National Cancer Institute NCI Cancer Bulletin: A Trusted Source for Cancer Research News
February 9, 2010 • Volume 7 / Number 3

Community Update

Operation Cessation: Curbing Military and Veteran Tobacco Use

A poster from the Department of Defense 'Quit Tobacco, Make Everyone Proud' campaign

The U.S. military has a long history with tobacco products. Cigarettes were issued in daily rations throughout World Wars I and II, and even into the Vietnam War. This unhealthy tradition came to a formal end in 1975, and today many military leaders hope that tobacco use will soon be just that—a thing of the past. The Department of Defense (DoD) has launched an online interactive tobacco cessation program that developers hope will help bring military tobacco use rates down.

Quit Tobacco, Make Everyone Proud promotes quitting tobacco as a matter of duty and pride and features campaign materials that convey two themes: role modeling and readiness. The campaign’s Web site and materials present service members as role models for their children and other loved ones, and senior leaders send strong messages about military readiness.

Rates of smoking in the military are higher than in the civilian population. According to a June 2009 Institute of Medicine (IoM) report commissioned by the Department of Veterans Affairs (VA) and the DoD, 32 percent of active duty military and 22 percent of all veterans smoke, compared with about 20 percent of the civilian adult population. Smoking rates are even higher among military personnel who have been deployed, and an increasing number of service members use smokeless tobacco products. 

The VA provides care for 6.7 million of the nation’s 24 million veterans and is the largest provider of care for adults with chronic psychiatric disorders, such as post-traumatic stress disorder. This population smokes at a very high rate, and the VA continues to invest in research on the most effective ways to provide tobacco cessation for these veterans. Researchers are also exploring policy interventions to promote tobacco cessation, such as further restricting the sale of tobacco products on military bases and increasing their price.

The June 2009 IoM report, titled “Combating Tobacco Use in Military and Veteran Populations,” includes numerous recommendations for the DoD and VA to make progress towards a tobacco-free military, and concludes that, “given the effects of tobacco use on military readiness and on the health of military personnel, retirees, their families, and veterans, the time has come for DoD and VA to assign high priority to tobacco control.” 

Quitting Tobacco and Reducing Stress

Active military personnel most often report using tobacco to relieve stress and boredom, said Dr. Keith Haddock, a veteran of the Air Force and senior principal investigator at the National Development and Research Institutes, Inc., who has studied the relationship between nicotine addiction and perceived feelings of stress, particularly among members of the military.

Using DoD survey data, Dr. Haddock and his colleagues looked at current smokers, former smokers, never smokers, and dual users (those who both smoked and used smokeless tobacco). They found that the more tobacco respondents used, the more stressful they considered their lives to be, both within and outside of military duty. Dual users reported the highest stress levels (Stein et al., Military Medicine 173(3), 2008).

“People who had quit smoking saw their lives, their work, and their deployment as less stressful than current smokers,” Dr. Haddock explained. Finally, tobacco users were more likely to use other negative coping behaviors (e.g., alcohol) and less likely to use positive coping strategies (e.g., problem solving) that those who did not use tobacco. The results, Dr. Haddock said, reinforce the evidence that tobacco use is not an effective method for coping with the stresses of military life and may actually make it less likely that soldiers will use positive coping strategies.

A Tailored Approach

The IoM report has raised awareness of additional opportunities for the VA and DoD to collaborate, emphasized Dr. Kim Hamlett-Berry, director of the VA’s Office of Public Health Policy and Prevention. “Our goal is to increase access to a menu of evidence-based options, so that any veteran who wants tobacco cessation resources can get them,” she said. “Our next steps are to take this even further and look at how the two systems could work together.”

This would build upon years of collaboration, particularly in the development of the DoD/VA Clinical Practice Guidelines, which draw upon evidence-based tobacco cessation tools and the specific prevention and treatment needs of both populations.

This commitment to tobacco cessation is reflected in the resources both departments provide to address tobacco addiction. All VA medical centers have tobacco cessation specialty clinics and use electronic medical records to build in clinical reminders for tobacco-use screening. The clinics provide free counseling and FDA-approved smoking cessation medications, including over-the-counter smoking cessation medications available on the Veterans Health Administration national formulary.

Veterans seen in primary care and outpatient mental health clinics are screened for tobacco use at least once a year. Providers offer brief cessation counseling to current tobacco users, as well as prescriptions for FDA-approved medications and referrals to more intensive counseling to assist veterans with quitting. 

The DoD’s Quit Tobacco, Make Everyone Proud campaign provides an opportunity to submit questions to tobacco cessation counselors in real time; computer games to distract from tobacco cravings; and short videos and audio podcasts—quitcasts and spitcasts—in which service members share testimonials and advice.

The U.S. Air Force’s (USAF) Wilford Hall Medical Center in San Antonio, TX, has developed a military-specific tobacco quitline currently being tested in an NIH-sponsored clinical trial. Col. Wayne Talcott, chair of the Department of Behavioral Medicine at the medical center, oversees the study, which provides quitline access to 27 USAF bases, including Osan Air Base in South Korea.

“My great hope is that this provides some flexibility so, when people are ready, they actually get help right away,” he said. “The bottom line is anybody who calls the quitline and who is a beneficiary of our healthcare system is going to get care—they don’t have to be at a particular location.”

Initial feedback indicates participants also appreciate reaching counselors who have first-hand military experience. “Having that feeling that you’re talking to someone who understands is an important part of this,” Col. Talcott said.

Dr. Robert Klesges of the University of Tennessee Health Science Center and the principal investigator of this study agreed that quitlines are an effective way to deliver smoking cessation services, and an effective way to reduce logistic barriers to accessing services. “A tobacco quitline or a tailored Internet program, military personnel can use anytime day or night. So a lot of what we are doing is tailoring these cessation tools to the intense job demands associated with the military,” Dr. Klesges commented.

Marching Forward on Tobacco Control

The challenge of reducing military tobacco use is especially large today, when many military personnel are or have been deployed in support of the war efforts in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom). The tobacco control and prevention landscape within military and veteran communities is complex.

Tobacco use is prohibited in basic military training (BMT) in all branches of the military, and technical training programs following BMT often impose restrictions on tobacco use. But this prohibition often does not extend far beyond training, which can create a window for relapse or tobacco initiation. As many as 40 percent of junior enlisted smokers start using tobacco after joining the military, making prevention strategies a necessity and a challenge.

Dr. Klesges noted, “We had these nice cessation rates among our smokers—23 percent of those who smoked had quit, and 37 percent of those who used smokeless tobacco had quit—but the initiation among never smokers was so great, that we actually saw an increase in the prevalence of tobacco use.”

As the DoD and VA consider how to implement the IoM’s recommendations, researchers are trying to determine which types of tobacco interventions have the necessary support in this population. For example, the report encourages the military to treat tobacco use as it does other health-related behaviors that impair readiness, such as alcohol abuse and weight management. Dr. Klesges, who served on the committee that authored the report, put it plainly, saying, “We enforce weight standards, why wouldn’t we enforce tobacco-free standards?”

—Holly Aprea Gibbons