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5 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES The Department of Defense (DoD) is the largest agency in the federal government. Headed by the secretary of defense, it is responsible for over 1.3 million men and women on active duty and 684,000 civilians. Another 1.1 million serve in the National Guard and reserves. In addition to over 2 million military retirees and their family members who receive benefits, all active-duty members and their families are eligible to receive health care from DoD. National Guard and reserve members are also eligible for DoD health care while deployed. DoD and each of the armed services have stated that tobacco use is not an acceptable activity for military personnel (see Table 5-1). Tobacco use is not the norm for the majority of military personnel: about 70% of active-duty military do not use tobacco. Nevertheless, as described in Chapter 2, tobacco-use rates by military personnel are higher than in a comparable civilian population. Many recruits enter the service as smokers, but many military personnel who did not use tobacco before they were recruited begin to use it during their military service. This trend is of concern because tobacco use impairs military readiness (Chapter 2) and leads to short- and long-term tobacco-related health problems and increased health-care costs. DoD needs to attach high priority to preventing initiation and promoting cessation of use of tobacco products to ensure the healthiest military force possible. In this chapter, the committee examines DoDâs tobacco-control activities, discusses how they might fit into the evidence-based comprehensive tobacco-control program described in Chapter 4, and identifies institutional and programmatic barriers and opportunities in DoD that hinder or help tobacco-control efforts. The committee describes current DoD activities in all four services and provides advice on how these activities might be enhanced or integrated to reduce tobacco use by active-duty military personnel, retired military personnel, and personnel in the National Guard and reserves. Many aspects of the tobacco-control 197
198 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS TABLE 5-1 Tobacco Use Goals of the DoD and Armed Services DoD Army Navy Marine Corps Air Force âIt is DoD âReadiness âReduce âIt is Marine âThe Air policy . . . that will be tobacco use, Corps policy to Forceâs goal is smoke-free enhanced by prevent discourage the a tobacco free DoD facilities promoting the tobacco use of tobacco forceâ (Air be established standard of a product use products. . . . Force to protect all tobacco-free initiation, The objective Instruction 40- DoD civilian environment reduce non- is to establish a 101, 2008). and military that supports usersâ safe, healthy, personnel and abstinence exposure to and tobacco/ members of from and ETS smoke free the public discourages the [environmental environment visiting or use of any tobacco for all using DoD tobacco smoke] and personnelâ facilities from productâ residue, (Marine Corps the health (Army promote Order 5100.28, hazards caused Regulation quitting, and 1992). by exposure to 600-63, 2007). establish tobacco tobacco-free smokeâ (DoD, facilities . . . Instruction Department of 1010.5, 2001). the Navyâs vision is to be tobacco freeâ (SECNAV Instruction 5100.13E, 2008). program may also be applicable to DoD civilian employees and contractors who work at military facilities. ORGANIZATIONAL OVERVIEW The president and the secretary of defense form the National Command Authority, which provides direction for the military. The Office of the Secretary of Defense carries out the secretaryâs policies by tasking the military departments that train and equip the forces, the chairman of the Joint Chiefs of Staff plans and coordinates military deployments and operations, and the unified commands conduct military operations. The secretary of defense is advised by under secretaries for policy, finance, acquisitions, intelligence, and personnel and readiness. It is the under secretary for personnel and readiness who is responsible for the DoD Military Health System (MHS; see Figure 5-1).
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 199 SECDEF DEPSECDEF USD (P+R) CJCS Military Departments Joint Chiefs of Staff ASD (HA) CINCs Service TMA Surgeons General TRICARE Regional Offices MTFs MCSCs FIGURE 5-1 Organizational relationships for health-care activities in DoD. ASD(HA) = assistant secretary of defense for health affairs, CINCs = regional combatant commanders, CJCS = chairman of Joint Chiefs of Staff, DEPSECDEF = deputy secretary of defense, MCSCs = managed-care support contractors, MTFs = medical-treatment facilities; SECDEF = secretary of defense, TMA = TRICARE Management Activity, USD(P+R) = undersecretary of defense for personnel and readiness. The policy organization starts with the secretary of defense and runs through the under secretary for personnel and readiness to the assistant secretary of defense for health affairs, ASD(HA). The ASD(HA) has no direct-line command and control relationship with the surgeons general of the military departments. However, policy guidance issued by the secretary of defense through the ASD(HA) is binding on the military departments. Military Health System The 2007 MHS Strategic Plan1 states that its primary mission is to âprovide a medically ready and protected force and medical protection for communitiesâwe continuously monitor health status, identify medical threats and find ways to provide protection and improve health 1 MHS, DoD. 2008. The Military Health System Strategic Plan: A Roadmap for Medical Transformation. http://www.health.mil/StrategicPlan (accessed April 3, 2009).
200 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS for individuals, communities and the Nation. These surveillance activities focus our delivery of Individual Medical Readiness services to improve health and enhance human performance and make the environment safer so service members can withstand health threats in hostile settings.â Specifics on how that mission is to be achieved are not provided in the plan, nor is tobacco use identified as a readiness issue although it is acknowledged to be an unhealthy behavior. There are over 9 million beneficiaries of the MHS, including active-duty personnel and their dependents as well as retired personnel and their dependents. The MHS is charged with providing health-care services to the operating forces and managing health benefits for all beneficiaries via the TRICARE program. The MHS employs over 132,000 military and civilian medical personnel. The major components of the system include a direct-care system of 65 hospitals, 413 medical clinics, and 413 dental clinics (DoD, 2009); a series of contracts, including 3 managed-care support contracts; a retail and mail-order pharmacy program; the Uniformed Services Family Health Plan (or designated providers); dental benefits; and the TRICARE for Life program. Each component is involved in activities of preventive medicine and healthy-behaviors programs on behalf of military beneficiaries. As the program manager for all military health activities, the Office of the Assistant Secretary of Defense for Health Affairs (OASD[HA]) oversees all direct and purchased health-care activities of the DoD. The OASD(HA) was responsible for planning, programming, and budgeting to support outlays of over $39 billion in fiscal year (FY) 2008 for the direct-care system and all purchased care. The OASD(HA) manages those programs through staff at the Pentagon. TRICARE Management Activity TRICARE is a managed health-care program in DoD that provides health care for active-duty military and their dependents, including personnel in the reserves and National Guard who have been on active duty for more than 30 consecutive days, retirees and their dependents, and beneficiaries from other services, such as the Coast Guard and Public Health Service. TRICARE offers several health plans: TRICARE Prime, the health-maintenance option; TRICARE Extra, which has a larger provider network but also has a deductible; and TRICARE Standard, a fee-for-service option that allows beneficiaries other than active-duty personnel to see any TRICARE-authorized provider. There is also TRICARE Reserve Select for eligible National Guard and reserve members, who can buy into the plan with monthly
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 201 premiums; it is open to reservists who are not on active duty. TRICARE for Life is an entitlement program offered to retirees and their family members or survivors who are eligible for Medicare and for whom Medicare is the first payer. A policy gap exists between the legally authorized TRICARE benefits and the need to support tobacco-cessation programs. The FY 2009 National Defense Authorization Act (NDAA) remedies the gap at least partially: Section 713, âSmoking Cessation Program Under TRICARE,â states that not later than 180 days after enactment, the secretary of defense must establish a smoking-cessation program under TRICARE for all beneficiaries except those who are Medicare-eligible. The program must include, at a minimum, âthe availability, at no cost to the beneficiary, of pharmaceuticals used for smoking cessation, with a limitation on the availability of such pharmaceuticals to the national mail-order pharmacy program under the TRICARE program if appropriate,â counseling, âaccess to a toll-free quitline,â and âaccess to printed and Internet Web-based cessation material.â The secretary of defense must âprovide for involvement by officers in the chain of command of participants in the program who are on active duty.â Within 90 days after enactment, the secretary must submit a program- implementation plan to Congress; and within a year after enactment, the secretary must report to Congress on the program. The NDAA also authorizes the secretary of defense to reimburse TRICARE beneficiaries for some costs related to smoking-cessation programs. The program called for under the law is directed at smoking and not at broader tobacco-useâcessation programs. However, Congress does recognize the importance of the need to engage those in the chain of command to ensure that the program is effective. This TRICARE program will cover nonâactive-duty MHS beneficiaries. Active-duty service members will still rely on the direct- care component of the MHS for tobacco-cessation counseling and medication support. The committee finds that the current health- maintenance organization preventive-care benefit package as set forth in 32 Code of Federal Regulations (CFR) Article 199.18, Section (b)(2), specifies a number of preventive-care services that are available to beneficiaries under the Civilian Health and Medical Program of the Uniformed Services, now TRICARE Standard. Smoking cessation is not a listed benefit, but Section (b)(3) of the regulation states that âin addition to preventive care services [listed above], other benefit enhancements may be added and other benefit restrictions may be waived or relaxed in connection with health care services provided to include the Uniform HMO Benefit.â The ASD(HA) must approve any additions. Nonetheless, the committee believes that this would provide
202 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS considerably greater latitude to include cessation of tobacco use, not only smoking, in TRICAREâs benefit package. In 1999, the DoD Prevention, Safety, and Health Promotion Council (PSHPC) established the Alcohol Abuse and Tobacco Use Reduction Committee (AATURC), now the Alcohol and Tobacco Advisory Council (ATAC), to provide advice on policies related to the supply, responsible use of, and the demand for alcohol and tobacco products (DoD, 1999). ATAC recommendations are given to the DoD Medical Personnel Council for consideration. ATAC members represent the servicesâ alcohol, substance-abuse, and health-promotion programs, their medical departments, the DoD Office of Personnel and Readiness, the DoD Office of the Chief Medical Officer, and a number of other DoD offices with an interest in alcohol and tobacco policy (DoD, 2007). The committee believes that between 1999 and 2001 the ATAC had been making good progress in addressing tobacco use in DoD. However, perhaps understandably, the high interest in, and impact of, this committee seems to have diminished since the terrorist attacks on America in 2001 as the US military addressed higher priorities. Nevertheless, over the long term, tobacco use poses one of the primary risks to the health and readiness of US military forces, and a plan must be established for once again assigning high priority to tobacco use with respect to health in DoD. TOBACCO-CONTROL PROGRAMS IN THE DEPARTMENT OF DEFENSE The MHS strategic plan for 2008 cites the military tobacco-use rate as a mission element for achieving healthy and resilient personnel, families, and communities. In 1999, the ATAC developed a Tobacco Use Prevention Strategic Plan that outlined goals and tasks; metrics and objectives; requirements for policy, programs, practices, and resources; and a timeline for achieving the goals (see Appendix B for the entire 1999 strategic plan). The plan, which is still in effect but has not been updated in 10 years, has the following goals: â¢ reducing the smoking rate by 5%/year (Goal A.1), â¢ reducing the smokeless-tobacco-use rate by 15% by 2001 (Goal A.1), â¢ promoting a tobacco-free lifestyle and culture through education and leadership (Goal B.1), â¢ educating commanders on how best to encourage healthy lifestyles (Goal B.2), â¢ promoting the benefits of nonsmoking and providing tobacco counteradvertising (Goal B.3),
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 203 â¢ decreasing accessibility via increased pricing and restrictions on smoking areas and tobacco use (Goal C.1), â¢ MHS identification of users and provision of targeted interventions (Goal D.1), â¢ MHS provision of effective cessation programs (Goal D.2), and â¢ continual assessment of best practices in tobacco-use prevention (Goal E). In Chapter 4, the committee identified the key implementation components of a comprehensive tobacco-control program: a strategic plan, dynamic leadership, essential intervention components (enforceable and enforced policies, communication interventions, and evidence-based treatments), adequate resources, surveillance and evaluation of the programâs effectiveness, and management capability to adjust the program in response to that evaluation. The ATAC strategic plan covers many of those components: the strategic plan itself, policy review and development, public-relations activities, the use of evidence-based tobacco-cessation interventions, and surveillance and evaluation mechanisms. Furthermore, the plan requires specific policies on tobacco pricing and access, and it restricts when and where tobacco can be used on installations. In the following sections, the committee examines the progress that DoD has made toward achieving the goals set forth in the 1999 Tobacco Use Prevention Strategic Plan, identifies the gaps between the plan and the key program components of an evidence-based comprehensive plan as endorsed by the committee, and discusses actions that DoD can take to eliminate the gaps. The committee based its findings and recommendations on published instructions, directives, and other regulations or documents available publicly from the DoD ASD(HA) and each armed service. Reducing Tobacco Consumption Goal A.1 of the 1999 DoD Tobacco Use Prevention Strategic Plan seeks to reduce the smoking rate by 5%/year and the rate of the use of smokeless tobacco by 15% by 2001 from 1998 baseline rates. The goal was to be accomplished by establishing the AATURC to coordinate and monitor DoD progress on the prevention plan. An annual DoD survey of tobacco-use rate by active-duty personnel, National Guard and reserve personnel, DoD civilian employees, and TRICARE Prime enrollees was called for to determine progress. Populations at high risk for tobacco initiation, such as young military personnel and adolescent beneficiaries, were also to be identified. DoD established the AATURC, now the ATAC, which continues to provide recommendations on
204 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS tobacco policies and programs to the OASD(HA) through the PSHPC. The ATAC does not appear to have conducted smaller studies of tobacco use in select DoD populations; however, the DoD Survey of Health- Related Behaviors Among Military Personnel is conducted periodically (the latest survey for which data are publicly available was conducted in 2005) and reports on tobacco use by active-duty personnel (DoD, 2006). The survey does not include National Guard or reserve personnel, civilian employees, TRICARE Prime enrollees, or high-risk groups, so it is difficult to assess the full extent of the impact of the DoD tobacco- control program on all target populations. Finding: DoD does not survey tobacco use by all beneficiaries of the MHS, including all TRICARE beneficiaries. Recommendation: DoD should undertake such a survey to help to determine the needs of military personnel and their dependents for tobacco-control interventions. Tobacco-Control Programs in the Armed Services Independent tobacco-control programs have been developed by the armed services. The Army Health Promotion Program (AHPP) includes a tobacco-control component (Army Regulation 600-63, 2007). The program states that commanders and supervisors will encourage antitobacco activities in family members and retirees; that health-care providers will ask, advise, and assist patients with cessation information (3 of the 5 Aâs described in Chapter 4); and that commanders at all levels will âdemonstrate positive efforts to deglamorize the use of all forms of tobacco products.â Army installations are also directed to provide tobacco-cessation programs and, if they are not available on an installation, to coordinate such programs with local community resources. The Navy and Marine Corps Tobacco Policy (SECNAV Instruction 5100.13E, July 31, 2008) also details when and where tobacco may be used by naval personnel on installations (including housing; morale, welfare, and recreation (MWR) facilities; ships; and submarines), restricts the promotion of tobacco products, and stipulates that tobacco users should have access to tobacco-cessation treatment either on their installations or through referral to community resources. The Marine Corps, which has health-promotion personnel from the Navy, has incorporated the Navy requirements into base orders for those programs. For example, Base Order 6200.2C, âTobacco Use Prevention Program for Camp Pendletonâ (November 1993), and Base Order
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 205 6200.3C, âMarine Corps Tobacco Prevention and Control Program for Camp LeJeuneâ (February 2006) emphasize smoke-free workplaces, restrictions on tobacco use and disposal, and commander education on tobacco control. The Air Force has issued two instructions that pertain to tobacco: Air Force Instruction 40-102, âTobacco Use in the Air Forceâ (June 2002) and Air Force Instruction 40-102, Air Education and Training Command (AETC) Supplement 1, âTobacco Use in the Air Forceâ (August 2002). Those complementary instructions cover tobacco- use restrictions in the workplace, dormitories, and housing facilities; the sale and advertisement of tobacco; tobacco-cessation education programs for health-promotion personnel; and application to civilian and contractor employees. Goal B.1 of the DoD Tobacco Use Prevention Strategic Plan is to promote a tobacco-free lifestyle and culture through education and leadership. Requirements to meet the goal include education programs (discussed under âLeadership Education and Trainingâ below) and guidance on how to ensure effective leadership for tobacco control. Army Regulation 600-63 (2007) states that commanders at all levels will âdemonstrate positive efforts to deglamorize the use of all forms of tobacco products.â The Navy requires that unit commanders, commanding officers, and officers in charge must ensure that tobacco use is not part of the Navy culture and must encourage a tobacco-free lifestyle and support abstinence by personal example and command climate. Although leaders are not required to be tobacco-free, they are strongly encouraged to be (SECNAV Instruction 5100.13E, July 2008). Air Force Instruction 40-101 (May 1998) states that installation commanders are to provide leadership and guidance for integrated and comprehensive health-promotion programs but does not specify that they be tobacco-free, and Instruction 40-102 (June 2002) states that given the AETC goal of not using any tobacco products, commanders and supervisors are expected to lead by example and actively identify and use resources to help tobacco users to quit. DoD Directive 1010.10 (November 2003) establishes health- promotion programs to improve and sustain military readiness as well as the health, fitness, and quality of life of military personnel, DoD personnel, and other beneficiaries. DoD policies to prevent smoking and encourage cessation are specified in the 32 CFR 85.6, and each armed service is to develop its own health-promotion plan. The plans are implemented by the offices of the surgeons general of the military departments. The AHPP (Army Regulation 600-63, May 2007) addresses program responsibilities, from the Army deputy chief of staff to installation commanders, with implementation guidance; the tobacco- control-program guidance is brief. The program includes the Army
206 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Reserve and National Guard. The Air Force has addressed tobacco use in its Health Promotion Program (Air Force Instruction 40-101, May 1998). The Navy health-promotion plan (OPNAVINST 6100.2A, March 2007) also addresses tobacco-use prevention and cessation and delineates program responsibilities; this program is also used by the Marine Corps. Each of those regulations specifies the responsibilities of military leaders for implementation. The committee notes that although the goals of the 1999 strategic plan are in harmony with many of the components required of a comprehensive tobacco-control plan, there have been obstacles to the implementation and evaluation of the plan. The obstacles include insufficient allocation of human and financial resources, lack of engaged leadership, ineffective communication, and incomplete surveillance. Program Leadership Tobacco control has not had high priority in DoD, for several possible reasons. The committee recognizes that in a time of military conflict, DoD must first allocate resources to meet the needs of deployed forces and those who support them. The effect of tobacco products, particularly of smoked tobacco, on military readiness and performance may not be immediately apparent to commanders or even to military personnel themselves. Furthermore, the direct influence of the tobacco industry on DoD and its indirect influence via Congress in maintaining easy access to tobacco products cannot be ignored and has had the effect of keeping the DoD in the business of selling tobacco products. The tobacco industry creates relationships with groups that pressure policymakers to pass or hinder industry-favorable legislation. Research has shown that heavy lobbying by the tobacco industry and veteransâ groups helped thwart previous efforts to raise tobacco prices in commissaries (Arvey and Malone, 2008). Although the OASD(HA) and the armed services have attempted to address tobacco control, the full impact of tobacco on military readiness and health is not recognized by all military leaders. Some leadership in DoD, however, has spoken out against tobacco use. For example, in August 1996, efforts by the Assistant Secretary of Defense for Force Management Policy resulted in a price increase for cigarettes sold in commissaries in 1996, although his efforts were resisted by some members of Congress (Smith et al., 2007). The committee emphasizes that until the highest strata of DoD leadership are engaged in tobacco control, military readiness will continue to be impaired by tobacco use by active-duty personnel. As a result, all military personnel and their families, civilian employees, retirees, and the general public will bear the burden of both the adverse health effects of exposure to secondhand smoke as well as increased
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 207 health-care costs. In many cases, senior military leaders have actively engaged in and been positive role models for physical fitness, for example, by leading troops in running the Marine Corps Marathon, the Army 10-Miler, or local physical-training programs. A similar approach, in which tobacco use in the military becomes a leadership issue, and not just a medical issue, has the potential to have a major effect on tobacco use in military personnel. In the sections below, the committee follows the framework given in Chapter 4 for a comprehensive tobacco-control program. Key components of a comprehensive program are examined, including communication interventions, tobacco-use restrictions, the tobacco retail environment, cessation interventions, special populations, relapse- prevention interventions, and surveillance and evaluation, as available in DoD and the armed services. Finding: DoD has developed and put into effect a Tobacco Use Prevention Strategic Plan with goals, metrics, requirements, and a timeline. The plan is a good framework for DoD and the armed services to use to build a comprehensive tobacco-control program. Finding: Tobacco use in the armed forces continues to be considered socially acceptable behavior, with higher use than in the general population. Tobacco cessation is not a clearly stated high priority for the OASD(HA). Finding: Effective, committed, and supportive leadership from the highest levels of the departments and a designated chain of accountability for program execution are needed to increase the success of tobacco-control efforts in the DoD. Finding: There is need for a consistent and comprehensive approach to tobacco-control programs in the military community. Recommendation: Authority for developing tobacco- control policies and strategies should reside in a single high-level entity in DoD.
208 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS COMMUNICATION INTERVENTIONS On military installations, there are numerous opportunities for exposure to both positive and negative tobacco-use messages (Haddock et al., 2008) and for changing the social norm for tobacco. Given the unique environment of military installations, media campaignsâ including advertising and public educationâcan be used to inform personnel about products and issues with relative ease and through a variety of media. On many installations, active-duty personnel work and live in the same area; the installations are accessible to their dependents, retired military and their families, and National Guard and reserve members who shop at the commissaries and exchanges. Civilian employees are also exposed to mass-media messages on an installation. There are several outlets where protobacco and antitobacco messages can be conveyed to military and civilian audiences on a military installation, such as the commissaries and exchanges where tobacco and tobacco- cessation products are sold, a variety of military newspapers, posters in and on buildings around the installation, the military television channel and radio station on the installation, military Web sites, and direct mail. Finally, as noted above, leadership is vital for setting a tobacco-free example and for encouraging military and civilian personnel to follow this example by making them aware of tobacco-cessation services. First, however, the leaders themselves must be educated about the services. Advertising and Promotions Goal B.3 of the 1999 DoD Tobacco Use Prevention Strategic Plan is to promote the benefits of being a nonsmoker and to provide tobacco counteradvertising by using public-affairs and other military media. To achieve this goal, the plan requires an assessment of the armed servicesâ current policies on commercial solicitation to buy tobacco products (such as advertising, promotions, and donations) and compliance with these policies. Haddock et al. (2008) found that among 793 issues of 16 military installation newspapers over a year, there were 308 antialcohol advertisements and 82 antitobacco advertisements. The Navy had the greatest proportion of protobacco advertisements (16%); the Air Force had none. Tobacco control received less coverage than seatbelt use, alcohol, and exercise and fitness, particularly in newspapers serving Marine Corps installations (Haddock et al., 2005). In a year-long analysis of cigarette and smokeless-tobacco advertising in the 2005 issues of Military Times newspapers for each armed serviceâwhich are widely read by service members as a major source of news and informationâno advertisements for cigarettes or other forms of smoked tobacco (such as cigars) were found.
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 209 Advertisements for smokeless tobacco, however, were common: 11 different advertisements occurred in 105 placements. The authors estimated that those advertisements for smokeless tobacco generated over $500,000 in revenue for the newspapers (Haddock et al., 2008). The DoD-authorized newspaper, Stars and Stripes, does not accept advertising in its electronic or print forms (Douglas Doherty, Stars and Stripes Newspaper, personal communication, September 16, 2009). As seen above, the Military Times newspaper for each service may carry advertising for tobacco products as well as antitobacco campaigns and products. Individual installation newspapers vary as to whether they accept advertising of tobacco products. For example, the Northwest Guardian, the Army post newspaper for Fort Lewis, Washington, is not allowed to accept tobacco advertising (Cynthia Hawthorne, US Army, personal communication, March 5, 2009); this has been written into the commercial publisherâs contract. Table 5-2 summarizes the armed servicesâ regulations pertaining to the advertising and promotion of tobacco products in military publications. Air Force Instruction 40-102 (June 2002) prohibits advertising of all tobacco products in official Air Force publications and the distribution of tobacco samples on installations, and Air Force installation newspapers do not appear to carry such advertising (Haddock et al., 2005). The Navy and Marine Corps Tobacco Policy (SECNAV Instruction 5100.13E, July 2008) also prohibits the advertising and promoting of tobacco products âwhile in an official capacityâ or the distribution of free tobacco products on installations. The committee is pleased to see that many installation commanders do not permit tobacco advertising on their installations. The committee finds that such venues could be leveraged to increase antitobacco messages and promotion of tobacco-cessation products and services. Military exchanges are required to support DoD policy to communicate that âtobacco use is detrimental to health and readinessâ (DoD Instruction 1330.09, Armed Services Exchange Policy, Section 4.2.3, December 7, 2005) (see Chapter 2 for a description of military exchanges and commissaries). The strategic plan has Requirement C.1.6ââDevelop draft policy that indicates resale activities (Commissaries and Exchanges) will endeavor to display tobacco- cessation products in areas that provide visibility and opportunity to customers who desire to change their tobacco habits.â DoD Instruction 1330.21, Armed Services Exchange Regulations (July 14, 2005, Section 6.4.3) helps meet the strategic-plan requirement but the committee notes that this instruction does not appear to mandate that tobacco-cessation products be prominently displayed with tobacco products. Instruction 1330.21 also prohibits any new merchandise displays or promotion
210 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS TABLE 5-2 Advertising and Promotion of Tobacco Products in Military Publications Restriction Army Navy/Marines Air Force Advertising of Installation- Prohibits Prohibited in all tobacco products specific participation in official Air Force requirements for promotional publications advertising in base programs, (Air Force newspapers activities, or Instruction 40-102, contests aimed 2002) primarily at service members and prohibits the advertising of tobacco products (SECNAV Instruction 5100.13E, 2008) agreements for tobacco products although couponing is allowed as long as it is not âmilitary only.â Defense Commissary Agency (DeCA) Directive 40-13 (July 1992) spells out several policies aimed at deglamorizing tobaccoâsuch as avoiding special signs for tobacco departments, promotional activities (such as lighters, giveaways, and cents-off promotions), and special military-only couponsâbut contains no language regarding tobacco-cessationâproduct availability, pricing, or display. The directive also requires that posters about the surgeon generalâs warnings be in conspicuous places in the tobacco department. Finding: The armed services have made progress in reducing, but not eliminating, the advertising of tobacco products in military publications. Official publications do not carry such advertising, and relatively few commercial newspapers and magazines do. Recommendation: A DoD-wide or servicewide policy banning tobacco advertising and promotion activities on military installations should be adopted. Counteradvertising and Public Education DoD has initiated a number of public-education campaigns to promote the health benefits of weight management, avoiding alcohol abuse, and many other health concerns. Hoffman et al. (2008) studied
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 211 tobacco-related counteradvertising messages directed toward the military. The authors conducted focus groups to determine which counteradvertising messages might be most effective in discouraging tobacco use by junior enlisted members of the Air Force and Army. Four messages appealed to most of the members: 1. It is difficult to be a positive role model if you smoke. 2. Smoking increases your likelihood of early discharge from the military. 3. Smoking lowers your readiness to fight. 4. Smoking lowers your productivity. Messages about tobacco-industry manipulation of tobacco users or about the adverse health effects of tobacco were not effective antitobacco messages for this audience (Hoffman et al., 2008). The 1999 strategic plan includes public education in Goal B.3, âPromote the benefits of being a nonsmoker and provide tobacco counteradvertising using Public Affairs and other military media.â DoD has initiated a major military counteradvertising campaign aimed at that goal. The âQuit Tobacco. Make Everyone Proudâ tobacco-cessation program targets 18- to 24-year-old male service members in pay grades E-1 to E-4, and it also includes program components that may be used by all service members and their families. The program, available at www.ucanquit2.org, is multifaceted and has sections that are designed for members of each of the armed services. It includes screens that take users through â4 Steps to Quitting.â Additional features allow users to access a message board to ask questions, share opinions, and get support anonymously; to develop their own plan for quitting; to post stories to âTobacco Talesâ; to learn about tobacco-cessation medications and how to obtain them; to listen to podcasts; to participate in a live chat link; to identify tobacco-cessation programs at military installations and other program or information sources; to play games for distraction if they have an urge to smoke; and to take quizzes to assess their knowledge about tobacco use and the benefits of quitting. The site also has live access 7 days/week to trained tobacco-cessation counselors for instant- message advice that is private and anonymous. The page called âHelp Someone Quitâ is also useful for health-care providers and friends and family of tobacco users and provides materials to motivate and assist tobacco users to quit. From the site, health-care providers can order educational materials that have been tailored to each service. The committee finds that the DoD âQuit Tobacco. Make Everyone Proudâ campaign has innovative features that may be particularly effective in reaching target audiences, such as appealing to young male military
212 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS personnel to act as role models for children. Some of the outreach activities being proposed or conducted for the program include advertisements in Military Times and public-service announcements in commercial theaters, on pizza-delivery boxes, and on gasoline-pump toppers at commercial locations within 5 miles of military installations. The program has not been evaluated to determine its reach or effectiveness. The committee applauds the DoD for working to change the social norm in the military regarding tobacco use. The MHS and TRICARE also promote the Through with Chew Week, which includes the Great American Spit Out, to coincide with the American Cancer Society (ACS) Great American Smokeout. This activity is covered by the Pentagon News Channel with news clips, a press release, videos from military leaders, and testimonials from participants. The Great American Smokeout receives prominent notice each year on military-health Web sites and in various print resources. The Army Center for Health Promotion and Preventive Medicine (CHPPM) provides a variety of posters and handouts that can be used around Army installations to promote tobacco cessation; its Web site lists tobacco cessation as a âhot topicâ with links to patient-education materials. TRICARE posts current and past news releases on tobacco control on its Web site (www.tricare.mil); five news releases featured tobacco in 2008. The TRICARE Health Beat E-Newsletter for beneficiaries also periodically publishes articles on tobacco control. The committee finds that DoD has launched an innovative public-education campaign to encourage tobacco cessation in military personnel to help meet Goal B.3. More information on the tobacco- cessation messages that have the greatest effect on military personnel would help DoD tailor its public-education campaigns more effectively. Although the target audience is enlisted men 18â24 years old, as is evident from the pictures and other promotional materials, much of the Web site is applicable to a wider audience. Modification of the materials for each armed service is particularly useful, and the use of interactive components would enhance the effectiveness of the site. Finding: DoD has initiated antitobacco counteradvertising campaigns, the most recent of which is the âQuit Tobacco. Make Everyone Proudâ program. Each of the armed services has developed similar campaigns tailored to the specific cultures of the services. These programs are appropriately aimed at young male personnel, the population with the highest tobacco use.
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 213 Recommendation: The effectiveness of the programs should be evaluated, and they should be modified as necessary. The DoD needs to focus its counteradvertising campaigns on changing the military norm for tobacco use and create the expectation that tobacco use is inconsistent with military readiness. Leadership Education and Training Goal B.1 of the DoD Tobacco Use Prevention Strategic Plan is to âpromote a tobacco-free lifestyle and culture through education and leadership,â and Goal B.2 is to âeducate commanders at all levels on how best to encourage healthy lifestyles as well as the benefits of being tobacco free.â Requirements to meet Goal B.1 include assessing the content of basic, technical, and professional military training programs to ensure that they address the risks posed by tobacco use and the benefits of being a nonsmoker, and that policy is drafted, if necessary, to inform all those selected for training of the servicesâ tobacco-free goal. The committee notes that those requirements are best addressed by the individual services, although the OASD(HA) might reserve the right to oversee that the messages are consistent or appropriately adapted to the particular needs of each armed serviceâs training programs. The committee was unable to determine whether the OASD(HA) tracks such information or has provided guidance to the armed services on incorporating antitobacco messages into their educational and training programs. The AHPP (Army Regulation 600-63, May 2007) requires that health-education classes during all military training include information on tobacco use. The committee assumes that this would include training that commanders receive when assuming a post, although it is not explicitly stated in the regulation. The Army has a tobacco-cessation policy in its training regulation, Enlisted Initial Entry Training Policies and Administration (TRADOC Regulation 350-6, May 2007), and the AHPP specifically states that tobacco use is to be included in health- education classes as part of professional military training, including basic and advanced courses for enlisted personnel and officers. Air Force Instruction 40-101 (May 1998) mandates that installation commanders support health-promotion program initiatives by authorizing regular senior leadership briefings by experts on such topics as tobacco. The Navy requires that unit commanders, commanding officers, and officers in charge include the topics of nicotine addiction, the harms of tobacco use, and treatment services in all command indoctrinations and orientations, general military training for all military and civilian
214 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS personnel, and command health-promotion programs (SECNAV Instruction 5100.13E, June 2008). To meet Goal B.2 to educate commanders on how to encourage healthy lifestyles and the benefits of being tobacco-free, DoD must assess and evaluate existing educational programs for commanders that include such information. Where this component is missing from the education programs, it should be added. The committee was unable to determine whether such education programs include guidance for commanders on encouraging healthy lifestyles, but it finds that this is an appropriate approach and should help commanders to appreciate the need to give tobacco cessation high priority for readiness and health and to convey this priority to those under their commands. Finding: Although leadership training includes tobacco- control education, the DoD, the armed services, and installation leadership is not sufficiently engaged in tobacco-control policies and their enforcement. Recommendation: Military leadersâ commitment to tobacco control, including being tobacco-free themselves, should be a consideration in promotion as a part of a larger goal of maintaining military readiness. Education programs for commanders should include guidance on tobacco-use prevention and cessation and how to encourage healthy lifestyles among installation personnel. TOBACCO-USE RESTRICTIONS As discussed in Chapter 4, restricting tobacco use and increasing the price of tobacco products are among the most effective mechanisms for reducing tobacco consumption. DoD has exercised its authority to prevent the use of tobacco products in many areas but has not achieved tobacco-free military installations. Goal C.1 of the 1999 Tobacco Use Prevention Strategic Plan is to âdecrease accessibility and availability of tobacco products through pricing, smoking area, and tobacco-use restrictions.â In this section, the committee examines policies of DoD and the armed services with regard to decreasing the use of tobacco products by restricting when and where they can be used in military workplaces, including military installations, ships, submarines, aircraft, vehicles, military lodgings, the service academies and other training facilities, and other settings peculiar to the military (for example, when in uniform and during basic training). Tobacco sales and access are discussed later under âTobacco Retail Environment.â
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 215 Workplace Settings Requirements in the strategic plan to meet Goal C.1 include review of âservice policies and practices on prohibiting tobacco use in all common areas used by non-tobacco usersâ and assessing âimplementation of Executive Order 13058âProtecting Federal Employees and the Public from Exposure to Tobacco Smoke in the Federal Workplace.â In 1997, Executive Order 13058 established the precedent for tobacco-free workplaces and for enclosed smoking areas, if separately ventilated, to prevent exposure of employees and visitors to tobacco smoke. The committee notes, however, that as discussed in Chapter 4, such ventilation does not eliminate exposure to secondhand smoke (US Surgeon General, 2004). DoD Instruction 1010.15, Smoke- Free DoD Facilities, issued in January 2001, applied the executive order to all facilities owned, rented, or leased by DoD, including military installations. The instruction allowed for the same indoor smoking-area exemption as the executive order. It stipulated that smoke-break areas be outdoors and include a measure of protection from the elements. An exemption was also given to DoD MWR facilities for a 3-year phase-in after which they were also to be smoke-free. All the armed services later adopted tobacco-free policies for their facilities (see Table 5-3). The committee notes that DoD Instruction 1010.15 does not specify that facilities be tobacco-free, only smoke-free. This instruction is to be implemented by the acquisition, technology, and logistics staff on installations. Some of the armed services have specific tobacco-use restrictions that are specific to them. For example, Navy Instruction TABLE 5-3 Tobacco-Use Restrictions in Military Settings Restriction Army Navy/Marines Air Force Workplace Tobacco use Tobacco use Tobacco use prohibited in all prohibited except prohibited in all areas except for designated indoor areas, designated smoking areas including medical- smoking areas; (SECNAV treatment facilities, must display notice Instruction except for that smoking is not 1500.13E, 2008) designated allowed (Army smoking areas (Air Regulation 600-63, Force Instruction 2007) 40-102, 2002) Designated Indoor smoking Indoor smoking Indoor tobacco-use tobacco-use areas areas must comply areas must display areas are separate with provision of tobacco-use from common
216 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Restriction Army Navy/Marines Air Force DoD Instruction warnings and areas and must be 1010.15 (Army availability of enclosed and Regulation 600-63, cessation exhausted directly 2007) programs; smoking outside; prohibited areas exist on ships in all recreation and submarines facilities oriented (SECNAV toward children Instruction (Air Force 1500.13E, 2008) Instruction 40-102, 2002) Smoke breaks Smokers not Same for users and Same for users and allowed additional nonusers nonusers (Air time for breaks (SECNAV Force Instruction (Army Regulation Instruction 40-102, 2002) 600-63, 2007) 1500.13E, 2008) Smokeless tobacco No information Allowed only in Same restrictions designated as for other tobacco-use areas tobacco products (SECNAV (Air Force Instruction Instruction 40-102) 1500.13E, 2008) MWR facilities Comply with Army Prohibited unless Indoor smoking Regulation 600-63 separately areas permitted in and DoD exhausted and recreation facilities Instruction authorized by that exhaust 1010.15; commanding directly outside; designated officer; may be may not be public smoking areas indoors (SECNAV common-use areas; must exhaust Instruction prohibited in directly outside 1500.13E, 2008) facilities with (Army Regulation childrenâs 215-1, 2007) programs (Air Force Instruction 40-102, 2002) Smoking in No information Not allowed while Not allowed while uniform walking in uniform walking in uniform (includes all (Air Force tobacco products) Instruction 36- (SECNAV 2903, 2006) Instruction 5100.13E, 2008)
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 217 5100.13E (June 2008) specifies that on surface ships, smoking is permitted on weather decks and in some unmanned indoor spaces if there is direct ventilation to the outside; the instruction also identifies numerous areas that may not be used as smoking areas. Smoking is permitted aboard submarines in well-ventilated areas away from stationary watch stations; several areas are not to be used as smoking areas. There is a restriction on the number of people that can use the smoking areas on submarines on the basis of ventilation capacity. Jackman et al. (2004) found that exposure of nonsmokers to secondhand smoke on submarines was minimal during a 10-day deployment (Jackman et al., 2004). Seufert and Kiser (1996), however, found that after 62 hours in a nonventilated submerged submarine the end- expiratory carbon monoxide (EECO) levels of nonsmoking crew members were equal to the initial EECO levels of crew members who smoked, suggesting that nonsmokers were exposed to elevated levels of carbon monoxide. The committee notes that smoking on submarines poses other risks, as demonstrated by a fire on a Russian submarine that might have been caused by unauthorized smoking. The Navy prohibits the use of smokeless tobacco during briefings, classes, formations, and inspections and while on watch. Tobacco spit must be held in containers with sealed lids and disposed of in a sanitary manner that prevents public exposure (Navy Instruction 5100.13E, June 2008). Each Marine Corps base has a separate base order that serves as its tobacco-prevention and -control policy. For example, Camp Pendleton has Base Order 6200.2C, Tobacco Use Prevention Program, dated November 1993; Quantico has Marine Corps Base Order 5313.1C, Smoke-Free Workplace, dated October 2002; and Marine Corps Air Station Iwakuni in Japan has Marine Corps Air Station Order 5100.24, Tobacco Prevention and Control Program, dated November 2000. The committee found a paucity of information on the attitude of military personnel toward tobacco-use restrictions in the workplace and other community settings. Hurtado et al. (1995) found that a slight majority of 2,221 crewmembers onboard an aircraft carrier, 36% of who were smokers, favored a newly implemented smoke-free policy, including 18% of the current smokers. However, 32% of the current smokers indicated that they planned to request a transfer off the ship as a result of the no-smoking policy (Hurtado et al., 1995). The committee notes that the no-smoking policy was voluntarily implemented by the commanding officer in response to the designation of secondhand smoke as a human carcinogen. Finding: There are inconsistencies between the armed services with regard to the use of tobacco on military
218 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS installations, while personnel are in uniform, and the location of designated tobacco-use areas. Recommendation: Any tobacco use while in uniform should be prohibited. Recommendation: Designated indoor and outdoor tobacco- use areas on military installations should be discontinued such that military installations are tobacco-free. Education and Training Settings New military recruits begin their enlistments by attending basic training or boot camp, which lasts for 8â12 weeks, depending on the service. The requirements for meeting Goal B.1 of the strategic plan, promoting a tobacco-free lifestyle and culture, also pertain to tobacco- use restrictions, including assessing and evaluating tobacco-use policies in the armed services for basic and initial skills training, assessing service policies on tobacco use by students and instructors during the duty day for all formal military training schools (such as basic training and officer-training school, technical schools, and professional military- education schools), drafting policy that extends the prohibition on tobacco use to cover all formal military training, and informing all personnel selected for such training of the armed servicesâ tobacco-free goal. Goal B.2, educating commanders on encouraging healthy lifestyles, requires the development of policy requiring instructors in formal positions to serve as ârole modelsâ regarding tobacco use in the school environment. All of the armed services have tobacco policies that apply to basic training, to technical training, or to the service academies (the US Air Force Academy, the US Military Academy, and the US Naval Academy) (see Table 5-4). All of the armed services require recruits to be tobacco-free during basic training. They also state that instructors should not use tobacco products in the presence or line of vision of recruits. The committee notes that although the requirements for basic training are effective in eliminating tobacco use by new recruits during this time, loopholes in the policies governing instructorsâ use of tobacco may send a contradictory message to recruits. For example, an instructor may smoke a cigarette out of the presence of a recruit, but residual tobacco odors on the instructor might make the recruit aware that the instructor smokes; such circumstances undermine the intent of the policy. Given the important role of instructors during basic training and their
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 219 influence on recruits, recruits might consider tobacco use after training to be acceptable. A recent study evaluated the influence of role models on the initiation of smoking by US Air Force personnel who recently completed basic training (Green et al., 2008). The results indicated that previous nonsmokers were more likely to initiate smoking if they perceived that their military-training leader or classroom instructor used tobacco products (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.12â 2.56). Similarly, previous smokers were more likely to resume smoking if their military-training leader or classroom instructor used tobacco products (OR, 1.95; 95% CI, 1.29â2.94). Those findings highlight the importance of military education and role models during training in preventing tobacco use by new recruits. TABLE 5-4 Tobacco-Use Restrictions in Military Education and Training Settings Restriction Army Navy/Marines Air Force Basic training Prohibited during Use or possession Use or possession initial entry of tobacco or prohibited by nonâ training (IET) tobacco prior-service weeks 1-9; paraphernalia airmen while on prohibited by cadre prohibited in post or while in and soldiers in Recruit Training uniform (Air Force areas where they Command Instruction 40-102; may be observed Instruction AETC Instruction by IET soldiers 5100.6K (May 36-2216); posters, (TRADOC 2008) pictures, or items Regulation 350-6, regarding tobacco 2007)a are prohibited in dormitories (AETC Instruction 36- 2216, 2006) Service academies Prohibited in all Prohibited in Prohibited in all buildings except uniform; may indoor areas; Five Star Inn; smoke only in prohibited during commandant may designated areas duty hours or while designate smoking (Commandant of in uniform; rooms if there is a Midshipmen designed outdoor separate ventilation Instruction tobacco-use areas system, 5400.6L, 2008); (Air Force Cadet nonsmokers may not use Wing Manual 36- prevail; may tobacco on large 3501) designate outdoor training ships
220 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Restriction Army Navy/Marines Air Force smoking areas that (DNAS Instruction are away from 3120.1D, 2000) entrances and exits and are not commonly used by nonsmokers (USMA Policy Memorandum Number 17-00, 2000; Army Regulation 215-1, 2007) Military instructors Prohibited in Prohibited in Prohibited in and staff presence or view presence of presence or line of of cadets while on students, recruits, sight of nonâprior- duty (USMA officer candidates, service airmen Policy and midshipmen (AETC Instruction Memorandum 17- (SECNAV 36-2216, 2004) 00, 2000; Army Instruction Regulation 600-63, 1500.13E, 2008; 2007) Recruit Training Command Instruction 5100.6K, 2008); prohibited in presence of marine recruits (MCO Semper Fit Manual P1700.29, 1999) a Tobacco use is also prohibited on the grounds of any DoD education-activity school over which the Army exercises control; visitors, faculty, and staff may not use tobacco products in the presence or view of students (Army Regulation 600-63, May 2007). Finding: All of the armed services ban tobacco use during basic training. The committee commends this ban on tobacco use and finds it to be an effective mechanism for reducing tobacco consumption. Recommendation: The ban on tobacco use during basic training should be extended to all technical and advanced training of enlisted and commissioned personnel.
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 221 Furthermore, the committee recommends that all service academies, following the trend among civilian universities and colleges, become tobacco-free within 2 years of the publication of this report. Living Areas and Transportation Military personnel may live in military housing on installations or in private residences in the surrounding community. Many military personnel are transient and live on or off an installation for only a few weeks, months, or years until they are reassigned. This makes it important that exposure to tobacco residue be minimized in living quarters. DoD and the armed services cannot mandate tobacco restriction in private residences off an installation, but they do have authority over on-installation housing. All of the armed services have policies that address tobacco use in living areas on military installations (see Table 5-5). For some lodging restrictions, the policies state that reasonable accommodations may be made for smokers, such as designating smoking areas or buildings, but in general the needs of nonsmokers prevail (see, for example, Air Force Instruction 40-102, June 2002). The 1999 Tobacco Use Prevention Strategic Plan requires a review of service policies and practices on prohibiting tobacco use in all common areas used by nonusers. Each of the armed services specifies that tobacco use is prohibited in common areas of living quarters and lodging (see Table 5-5). TABLE 5-5 Tobacco-Use Restrictions in Living Areas and Transportation Restriction Army Navy/Marines Air Force Living areas Permitted in Permitted in family Permitted in assigned individually or bachelor living government housing; assigned family quarters, lodges, and smokers and nonsmokers and multiple housing do not share rooms or unaccompanied- units unless adjoining rooms in personnel common heating, dormitories; prohibited housing with ventilation, and air in all lodging common separate conditioning are in areas and guest rooms ventilation use; prohibited in and in common areas of systems; common spaces of family housing (Air nonsmokers living areas Force Instruction 40-102, prevail; (SECNAV 2002) prohibited in Instruction common spaces 1500.13E, 2008) of any lodgings
222 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Restriction Army Navy/Marines Air Force (Army Regulation 600- 63, 2007) Transportation Prohibited in all Prohibited by Prohibited by military or equipment military vehicles soldiers and all civilian personnel in Air and aircraft others at West Point Force vehicles and in Air (Army in military vehicles Force or contract aircraft Regulation 600- and aircraft (USMA (Air Force Instruction 63, 2007) Policy 40-102, 2002) Memorandum Number 17-00, 2000) Finding: Tobacco use is banned in common areas of living quarters, but given the health effects described in Chapter 2, the committee finds that such a restriction may not be sufficiently protective against exposure to secondhand smoke. Recommendation: Tobacco use should be banned in all living quarters on military installations. Outdoor Areas The 1999 strategic plan does not call for elimination of the use of tobacco products in outdoor areas. All of the armed services permit tobacco use in at least some outdoor areas on military installations, including the service academies. The restrictions in general follow the stipulations on tobacco use in DoD Instruction 1010.15 (January 2, 2001). Designated smoking areas are supposed to provide some measure of protection from the elements, may not be within 50 ft of common points of entry or exit, and typically cannot be in areas that are used by nonsmokers, such as playgrounds or picnic tables (see Table 5-6). Finding: DoD and the armed services have developed regulations in compliance with federal requirements for tobacco-free workplaces, including recreational areas, educational settings, residential spaces, and transportation equipment. However, tobacco use is still allowed in designated areas, including areas at the service academies, on ships, and on submarines, thus increasing the risk of
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 223 exposure to secondhand smoke and encouraging the perception that tobacco use is acceptable by DoD and the armed services. Recommendation: Tobacco use should be banned on military installations and in all military aircraft, surface vehicles, and ships and submarines. TABLE 5-6 Tobacco-Use Restrictions in Outdoor Areas Restriction Army Navy/Marines Air Force Outdoor areas Permitted in Permitted in Permitted in designated outdoor designated outdoor designated outdoor smoking areas; areas, away from areas that are must have common points of reasonably protection from facility entry/ accessible and elements, be more egress, not in front provide some than 50 feet from of buildings or air measure of points of entry or intake ducts, and protection from exit, and not be in provide a measure elements; these areas commonly of protection from areas may not be used by the elements; near points of entry nonsmokers (Army areasm must be at or exit and must be Regulation 600- least 50 feet from at a distance that 63); MWR any building prevents smoke facilities may entrance, and intake into designate similar proximity to areas buildings (Air outdoor smoking used by other Force Instruction areas (Army personnel should 40-102, 2002) Regulation 215-1, considered when 2007) designating areas (SECNAV Instruction 1500.13E, 2008) TOBACCO RETAIL ENVIRONMENT Historically, DoD has made tobacco products widely available to military personnel (Joseph et al., 2005; Nelson and Pederson, 2008; Smith et al., 2007). Until 1975, DoD provided free cigarettes in military meal packages (K and C rations). Over the decades, DoD sold tobacco products at deeply discounted prices in commissaries and exchanges (see Chapter 2 for a description of commissaries and exchanges). Tobacco products are still sold at discounted prices on military installations in
224 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS exchanges, commissaries (except for Navy and Marine Corps commissaries), and package stores (which are similar to commercial convenience stores). Access to Tobacco Products Access to tobacco products on installations is regulated by DoD, the specific services, and even individual installations. Goal C.1 of the 1999 strategic plan, which is decreased accessibility and availability of tobacco products through pricing and restrictions, requires a determination of service practices for and of compliance with the prohibition of tobacco sales to persons under 18 years old; and it requires a draft of a policy that prohibits single-serve tobacco products (such as single packs) from being sold by self-serve at checkout registers. DoD Instruction 1330.21 (Section 6.4.1, July 14, 2005) limits the total amount of shelf-space allocated to tobacco products; this space may not be increased to accommodate new products. The committee does not know when the limit for shelf-space devoted to tobacco products was established. Some armed services limit access to tobacco products, but not consistently. For example, tobacco is not sold in Navy or Marine Corps commissaries, but it is sold in Navy and Marine Corps exchanges; however, the Navy is exploring having some exchanges, such as the one in Portsmouth, Virginia, not sell tobacco (Mark Long, US Navy, personal communication, July 23, 2008). The approach to the sale of tobacco products varies widely on Army bases. For example, the policies that force clients to access a separate part of an army exchange, require clearly posted information regarding smoking cessation, and limit in- store advertising contrast sharply with the extensive âpower wallsâ (areas of the commissary or exchange that prominently display large quantities of tobacco products) found in some commissaries and exchanges. Table 5-7 summarizes service regulations pertaining to access to tobacco products on military installations. Sales and Pricing Like tobacco-use restrictions, raising the price of tobacco products is highly effective in reducing tobacco consumption. DoD Instruction 1330.09, Section 4.10.3 (December 7, 2005), states that âprices of tobacco products . . . shall be no higher than the most competitive commercial price in the local community and no lower than 5 percent below the most competitive commercial price in the local community. Tobacco shall not be priced below the cost to the exchange.â Any changes in prices for commissary goods must be submitted to Congress (10 USC 2486[d]). Goal C.1 of the 1999 strategic plan,
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 225 TABLE 5-7 Restrictions on Access to Tobacco Products on Military Installations Restriction Army Navy/Marines Air Force Sale of tobacco â Yes (SECNAV Yes (Air Force products prohibited to Instruction Instruction 40-102, those under 18 years 1500.13E, 2008) 2002) old (DoD Instruction 1330.21, 2005) Sale of tobacco Yes, except Yes (SECNAV Yes (Air Force products in vending inareas where Instruction Instruction 40-102, machines on minors are not 1500.13E, 2008) 2002) installation prohibited allowed (Army Regulation 215- 1, 2007) Distribution of free â Yes (SECNAV Yes (Air Force tobacco products Instruction Instruction 40-102, prohibited 1500.13E, 2008) 2002) Sale in medical- â â Yes (Air Force treatment facilities on Instruction 40-102, installation prohibited 2002) decreased accessibility and availability of tobacco products through pricing and restrictions, also requires, in addition to other provisions that address tobacco sales, that tobacco products be priced at no more than 5% below the local competitive price (Requirement C.1.3). The 5% discount is based on the lowest local-retail shelf price for a product (which includes excise taxes). Because the price in the commissary or exchange excludes state and local sales taxes, the actual discount is often larger than 5%. Indeed, the wide variation in sales taxes among states and localities means that discounts can be substantial in jurisdictions that have high sales taxes. For sales of tobacco products in commissaries, the exchanges set the prices. This means that tobacco is not sold at cost, as are other commissary products; nor does the purchaser pay the 5% surcharge on commissary goods. 10 USC 2486(f) allows the secretary of defense to authorize the sale of tobacco products as noncommissary store inventory. As a result, the commissary shelf price equals the exchange retail price. Any revenue from the sale of tobacco products at a cost that is above the cost that the commissary pays to the exchange is treated as though it is a surcharge (10 USC 2484[B]).
226 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Exchanges, which are unsubsidized, sell goods at a discount approaching 20%. In 1996, policy was changed to bring commissary prices for tobacco products into line with exchange prices (Smith et al., 2007). Because the 1986 DoD authorization bill included language prohibiting price increases in commissaries, the price increase was achieved by requiring commissaries to sell tobacco products on consignment for exchanges. Tobacco sales fell by 27% after the policy change, but revenues from tobacco increased by $75 million (Smith et al., 2007). Despite the changes in tobacco pricing on military bases mentioned above, there is virtually no evidence on how the changes have affected smoking behavior in the military (as opposed to tobacco purchases in the commissaries). Nelson and Pederson (2008) reviewed over 80 studies on the correlates of tobacco use in the military. Only one study mentioned price as a factor in the perception of a âmixed messageâ from the military, that is, promoting tobacco cessation but discounting the price of tobacco (Nelson and Pederson, 2008). The 1999 strategic plan calls for support of pricing tobacco- cessation products below the local competitive price (Requirement C.1.7). Tobacco-cessation products are not mentioned specifically in DeCA directives, but DoD Instruction 1330.21 (2005) states that âArmed Service Exchanges shall endeavor to display tobacco-cessation products in areas that provide visibility and opportunity to customers who desire to change their tobacco habitsâ and that âmilitary departments shall support the pricing of smoking-cessation products below the local competitive price.â Finding: DoD indirectly encourages the use of tobacco by military personnel and dependents via the availability of discounted tobacco products in the exchange and commissary system in deployed and nondeployed locations. Recommendation: DoD should discontinue selling tobacco products on military installations. Until all tobacco sales are stopped, DoD should discontinue selling tobacco products at a discount; require separate, restricted access areas for sale and display of tobacco products; prohibit all promotion and advertising of tobacco products in exchanges and commissaries; and provide tobacco- cessation information, such as quitline telephone numbers, at all points of sale. At the very least, tobacco products should not be sold in Army and Air Force commissaries.
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 227 TOBACCO-CESSATION INTERVENTIONS DoD offers a variety of tobacco-cessation interventions to active- duty military personnel and their dependents, military retirees and their dependents, and active-duty National Guard personnel and reservists through the MHS and the TRICARE Management Activity (TMA). In contrast with general civilian medical settings in which the availability of community tobacco-cessation programs can vary considerably, DoD ensures that some form of tobacco-cessation program is available to the entire population of tobacco users. The 1999 Tobacco Use Prevention Strategic Plan has two goals for tobacco cessation: D.1, âMilitary Health System actively identifies tobacco users and provides targeted interventions,â and D.2, âMilitary Health System provides effective tobacco cessation programs.â The committee acknowledges that when the plan was prepared, the TMA was prohibited by statute from paying for tobacco-cessation treatments. The FY 2009 NDAA reversed that prohibition and mandated that TRICARE offer smoking-cessation programs to its beneficiaries. The committee stresses that the language in the appropriation act calls specifically for smoking-cessation programs: this might not cover programs for cessation of other forms of tobacco use. That may be of concern inasmuch as smokeless-tobacco use is increasing in some military populations (see Chapter 2). There are two mandates for smoking-cessation programs in DoD: DoD Instruction 1010.15, âSmoke-Free DoD Facilities,â and 32 CFR 85, âHealth Promotion.â DoD Instruction 1010.15, Section 6.4 states that DoD components shall âprovide effective smoking cessation at all levels of commandsâ with an emphasis on primary prevention practices and motivating users to quit smoking. It further states that all smokers and high-risk personnel shall receive medical counseling about the risks posed by smoking. The instruction does not mention access to any therapeutic interventions (such as behavioral and medication treatments). Section 6.5 says that information shall also be provided in health-promotion programs on the health risks posed by environmental tobacco smoke (secondhand smoke). Nevertheless, all of the armed services have established smoking- or tobacco-cessation programs that include health-care beneficiaries and usually civilian employees on a space-available basis: see Army Regulation 600-63 (2007), âArmy Health Promotionâ; Air Force Instruction 40-102 (2002), âTobacco Use in the Air Forceâ; and SECNAV Instruction 5100.13E (2008). The Navy instruction states that all medical treatment facilities must have tobacco- cessation programs; other installations must provide professional assistance, but referrals must be made if it is not readily available.
228 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS The CFR states thatâoperationallyâhealth promotion includes smoking prevention and cessation. 32 CFR 85 includes restrictions on smoking on military installations and in medical-treatment facilities, living quarters, and vehicles. Health-care providers are to advise pregnant smokers about risks to the fetus, and the armed services are required to provide public-education programs on the adverse health effects of smoking. The regulation does not require DoD to offer tobacco-cessation treatment. Although secondhand smoke is not considered in depth in this report, effective comprehensive tobacco-control programs in the DoD and the VA will inevitably reduce exposure to secondhand smoke. Secondhand-smoke exposure is of concern both for military personnel who are exposed on military bases and for families of military personnel or veterans whose health care is the responsibility of DoD or VA. Because secondhand smoke poses a well-documented and substantial risk to the health of nonsmokers, their protection should be given high priority by policy makers and providers of military and veteran health care. Nonsmokers, including families of military personnel, should be asked about exposure to secondhand smoke as part of their routine medical care; smokers should be strongly encouraged not to smoke at home or in vehicles occupied by nonsmoking family members or friends. In the sections below, the committee considers some of the activities that DoD and the armed services have taken to address the requirements listed in the strategic plan to identify tobacco users and provide effective tobacco-cessation programs. The committee notes that in the discussions of tobacco-use interventions and their delivery in the next section, the focus is on interventions offered by the DoD MHS, not the TMA. As discussed earlier, it is only with the FY 2009 DoD NDAA that smoking-cessation programs are now covered under TRICARE. It is too early to tell which programs TRICARE will select, how they will be implemented, and what effect they will have on smoking prevalence in TRICARE beneficiaries. Evidence-Based Treatments Requirement D.1.1 in support of Goal D.1 of the 1999 strategic plan calls for the development of a draft policy for the ASD(HA) that requires the MHS to use all avenues to identify and document tobacco users and their readiness to quit and to offer appropriate âstage of changeâ intervention. The âstage of changeâ interventions are specified in the requirements for Goal D.2 and include requirements to âassess and develop draft policy that requires tobacco cessation programs to include behavior modification, nicotine-replacement therapy (NRT)/other FDA-
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 229 approved medications as a TRICARE Prime preventive services benefitâ (D.2); to âsupport partnership with TRICARE managed care support contractors to identify interventions that work and to facilitate tobacco- use avoidance educationâ (D.2.3); and to âassess installation tobacco- cessation programs for flexibility to accommodate individual needs, to include: individual or group contact, recognition of problems encountered in quitting (skills training), at least 4 encounters and encouragement to use [NRT] appropriately [and] prepare policy recommendations as necessaryâ (D.2.4). With the publication in 2000 of the clinical-practice guideline Treating Tobacco Use and Dependence sponsored by the Public Health Service (PHS), DoD and VA established a working group to develop a similar guideline that would provide guidance to health-care providers in the MHS and the VA health-care system on assessment of, and treatment for, tobacco use in the military and veteran populations served by these systems. The resulting VA/DoD Clinical Practice Guideline for the Management of Tobacco Use, published in 2004, met that need by providing guidance on treatment for tobacco use in military and veteran populations and addressed Requirement D.2 of the strategic plan (VA/DoD, 2004). The VA/DoD guideline adheres closely to the 2000 PHS clinical-practice guideline (Fiore et al., 2000). The VA/DoD guideline presents evidence-based recommendations for assessment and treatment of military personnel and veterans and for prevention of tobacco use, and it includes several appendixes that provide specific information on counseling strategies and techniques, medications, and relapse prevention. Behavioral Interventions DoD follows the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use to determine which behavioral interventions should be offered by the MHS. For veterans who are tobacco users, the VA/DoD guideline advocates the 5 Aâs (ask, advise, assess, assist, and arrange). It also recommends the most intensive counseling that a patient is willing to attendâfour or more sessions of at least 10 minutes each, with brief counseling (under 3 minutes) as a minimal intervention. The guideline indicates that there is a doseâ response relationship between the length of counseling and the rate of abstinence. It states that effective counseling can be conducted in person or by telephone and that both group and individual counseling are effective when delivered in multiple sessions of sufficient duration. Self- help materials are also suggested for patients who receive brief
230 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS counseling or who might be motivated to quit or to supplement other interventions (VA/DoD, 2004). A 2007 DoD evaluation of tobacco-useâcontrol programs available at 130 military treatment facilities across the armed services found that over 90% of the programs contained content on assessing readiness to quit, understanding nicotine addiction, setting a quit date, understanding triggers, managing stress, handling withdrawal, problem- solving skills, preventing weight gain, finding support, and relapse prevention and management. Fewer programs offered pre-program interviews (63%) and telephone support after the classes (74%) (DoD, 2008). Tobacco-Cessation Medications Requirement D.2.2 in support of Goal D.2 is that DoD âdraft policy to fund Military Treatment Facilities pharmacies to specifically stock a variety of NRT and other approved pharmacological interventions that have substantial empirical support for their use (e.g., bupropion) to accommodate individualized therapy.â The armed services also use the VA/DoD guideline as a framework for their tobacco- cessation programs. Air Force Instruction 40-102 states that âtobacco- cessation programs incorporate cognitive and behavior change strategies, the âcold turkeyâ approach, or the use of [NRT] when appropriate.â The instruction also designates a provider from the military treatment facility to be the point of contact to assess appropriateness of NRT and contraindications for use and to prescribe therapy as needed. Air Force Instruction 40-101 (May 9, 1998) on health-promotion programs requires medical-group commanders to make NRT available to all eligible beneficiaries and requires tobacco-cessation facilitators to receive behavior-modification training to conduct the programs. On many bases, access to tobacco-cessation medications, including Food and Drug Administration (FDA)âapproved over-the-counter and prescription medications, requires a tobacco user to attend cessation classes (G. Wayne Talcott, US Air Force, presentation to committee, March 13, 2008). The committee finds that such a requirement is likely to pose a barrier for Air Force personnel seeking tobacco-cessation treatment as discussed in Chapter 4. The Navy Bureau of Medicine and Surgery has issued a position stating that all providers who are familiar with the VA/DoD guideline should be allowed to prescribe tobacco-control medications and that no restrictions should be placed on providers who wish to prescribe the medications to patients who use tobacco or on patients who wish to use the medications without attending tobacco- cessation programs. The statement provides some recommendations for
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 231 patient prescribing, follow-up, and adjunct treatments, such as counseling. The Naval Submarine Medical Research Laboratory conducted an analysis of the cost effectiveness and efficacy of tobacco- cessation aids and concluded that bupropion was the most cost-effective medication, but was inappropriate for nuclear fieldâservice personnel because of the risk of seizures; NRTs were found to be the least cost- effective; and varenicline was effective and safe and, with counseling, should be considered for use by submariners and nuclear field-service personnel (Brill et al., 2007). The committee considers that the Navy may have based this conclusion on a misunderstanding of the contraindications for bupropion. The committee was unable to locate specific information on the availability of tobacco-cessation medications at MHS pharmacies; however, in a survey of Army general medical officers in 1997, 53% of 153 respondents reported that nicotine patches were in the formulary whereas only 20% reported that nicotine gum was in the formulary, and 82% reported that smoking-cessation classes were available (Hepburn and Longfield, 2001). Combined Behavioral Interventions and Medications In response to Requirement D.2.4 of the 1999 strategic plan, each of the armed services offers some form of a tobacco-cessation program that includes individual or group contact (generally group), recognition of the problems encountered in quitting, at least four encounters (all of the programs appear to include a minimum of four group sessions), and NRT as appropriate pharmacotherapy (prescription required but available in all programs). The tobacco-cessation programs offered by the armed services include programs that were developed by the armed services themselves (for example, those developed by the Army CHPPM and by the Air Force) and programs that are commercially available (for example, the ACS Freshstart program and the American Lung Association [ALA] Freedom from Smoking program). The requirement of a prescription for all tobacco-cessation medications, including over-the-counter NRTs, may dissuade military personnel and their dependents from obtaining these medications and thus reduce their chance of remaining abstinent. The Army CHPPM provides materials to conduct a 6-week tobacco-cessation program with participant workbooks, slide presentations, registration forms, and medication information (http://usachppm.apgea.army.mil/dhpw/Population/TobaccoCessation.as px). The program is based on a program given at Fort Knox, Kentucky (Army, 2009); its effectiveness does not appear to have been evaluated.
232 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Several other studies have assessed smoking-cessation programs that combine behavior counseling and medications in military personnel (Bushnell et al., 1997; Carpenter, 1998; Earles et al., 2002; Helyer et al., 1998). A smoking-cessation program of 11 weekly 60-minute sessions that combined bupropion SR with cognitive-behavioral therapy had a 6- month follow-up abstinence rate of 35.4% (Earles et al., 2002), but a comparison of the ACS Freshstart program with a more intensive behavioral-counseling program developed by the Vanderbilt University Medical Center showed no difference in abstinence rates at 6 months (Bushnell et al., 1997). At 12-month follow-up, 26.7% of participants in a smoking-cessation program that combined a wellness approach with stress-management skills, problem-solving techniques, and NRTs reported not smoking (Helyer et al., 1998). The Army Health Promotion and Prevention Initiatives Program compared three tobacco-cessation programs in 2005: the Army CHPPM program (see above), the ACS Freshstart program, and the ALA Freedom from Smoking program. Abstinence rates were not determined. Participants in the CHPPM program found the medications to be most helpful, whereas the ACS and ALA participants found the group setting to be most helpful (Army, 2006). The Air Force Health Promotion personnel are now required to use the ACS Freshstart program for on-site classes or in-person education with adjunct tobacco-cessation medications as needed (Loftus, 2008). The Army is promoting the use of the ALA Freedom from Smoking program, and the primary source for spit-tobacco cessation is chewfree.com at the Oregon Research Institute (Brad Taft, US Army, personal communication, December 15, 2008). In spite of the strategic-plan requirement that partnerships with TRICARE managed-care support contractors be encouraged to identify interventions that work and to facilitate tobacco-use education, the committee was unable to find information on such partnerships. TRICARE, through the ATAC, has supported a demonstration project called Tobacco-Free Me, discussed below in the section on computer- based interventions. The ATAC also gathers information on innovative programs in tobacco cessation and provides such information to its members. Tobacco Cessation, Physical Fitness, and Weight Management Most people who quit smoking gain weight. This is of particular concern in the military, in which active-duty personnel must meet weight standards. Peterson and Helton (2000) found that 88% of active-duty Air Force members who completed an 8-week smoking-cessation program gained weight. The average gain was 5.5 lb in men and 9.8 lb in women.
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 233 Being close to or over the allowable weight standard may pose an additional barrier to tobacco cessation in active-duty military personnel and increase the likelihood of relapse (Russ et al., 2001). In a review of interventions for preventing weight gain after tobacco cessation, Parsons et al. (2009) found that tobacco-cessation medications were effective in reducing weight gain as long as they were used but had no long-term benefit. However, cognitive-behavioral therapy helped to reduce long- term weight gain. Peterson and Helton (2000) suggested that each service grant a one-time temporary weight waiver for active-duty military members who successfully quit, allowing for a temporary waiver so that ex-smokers have time not only to overcome their smoking addiction but to address the weight gain (Peterson and Helton, 2000). The committee has found in its review of the various tobacco- cessation activities an inconsistency in DoDâs determination of physical fitness for military personnel. For example, Army Regulation 350-1, Army Training and Leader Development (August 2007), states that âthe objective of the Army physical fitness training is to enhance combat readiness by developing and sustaining a high level of physical fitness in Soldiers as measured by . . . body composition standards as prescribed by AR 600â9 [The Army Weight Control Program]â and a âhealthy lifestyle (provide nutrition, avoid smoking and substance abuse, manage stress).â The justification for the physical-fitness requirement is to ensure a soldierâs safety and that of other unit members. The committee believes that although the regulation states that avoiding smoking is one aspect of physical fitness, the statement, which does not give tobacco-free living a priority equivalent to that of weight control, is not sufficiently stringent to ensure that tobacco cessation is considered crucial for military readiness. Finding: The VA/DoD Clinical Practice Guideline for the Management of Tobacco Use is a valuable resource for DoD and VA health-care providers. Recommendation: VA and DoD should revise their current guideline or adopt the 2008 PHS guideline with whatever modifications are necessary for military and veteran populations. Finding: Given the long- and short-term health consequences of tobacco use for military readiness, the armed forcesâ policies regarding tobacco use are inconsistent with those used for physical fitness, weight
234 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS control, personal hygiene, dress, appearance, and other lifestyle-related behaviors. To ensure military readiness and performance, the DoD requires that military personnel meet basic physical-fitness requirements, including weight management, when they enter the military and throughout their careers. Recommendation: DoD and individual armed services should review these policies and revise them to ensure that they are consistent and address the potential effects of all health-related behaviors on military readiness. Tobacco abstinence should be included as a physical-fitness requirement for the armed services as is weight management. Finding: Many tobacco-cessation programs do not address weight management. Recommendation: Weight-management education and counseling should be included in military tobacco-cessation programs. DELIVERY OF INTERVENTIONS In the sections below, the committee considers how each of the armed services provides tobacco-cessation interventions to its members, including behavioral and pharmacologic interventions in medical facilities or health-promotion facilities, quitlines, and computer-based programs. The committee also considers how the armed services ensure that their health providers are familiar with current tobacco-cessation interventions. Clinical Settings The VA/DoD Clinical Practice Guideline for the Management of Tobacco Use was last updated in June 2004 based on an evidence review through December 2002. Overall, the guideline follows the population approach recommended by the 2000 and 2008 PHS guidelines (see Chapter 4). The guideline recommends similar system-level resources for practitioners (such as dedicated practice staff, reminders, and vital-sign indicators) and access to behavioral and pharmacologic treatments. A 2007 DoD evaluation of tobacco-useâcessation programs available in medical treatment facilities across the armed services, found that only
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 235 about half of the 130 facilities in the survey followed any tobacco-useâ cessation clinical-practice guideline (DoD, 2008). VA/DoD guideline recommendations are mirrored in service- specific regulations and in the 1999 Strategic Plan. For example, Army Regulation 600-63 (May 7, 2007) on health promotion specifies that âas a part of routine physical and dental examinations and at other appropriate times . . . health care providers will inquire about the patientâs tobacco use . . . and advise the patient of risks associated with use . . . and where to obtain help to quit.â It recommends that patients be referred to the MEDCOM Web site on tobacco-use management: http://www.qmo.amedd.army.mil/smoke/smoke.htm. [Note: the committee was unable to access this page and suggests that the regulation be changed to refer patients to the DoD Web site, http://www.ucanquit2.com.] It also specifies that âinstallations will provide tobacco-cessation programs for all health care beneficiaries and as resources permit, for civilian employees.â The regulation requires that military treatment facilities use the most current VA/DoD clinical- practice guideline and that its use be enforced in all primary-care facilities on the installation. The SECNAV Instruction 5100.13E (June 2008) specifies that âMilitary Treatment Facilities [and] Fleet and Family Service Centers . . . shall provide current tobacco-use information, cessation encouragement, and professional assistance to those wishing to stop using tobaccoâ and also requires that all medical- care providers at all medical and dental facilities apply tobacco-useâ cessation clinical-practice guidelines. The committee notes that although Air Force Instruction 40-102 (June 3, 2002) requires that tobacco- cessation programs be available during both duty hours and nonduty hours at least quarterly, there is no requirement or guidance on using the VA/DoD guideline. Furthermore, holding classes quarterly may not be an effective strategy for tobacco cessation. Counseling should be available when the person wants to quit; a delay of even 24â48 hours may mean that the opportunity for abstinence is lost. Not all military installations have the resources to offer tobacco- cessation programs, and the committee was unable to determine the frequency with which such programs are offered. Lack of ready access to tobacco-cessation programs may prove to be a barrier to military personnel and their dependents who are seeking assistance with quitting. Army Regulation 600-63 (May 2007) states that if a tobacco-cessation program is not available through a military treatment facility, programs are to be coordinated through local community resources, such as ACS and ALA. Civilian employees on Army installations may also participate in tobacco-cessation programs, but civilians are to be referred to community resources if space is not be available or if there is no such
236 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS program in the occupational-health clinic. The committee was unable to identify tobacco-use rates in DoD civilian employees or their need for tobacco-cessation services. Primary-Care Providers Medical-care and health-promotion activities are often conducted by different but complementary staff on military installations. In each service, the major responsibility for tobacco-prevention and -cessation education and programs falls to the health-promotion staff. Depending on the professional discipline, the health-promotion staff might not have the authority to prescribe NRTs or other tobacco-cessation medications, such as bupropion and varenicline. That authority resides in the medical staff, that is, physicians, physician assistants, and nurse practitioners (Kathy Green, US Air Force, personal communication, December 12, 2008). In most cases, the health-promotion and medical staff deliver their care concurrently as part of a comprehensive tobacco-cessation program, but this approach requires that military personnel interested in quitting tobacco use to seek assistance from two sources. The committee believes that this multilevel process may be a barrier to using evidence-based treatment for achieving tobacco cessation. Implementation of the VA/DoD guideline that primary-care providers use brief counseling, as well as prescriptions for medications, might help motivate patients to quit. Alternatively, allowing health-promotion staff to write prescriptions for NRTs that can be obtained over the counter in the civilian sector might encourage tobacco users to use those medications. Other Health Professionals Some health professionals conduct tobacco-cessation programs at military treatment facilities, although this varies by service. The 2007 DoD evaluation of tobacco-useâcessation programs at 130 medical treatment facilities found that most cessation classes were conducted by health educators (63%) or nurses (36%), with fewer classes conducted by providers (the survey does not specify what type of provider), technicians, behavioral health professionals, and others (DoD, 2008). Air Force Instruction 40-102 states that âhealth-promotion personnel ensure installation health-promotion programs . . . incorporate education programs and information on resources available in the community to discourage tobacco use.â Health-promotion staff are also the lead advocates for tobacco cessation on Navy installations, as are Semper Fit (health-promotion) staff on Marine Corps installations (Navy BUMED Position Statement, February 2, 2008). The health-promotion staff coordinate tobacco-prevention and -cessation programs and
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 237 education with other base health and fitness groups, and interact with community resources (SECNAV instruction 5100.13E, 2008). Army Regulation 600-63 (2007) requires that health-care providers ask about tobacco use at all routine physical and dental examinations. In the Army, nurses conduct the overwhelming majority of tobacco-cessation programs (77%), whereas in the Navy and Air Force, most of the programs are conducted by health educators and clinical psychologists (Mark Long, US Navy, personal communication, December 16, 2008; Kathy Green, US Air Force, personal communication, December 12, 2008). Even a 1-hour presentation on the hazards of tobacco by an Army nurse certified to teach the ACS Freshstart program had an effect on motivating tobacco users to contemplate quitting (Morgan, 2001). Other health-care professionals who are tasked with tobacco- prevention and -cessation responsibilities include Air Force fitness- assessment monitors, who must ask about tobacco use at the physical fitness evaluation; medical providers, who are to ask about tobacco use at every encounter; and dental providers, who are to ask about tobacco use at least annually (Air Force Instruction 40-102, 2002). Medical, dental, and primary-care managers are to provide tobacco-cessation advice to all tobacco users, as stated in the 2000 PHS clinical-practice guideline, and to refer tobacco users who want a cessation program to health-promotion personnel. Unlike the civilian sector, all of the military services require that dental professionals ask patients about tobacco use and provide referrals. Inasmuch as military personnel are required to have annual dental and medical examinations, that provides an ideal recurring opportunity to assess tobacco use and encourage cessation. Military dentists can be a good source of tobacco-cessation guidance and patient education (Burns and Williams, 1995; Chaffin, 2003). The Army Dental Command has implemented a program that makes tobacco-use assessment mandatory during dental examinations. The tobacco- cessation program empowers dentists to provide clinical-level counseling (including the 5 Aâs, brief motivational interviewing, and âteachable momentâ techniques) and to prescribe NRTs (Covington et al., 2005). The Navy encourages Navy dentists and pharmacists to be active in using the 5 Aâs (at the very least, to ask, advise, and refer patients) to assist patients to quit tobacco use, including the prescribing of tobacco- cessation medications if they are properly trained and follow the VA/DoD guideline (Navy BUMED position statements, February 21, 2008). Occupational-health clinics in the Army are designated to provide tobacco-cessation programs for civilian employees or, if such programs are not feasible on an installation, to provide referral to local community programs (Army Regulation 600-63, 2007), but the
238 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS committee was unable to determine whether these clinics do so, inasmuch as it does not appear that this information is collected or is made public if it is collected. Finding: Lack of easy access to tobacco-cessation medications may pose a barrier to military personnel seeking to quit tobacco use. Military health providers see all military personnel at least once a year; this is an ideal opportunity for all of them to motivate and counsel personnel who use tobacco to quit. Recommendation: DoD should consider allowing health educators to provide medications, especially NRTs, to patients interested in quitting tobacco use. Medical providers should receive training and be encouraged to use the 5 Aâs for tobacco cessation. Quitlines Military personnel have access to several quitlines. The first source is the National Cancer Institute quitline; the second is the state quitlines, which are generally open to residents of the individual states; and the third is quitlines that have been contracted to provide services to military personnel. For example, the Air Force encourages bases to fund their own quitlines; if they are unable to do so, they are to promote their statesâ quitlines (Loftus, 2008). As of July 2008, 30 of 76 Air Force bases had contracted telephone quitlines. The Air Force is also working to obtain funding for an Air Forceâwide telephone quitline so that individual bases do not need to contract for these services on their own (Kathy Green, US Air Force, personal communication, July 30, 2008). The Army and the Navy do not appear to have similar requirements. The committee was unable to determine whether Army or Navy installations have contracted with commercial quitlines or with state quitlines to offer tobacco-cessation services to military personnel. The committee further notes that although the Air Force is to be commended in encouraging the use of quitlines, it does not provide guidance to health-promotion staff or installation commanders on which quitlines are the most helpful or provide the best services. There is no information on the training received by quitline counselors to deal with military personnel. Counselors should be familiar with military terminology and jargon and with the stressors and triggers for tobacco use in military personnel, particularly deployment.
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 239 Quitlines tailored to meet the needs of military personnel are being studied, but results are not yet available. The National Heart, Lung, and Blood Institute and the Air Force are sponsoring a study to assess the effectiveness of a tobacco quitline program (in conjunction with nicotine patches) in helping active-duty Air Force personnel to quit smoking (http://clinicaltrials.gov/ct2/show/NCT00632411). Finding: Quitlines may be particularly helpful for military personnel in that they can be accessed remotely and are generally available during nonwork hours when military personnel may be more likely to access them. Recommendation: DoD and the armed services should explore, possibly via a demonstration program, the effectiveness of having either a DoD-wide or servicewide quitline with counselors trained to work with military personnel, their families, and retirees; such a quitline should be evidence-based and validated. Computer-Based Interventions DoD has been active in promoting computer-based tobacco- cessation services. Its primary resource is the âQuit Tobacco. Make Everyone Proudâ Web site, which provides all military personnel and their dependents with tobacco-cessation advice. An important feature of the Web site is the link to a live tobacco-cessation counselor who can provide real-time advice. The site was discussed earlier in the section âCounteradvertising and Public Education.â DoD also has educational information about tobacco use on its âMilitary OneSourceâ Web site (http://www.militaryonesource.com), which may be accessed by all service personnel and their families. The Web site contains articles about tobacco use and cessation, audios, worksheets, booklets, and other materials, including information on smoking and pregnancy and on smoking and chronic obstructive pulmonary disease. There is also a link to the âQuit Tobacco. Make Everyone Proudâ site. The committee notes that this site contains âtoolkitsâ with a variety of information to deal with such issues as Internet security, applying to college, and weight loss; this might be expanded to include a similar tobacco-cessation toolkit. Each armed service has a health-promotion Web site that provides patient-education materials. For example, the Army has information about tobacco control on the CHPPM Web site (see Box 5-1); more patient-education materials are found at the Army HOOAH 4
240 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS BOX 5-1 Military Web Sites for Tobacco-Cessation Information â¢ Army CHPPM: http://chppm-www.apgea.army.mil/dhpw/Population/ tobaccoCessation.aspx http://usachppm.amedd.army.mil/dhpw/population/ tobaccocessation.aspx http://www.hooah4health.com/4You/stoptobaccoshop/ default.htm â¢ Navy and Marine Corps: http://www-nehc.med.navy.mil/hp/tobacco/ Tobacco_smoking.htm â¢ Air Force: Installation-specific Web sites and http://www.afcrossroads.com/medical/medical.cfm Health Web site where tobacco cessation is listed as the first of five top DoD health goals. The Navy and Marine Corps public-healthâcenter Web site also lists smoking and other forms of tobacco use as a core health issue and provides a long list of cessation resources. The site has the âSmoking Lamp Is Outâ Navy tobacco-cessation program with a number for calling tobacco-cessation counselors. The Air Force does not have a central Web site for tobacco cessation, but each base has such information on its local site. The Air Force Crossroads Web site on health and wellness or medical issues refers people to the DoD âQuit Tobacco. Make Everyone Proudâ site. The TMA with the ATAC sponsored an Internet-based smoking- cessation demonstration program, âTobacco-Free Me,â from 2006 to 2008 for TRICARE Prime enrollees 18â64 years old. The program included access to a toll-free quitline 24 hours/day, 7 days/week; behavioral counselors available by appointment to discuss behavior- change strategies; access to print and Web-based tobacco-cessation materials; and access to NRT and bupropion via the TRICARE mail- order pharmacy with a prescription from the participantâs primary-care manager. DoD is analyzing the results and recommendations from the project. Finding: DoD is attempting to take advantage of computer- based tobacco-cessation programs, such as the âQuit
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 241 Tobacco. Make Everyone Proudâ program. Such programs may need to be tailored for each of the armed services and specific military users, including retirees, dependents (children or spouses), and members of the reserve and National Guard. A series of demonstration programs may be an effective way to determine the audience for, and content of, such programs. Recommendation: DoD computer-based interventions should be evaluated for efficacy and effectiveness, as well as content and audience. Provider Education All of the armed services call for the education of military health-care providers regarding tobacco-use prevention and cessation. This education component has two aspects: informing health providers themselves about tobacco-prevention and -cessation treatments, and ensuring that health-promotion programs for all military personnel, retirees, and their dependents include information on tobacco-use prevention and cessation. Educating health-care providers about the health effects of tobacco and the psychologic and pharmacologic treatments for tobacco cessation and giving them access to public-education materials are important for ensuring that the most effective approaches for reaching tobacco users are available. Air Force Instruction 40-101 (1998) requires that health-promotion staff be trained to provide oversight and training on health-promotion topics to other base agencies, and recommends that Air Force tobacco-cessation facilitators have behavior-modification training. The Army MEDCOM Quality Management Office maintains a Web page on the management of tobacco use. The page has links to online resources for provider education, including courses on treating tobacco use and dependence with continuing-medical-education (CME) credits for physicians, and courses on smoking-cessation approaches for primary-care providers. Other links on the site promote resources for hospital and clinic staff to obtain tobacco-cessation information and patient- and provider-education materials (available at https://www.qmo.amedd.army.mil/smoke/smoke.htm). CHPPM offers a Tobacco Cessation Provider Competency Course on its Web site to train providers in prescribing NRTs. The course covers the effects of tobacco, the mechanism of nicotineâs effects, tobacco-cessation assessment tools, discussion of FDA-approved medications for tobacco cessation, alternative tobacco-cessation modalities, patient management, and the
242 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS connection among stress, depression, and tobacco use in relation to triggers and relapse (available at http://usachppm.apgea.army.mil/dhpw/ Population/TobaccoCessation.aspx). The site also offers other materials that may be used by medical or health-promotion staff to provide tobacco-cessation guidance for new trainees. The Navy has a comprehensive provider-education page (http://www-nmcphc.med.navy.mil/hp/tobacco/educators.htm) that contains training materials for primary-care providers, nurses, and tobacco-cessation facilitators as well as patient-education materials. The site also has links to tobacco-cessation training for CME credit. The Marine Corps has a tobacco-cessation training guide as part of its Semper Fit health-promotion program (http://www.usmc- mccs.org/healthpromotions /tobacco_cess.cfm). The program includes a Through with Chew toolkit and links to other tobacco-cessation resources in the government. Overall, those programs appear beneficial and tend to follow the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use; however, the effectiveness of most programs is not known, and the military would benefit from conducting program-evaluation research. Tobacco-cessation education programs such as Rxforchange (see Chapter 4) may also be considered for training military health-care providers in tobacco-cessation interventions. Finding: All of the armed services have educational materials on tobacco-use prevention and cessation available to health-care providers. They also make training opportunities available to medical and health-promotion staff. Recommendation: Education programs should be consistent with the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use and should be coordinated across the services. SPECIAL POPULATIONS Active-duty military personnel traditionally are thought of as being in top physical and mental condition, however, the MHS and TRICARE provide health care for diverse populations, including those with mental illness, dependents, retirees with comorbidities, pregnant women, and smokeless-tobacco users. Each population may have specific tobacco-use needs and require modifications of standardized tobacco-cessation treatments. Goal D.1 of the 1999 strategic plan calls for the MHS to identify tobacco users and provide targeted interventions.
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 243 In the sections below, the committee considers selected military populations that might require specialized tobacco-prevention and -cessation treatments: military personnel with mental-health disorders, particularly posttraumatic stress disorder (PTSD); smokeless-tobacco and dual tobacco users; deployed personnel; women; and National Guard personnel and reservists. Among the military populations that might be targeted for tailored interventions are those who indulge in high-risk drinking. Williams et al. (2002) found that high-risk military drinkers (those that responded positively to 2 or more CAGE2 assessment questions) tended to be enlisted male soldiers who were young, white, never married, had a high-school education or lower, and had a military occupational specialty of infantry or craftsworker. These men were also more likely to drive more than 15 miles over the speed limit, wear a seatbelt less often, and smoke more than a pack of cigarettes per day (Williams et al., 2002). Tobacco Users with Mental-Health Disorders Many active-duty personnel have been wounded, both physically and mentally, during deployment. The data suggest that treating tobacco use in military personnel who have mental-health disorders is important for the health of military personnel and their dependents. Of the almost 1.7 million military personnel who have been deployed to Iraq and Afghanistan, 5â17% met the screening criteria for PTSD on return, 7â 17% met the screening criteria for anxiety disorders, 7â15% met the screening criteria for depression, and 18â35% indicated some level of alcohol misuse (Hoge et al., 2004, 2006). The rates of PTSD symptoms increased 3â6 months after return from deployment and were highest (24.5%) in National Guard and reserve personnel (Milliken et al., 2007). Tobacco use in military members with PTSD has been estimated to range from over 32% (DoD, 2006) to almost 50% (Smith et al., 2008). The 2008 suicide rate in the Army was estimated to be 20.2 per 100,000 soldiers, higher than the national average of 19.2 per 100,000 (Kuehn, 2009). Tobacco use by deployed military personnel is higher than for nondeployed personnel (see Chapter 3). 2 CAGE is an acronym formed from the following four questions: (1) Have you ever felt you should cut down on your drinking? (2) Have people annoyed you by criticizing your drinking? (3) Have you ever felt bad or guilty about your drinking? (4) Have you ever had a drink first thing in the morning (as an âeye openerâ) to steady your nerves or get rid of a hangover? Available at: https://www.merck. healthinkonline.com/merckTools/ AssessMerckSourceCAGE.asp (accessed March 4, 2009).
244 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Specific programs should be developed and evaluated to ensure the availability of effective tools to address tobacco cessation in military personnel with PTSD. It should be noted that one of the most promising new medications for tobacco cessation, varenicline, was given a safety alert by FDA in 2008. In June 2008, the following DoD medication safety notice was issued (http://www.health.mil/Press/Release.aspx? ID=244): âIn light of recent reports linking varenicline (Chantix) to hallucinations and even suicide, the [MHS] would like to re-issue our Medication Safety Notice concerning the use of varenicline (Chantix), a prescription drug used across the country in smoking-cessation programs. While the drug is not on the TRICARE formulary, many MHS patients have prescriptions for it. It is highly recommended that a doctor be consulted immediately in rare cases of psychiatric side effects including nightmares, paranoia, or feelings of suicide. In response to the recent FDA warnings, the [MHS] is analyzing all available information in a continuing effort to maintain the highest levels of safety and security for our beneficiaries.â Finding: Military service, particularly deployment, increases the likelihood of tobacco use as a result of stress and boredom (see Chapter 3). Deployed military personnel have higher rates of mental-health disorders than nondeployed personnel. Evidence suggests that people with mental-health disorders are willing and able to participate in tobacco-cessation treatments. Recommendation: Military health-care providers should continue to ask patients who have mental-health disorders about their interest in tobacco cessation and should provide cessation treatments to patients willing to make an attempt to quit. Smokeless Tobacco and Dual Use One of the groups at highest risk for adoption and use of smokeless tobacco is the US military (Peterson et al., 2007). Recent data (DoD, 2006) indicate that 14.5% of all military personnel regularly use
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 245 smokeless tobacco; the largest group of users (21.6%) is white men 18â 24 years old. The Marine Corps has the greatest use (22.3%), and the Air Force the lowest (9.2%). Smokeless-tobacco use decreased from 1995 to 2002 in the armed services, but all armed services showed an increase from 2002 to 2005 (DoD, 2006). Initiation of smokeless-tobacco use was greatest in the Army and the Marine Corps (DoD, 2006). Initiation and continuation of use of smokeless tobacco may be higher in the military than in the general population for several reasons. First, the demographics (young men) place the military at higher risk for adoption and use (SAMHSA, 2007). Second, all indoor military facilities are smoke-free, and smokeless tobacco is the only form of tobacco that can be used during active-duty hours. In the Navy and Air Force, smokeless tobacco is subject to the same restrictions as smoked tobacco (SECNAV Instruction 1500.13E, 2008, and Air Force Instruction 40-102, 2002, respectively), but this may be harder to enforce for spit-less tobacco products. Third, as noted in the section âAdvertising and Promotions,â smokeless tobacco is advertised in military periodicals. Another possible reason for the increased use of smokeless tobacco is deployment to a war zone (Wilson, 2008). In a survey of 408 marines stationed in Iraq in 2007â2008, tobacco use was nearly double that of the civilian US population. The survey found that 64% of troops used some form of tobacco: 52% smoked cigarettes, 36% used smokeless tobacco, and 24% were dual users of smokeless tobacco and cigarettes. Most of the marines surveyed stated that both being in the military and being deployed increased their tobacco use, and most were also interested in quitting (Wilson, 2008). Effective interventions for smokeless-tobacco use in the military are largely lacking, because little is known about the specific determinants of initiation and cessation of smokeless-tobacco use in this population (see Chapter 4). Some behavioral interventions, such as proactive telephone counseling and oral examinations, have been shown to be effective in increasing long-term smokeless-tobacco abstinence rates in military personnel (Cigrang et al., 2002; Klesges et al., 2006). Only one randomized clinical trial has been conducted to evaluate the efficacy of a smokeless-tobaccoâcessation program in military personnel (Severson et al., 2009). Participants were 785 active-duty military personnel who were randomly assigned to receive a minimal-contact behavioral treatment (n = 392) or usual care (n = 393). The behavioral treatment included a smokeless-tobaccoâcessation manual, a videotape cessation guide tailored to military personnel, and three 15-minute telephone counseling sessions that used motivational interviewing methods. Usual care consisted of standard procedures that are part of the annual dental examination, including recommendations to quit using
246 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS smokeless tobacco and referral to existing local tobacco-cessation programs. Results showed that participants in behavioral treatment were significantly more likely to be abstinent from all tobacco at the 6-month follow-up point than participants in usual care (25.0% vs. 7.6%, respectively, using 7-day point prevalence), including smokeless tobacco abstinence (16.8% vs. 6.4%). Those results indicate that minimal-contact behavioral treatment can significantly reduce smokeless-tobacco use in military personnel (Severson et al., 2009). Most smokeless-tobacco users also smoke cigarettes; current smokers are 3 times as likely as never-smokers to use smokeless tobacco (Ebbert et al., 2006). In a study of over 36,000 Air Force personnel, the prevalence of self-reported smokeless-tobacco use was 24%, but 95% of smokeless-tobacco users also âregularlyâ or âoccasionallyâ used another form of tobacco, commonly cigarettes. At least 82% of all smokeless- tobacco users were regular cigarette smokers (Robert Klesges, University of Tennessee Health Science Center, personal communication, January 23, 2009). In addition, restrictions on where and when tobacco may be smoked may encourage smokers to use smokeless tobacco during active- duty hours. Because dual users have a higher estimated nicotine exposure (Wetter et al., 2002) and are less likely (relative to those who use cigarettes or smokeless tobacco exclusively) to quit smoking (Rodu, 2003; Wetter et al., 2002), obtaining onset and cessation data on dual users in the military should have high priority in planning tobacco- control programs for the military services. The committee believes that finding effective tobacco-cessation interventions for dual tobacco users will be challenging. Finding: Smokeless tobacco should be subject to the same restrictions as smoked-tobacco products. Recommendation: DoD and the armed services should make tobacco-cessation interventions for smokeless-tobacco use as available as those for smoked tobacco. Furthermore, they should track its use by military personnel to determine the effectiveness of any interventions. Given the growing rate of dual use of tobacco products by military personnel, DoD should develop targeted interventions for these tobacco users, including a comparable pricing structure with cigarettes and counteradvertising campaigns.
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 247 Women Goal D.1 of the 1999 DoD strategic plan requires that targeted interventions be developed by the MHS for selected groups, such as pregnant women, but there is little evidence that such interventions exist or have been studied in selected military populations, particularly women. Although military women have lower tobacco-use rates than military men, their rates are higher than those of their civilian counterparts (see Chapter 2). As the number of women in the military continues to increase, tailored interventions to assist them may become more necessary. Validated target interventions for pregnant active-duty personnel are also needed. Like male military recruits, female recruits are prohibited from using tobacco during basic training. Conway et al. (2004) compared three tobacco-cessation methods in female recruits who used tobacco before basic training. The women received either standard treatment (a tobacco ban and a small amount of health education) during basic training, a year-long series of mailings of motivational literature to support relapse prevention and encourage quit attempts, or access to a toll-free telephone help line for counseling, encouragement, and support. The interventions used a cognitive-behavioral approach and were designed to address issues peculiar to Navy life and to women. At the 12-month follow-up, however, smoking rates in the two intervention groups did not differ from that in the standard-treatment group, although the rate of smoking at 12 months was lower overall (57%) than the rate in the incoming female recruits (77%). Daily smokers were more likely to relapse to smoking after basic training than experimenters; the authors did not determine how many women initiated smoking after Navy basic training (Conway et al., 2004). The VA/DoD Clinical Practice Guideline for the Management of Tobacco Use and the 2008 PHS clinical-practice guideline Treating Tobacco Use and Dependence both recommend that health-care professionals advise pregnant women to quit tobacco use and provide tobacco-cessation treatment. That is codified in 32 CFR 85.6(d)(1), which requires all appropriate DoD health-care providers to advise all pregnant smokers of the risk posed to the fetus by tobacco use. In 2005, there were 42,833 deliveries in DoD military treatment facilities in the continental United States, including both military women and military spouses (David Arday, OASD[HA] TRICARE Management Activity, personal communication, November 7, 2008). The Navy Bureau of Medicine and Surgery has issued a position statement on tobacco cessation and pregnancy, recommending that all pregnant women receive behavioral counseling to quit tobacco use before, during, and after
248 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS pregnancy and be provided with NRT or bupropion if necessary to supplement the counseling. New mothers should also be screened for postpartum depression to prevent the use of tobacco for depression (Navy, 2008). Finding: Women in the military use tobacco at higher rates than their civilian counterparts. Recommendation: DoD and the armed services should follow the treatment guidelines for women as given in the VA/DoD and PHS guidelines. Further research is needed to determine whether there are sex-specific issues with regard to tobacco cessation in military women. Deployed Personnel Deployment is associated with increased tobacco use (Cunradi et al., 2008; Smith et al., 2008; Wilson, 2008) (see also Chapter 3). The Army conducted a small feasibility study of service members stationed at Camp Cropper, Iraq, during June 2006âJune 2007 to determine whether personnel who had received prescriptions for NRT or bupropion during this time would be interested in participating in behavioral group counseling once a week for tobacco cessation; 81% of survey respondents stated that they would not attend a 90-minute weekly group session. The medications were not effective in improving quit rates but did reduce the number of cigarettes smoked; the medications had no effect on smokeless-tobacco use (Army, 2008). Van Geertruyden and Soltis (2005) also assessed the feasibility of conducting a smoking- cessation program at an Army Level 1 aid station in Iraq. Providers screened soldiers for willingness to quit, requested that participants pick a quit date, provided bupropion and NRT, and encouraged soldiers to avoid areas that they associated with smoking. The authors reported anecdotally that several long-term âhard-coreâ smokers quit and encouraged others to use the program (van Geertruyden and Soltis, 2005). Junior enlisted personnel are particularly at risk for tobacco initiation during deployment. Poston et al. (2008) conducted 24 focus groups at Air Force and Army installations of junior enlisted personnel who had been deployed. Reasons for smoking during deployment included managing stress, anxiety, boredom, and sleep deprivation; lack of activities and privileges; the perception that dangers in the field were greater than the health effects of smoking; and the encouragement of smoking by the military environment in spite of rules against it (for
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 249 example, smokers were able to take more breaks than nonsmokers). The authors suggest that in spite of DoD efforts to reduce tobacco use by military personnel, there is a pervasive attitude that tobacco is not of great concern to DoD, particularly during deployment (Poston et al., 2008). Similar reasons for smoking during deployment to Iraq were cited by Army personnel (Army, 2008). Finding: There is anecdotal evidence that deployed personnel may use tobacco-cessation programs. The tobacco-use rate in deployed personnel is much higher than that in nondeployed military personnel or civilians, and there is a pervasive attitude that tobacco use by deployed personnel does not have DoD priority. There is a lack of information on tobacco-cessation needs and treatments for deployed personnel. National Guard and Reservists Many National Guard and reserve personnel, particularly Army National Guard members, have been federalized and activated. While on active duty, these service members are subject to the same policies and eligible for the same benefits as any other active-duty personnel, and when they leave active duty, they are eligible for TRICARE for 6 months. They are also eligible to sign up for the TRICARE Reserve Select program to receive coverage. TRICARE now covers smoking- cessation services, so National Guard and reserve members have access to these services. The committee is concerned that there is a lack of basic information on these service members. They do not appear to have been included in the 2005 DoD Survey of Health Related Behaviors Among Active Duty Personnel (the committee has no information on whether they were included in the 2008 survey); if they were included with regular active-duty military personnel, there is no information about them after deactivation. That is of particular concern given the large number of Army National Guard members who have been deployed to Iraq (over 145,000 as of 2008), many of them more than once. National Guard and reserve members appear to have about the same smoking prevalence as regular military (Smith et al., 2008). Finding: Many National Guard and reserve personnel are deployed and then return to civilian life with little or no access to tobacco-cessation programs in military or VA health-care facilities. Additional information is required about tobacco use by National Guard and reserve members
250 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS and their need for, and access to, military and civilian tobacco-cessation programs. RELAPSE-PREVENTION INTERVENTIONS DoD is unique as an employer with regard to tobacco use. All new employees (recruits) are required to be 100% tobacco-free during basic training. However, the relapse rate after basic training ends is substantial. Furthermore, many young people who enter the military and were not tobacco users or had only experimented with tobacco before entering the service become tobacco users after completing basic training. Approaches for reducing the relapse rate and preventing the initiation of tobacco use after basic military training are the focus of this section. Basic Training All of the armed services prohibit smoking by recruits during basic training (Army TRADOC Regulation 350-6, May 8, 2007; Navy Recruit Training Command Instruction 5100.6K, May 8, 2008; Air Force Instruction 40-102, June 3, 2002; Air Force Education and Training Center Instruction 36-2216, June 16, 2004). The bans create, albeit for a brief period, a tobacco-free force. The total bans do not extend beyond initial training, and service members, to varied degrees, initiate or resume smoking after, in some cases at higher rates than before entry into the service. The early unqualified success in tobacco cessation may lead to equally successful opportunities after basic training. For example, the Air Force has extended its tobacco-use ban into some phases of technical training that follow basic training. A major question is whether the forced cessation during basic military training is related to long-term smoking rates. Two studies have evaluated the impact of the smoking ban on long-term (1-year) cessation rates to determine whether a brief intervention (a 50-minute session with questions and answers in computer-interactive format, facilitated role- playing situations, and commitment cards) can augment the cessation rates associated with the smoking ban during the 6-week basic training. In the first study (Klesges et al., 1999), 75% of the 25,996 active-duty enrollees in Air Force basic training were randomized to receive a brief (1-hour) tobacco-control intervention and the remaining 25% were only banned from tobacco use. At the 1-year follow-up, 18% of all the recruits were abstinent. There were no statistically significant differences between the two groups. However, female recruits were nearly 30% more likely to quit smoking than male recruits (21% vs. 17%), ethnic minority-group members were 40% more likely to quit than white
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 251 recruits (22% vs. 17%), and those reporting an intention to remain nonsmoking after the ban were nearly 60% more likely to quit than those who were either thinking of returning to smoking or actively planning to resume smoking (19% vs. 13%). The intervention had an impact on the highest-risk group, those planning to resume smoking (13% vs. 8%). Among minority-group members who were not planning to quit, the intervention had a particularly large impactâa 14% difference in cessation rates between treatment and controls (18% vs. 4%)âalthough there was no overall intervention effect (Klesges et al., 1999). In a follow-up study, Klesges et al. (2006) evaluated the effect of a brief tailored tobacco-control intervention during Air Force basic training. The 33,215 participants were randomized to receive an intervention based on their prior tobacco use: those who smoked cigarettes before basic training received a smoking-cessation intervention, and those who used other tobacco products before basic training received a smokeless-tobacco intervention, those who did not use tobacco received a prevention intervention. The controls viewed health-related and first-aid videos. The smoking interventions proved to be associated with long-term tobacco cessation. Based on 7-day point prevalence and continuous abstinence, respectively, smokers who received the active intervention were 1.16 (95% CI, 1.04â1.30) and 1.23 (95% CI, 1.07â1.41) times more likely to be abstinent from smoking cigarettes than controls at the 1-year follow-up (p < 0.01). The cessation- rate difference was 1.60% (31.09% vs. 29.49%) and 1.73% (15.47% vs. 13.74%) for point prevalence and continuous abstinence, respectively. Smokeless-tobacco users were 1.33 times (95% CI, 1.08â1.63) more likely than controls (p < 0.01) to be continuously abstinent at the follow- up with an overall cessation-rate difference of 5.44% (33.72% vs. 28.28%). However, the smoking-prevention program had no impact on smoking initiation. A study of Air Force recruits who were tobacco users before basic training and received NRTs at the end of basic training found that those who used NRTs were more likely than those who did not use them to plan to resume tobacco use after military training, to have friends who smoked, and to take cigarettes from friends who smoked and were less likely to be abstinent (7-day point prevalence) (Klesges et al., 2007). A variety of focus groups targeting tobacco-use policies and practices were conducted during Air Force technical-school training, which occurs immediately after the completion of basic training (Peterson et al., 2003). Several focus groups included trainees who had been regular smokers before basic training. The results were surprising: most trainees reported that they had no difficulty in quitting, and most did not report any withdrawal symptoms. Most reported that basic
252 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS training was so intense that they did not even recognize that they had quit smoking; sleep deprivation, intense physical conditioning, and an overall demanding training schedule left most with no time to think about tobacco use. Focus-group participants were also asked their opinions of the tobacco-free policy in basic training. The vast majority of former smokers indicated that they approved of the policy and thought it was consistent with the overall training mission. In addition, focus groups with Air Force technical-school students who had relapsed to smoking indicated that if the Air Force wanted them to remain tobacco-free, it should just extend the tobacco ban for the duration of their enlistment. Most felt that staying tobacco-free after the completion of basic training would be relatively easy if a policy prohibited the use of tobacco (Peterson et al., 2003). Preventing Initiation and Relapse After Basic Training There appears to be substantial initiation in the first year of military service in those who were not tobacco users before entering the military (Williams et al., 1996). Two studies that evaluated smoking initiation in the military (Klesges et al., 1999, 2006) found that 8â10% of trainees who reported never smoking (ânot even a puffâ) before basic training were smoking at a 1-year follow-up, and 26â30% of experimental smokers, defined as having had one to two cigarettes in their lifetimes, reported smoking at follow-up. Klesges et al. (2006) randomized Air Force personnel who entered basic training and reported either being nonsmokers or experimental smokers into a smoking- prevention intervention group or a control group. The prevention program had no effect on smoking initiation (Klesges et al., 2006). Similar results were found by Conway et al. (2004), who posited two possible reasons for the finding: either the prevention-intervention strategy validated on younger people did not translate to the slighter older population, or military personnel may be particularly recalcitrant to tobacco-use prevention efforts. The VA/DoD clinical-practice guideline provides a detailed discussion of tobacco-use prevention and relapse. Approaches include motivating current tobacco users to quit with such strategies as the 5 Râs (relevance, risks, rewards, repetition, and roadblocks), motivational interviewing, and encouraging continued abstinence for those who do quit. Of particular relevance to DoD is preventing the initiation of tobacco use in military personnel who had not used tobacco before entering the service. The guideline provides practical advice on assessing the likelihood that these people will start to use tobacco and encouraging them not to do so. All military personnel see a health-care provider,
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 253 which includes seeing a dentist, at least once a year; this is an ideal opportunity to provide them with strategies to resist trying tobacco. Finding: Ironically, the very environment that appears to be conducive for tobacco users to remain abstinent (the postâbasic-training period) also appears to be conducive to tobacco initiation by never-users and experimental users. Recommendation: Given the high rate of eventual tobacco- use initiation, the committee believes that future research in tobacco-use prevention efforts in the military should have high priority. Finding: The committee commends the armed services for their bans on tobacco use during basic training. Recommendation: The committee recommends that DoD promptly establish a timeline to extend the tobacco ban beyond entry-levelâenlisted and officer- training programs to eventually close the pipeline of new tobacco users entering military service and to eliminate tobacco use on all US military installations. SURVEILLANCE AND EVALUATION Surveillance activitiesâthe processes of monitoring tobacco- related attitudes, behaviors, and health outcomes at regular intervalsâ can occur at many organizational levels and serve a variety of functions. Survey instruments are one mechanism for collecting short-, intermediate-, and long-term data on process and population outcomes and eliminating disparities. The data are evaluated to provide an indication of how tobacco-control programs are operating and whether they are meeting their goals. The 1999 strategic planâs Goal D.1 specifies that the MHS should actively identify tobacco users and provide targeted interventions. To identify tobacco users, a systematic approach is best. The strategic plan calls on DoD to âdevelop and monitor a centralized, Tri-Service (Army, Navy, and Air Force) reporting and surveillance system to track tobacco useâ (Requirement D.1), âdevelop a plan to annually conduct a health-risk appraisal that includes the assessment of tobacco-use habits and mandates participation for active-duty personnelâ (Requirement D.1.3), âdevelop a draft policy that requires tobacco use to be documented as â5th vital signâ at all medical and dental appointmentâ
254 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS (Requirement D.1.4), and âassess Service policies, and draft policy if necessary, to require routine screening of all beneficiaries as part of âPut Prevention Into Practiceâ program, with providers using guidelines from the Agency for Health Care Policy and Researchâ (Requirement D.1.5). DoD and the armed services have made great strides in meeting those requirements. DoD conducts periodic surveys to ascertain tobacco use by active-duty military personnel. The most recent one for which data are available, the 2005 DoD Survey of Health Related Behaviors Among Active Duty Military Personnel (DoD, 2006), determined the prevalence of alcohol use, tobacco use, and illicit-drug use on the basis of self- reports by 16,146 military personnel in all four armed services. Achievement of selected Healthy People 2010 objectives and adverse outcomes were also assessed. The TMA conducts the annual congressionally mandated Health Care Survey of Department of Defense Beneficiaries to assess user satisfaction with, and access to, the MHS. The healthy-behaviors section asks participants whether they have ever smoked; if so, how much; if they quit, for how long; whether they were advised by their doctors to quit; and whether their doctors or other health-care providers discussed methods and strategies (other than medication) to assist in smoking cessation. Questions on the use of medications are not included. Composite data from both surveys are publicly available. The DoD Health Plan Analysis and Evaluation staff conduct beneficiary surveys that include information on smoking and advice to quit. DoD also maintains the Medical Data Repository, which contains information on the use of tobacco-related diagnosis and treatment codes within the MHS direct-care system. Each armed service uses a variety of self-reported metrics to assess its tobacco-cessation programs in support of its health-promotion activities. The Navy and the Air Force use metrics to track tobacco use and cessation by service personnel. The Navy Health Promotion Wellness Tobacco Program metrics are used by staff at 32 military treatment facilities, including 3 medical centers, 15 naval hospitals, and 14 health and medical clinics. Metrics are submitted semiannually and cover the number of tobacco-cessation programs offered, individual and group counseling sessions held, training of facilitators, and costs for tobacco-cessation medications (Navy, 2009). NAVHOSPGLAKES Instruction 6220.7 (July 8, 2005) on tobacco-cessation services for the Great Lakes Naval Hospital includes a tobacco-cessation form to be used when a patient inquires about quitting tobacco use. The form is used to conduct follow-up with patients and to track success rates. The Air Force, like the Navy, uses the National Committee for Quality Assuranceâs Healthcare Effectiveness Data and Information Set
DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES 255 to assess compliance with standards of care. The Air Force has also developed a list of metrics to evaluate its tobacco-cessation programs. Those metrics, which track only active-duty personnel, include reporting of the number of personnel who are tobacco users, the type of product used, the number of personnel making or contemplating quit attempts, attendance at cessation classes, referrals to outside resources (such as the ALA Freedom from Smoking Web-based program), the number of installations funding quitlines, and the number of calls to the quitlines (Kathy Green, Air Force, personal communication, July 30, 2008). The Army does not appear to use any comparable metrics. Two goals in the 1999 DoD Tobacco Use Prevention Strategic Plan apply to the evaluation of tobacco-cessation programs. Goal D.2 states that tobacco-cessation programs in the MHS are to be evaluated for effectiveness. Goal E, to âcontinually assess best practices in the area of tobacco prevention,â is to be reached by developing plans to assess prevention and early-intervention strategies and by developing and evaluating pilot programs of best prevention practices. The committee notes that each of the goals in the strategic plan has an accompanying metric or objective that helps in addressing the requirements to meet it. For example, Goal D.1, which includes identifying tobacco users, requires the development of a âcentralized, Tri-Service reporting and surveillance system to track tobacco use.â The metric for determining whether the goal is being met is the percentage of medical records that note tobacco-use status on forms DD2766 or AF 1480A (adult preventive-care and chronic-care flowsheets, which were in development when the strategic plan was developed). The Army CHPPM Web site has a document, âEvaluation of Tobacco-Use Cessation Efforts in the Military Health System (MHS) Direct-Care System,â that describes an in-depth evaluation of the tobacco-cessation efforts at installations and among the armed services. The evaluation assesses the types of programs; which health professionals conduct the programs; how quit rates are measured by program and tobacco-use type at 1, 6, and 12 months; which tobacco- cessation medications are used and whether they have an effect on quit rates; and how frequently tobacco-use and intervention ICD-9 and CPT-4 codes are used in the MHS. The committee understands that this evaluation has been undertaken by a DoD contractor and that results are available but cannot be released to the public, including this committee, for confidentiality reasons. A 3-page factsheet, based on the evaluation and available in the Spring 2009, reported that the MHS offers comprehensive programs for tobacco use and prevention with most military treatment facilities offering formal programs with some outreach (DoD, 2008). The committee believes that such data should be available
256 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS publicly so that military personnel, retirees, families, and other interested parties can independently assess the tobacco-cessation efforts that are being undertaken by DoD and the armed services, identify problems with the programs, and propose solutions to the problems. Finding: DoD and the armed services appear to track and evaluate some important tobacco-related activities, such as revenue from the sale of tobacco in commissaries and exchanges and a variety of tobacco-cessation metrics, including number of patients asked about their tobacco use and tobacco-cessation medications prescribed. However, important information gaps exist. Those gaps include rates and types of tobacco advertising in military publications, abstinence rates for various tobacco-cessation programs, the number of policy changes that have been made in response to the 1999 DoD strategic plan, and the extent to which the policies are enforced. If such information has been collected, it is not publicly available, nor is there any indication of how the OASD(HA) or the armed servicesâ surgeons general should use the information or how it informs policy and program changes by senior leaders. Recommendation: DoD should report regularly and publicly on the performance of its tobacco-control programs, adherence to clinical-practice guidelines for tobacco-use management, and tobacco-cessation rates. REFERENCES Army. 2006. Technical Report: Tobacco Cessation Program Comparison. Health Promotion and Prevention Initiatives Program. MCHB-TS-HPR. http://chppm-www.apgea.army.mil/dhpw/ population/Documents/HPPI_Summary_STIs.pdf (accessed November 13, 2008). Army. 2008. Memorandum: Tobacco Cessation AnalysisâCamp Cropper, Iraq (July 2007). Camp Cropper, Iraq. http://chppm- www.apgea.army.mil/dhpw/Population/TobaccoCessationReportCam pCropper.pdf (accessed December 21, 2008).
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