Combating Tobacco Use in Military and Veteran Populations (2009) / Chapter Skim
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5 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES
5 DEPARTMENT OF DEFENSE TOBACCO-CONTROL ACTIVITIES
Pages 197-262
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From page 197... ...
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 DoD's 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.
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From page 198... ...
and personnel" facilities from product" residue, (Marine Corps the health (Army promote Order 5100.28, hazards caused Regulation quitting, and 1992)
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From page 199... ...
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)
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From page 200... ...
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.
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From page 201... ...
remedies the gap at least partially: Section 713, "Smoking Cessation Program Under TRICARE," 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, "the 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," counseling, "access to a toll-free quitline," and "access to printed and Internet Web-based cessation material." The secretary of defense must "provide for involvement by officers in the chain of command of participants in the program who are on active duty." Within 90 days after enactment, the secretary must submit a programimplementation plan to Congress; and within a year after enactment, the secretary must report to Congress on the program.
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From page 202... ...
, to provide advice on policies related to the supply, responsible use of, and the demand for alcohol and tobacco products (DoD, 1999)
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From page 203... ...
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.
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From page 204... ...
, 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.
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From page 205... ...
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.
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From page 206... ...
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.
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From page 207... ...
Key components of a comprehensive program are examined, including communication interventions, tobacco-use restrictions, the tobacco retail environment, cessation interventions, special populations, relapseprevention 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.
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From page 208... ...
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 services' current policies on commercial solicitation to buy tobacco products (such as advertising, promotions, and donations)
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From page 209... ...
will endeavor to display tobaccocessation products in areas that provide visibility and opportunity to customers who desire to change their tobacco habits." 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.
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From page 210... ...
The directive also requires that posters about the surgeon general's 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.
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From page 211... ...
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 "4 Steps to Quitting." 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 "Tobacco Tales"; 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.
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From page 212... ...
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.
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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)
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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 "decrease accessibility and availability of tobacco products through pricing, smoking area, and tobacco-use restrictions." 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)
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From page 215... ...
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)
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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)
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Finding: There are inconsistencies between the armed services with regard to the use of tobacco on military
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From page 218... ...
The requirements for meeting Goal B.1 of the strategic plan, promoting a tobacco-free lifestyle and culture, also pertain to tobaccouse 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 militaryeducation 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 services' tobacco-free goal.
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. 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, 1.29–2.94)
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. Finding: All of the armed services ban tobacco use during basic training.
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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)
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From page 222... ...
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.
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From page 223... ...
. Tobacco products are still sold at discounted prices on military installations in
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From page 224... ...
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.
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From page 225... ...
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)
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From page 226... ...
states that "Armed Service Exchanges shall endeavor to display tobacco-cessation products in areas that provide visibility and opportunity to customers who desire to change their tobacco habits" and that "military departments shall support the pricing of smoking-cessation products below the local competitive price." 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.
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From page 227... ...
The 1999 Tobacco Use Prevention Strategic Plan has two goals for tobacco cessation: D.1, "Military Health System actively identifies tobacco users and provides targeted interventions," and D.2, "Military Health System provides effective tobacco cessation programs." 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.
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From page 228... ...
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.
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From page 229... ...
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 A's (ask, advise, assess, assist, and arrange)
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From page 230... ...
. A 2007 DoD evaluation of tobacco-use–control 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, problemsolving skills, preventing weight gain, finding support, and relapse prevention and management.
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. 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)
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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.
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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.
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From page 234... ...
and access to behavioral and pharmacologic treatments. A 2007 DoD evaluation of tobacco-use–cessation programs available in medical treatment facilities across the armed services, found that only
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From page 235... ...
[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 "installations will provide tobacco-cessation programs for all health care beneficiaries and as resources permit, for civilian employees." The regulation requires that military treatment facilities use the most current VA/DoD clinicalpractice guideline and that its use be enforced in all primary-care facilities on the installation.
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From page 236... ...
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.
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From page 237... ...
. 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.
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From page 238... ...
Medical providers should receive training and be encouraged to use the 5 A's for tobacco cessation. Quitlines Military personnel have access to several quitlines.
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From page 239... ...
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 tobaccocessation services.
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From page 240... ...
The site has the "Smoking Lamp Is Out" 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.
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From page 241... ...
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)
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From page 242... ...
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.
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. Tobacco Users with Mental-Health Disorders Many active-duty personnel have been wounded, both physically and mentally, during deployment.
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From page 244... ...
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.
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From page 245... ...
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.
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From page 246... ...
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.
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. 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
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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.
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From page 249... ...
. 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.
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From page 250... ...
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)
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From page 251... ...
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.
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From page 252... ...
. 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)
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From page 253... ...
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-level–enlisted 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.
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From page 254... ...
, determined the prevalence of alcohol use, tobacco use, and illicit-drug use on the basis of selfreports by 16,146 military personnel in all four armed services. Achievement of selected Healthy People 2010 objectives and adverse outcomes were also assessed.
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From page 255... ...
Direct-Care System," 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 tobaccocessation 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.
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From page 256... ...
If such information has been collected, it is not publicly available, nor is there any indication of how the OASD(HA) or the armed services' surgeons general should use the information or how it informs policy and program changes by senior leaders.
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From page 257... ...
1998. Promoting tobacco cessation in the military: An example for primary care providers.
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2006. Predictors of smokeless tobacco initiation in a young adult military cohort.
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2006. Efficacy of a tailored tobacco control program on long-term use in a population of US military troops.
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From page 260... ...
2008. BUMED Position Statement: Tobacco Cessation and Pregnancy.
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From page 261... ...
2009. Smokeless tobacco cessation in military personnel: A randomized controlled trial.
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2002. Concomitant use of cigarettes and smokeless tobacco: Prevalence, correlates, and predictors of tobacco cessation.
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