Combating Tobacco Use in Military and Veteran Populations (2009) / Chapter Skim
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3 FACTORS THAT INFLUENCE TOBACCO USE
3 FACTORS THAT INFLUENCE TOBACCO USE
Pages 79-114
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From page 79... ...
to examine the factors that encourage and sustain tobacco use in military and veteran populations. On the basis of a socioecologic approach (Figure 3-1)
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From page 80... ...
. The greatest changes in smoking prevalence have resulted from populationwide interventions: economic measures to reduce access to tobacco; laws and regulations restricting tobacco use, advertising, promotion, and sales of tobacco products; and multicomponent public-education campaigns (Fisher et al., 2004; Task Force on Community Preventive Services, 2005)
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From page 81... ...
That dynamic interplay may account for increasing trends of tobacco use in the military and veteran populations over the last decade. At the individual level, the physiologic processes that underlie nicotine addiction and the high rates of physical and mental comorbidity found in these populations are addressed.
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Future chapters will provide specific proposals for interventions to advance tobacco control in the military and veteran populations. Figure 3-2 illustrates some of the influences that may affect a person's decision to start or continue tobacco use in the military and veteran populations.
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From page 83... ...
-- in other words, the drug has come to control behavior to an extent that is considered detrimental to the individual. Specific criteria have been defined and developed for nicotine dependence and nicotine withdrawal by the American Psychiatric Association (2000)
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. Nicotine dependence has also been defined as meeting three of the seven criteria for dependence in the Diagnostic and Statistical Manual of Mental Disorders–IV during the preceding year (American Psychiatric Association, 2000)
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Animal studies have found that repeated nicotine exposure increases the behavioral control of conditioned reinforcers (such as tobacco cues) contributing to the compulsivity of smoking behavior (Olausson et al., 2004)
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, but studies of the genetics of nicotine dependence and smoking behavior are problematic because such complex behaviors are determined by multiple genes and by environmental factors. Recent genomewide association studies have pointed to several genes that are promising signals for genetic determinants of nicotine dependence.
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US Current Lifetime Smoking Lifetime Diagnosis Population Smokers Smokers Quit Ratesa No psychiatric disorder 50.7 22.5 39.1 42.5 Anxiety disorders: Social phobia 12.5 35.9 54.0 33.4 Posttraumatic stress disorder 6.4 45.3 63.3 28.4 Agoraphobia 5.4 38.4 58.9 34.5 Generalized anxiety disorder 4.8 46.0 68.4 32.7 Panic disorder 3.4 35.9 61.3 41.4 Mood disorders: Major depression 16.9 36.6 59.0 38.1 Dysthymia 6.8 37.8 60.0 37.0 Bipolar disorder 1.6 68.8 82.5 16.6 Psychotic disorder 0.6 49.4 67.9 27.2 (nonaffective) a Smoking quit rate defined as proportion of lifetime smokers who were not current smokers (no significant difference in rates when quit rate was defined as not having smoked for more than preceding year)
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found that quit rates increased with length of abstinence from substance use. Although some substance abusers may not benefit from or may even be harmed by concurrent treatment, for most "attempting to quit smoking does not seem to interfere with recovery from other substances .
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This dysfunction in areas of the brain that modulate reward, that is, the frontal lobe, hippocampus, and nucleus accumbens, is purported to promote nicotine dependence. Tobacco Use and Depression Depression is a common psychiatric disorder with a variety of subtypes and severity levels.
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According to the 2005 DoD Survey of Health Related Behaviors Among Active Duty Military Personnel, the most commonly endorsed reasons for initiating smoking in the services, particularly in the Army and Marine Corps, included "to help relieve stress" (25.4%) , "to help me relax or calm down" (26.2%)
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TABLE 3-3 Stress and Mental-Health Indicators by Smoking Statusa Current but Current Never Former Not Heavy Heavy Problem/Level Smoked Smokers Smokers Smokers Stress at work, past 12 months A lot 15.4 (0.6)
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From page 92... ...
Between 2004 and 2006, the prevalence of smoking among the study population increased by 48%; smoking rates increased by 57% among those deployed and by 44% among those not deployed. Of those who reported never having smoked at baseline, 1.3% of nondeployed and 2.3% of deployed reported initiating smoking on entry into the military.
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From page 93... ...
. Nearly 9% of the participants in the 2005 DoD survey started smoking "to fit in with my friends"; this rate varied somewhat among the services -- 5.6% of Army personnel and 11% of Air Force personnel reported fitting in with others as a factor in smoking initiation.
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From page 94... ...
TABLE 3-4 Perceived Cigarette Availability and Acceptability and Reasons for Starting Smoking Regularly, by Service (%) Marine Air Total Measure/Type of Estimate Army Navy Corps Force DoD Perceived availability and acceptability Most of my friends in the military 50.8 41.5 50.6 30.2 42.5 smoke My spouse, live-in partner, or the 41.3 42.1 42.6 45.0 42.7 person I date disapproves of my smoking Why started smoking regularly To fit in with my friends 5.6 10.3 7.8 11.0 8.5 To fit in with my military unit 1.1 3.9 1.5 1.7 2.1 To rebel against my parents or 4.5 5.6 4.2 4.8 4.8 other in authority To look "cool" or be "cool" 4.2 9.0 6.0 8.8 6.9 To look or feel like an adult 2.9 5.8 3.2 5.6 4.4 Most in my family smoked 5.2 6.5 5.3 5.5 5.6 To be like someone I admired 1.7 3.8 1.7 2.1 2.4 SOURCE: Adapted from DoD (2006)
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. COMMUNITY FACTORS This section discusses organizational factors -- such as culture, tolerance of tobacco use, organization-level activities, and policy and leadership -- that may influence tobacco use by military personnel and veterans.
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From page 96... ...
Access to and Cost of Tobacco Products on Military Installations Almost 50% of Army and Marine Corps personnel, 33% of Air Force personnel, and 38.4% of Navy personnel reported that a reason for smoking was availability -- there are numerous locations to buy on installations, such as commissaries, exchanges, and package stores (DoD Instruction 1330.09, December 7, 2005)
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From page 97... ...
Smoking Breaks Although the Army and Air Force recognize that work breaks for tobacco users and nontobacco users are equal, there is a perception among junior enlisted personnel that those who smoke or use tobacco products have longer and more frequent respites from work. For example, Haddock (2008)
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From page 98... ...
To further complicate the issue, reservists and National Guard personnel cycle between civilian life and military deployment, which have different standards of behavior. Difference in Support Between Active-Duty and Retired Military Personnel Regardless of such factors as designated smoking breaks that may undermine cessation activities, there is a support network that can encourage military members on active duty to stay abstinent.
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From page 99... ...
Another major barrier limiting primary-care–based treatment is a lack of adequate provider time and knowledge regarding smoking treatment. Mental health-care providers may be veterans' primary-care physicians, so they must understand the clinical-practice guidelines and be educated in simultaneous treatment for mental-health disorders and tobacco control (VA/DoD, 2004)
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From page 100... ...
Influence of the Tobacco Industry The tobacco industry has a long history of thwarting attempts to advance tobacco control in the United States military and VA. In particular, analyses of tobacco-industry documents dating back several decades have shown dedicated efforts, beginning in the middle 1980s, to block attempts to raise commissary tobacco prices (Smith et al., 2007)
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From page 101... ...
(2008) conducted focus groups at Air Force and Army installations, a military supervisor said the following with regard to junior enlisted personnel: "If they see a tough soldier, say a drill sergeant for example, if they smoke, that's the image they want to be, and they have that image of what they want to be." Conway (1998)
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Such findings of "bounded rationality" have clear implications for policies toward tobacco that are applicable to military and veteran populations (Thaler and Sunstein, 2008)
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For example, how tobacco products are displayed varies widely even among vendors on a single military base. Some exchanges promote cigarette sales with "power walls" (large portions of wall space devoted to promotional materials and the display of tobacco products)
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From page 104... ...
SUMMARY Numerous factors interact and contribute to high rates of tobacco use among the military and veteran populations. Evidence-based changes -- such as reducing tobacco access, restricting tobacco use through proper enforcement of existing and new policies, and expanding access to effective cessation programs -- should not be difficult to attain.
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2006. Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC)
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Tobacco Control 7(3)
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From page 107... ...
2004. Nicotine dependence and psychiatric disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions.
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2008. A formative examination of messages that discourage tobacco use among junior enlisted members of the United States military.
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2005. A twin registry study of the relationship between posttraumatic stress disorder and nicotine dependence in men.
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2008. Genetics of nicotine dependence and pharmacotherapy.
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2008. Crossing borders: The impact of the California Tobacco Control Program on both sides of the US-Mexico border.
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2007. Cholinergic nicotinic receptor genes implicated in a nicotine dependence association study targeting 348 candidate genes with 3713 SNPs.
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2007. Death at a discount: How the tobacco industry thwarted tobacco control policies in US military commissaries.
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2003. Framework Convention on Tobacco Control.
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