Combating Tobacco in the Military

The health and economic costs of tobacco use in military and veteran populations are high. In the short term, tobacco use impairs military readiness by reducing physical fitness, impairing visual acuity, and contributing to hearing loss. Over the long term, it causes serious health problems, including lung cancer and chronic obstructive pulmonary disease (COPD), and contributes to numerous other health problems, including cardiovascular disease, infections, and delayed wound-healing. Smokeless tobacco use also causes oral and pancreatic cancer and periodontal disease.

Fewer than one in five Americans uses tobacco, but more than 30 percent of active-duty military personnel and about 22 percent of veterans use tobacco. Of greater concern, the rate of tobacco use in the military has increased since 1998, threatening to reverse the steady decline of the last several decades. Furthermore, smoking rates among military personnel returning from Iraq and Afghanistan may be 50 percent higher than rates among nondeployed military personnel.

The Department of Defense (DoD) and the Department of Veterans Affairs (VA) bear the heavy costs of treating tobacco-related diseases. DoD spends more than $1.6 billion per year on tobacco-related medical care, increased hospitalizations, and lost days of work. In 2008, VA spent more than $5 billion to treat veterans with COPD, which is strongly associated with tobacco use.

In 2007, VA and DoD requested that the Institute of Medicine (IOM) Committee on Smoking Cessation in Military and Veteran Populations make recommendations on how to reduce tobacco

TOWARD A TOBACCO-FREE MILITARY

DoD and four armed services (Army, Navy, Marines, and Air Force) have set goals to become tobacco-free, but have yet to achieve them despite promoting tobacco-free lifestyles through public-education campaigns, commander training, the banning of all tobacco use during basic training, and the prohibition of tobacco use by instructors in the presence of students. The committee recommends that DoD establish a timeline to eliminate all tobacco use on military installations to protect the health of all military personnel, civilian employees, family members, and visitors. The committee finds that achieving a tobacco-free military begins by closing the pipeline of new tobacco users entering the military and by promoting cessation programs to ensure abstinence. Using a phased approach, the military academies and officer training programs in both universities and the military should become tobacco-free first, followed by new enlisted recruits, and finally all other active-duty personnel.

Although DoD and the armed services acknowledge that tobacco use impairs the readiness of military personnel and results in enormous health and financial costs,

DoD sells tobacco products at a discount, permits tobacco use in designated areas of military installations, and gives less attention to tobacco use than to alcohol abuse, physical fitness, and weight management. Therefore DoD should:

• Stop selling tobacco products in military commissaries and exchanges. Until accomplishing that, DoD should at the very least sell tobacco products at prices equal to those in local civilian retail stores.
• Prohibit tobacco use anywhere on military installations.
• Treat tobacco use in the same way as other health-related behaviors, such as alcohol abuse and poor physical fitness, which impair military readiness.

TOWARD TOBACCO-FREE VETERANS

VA has a long history of attempting to reduce smoking among veterans and has been responsible for numerous scientific findings regarding the health effects of smoking.While tobacco-use initiation is uncommon in the veteran population treated by VA, those who already use tobacco may need help both to quit using tobacco and to prevent relapse if they quit. People with mental-health disorders have a higher prevalence of tobacco use - and the growing number of veterans returning from deployment with mental-health disorders, especially posttraumatic stress disorder and depression, may increase the demand for tobacco-cessation treatment.

VA's tobacco-cessation activities include the development of a National Smoking and Tobacco Use Cessation Program, and a recently strengthened Smoke-Free Policy for VA Health Care Facilities. But federal legislation that requires VA medical facilities to establish designated smoking areas has precluded VA from going entirely smoke-free. The committee finds that this requirement prevents VA from protecting its patients, employees, and visitors from exposure to tobacco smoke, and also hinders efforts to encourage tobacco cessation.

DOD AND VA COMPREHENSIVE TOBACCO-CONTROL PROGRAMS

The committee concludes that to prevent tobacco initiation and encourage cessation, both DoD and VA must implement comprehensive tobacco-control programs. DoD and VA should run these programs according to a strategic plan, enforced by an engaged leadership, supported by adequate resources, and implemented by effective and enforceable policies. They must also provide appropriate therapeutic and communication interventions (including those for special populations), include surveillance mechanisms, and require regular evaluation of the programs' effectiveness with feedback and management capability to effect change. Both departments already have some of these components; for example, both run counteradvertising activities to encourage tobacco cessation and provide free-of-charge tobacco cessation medications and counseling to beneficiaries. The committee recommends that both DoD and VA:

• Engage high-level leadership and require that they implement and enforce comprehensive tobacco-control programs.
• Provide barrier-free access to tobacco-cessation services to all DoD and VA staff and patients.
• Make available adequate tobacco-control resources, including infrastructure and funding, for all facilities.
• Ensure that a trained tobacco-cessation counselor and tobacco-cessation program are available at each health-care facility.
• Train all DoD and VA health-care providers to provide brief counseling and nicotine-replacement therapy to patients.
• Report regularly and publicly on the status and progress of these tobacco-control programs, including tobacco-cessation rates.

An integrated approach, as demonstrated by the joint DoD and VA Management of Tobacco Use Working Group that developed the 2004 clinical-practice guidelines, will ensure greater continuity in tobacco-cessation services as military personnel move from DoD to VA health-care system.