with the risk in nonsmokers. The prevalence of nicotine dependence was 71.2% in veterans who had PTSD compared with 40% in those who did not. Shared genetic effects accounted for about 63% of the association. Trauma alone and PTSD were associated significantly but less strongly than with nicotine dependence. Alterations in the function of the hypothalamic-pituitary-adrenal (HPA) axis seen in people who have PTSD may increase the risk of nicotine dependence. In a review of the neurobiologic association between smoking and PTSD, Rasmusson et al. (2006) suggested that activation of the HPA axis in response to a threat or stress releases neurohormones that can lead to arousal and anxiety. This dysfunction in areas of the brain that modulate reward, that is, the frontal lobe, hippocampus, and nucleus accumbens, is purported to promote nicotine dependence. Tobacco Use and Depression Depression is a common psychiatric disorder with a variety of subtypes and severity levels. Among patients who have depression, over 30% are daily smokersâa higher rate compared with that in the general
90 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS US population (Grant et al., 2004; Waxmonsky et al., 2005). Nearly 60% of those with a lifetime history of depression are current or past smokers (Lasser et al., 2000). Smokers have significantly higher rates of lifetime depression than nonsmokers (lifetime prevalence rates of major depressive disorder may reach 64% among those in clinic-based smoking treatment). Specifically, those who are nicotine-dependent are twice as likely as nonsmokers to have a history of depression (Breslau and Johnson, 2000; Breslau et al., 1991; Hitsman et al., 2003). Some studies have suggested that daily and chronic smoking may increase a personâs susceptibility to depression because of compensatory neurophysiologic changes (Hughes, 1999; Markou and Kenny, 2002; Markou et al., 1998). Tobacco Use and Schizophrenia Although rates vary by study setting and the presence of other comorbidities, such as substance-use disorders, about 70â85% of people who have schizophrenia are tobacco users (Hughes et al., 1986; Workgroup on Substance Use Disorders, 2006). As seen with other psychiatric disorders, about 50% of those who have schizophrenia are heavy smokersâdefined as people who smoke more than 25 cigarettes/day (Lasser et al., 2000; Ziedonis et al., 1994). According to a meta-analysis of 42 studies conducted in 20 nations, the odds ratio (OR) for current smoking in schizophrenics compared with the general population is 5.9; rates were higher in males (OR, 7.2) than in females (OR, 3.3) (de Leon and Diaz, 2005). Psychologic Stress and Comorbid Conditions in the Military It has been estimated that cigarette consumption in the general population increases by nearly 10% in stressful times, such as after the terrorist attacks on September 11, 2001 (Galea and Resnick, 2005). Smoking initiation, specifically in military populations, has been found to be associated with stress and boredom. According to the 2005 DoD Survey of Health Related Behaviors Among Active Duty Military Personnel, the most commonly endorsed reasons for initiating smoking in the services, particularly in the Army and Marine Corps, included âto help relieve stressâ (25.4%), âto help me relax or calm downâ (26.2%), and âto relieve boredomâ (22.2%) (DoD, 2006). Haddock et al. (2008) found that âstressâ and âboredomâ were frequently cited as reasons for smoking in the military, particularly during deployment. In a survey of military personnel, a junior enlisted member discussed tobacco use in the military: âI think this one too can be tied back into itâs a good way to deal with boredom or stress because when youâre deployed there was a lot of tobacco as opposed to other essential things that you need like over
FACTORS THAT INFLUENCE TOBACCO USE 91 in the desert, when we were there, too, and thereâs nothing to do over there, and we figure you know youâre going to die from smoking but we might die from being hit by a rocketâ (Haddock, 2008). See Table 3-3 for specific numbers regarding stress and smoking. TABLE 3-3 Stress and Mental-Health Indicators by Smoking Statusa Current but Current Never Former Not Heavy Heavy Problem/Level Smoked Smokers Smokers Smokers Stress at work, past 12 months A lot 15.4 (0.6) 17.6 (1.1) 23.4 (1.2) 29.8 (1.5) Some/A little 59.4 (1.0) 62.1 (1.4) 55.2 (1.7) 53.4 (1.7) None at all 25.3 (1.0) 20.3 (1.3) 21.4 (1.2) 16.8 (1.0) Stress in family, past 12 months A lot 26.9 (1.0) 31.4 (1.6) 38.3 (1.3) 51.0 (2.2) Some/A little 58.0 (1.0) 57.9 (1.6) 51.6 (1.0) 40.7 (2.1) None at all 15.1 (1.1) 10.7 (0.9) 10.1 (0.8) 8.4 (0.9) Days in past month limited usual activities due to poor mental health 11 or more days 2.2 (0.3) 2.0 (0.4) 3.5 (0.4) 6.4 (0.9) 4-10 days 2.3 (0.3) 2.2 (0.4) 4.6 (0.6) 5.2 (1.0) 1-3 days 7.9 (0.4) 7.4 (0.8) 11.7 (0.9) 11.7 (0.8) None 87.6 (0.7) 88.4 (0.9) 80.3 (0.9) 76.8 (1.6) Need for further anxiety evaluation, past 30 days Yes 15.6 (0.8) 16.1 (1.0) 20.7 (1.1) 32.2 (2.1) No 84.4 (0.8) 83.9 (1.0) 79.3 (1.1) 67.8 (2.1) Need for further depression evaluation Yes 18.5 (0.9) 19.6 (1.0) 26.9 (1.5) 36.3 (2.2) No 81.5 (0.9) 80.4 (1.0) 73.1 (1.5) 63.7 (2.2) Suicidal ideation, past year Yes 3.8 (0.4) 3.6 (0.7) 6.5 (0.6) 9.3 (1.5) No 96.2 (0.4) 96.4 (0.7) 93.5 (0.6) 90.7 (1.5) Serious psychological distress, past 30 days Yes 6.5 (0.5) 6.0 (0.6) 10.0 (0.8) 14.5 (1.5) No 93.5 (0.5) 94.0 (0.6) 90.0 (0.8) 85.5 (1.5) Need for further PTSD evaluation, past 30 days Yes 0.9 (0.2) 0.7 (0.2) 2.0 (0.2) 4.0 (0.6) No 99.1 (0.2) 99.3 (0.2) 98.0 (0.2) 96.0 (0.6)
92 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Current but Current Never Former Not Heavy Heavy Problem/Level Smoked Smokers Smokers Smokers Any physical/sexual abuse Yes 31.5 (1.1) 37.4 (1.6) 39.1 (1.2) 42.7 (2.1) No 68.5 (1.1) 62.6 (1.6) 60.9 (1.2) 57.3 (2.1) a Percentage of military personnel by smoking status who reported the stress and mental health problems noted; standard error of each estimate is in parentheses. SOURCE: Reproduced from DoD (2006). A 2008 publication from the Millennium Cohort Study, a 21- year longitudinal study of risk factors related to military service, has provided more recent information about tobacco use in the military (Smith et al., 2008). The authors found that military deployment is associated with smoking initiation. Between 2004 and 2006, the prevalence of smoking among the study population increased by 48%; smoking rates increased by 57% among those deployed and by 44% among those not deployed. Of those who reported never having smoked at baseline, 1.3% of nondeployed and 2.3% of deployed reported initiating smoking on entry into the military. Nearly 30% of those who were past smokers at baseline and were not deployed reported resuming smoking; 39.4% of those who were past smokers at baseline and were deployed reported reinitiating the behavior. Combat exposure was found to be associated with smoking: baseline never smokers with combat exposure were at 1.6 times greater risk of initiating smoking, and baseline past smokers with combat exposure were at 1.3 times greater risk of resuming smoking than those who were not exposed to combat (Smith et al., 2008). In the current conflicts in Iraq and Afghanistan, rates of mental illness and substance-use disorders (for example, alcohol abuse and marijuana use) are increased, and, as described earlier, those with such comorbid conditions are more likely to use and be addicted to tobacco. Hoge et al. (2006) noted that 19.1% of military personnel returning from Iraq met the risk criteria for a mental-health concern compared with about 8.5% of soldiers surveyed before initial deployment to Iraq or Afghanistan. Specifically, the prevalence of PTSD in Iraq war veterans a year after the end of deployment was 16.6%; the predeployment rate in a comparable sample was 5%. Mental-Health Disorders in Veterans As stated in Chapter 2, veterans enrolled in the VA health-care system are generally older, are more financially disadvantaged, and have
FACTORS THAT INFLUENCE TOBACCO USE 93 higher rates of medical and psychiatric disorders than the general population. For example, over 36% of enrolled veterans reported fair or poor health status compared with excellent, very good, or good health. In addition, 26.3% of enrollees reported that they had experienced difficulty in concentrating, remembering, or making decisions because of a physical, mental, or emotional condition (VA, 2006). VA treats a large number of veterans returning from Operation Iraqi Freedom (OIF) in Iraq and Operation Enduring Freedom (OEF) in Afghanistan with psychiatric disorders. Seal et al. (2007) surveyed 103,788 OEF and OIF veterans seen at VA health-care facilities and found that 25% received mental- health diagnoses; of those, 56% had two or more distinct mental-health diagnoses. INTERPERSONAL FACTORS The experience of serving in the military is a risk factor for tobacco use and may play a role in the initiation of smoking among military personnel (Cronan and Conway, 1988). DoD (2006) found that 18.4% of military personnel who responded to a 2005 survey said that they started smoking after joining the military, including 37.5% of current smokers. Certain aspects of the military experience may encourage tobacco use, such as acceptability of smoking by oneâs social networks. Family, friend, and peer influences are sources of behavioral models and social support that are predictors for smoking and its initiation (Vink et al., 2003). Haddock et al. (1998) stated that social factors are the strongest predictors of tobacco use; for example, having friends who smoke and view smoking as attractive significantly increases oneâs own risk of smoking. In addition, by modeling the influence of social networks on smoking behaviors, Christakis and Fowler (2008) found that people seem to act in accordance with and under the collective pressures of their social niche. Surveys of health behaviors in the military have noted similar findings linking peer influence to tobacco use (DoD, 2006; Nelson et al., 2009). Nearly 9% of the participants in the 2005 DoD survey started smoking âto fit in with my friendsâ; this rate varied somewhat among the servicesâ5.6% of Army personnel and 11% of Air Force personnel reported fitting in with others as a factor in smoking initiation. Servicewide, nearly 7% reported that they started smoking âto look âcoolâ or be âcoolââ (DoD, 2006) (see Table 3-4 for more detailed responses). In another survey of tobacco use in military personnel, a supervisor stated the following: âYouâre an Airman and you are hanging out with fellow Airmen and the thing to do was go to the club. You could go to the gym too, but you also went to the club and at the club it was
94 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS drink and then you started smokingâ (Haddock, 2008). Over 40% of those responding to the 2005 DoD survey, specifically, over 50% of those in the Army and Marine Corps and 30% in the Air Force reported that most of their friends in the military smoked (DoD, 2006). According to a junior enlisted member, âI have friends and theyâd maybe smoke occasionally when they drink or something, when theyâd go out socially. When we went to Baghdad they smoked every day. Pack a day. Just went out of control. Theyâd say it was a stress relieverâ (Haddock, 2008). Smoke pits are designated areas for military personnel to take regular smoking breaks; they provide an opportunity to socialize with others while possibly encouraging tobacco use by both smokers and nonsmokers. A junior enlisted smoker stated: âIâve been out to the smoke pit all the time and two or three people that donât normally smoke bum a cigarette so they can stay.â In addition, junior military personnel report additional pressure to socialize with the senior military personnel who often frequent the smoke pits (Haddock, 2008). Wanting to remain in good standing with oneâs superiors and building camaraderie among peers may drive military personnel to increase their frequency of smoke- pit visits and facilitate joining by those who would not normally attend. TABLE 3-4 Perceived Cigarette Availability and Acceptability and Reasons for Starting Smoking Regularly, by Service (%) Marine Air Total Measure/Type of Estimate Army Navy Corps Force DoD Perceived availability and acceptability Most of my friends in the military 50.8 41.5 50.6 30.2 42.5 smoke My spouse, live-in partner, or the 41.3 42.1 42.6 45.0 42.7 person I date disapproves of my smoking Why started smoking regularly To fit in with my friends 5.6 10.3 7.8 11.0 8.5 To fit in with my military unit 1.1 3.9 1.5 1.7 2.1 To rebel against my parents or 4.5 5.6 4.2 4.8 4.8 other in authority To look âcoolâ or be âcoolâ 4.2 9.0 6.0 8.8 6.9 To look or feel like an adult 2.9 5.8 3.2 5.6 4.4 Most in my family smoked 5.2 6.5 5.3 5.5 5.6 To be like someone I admired 1.7 3.8 1.7 2.1 2.4 SOURCE: Adapted from DoD (2006).
FACTORS THAT INFLUENCE TOBACCO USE 95 Family attitudes may also affect the perceived acceptability of smoking by either encouraging or discouraging tobacco use. For example, in response to âwhy military personnel started to smoke,â 5.6% reported that most members of their family smoked. With respect to acceptability, only 43% of respondents said that their âspouse, live-in partner, or the person I date disapproves of my smoking (or would disapprove if I did smoke).â Male military personnel who reported high levels of family-related stress were more likely to be current smokers than those with low stress (Cunradi et al., 2008). Married personnel were less likely to use smokeless tobacco than unmarried personnel (Ebbert et al., 2006). COMMUNITY FACTORS This section discusses organizational factorsâsuch as culture, tolerance of tobacco use, organization-level activities, and policy and leadershipâthat may influence tobacco use by military personnel and veterans. The committee recognizes the numerous policies and practices implemented by DoD and VA (discussed in Chapters 5 and 6) that restrict and discourage use of tobacco by military personnel and veterans. However, the goal of this section is to indicate how a lack of policy or restriction may lead one to assume that tobacco use is condoned or tolerated by DoD and VA leadership. To appreciate the origin and implementation of tobacco-use policies, one must understand the organizational structures of DoD and VA. These Cabinet-level departments are extensive, with budgets in the billions of dollars; DoD employs over 2 million people and VA over 280,000 people (Office of Citizen Services and Communications, 2009). The following is a brief overview of each organizational structure to indicate the chain of command and the location of responsibility for tobacco-use policies and programs. Department of Defense DoD is headed by the secretary of defense. Reporting to the secretary and deputy secretary of defense are the secretaries of the Department of the Army, Navy (which includes the Marine Corps), and Air Force. The secretary also oversees the Office of the Secretary of Defense, which is staffed by four under secretaries, including the under secretary of defense for personnel and readiness (USD[PR]). The assistant secretary of defense for health affairs reports to the USD(PR), as does the head of the TRICARE Management Activity. The Departments of the Army, Navy, and Air Force each have a surgeon general, who is responsible for service membersâ health. The sections
96 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS below discuss some organizational factors likely to contribute to tobacco use by active-duty and retired military personnel. Acceptability of Tobacco Use As discussed earlier in this report, with the exception of the Air Force, the armed services have tobacco-use rates that are greater than those in the general US population. Rates are even higher for military personnel deployed to war zones, such as Iraq and Afghanistan. A fitness and health promotion program manager in the Marine Corps reported that marines, including commanding officers, believe that they have a right to smokeâthat the military should not put unnecessary restrictions on troops who are already making sacrifices (DoD, 2007). Army and Air Force junior enlisted personnel (including current smokers, ex-smokers, and never smokers) and their supervisors agreed that smoking was more common during deployment, partially because of a feeling that antitobacco rules were not enforced. Interviews with policy leaders from the Tobacco Policy Study indicated various levels of enforcement, from the proper enforcement of no smoking in vehicles to general disregard of designated smoking areas (Haddock, 2008). Junior enlisted personnel in the Army and Air Force indicated that such rules as that prohibiting smoking in military vehicles are routinely ignored without consequences. In a series of focus groups conducted with the same population, Haddock (2008) found that many service members still believe that the military encourages tobacco use during deploymentâsmokers are allowed to take breaks when nonsmokers are not, inexpensive cigarettes are readily available, and there still exists an underlying historical association between smoking and the military. Access to and Cost of Tobacco Products on Military Installations Almost 50% of Army and Marine Corps personnel, 33% of Air Force personnel, and 38.4% of Navy personnel reported that a reason for smoking was availabilityâthere are numerous locations to buy on installations, such as commissaries, exchanges, and package stores (DoD Instruction 1330.09, December 7, 2005). There is an added monetary incentive: DoD Instruction 1330.09 states that âprices of tobacco products sold in military resale outlets in the United States, its territories and possessions, shall be no higher than the most competitive retail price in the local community and no lower than 5 percent below the most competitive commercial prices in the local community.â
FACTORS THAT INFLUENCE TOBACCO USE 97 Leadership of Antitobacco Campaigns The Tobacco Policy Study noted that military personal and leaders do not view tobacco use as having high DoD health-service priority; other more pressing issues take precedence. It is also the opinion of some junior enlisted personnel that numerous senior leaders still view smoking as being as socially acceptable as when they joined the military in the 1970s (Haddock, 2008). Those perceptions inhibit actions against tobacco use. Smoking Breaks Although the Army and Air Force recognize that work breaks for tobacco users and nontobacco users are equal, there is a perception among junior enlisted personnel that those who smoke or use tobacco products have longer and more frequent respites from work. For example, Haddock (2008) found that âsmoking is one of the only reasons a military member can take a break or leave a duty area. . . . Breaks for other reasons are not socially sanctioned.â Lack of Activities and Privileges During Deployment A junior enlisted member commented on the lack of freedom in the military for some activities, such as drinking alcohol, sex, and listening to music. Haddock (2008) stated that the ability to smoke a cigarette, however, restores a sense of personal freedom that may have dissipated because of those restrictions. Concern About Weight Close monitoring of weight seems omnipresent in the military; those who exceed weight guidelines are reprimanded. As reported by a junior enlisted nonsmoker, weight control is another reason cited for tobacco use: âI know a lot of soldiers have told me that they want to quit, but one deterrent to quit smoking is that theyâre afraid theyâre going to gain weight, and thatâs a big deterrent.â According to the 2005 DoD survey of health-related behaviors, about 4.6% of those who smoke regularly reported that they started smoking to avoid gaining weight, and 6.4% said that they started smoking to control appetite (DoD, 2006). Lack of Consistent and Comprehensive Antitobacco Policies and Programs Interviews with policy leaders demonstrated that tobacco policies and their enforcement, or lack thereof, are inconsistent among
98 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS bases (Haddock, 2008). For example, Army representatives have indicated that leadership does not enforce the âno using smokeless tobacco while indoorsâ restriction. That is of particular concern because it may prompt cigarette users to switch to or additionally use smokeless tobacco in order to avoid going outside. Among the services and their installations, there is no consistency in smoking-cessation or tobacco-use programs. The Air Force is the only service that provides guidance on what tobacco- cessation programs are to be used by health-promotion staff (Loftus, 2008). In addition, military personnel frequently transfer to new bases, which can result in a lack of continuity in access to or level of care. To further complicate the issue, reservists and National Guard personnel cycle between civilian life and military deployment, which have different standards of behavior. Difference in Support Between Active-Duty and Retired Military Personnel Regardless of such factors as designated smoking breaks that may undermine cessation activities, there is a support network that can encourage military members on active duty to stay abstinent. Retired military personnel, however, do not appear to have such readily available access to support systems. To help remedy that situation, the DoD appropriation bill for 2009 (HR 5658) contains language that requires that DoD establish a smoking-cessation program under TRICARE; it will include all beneficiaries and will provide smoking-cessation medication (prescription and over the counter) through the TRICARE mail-order pharmacy at no cost to the beneficiaries, access to a 24/7 toll-free quitline, and access to printed and Internet Web-based tobacco-cessation material. The program has yet to be implemented. There can be a lack of continuity of care when military personnel leave the DoD medical system and either enter the VA health-care system (in which they must find new tobacco-cessation programs), obtain private insurance through civilian employers, or become uninsured. Department of Veterans Affairs Numerous organizational and community factors in VA are likely to contribute to continuing tobacco use by veterans (see Chapter 6), including the lack of a coordinated approach to tobacco-cessation programs among and within Veterans Integrated Service Networks (VISNs), a lack of funding for health care providers, and a lack of emphasis on treating tobacco users, particularly in mental health settings. Each medical center has its own approach to treating people for tobacco
FACTORS THAT INFLUENCE TOBACCO USE 99 useâresources devoted to programs, and the programs themselves, vary among the centers. VA medical facilities are required to use electronic medical records and to meet the performance standard of asking veterans about smoking and then offering brief counseling sessions, but the tobacco-cessation programs vary. Health-care providers at VA community-based outpatient clinics (CBOCs) are required to ask patients about tobacco-use status and may conduct brief counseling, but CBOCs are not required to have tobacco-cessation programs or tobacco lead clinicians (Kim Hamlett-Berry, VA, personal communication, June 4, 2008). Headquarters staff lack the authority to implement or enforce changes in VISNs, VA medical centers (VAMCs), or CBOCs regarding smoking-cessation activities. The director for the Public Health National Prevention Program in the Public Health Strategic Health Care Group at headquarters has responsibility for tobacco-use programs in VA. The director is âresponsible for the development and oversight of public health policy and clinical programs for the VA Health Care System relating to smoking and tobacco-use cessationâ and works with a technical advisory group of smoking-cessation clinicians from several VISNs (VA, 2009). Not all VISNs are represented on the technical advisory group. Another major barrier limiting primary-careâbased treatment is a lack of adequate provider time and knowledge regarding smoking treatment. Mental health-care providers may be veteransâ primary-care physicians, so they must understand the clinical-practice guidelines and be educated in simultaneous treatment for mental-health disorders and tobacco control (VA/DoD, 2004). Many VA CBOCs do not have smoking-cessation programs, and although patients can receive cessation medications at these clinics, they are referred to local health departments or state quitlines for programs. The lack of treatment coordination between VA health-care providers and community tobacco-cessation providers and the lack of structured follow-up by VA are likely to discourage a patientâs interest in tobacco cessation. Although the committee finds quitlines to be effective (see Chapter 4), it acknowledges that it may be difficult for VA health-care providers to determine whether a veteran uses a state quitline. However, a provider can take an active role by asking veterans about cessation interventions at each health-care appointment and noting their use of interventions in their medical records. SOCIETAL FACTORS This section discusses the more global influences on tobacco useâfactors that act on the societal level and may promote the use of
100 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS tobacco by military personnel and veterans. Specifically, the tobacco industry, the historical association between the military and tobacco use, and the current state of conflict are all pivotal components in helping to encourage tobacco use and hinder cessation. Influence of the Tobacco Industry The tobacco industry has a long history of thwarting attempts to advance tobacco control in the United States military and VA. In particular, analyses of tobacco-industry documents dating back several decades have shown dedicated efforts, beginning in the middle 1980s, to block attempts to raise commissary tobacco prices (Smith et al., 2007). The tobacco industry has extraordinary economic and political influence. It lobbies Congress heavily, exploits DoDâs lack of unity regarding positions on tobacco pricing, and has built alliances with the House Armed Services Committee and DoDâs morale, welfare, and recreation programs. Panels responsible for military oversight helped to advocate tobacco use as a ârightâ and low price as a âbenefit.â Another example of industry clout is the ability to block complete implementation of an Army tobacco-control program first announced in 1986 in Directive 1010.10 (Arvey and Malone, 2008). Smith et al. (2007) reviewed tobacco-industry, government, and military documents and interviewed key people to establish the influence of the tobacco industry and some members of Congress in thwarting DoD efforts to raise the price of tobacco products sold in commissaries. The tobacco industry created a âmilitary coalitionâ of military personnel, retirees, and their families to protest the proposed price increases in commissaries on the grounds that the increases would erode their compensation benefits. Ultimately, that resistance resulted in the commissariesâ selling cigarettes on consignment for the exchanges at the less discounted exchange prices (Congress does not have oversight of military exchanges). The end result of this history is a persistent and long-standing military tradition of readily available cigarettes at prices below those seen in the civilian sector (Smith et al., 2007). The tobacco industry has also had a role in resisting tobacco- control initiatives in VA, working primarily through Congress. The Veterans Health Care Act of 1992 (PL 102-585, Â§526) required that VA establish and maintain either indoor smoking areas in VAMCs, nursing homes, and domiciliary-care facilities for veterans or detached smoking areas that are accessible to patients and have heating and air- conditioning. It should be noted that many veterans have also opposed VA efforts to become tobacco-free (Hamlett-Berry, 2004).
FACTORS THAT INFLUENCE TOBACCO USE 101 Cultural Factors Smoking has long been associated with the image of a tough, fearless warrior. Movies, novels, and articles in the mass media have traditionally depicted soldiers as tobacco users. Specifically, Nelson and Pederson (2008) noted that by the end of World War I, tobacco use was collectively viewed as patriotic and as a staple for the American soldier. Even today, although to a smaller extent, military culture has encouraged the stereotype of a heavy-smoking, hard-drinking, and adventuresome service member (Conway, 1998). Implemented in 1987, the ban on tobacco use during basic training signified an important step in modifying both the behavior and the view of tobacco use among service members (Conway, 1998). It represented a pivotal period in which attitudes toward smoking began to shift in response to efforts by those in positions of authority to reshape ideas about the acceptability of tobacco use in the military. Although a positive change in the culture of smoking seems to have occurred, old beliefs linger and are immortalized through the myriad images of a soldier in a helmet, covered with dust and debris, and with a cigarette in his mouth. When Hoffman et al. (2008) conducted focus groups at Air Force and Army installations, a military supervisor said the following with regard to junior enlisted personnel: âIf they see a tough soldier, say a drill sergeant for example, if they smoke, thatâs the image they want to be, and they have that image of what they want to be.â Conway (1998) identifies and acknowledges the attitudes of tobacco use in the military and calls for their adjustmentââfurther reductions in military tobacco use rates are likely to require stepped-up efforts involving educational, motivational, and social or environmental changesââand the initiation of stronger educational messages, including ones focused on changing the accepted culture of smoking in the military. For military personnel and veterans alike, there is a permeating belief that the tobacco issue has low priority with respect to health services; according to interviews with policy leaders, tobacco is at the bottom of the list of behaviors to remedy: âDangers in the field trump the health impact of smoking. . . . Basically, if youâre putting your life on the line and itâs a cigarette, you know pretty much that itâs the least of the evils that are out thereâ (Haddock, 2008). In addition, veterans experience a multitude of ailmentsâfrom PTSD and other psychologic disorders, to drug and alcohol abuse, to musculoskeletal problemsâthat allow them to perceive smoking as a less pressing concern. Military personnel and veterans may not appreciate that their use of tobacco may
102 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS aggravate and even lead to other medical and psychologic problems, as noted in Chapter 2. Behavioral Economics Over the last 2 decades, a burgeoning literature at the intersection of psychology and economics has produced consistent evidence of situations in which competent, often well-informed people behave in ways that are more detrimental to them than slightly changed behavior would be. Such findings of âbounded rationalityâ have clear implications for policies toward tobacco that are applicable to military and veteran populations (Thaler and Sunstein, 2008). The first finding, documented repeatedly in behavioral economics, stems from âstatus quo bias,â the idea that people make choices regarding policies, consumption, and other decisions without a compelling incentive even though change would be beneficial and nearly cost-free. For example, for many people, the probability of participating in an employer-sponsored tax-deferred savings account rests on whether the employer automatically enrolls employees in such an account, despite the fact that most people say that they want to contribute to tax-deferred retirement savings plans. The second finding is that the âframingâ of situations matters; people often act on information that, if their decision- making was rational, should be irrelevant. People respond in dramatically different ways to messages that convey the same information, depending on how the information is presented. Third, behavioral economists describe the âpresent-biased preference,â the tendency to overestimate the value of short-run benefits (continued smoking relieves boredom or stress today) and underestimate the long- run benefits of quitting (quitting smoking will improve my military performance in the coming months and my long-term health). Economists and others have suggested responding to those tendencies by designing policies that preserve choice but make the âoptimalâ or greatest-welfare options for a person easier to select (Camerer et al., 2003). There are several ways in which these predictable âerrorsâ may play a role in tobacco use among military and veteran populations, as elsewhere. Status quo bias seems to exist for new recruits, and, in the short term, evidence suggests that it helps them to avoid tobacco. In an organization in which smoking was historically a behavior of the majority, the practice of tobacco-free basic training was phased in without incident, and it occurs today with little complaint from recruits and virtually 100% compliance. Those who smoked before basic training seem to have little trouble with the change to a nonsmoking environment. Thus, as the military makes nonsmoking the status quo, people may find
FACTORS THAT INFLUENCE TOBACCO USE 103 it easier to remain tobacco-free. That is echoed in the voice of young recruits who voiced their views toward tobacco policy: âIf you want us to quit smoking, tell us we cannot smokeâ (Peterson et al., 2003). Studies have shown that point-of-sale promotions of tobacco products can increase impulse buying (Carter et al., 2009) and result in recent ex-smokersâ having urges to resume tobacco use (Paynter and Edwards, 2009). Furthermore, because of the framing issues described above, several practices now in place for some military personnel may induce greater consumption of cigarettes. For example, how tobacco products are displayed varies widely even among vendors on a single military base. Some exchanges promote cigarette sales with âpower wallsâ (large portions of wall space devoted to promotional materials and the display of tobacco products) without any smoking-cessation products placed nearby (Hawthorne, 2008). In contrast, some commissaries that sell tobacco products place them in a separate section of the store enclosed in a cage-like structure and display telephone numbers for tobacco quitlines and promotion of smoking-cessation products prominently in the same location. Aside from the fact that enclosing tobacco products in a separate structure makes them harder to access and thus creates a physical barrier to purchase, the normative message sent by such a display differs greatly from that sent by a power wall. The cost of changing the display of tobacco and smoking-cessation products is low. Similarly, the procrastination that results from present-biased preferences is one reason why proactive quitlines may be more effective than passive quitlines. Such a policy incurs no cost to the people using the quitlines, but it may help them to quit. Similarly, when nicotine- replacement therapy is part of an appropriate treatment plan for smoking cessation, it should be made available with as few barriers as possible. People respond more than is ârationalâ to the delay in filling a prescription created by waiting for an hour at the pharmacy or when they need to fill out paperwork to obtain mail-order prescriptions. In summary, there are many ways in which leaders in DoD and VA could make relatively small changes in policy to exploit what we have learned from behavioral economics to reduce tobacco use (Hawthorne, 2008). Geopolitical Context The United States is engaged in two major military conflictsâ OEF began October 2001 in response to the terrorist attacks of September 11, 2001, and OIF began in March 2003 when US-led coalition forces invaded Iraq. DoD reported that as of September 30, 2008, 45,700 military personnel were deployed to OEF and 380,800 to OIF (DoD, 2008).
104 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS As noted earlier, combat-related and nonâcombat-related deployment stress is associated with increased tobacco use (DoD, 2006; Smith et al., 2008). Combat-related stressors, for example, include the need for constant vigilance against enemy attack and the difficulty in distinguishing insurgents from civilians. Noncombat stressors include separation from family and friends, loss of income, and fear of deployment to a war zone (IOM, 2007). The current large-scale military conflicts have put a strain on military and veteran resources. Priority- setting among health-care services has occurredâacute medical-care needs, such as treatment for traumatic brain injury or PTSD, are now a prominent focus of military and veteran health-care resources. For those reasons and others discussed in this chapter, tobacco-use prevention and cessation efforts do not have high priority in the DoD and VA. SUMMARY Numerous factors interact and contribute to high rates of tobacco use among the military and veteran populations. Evidence-based changesâsuch as reducing tobacco access, restricting tobacco use through proper enforcement of existing and new policies, and expanding access to effective cessation programsâshould not be difficult to attain. Long-term, sustained efforts will be required to achieve broad structural changes, such as changing social norms regarding tobacco among military and veteran populations, continuing the shift away from an association between tobacco and the military, and finding alternatives to coping with the stress and boredom of deployment. The socioecologic framework and evidence from exemplar tobacco-control programs show that factors at multiple levels of influence, from individual attributes to the social and political context, should be addressed to curb tobacco-use rates and generate a tobacco-free culture. All those efforts require leadership, strategic planning, capacity building, proper allocation of resources, and monitoring of process measures and outcomes. The following chapters provide guidance to DoD and VA on what the best approaches to tobacco control are, where DoD and VA stand with respect to the approaches, and the efforts they can undertake to leverage their resources. REFERENCES American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Publishing.
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