Combating Tobacco Use in Military and Veteran Populations (2009) / Chapter Skim
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2 SCOPE OF THE PROBLEM
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In veteran populations, it exacerbates pre-existing health problems and leads to new ones, and it results in increased absenteeism and decreased productivity. Military personnel who use tobacco may eventually enter the VA health system; this means more and sicker veterans who require medical care and, consequently, increases in health-care costs.
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TABLE 2-1 Demographic Profile of the Military Population Marine Army Navy Corps Air Force Active duty 502,790 345,098 180,252 344,529 Reservea 189,975 70,500 39,489 74,075 a Guard 346,288 -- -- 105,658 Total 1,039,053 415,598 219,741 524,262 Dependents About About About About 1,400,000 580,000 200,000 760,000 Female Personnel (% of total service) Active duty 14.0 14.5 6.2 19.7 a Reserve 23.3 20.3 4.7 23.9 a Guard 13.5 -- -- 18.0 Total 15.5 15.5 5.9 19.9 Minority-Group Personnel (% of total service)
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Active duty 46.2 42.4 30.1 45.8 a Reserve 40.2 51.8 20.7 50.4 a Guard 40.2 -- -- 48.7 Total force 43.1 44.0 28.4 47.0 Single Parent Personnel (% of total service) Active duty 6.5 5.1 2.7 4.8 a Reserve 8.5 9.6 2.9 9.5 a Guard 8.2 -- -- 8.5 Total force 7.4 5.9 2.7 6.2 a Includes only members of the selected reserve.
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(29%) , military personnel who served between Vietnam and the 1990–1991 Gulf War (23%)
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A series of surveys of health-related behaviors in active-duty military personnel showed that tobacco use within the 30 days before a survey decreased from 51.0% in 1980 to 32.2% in 2005 (see Figure 2-1) ; this trend was observed consistently among all the services (DoD, 2006b)
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. Associations in the military parallel those in the general population as tobacco use is more prevalent among military personnel who are younger, less well educated, and of lower SES.
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. Careerists in the enlisted ranks were significantly more likely to be current smokers and heavy smokers compared with careerist officers (Cunradi et al., 2008)
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38 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS TABLE 2-3 Tobacco Use in the Military (%) Army Navy Marine Corps Air Force Cigarette use and nicotine dependencea in preceding 30 days Any smoking 38.2 32.4 36.3 23.3 Heavy smokingb 15.3 9.9 11.1 7.0 Nicotine dependence 10.8 6.4 9.5 4.8 Prevalence of cigarette-smoking in preceding 30 days by sex and age Men 18–25 years old 49.0 37.8 42.8 37.0 26–55 years old 31.4 25.9 24.8 16.2 All ages 39.4 29.8 36.3 23.3 Women 18–25 years old 31.7 27.0 29.1 28.1 26–55 years old 19.2 18.6 19.7 18.3 All ages 26.0 22.2 26.6 22.8 c Cigarette-smoking initiation in the military Mend 21.6 19.1 21.7 14.9 Womend 13.5 16.0 20.4 12.8 d Total 20.5 18.7 21.6 14.5 Men (current 36.7 36.1 40.5 40.3 smokers)
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. Tobacco Use in Veteran Populations In a 2005 survey of the VA enrollee population, 71.2% reported that they smoked at least 100 cigarettes during their lifetime; 22.2% were current smokers, a slightly higher proportion than the 19.8% of the
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TABLE 2-4 Health Hazards Posed by Tobacco Use Health Hazards Cancer (see Table 2-6) Cardiovascular disease Sudden death Acute myocardial infarction Unstable angina Stroke Peripheral arterial occlusive disease (including thromboangiitis obliterans)
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Being tobacco-free is an essential component of physical fitness and provides myriad advantages to military personnel in terms of readiness and performance. In the sections below, the committee considers the performance and short-term health consequences of tobacco use that are of most importance for active-duty military personnel.
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The committee was surprised and dismayed by the lack of recent research on the effects of tobacco use on military readiness, given the number of tobacco users in the military and the need for military readiness during the last decade. Nicotine Withdrawal Smoking may impair performance both through direct exposures to nicotine, carbon monoxide (CO)
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. Smoking causes hearing loss predominantly in middle-aged and older people, but the risk of hearing loss is also strongly increased by smoking in people under 35 years old (Sharabi et al., 2002)
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. Thus, in deployment circumstances in which military personnel are unable to smoke, nicotine withdrawal may impair performance.
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There is a dose-response relationship between intensity of smoking and severity of decompression symptoms. Thus, divers who smoke are at increased risk for both aggravation of acute obstructive lung changes and decompression illness (Buch et al., 2003)
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. A study of 87,991 active-duty US Army men and women (26% current smokers, 16% former smokers, and 58% never smokers)
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(2006) , in a study of smoking effects on productivity in a large sample of US employees, found that current smokers missed more work and reported more unproductive time at work than former smokers and nonsmokers; current smokers lost a mean of 76.5 hours/year, nonsmokers, 42.8 hours/year, and former smokers, 56 hours/year.
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. Smoking is strongly associated with invasive pneumococcal disease in otherwise healthy adults and with a nearly twofold increased risk of communityacquired pneumonia, with 32% of the risk attributable to smoking (US Surgeon General, 2004)
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. Smoking was associated with an increased risk of postoperative hemorrhage in adults treated in a US military hospital.
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. BOX 2-1 Effects of Smoking on Military Readiness and Performance Tobacco use affects military readiness by • impairing physical endurance and performance capacity; • impairing visual performance, dark adaptation, and night vision; • accelerating age-related hearing loss and potentially interacting with noise-induced hearing loss; • impairing vigilance and cognitive function (nicotine withdrawal)
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. Exposure to such industrial solvents as benzene, with which military personnel may work, presumably adds to the effect of the benzene in tobacco smoke in causing leukemia (US Surgeon General, 2004)
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. Smoking causes 20% of cardiovascular deaths in the United States; it increases the risk of coronary heart disease, including acute myocardial infarction; sudden death; stroke; and peripheral vascular disease, including abdominal aortic aneurysm (Burns, 2003)
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Among asthmatics, current smokers experience more severe asthma, that is, more frequent symptoms and attacks. Exposure to secondhand smoke has been associated with increased risk of asthma in nonsmoking adults.
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. In nonsmoking adults, secondhand-smoke exposure is associated with an increased risk of lung cancer and acute myocardial infarction (MI)
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. A recent systematic review of 11 studies, however, found that smokeless tobacco use was not associated with an increased risk of pancreatic cancer (RR, 1.03; 95% CI, 0.71–1.49)
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In summary, smokeless-tobacco use poses a health risk to military personnel and veterans in that it causes oral and pancreatic cancer and periodontal disease, maintains tobacco use, and may increase the risk of cardiovascular disease. ECONOMIC IMPACTS The societal costs of tobacco use in the military and veteran populations are expansive.
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(1998) estimated the direct health-care costs for prevention, diagnosis of, and treatment for tobacco-related diseases in US military personnel in 1995 to be $584 million -- mostly for hospitalization (77%)
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(1998) estimated that in 1995, the cost of lost productivity of active-duty US military personnel due to smoking breaks (30 min/day for 220 workdays/year)
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, exchanges have the dual mission of providing merchandise and services and of generating earnings that help to fund military MWR programs, including child care for dependents of military personnel. Exchanges are supported solely by nonappropriated funds, which are derived from the sale of goods and services to DoD military and civilian personnel and their family members.
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, this policy became effective on November 1, 1996. The reason for the decision was "to support DoD efforts to enhance military readiness by discouraging smoking and promoting healthier lifestyles" (DeCA Directive 405, Chapter 6, Tobacco Products, 6-1[a]
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(2007) assessed the cost of buying tobacco for activeduty junior enlisted military personnel who responded to the 2002 DoD Survey of Health Related Behaviors Among Active-Duty Military Personnel.
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According to the Congressional Budget Office, 7.4 million veterans were enrolled in the VA health-care system in 2004, or about 30% of the total population of veterans (Congressional Budget Office, 2005)
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report that "sensitivity analyses varied the ratio of health costs incurred by exsmokers relative to those of current smokers. A ratio of 0.8 yielded a total 10 year NPV of $15.643 billion ($17,040 per current VA smoker)
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Assigned on basis of annual spending for persons with the condition multiplied by the share of smoking-attributable mortality from that condition, according to p. 860 of surgeon general's 2004 report, The Health Consequences of Smoking.
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2007. Cigarette Smoking and Food Insecurity Among Low-Income Families in the United States, 2001.
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2007. Substance use trends among active duty military personnel: Findings from the United States Department of Defense Health Related Behavior Surveys, 1980-2005.
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1998. Cigarette smoking and hearing loss: The epidemiology of hearing loss study.
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2006b. 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel.
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1983. Cigarette smoking, road traffic accidents and seat belt usage.
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2003. Cigarette smoking and cognitive performance in healthy Swedish adults.
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2007. The impact of cigarette smoking on periodontal disease and treatment.
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2009. Individual risk factors associated with premature discharge from military service.
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2001. Cigarette smoking in the Oregon Air National Guard: Findings from a health promotions survey.
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1972. Changes in behavioral and physiological activation induced by cigarette smoking in habitual smokers.
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2002. Cigarette smoking and hearing loss: Lessons from the young adult periodic examinations in Israel (YAPEIS)
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2007. Cigarette smoking and periodontal disease among 32-year-olds: A prospective study of a representative birth cohort.
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2007. Children and Secondhand Smoke Exposure -- Excerpts from The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General.
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1973. Cigarette smoking, disability days and respiratory conditions.
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