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Smoking Cessation Efforts Battling Entrenched Tobacco Culture in Military

by U.S. Medicine

January 10, 2012

“Smoke ’em if you got ’em.”

For generations of military personnel, that phrase originating in World War II was the signal to take a break or at least to cool their heels while waiting. So ingrained was tobacco use in military culture, it was reasonable to assume that cigarettes would be an integral part of relaxing or, ironically, taking a breather.

A U.S. Army soldier from Charlie Company, 1st Battalion, 24th Infantry, took a smoke break while at a firing range in Qalat, Afghanistan this summer. DVIDS photo by Master Sgt. Jeffery Allen.

After all, cigarettes were included in C-rations until 1975 and still are sold without expensive taxes at military bases throughout the world.

So, persuading military personnel to give up smoking and creating a smoke-free military is, to say the least, a mammoth challenge.

Paul Fitzpatrick, manager for TRICARE’S “Quit Tobacco-Make Everyone Proud” program, suggested that cultural barriers are “probably the No. 1 issue” in promoting smoking cessation.

“Tobacco products are culturally associated with the military, going back to companies providing cigarettes and rations in World War II. Pop culture, movies and television link cigarette use to machoism and military actions.”

Even as it has become increasingly stigmatized in civilian culture, “tobacco use remains socially acceptable in military culture. The military is a much different environment,” said Steven S. Fu, MD, MSCE, co-associate director of the VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR) at the Minneapolis VAMC.

Fu told U.S. Medicine that returning troops sometimes face culture shock when they come home and find their workplaces and many public facilities are smoke-free.

Yet, the smoking cessation efforts are worth it, not only for the health of young veterans, who smoke at much higher rates than the civilian population, but also for healthcare budgets, which strain under the cost of caring for smokers with preventable long-term health problems.

More than 30% of military personnel smoke, a rate 50% more prevalent than in the civilian population, according to an Institute of Medicine (IoM) report in 2009. That hinders military readiness in the short term, by harming physical fitness, vision and hearing, according to that report.

The longer-term costs are nothing short of astronomical. IoM found that DoD’s cost of treating tobacco-related diseases is estimated to be more than $500 million per year for medical care and $346 million in lost productivity. The VA, meanwhile, spent more than $6 billion in 2008 treating diseases such as chronic obstructive pulmonary disease and arteriosclerosis, which are strongly associated with smoking. The smoking rate among veterans treated at the VA (22%) also is higher than the civilian population.

Educating active-duty personnel and veterans about the dangers of smoking and other tobacco use is not enough to get them to stop. Programs supported by DoD and VA must approach the issue on different levels that speak to the specific population.

Also, despite the efforts to get servicemembers to quit using tobacco, some military practices continue to not only look the other way when it comes to smoking but to actually promote it.

“I don’t think anyone in the United States today doesn’t know smoking is bad for them,” said Rachel Widome, PhD, MHS, core investigator at the Minneapolis CCDOR. Yet, she said, the active-duty servicemembers she has interviewed “talked a lot about the benefits of using tobacco in the military. It is a stress reliever, something to do when you are bored, a way to socialize with other people and a way to take breaks.” 

In some military facilities, smokers are allowed breaks, while nonsmokers are not, she said, so many “smoke because they get a break.”

In addition, according to Fitzpatrick, “there is less of a financial prohibitive for using tobacco products because of lack of state and federal taxes when purchased in military exchange,” so smoking-cessation programs find it more difficult to use cost as leverage to get military personnel to give up tobacco.

Smoking Cessation Efforts Battling Entrenched Tobacco Culture in Military Cont.
Smokeless Tobacco Can Make It Harder to Quit

A complicating factor in battling tobacco use in the military is that smokeless tobacco, which appears to be growing in use, may be even harder to combat than cigarettes. Paul Fitzpatrick, manager for TRICARE’S “Quit Tobacco-Make Everyone Proud” program, said the most recent survey reported that 13.6% of servicemembers used smokeless-tobacco products. Smokeless tobacco generally comes in three forms: chewing tobacco in which users chew a plug or twist; snuff, a flavored powder which is dipped by placing a pinch between the cheek and gum; and dry snuff, which is finely ground tobacco that is snuffed through the nostrils. Dry snuff is rarely used in the United States. “I don’t think servicemembers are misguided in thinking smokeless tobacco is healthier,” Fitzpatrick said, noting that military dentists are very active in educating patients about the risks smokeless tobacco presents for mouth and throat cancer. Instead, he said, it is likely an issue of convenience. “There are limitations on where servicemembers can smoke. Smokeless tobacco use may be more convenient,” Fitzpatrick explained. “In the military, there are a lot of indoor spaces that are actually smoke-free. In Iraq and Afghanistan, you are technically not supposed to smoke in vehicles or any other kind of enclosed space. [Servicemembers] talk about using smokeless tobacco during those times,” reiterated Rachel Widome, PhD, MHS, core investigator at the VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR) at the Minneapolis VAMC. Unfortunately, substituting smokeless tobacco for cigarettes rarely helps with cessation and can even lead to use of both. “Smokeless tobacco probably disrupts quit attempts,” suggested Steven S. Fu, MD, MSCE, co-associate director of the Minneapolis CCDOR. “You try to quit, and you fall back on use of smokeless tobacco. We would say there is no such thing as a safe level of tobacco use, but it’s fair to say that the level of knowledge about harm from smokeless tobacco use is less known. That might contribute to people having less interest in quitting.” A study discussing some controversial treatment programs that have attempted to “reduce the harm” related to cigarette smoking by encouraging the use of smokeless tobacco underscored the risks of servicemembers’ adopting dual use of both tobacco forms. The study, published in the American Journal of Public Health last December, found that a group of airmen was highly likely to move from smoking to use of both or from smokeless tobacco use to smoking or dual use if they started with smokeless tobacco. The TRICARE smoking cessation website also makes a strong argument against use of electronic cigarettes, pointing out that they include liquid nicotine, which is highly addictive. Furthermore, the site notes that electronic cigarettes are not approved by the Food and Drug Administration for effectiveness and safety and that better alternatives are available to help military personnel and their families quit smoking.

Programs Showing Success

Despite those barriers, the TRICARE program managed by Fitzpatrick has shown success with its marketing techniques to spur smoking cessation. In the past three years, 6% of those who reported visiting the www.ucanquit2.org website reported stopping tobacco use. Many more said they were considering quitting.

The site is promotional and offers referrals to appropriate treatment, not smoking-cessation programs.

Socialization is one of the main tools of that campaign, which focuses on 18- to 24-year-old males on active-duty across the services.

In that cohort, about 40% use some kind of tobacco products, which is statistically higher than the civilian population. What is especially notable, however, is that about 30% of nonsmokers who enlist are smoking by the time they get through basic training and reach their first assignment, Fitzpatrick said.

In many cases, he noted, these young men are “away from home for the first time. They want to fit in, and smoking, in a lot of respects, is a social activity for young people who want to fit in.”

To combat that, the TRICARE smoking-cessation program tells servicemembers “that many of your peers actually disapprove of smoking, that it causes bad breath, smelly clothes and the like and that you’d be better fitting in with the nonsmoking group.”

Another tactic, according to Fitzpatrick, is to “leverage the 18 to 24 mindset of wanting to succeed and want to please others,” and bring in “Make Everyone Proud.”.

That fits in well with the younger generation’s life experience where “everyone gets a trophy,” Fitzpatrick pointed out. “We’ve raised a generation with a very high level of acceptance of expectations. If you quit tobacco, you’ll make peers and loved ones proud of you as well, we tell them.”

If they succeed, he noted, they’ll gain respect from peers and praise from authority figures.

“A lot of military culture is being someone to look up to,” added Widome. So, modeling can be a strong motivator to inspire young servicemembers to quit.

“Something that comes up a lot is talk about family, being the role model in general,” she said. “Their partner might want them to have quit before the baby came. Or they are looking through their kid’s eyes to see how the child sees them as a tobacco user.”

Widome also said pride could be at stake. “I talk to groups of military folks who think that their smoking might impede performance [on physical fitness tests], that it lessens endurance and stuff like that.” Conversely, she said, it is sometimes seen as a “badge of honor” to do well on fitness measures, despite smoking.

Similar attitudes often keep young troops from seeking help with smoking cessation, she noted. “There’s a bit of sense in the culture that ‘I can quit when I want to, cold turkey, do it on my own, alone.’ That is a common sentiment in young adults. They think they are invulnerable, and you tough things out in the military culture.”

Go-it-alone efforts rarely are successful, however, according to Fu. “Tobacco is an addiction. It is hard to quit on your own. The goal is to make available and make it easier for [servicemembers] to access evidence-based treatment.”

A combination of medications and counseling is most effective in helping patients quit smoking, according to Yu, who said that counseling could be one-on-one, in a group, over the telephone or even online.

Prescriptions for smoking cessation generally are increasing. At the VA, for example, the rate of medication use for smoking cessation at VA has increased steadily, from 7-10% before 2003 to 31% in 2008, according to a VA QUERI Update on Treatment of Tobacco Dependence in February.

Yu noted that VA’s patient-centered medical home program will be putting even greater emphasis on smoking cessation with key support personnel available to spearhead it.

Eric A. Dedert, PhD, of the Traumatic Stress & Health Research Laboratory at the Durham, NC, VAMC, told U.S. Medicine that the VA’s electronic medical record also plays a pivotal role in improving smoking-cessation outcomes.

“One of the things we have found, over time, is that smoking tends to be a chronic problem. Patients try to quit smoking but relapse,” Dedert said. “Instead of the model with one short intervention, what seems to work well is interventions with long-term follow-ups.”

These can be achieved with a reminder in the patient’s medical record for primary-care physicians to discuss smoking- cessation efforts at each appointment, he said.

The process is complicated in servicemembers suffering from PTSD, who have an extremely high rate of smoking and unique difficulties in quitting. Some studies have suggested the smoking rate is as high as 45% among those with the disorder.

Dedert published a study in 2011 which found that PTSD smokers experienced worse withdrawal symptoms and greater urges to smoke, whether the smoking-cessation program used positive or negative reinforcement.

The high smoking rates and difficulty giving up tobacco also could account for some of the higher prevalence of cardiovascular and metabolic disease in PTSD. 

“The issue of long-term health effects of PTSD is far from settled,” Dedert said. “A few studies I’ve seen look at smoking as one of the explanations for that.”

On the other hand, he added, “there are some effects above and beyond just smoking.” 

Researchers are teasing out new methods to reach smokers with PTSD, he said, citing a recent study which found that smoking cessation rates are better if the patients’ existing therapists are trained in smoking-cessation treatment.

“They are already seeing the person,” Dedert said. “That helps with long-term care. [Researchers] found that results in some better rates of cessation.”

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