Combating Tobacco Use in
Military and Veteran Populations
Committee on Smoking Cessation in Military and Veteran
Populations
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
STUART BONDURANT, MD (Chair), University of North Carolina at Chapel Hill
NEAL L. BENOWITZ, MD, University of California, San Francisco
SUSAN J. CURRY, PhD, University of Iowa
ELLEN R. GRITZ, PhD, University of Texas and M.D. Anderson Cancer Center
PETER D. JACOBSON, JD, MPH, University of Michigan School of Public Health
KENNETH W. KIZER, MD, MPH, Medsphere Systems Corporation
ROBERT C. KLESGES, PhD, University of Tennessee Health Science Center/St.
Jude Children's Research Hospital
HOWARD K. KOH, MD, MPH, Harvard School of Public Health (resigned March 25,
2009)
WENDY K. MARINER, JD, LLM, MPH, Boston University School of Public
Health/School of Law
ANA P. MARTINEZ-DONATE, PhD, University of Wisconsin–Madison
ELLEN R. MEARA, PhD, Harvard Medical School
ALAN L. PETERSON, PhD, University of Texas Health Science Center at San
Antonio
FRANCES STILLMAN, EdD, Johns Hopkins Bloomberg School of Public Health
EDWARD P. WYATT, EWyatt Consulting, LLC
DOUGLAS M. ZIEDONIS, MD, MPH, University of Massachusetts Medical School
Committee’s Charge
Identify ways in which the DoD and the VA can work together to improve the
health of both active duty and veteran populations with regard to smoking
initiation and cessation. Specifically:
•
Identify policies and practices that might beused by the DoD and the VA to prevent initiation of
smoking and tobacco use in the military.
•
Identify policies or potential barriers that might inhibit broader implementation of evidence-based
tobacco use cessation care within both DOD and VA.
•
Identify opportunities for increased access to evidence-based smoking and tobacco use cessation
programs within VA and DOD.
•
Evaluate changes, including changes in policy, that could help lower smoking and tobacco use rates
in military and veteran populations.
•
Identify policies and practices that address unique tobacco use prevention and cessation needs of
special populations in DOD and VA, including populations such as those with psychiatric or other
substance use disorders, populations with chronic medical comorbidities, women, and others.
•
Recommend research approaches for reducing initiation of tobacco use and promoting tobacco use
cessation.
Committee’s Approach
• 2 public sessions to hear from VA and DoD
representatives, including Army, Navy and Air
Force
• Reviewed publicly available VA and DoD
documents and published literature
• Requested information from VA and DoD contacts
• Reviewed state of the art tobacco programs
Scope of the Problem
• Over 32% of military personnel and 22% of
veterans smoke and 15% of military
personnel use smokeless tobacco.
• Tobacco use impairs military readiness
• Short-term health effects
• Long-term health effects
• Involuntary exposure to secondhand
smoke
Factors that Influence the Use of
Tobacco
• Individual (genetic makeup, age, sex,
psychological/behavioral status)
• Interpersonal (family, colleagues, friends)
• Community (work environment,
educational and recreational environment)
• Societal (government, industry, media)
• Overarching factors include tobacco
product availability and cost
Goal: Tobacco-free populations
• In the short-term:
– Reduced tobacco use initiation
– Increased tobacco use cessation
• In the long-term
– Have tobacco-free VA facilities
– Achieve the DoD and Armed Services
stated goal of being tobacco-free
Comprehensive Tobacco-Control
Programs
• Program Components
– Strategic Plan (evidence-based and adapted to local
circumstances and population)
– Engaged leadership
– Effective and enforceable policies
– Communication interventions
– Therapeutic interventions
– Surveillance
– Evaluation
– Management capacity to effect change in response to
evaluation
VA already has some components
in place
•
•
•
•
•
•
•
An operating comprehensive health-care organization
Smoke-free facilities policy
Communication opportunities
Tobacco cessation interventions without copay
Some trained tobacco-cessation health-care providers
Surveillance tools
Periodic program evaluations
DoD also already has many
program components in place
• A strong operating, comprehensive health care
organization
• Tobacco Use Prevention Strategic Plan
developed in 1999
• Many tobacco restrictions in place
• New communication tool, “Quit Tobacco. Make
Everyone Proud”
• Tobacco-cessation interventions
But…..
• VA cannot go entirely smoke-free because of
legislative requirements
• VA programs are not consistent or coordinated
• Tobacco cessation has not received highly visible
support from senior leadership
• Lack of information on program effectiveness:
what is really working for veterans?
And….
• DoD continues to sell tobacco at a
discount
• Tobacco is perceived by many as part of
military culture
• Rules and regulations on the books are
not consistently enforced
• Tobacco use is still permitted on
installations albeit in designated areas
Some Barriers to Care for
Veterans
• Cannot attend counseling sessions when offered
• Difficult to get a prescription for tobacco-cessation
medications
• Spouse cannot participate in VA tobaccocessation program
• Cannot immediately access tobacco-cessation
intervention when motivated to quit so opportunity
may be lost
• Lack of concurrent treatment for tobacco use and
mental health disorder
Institutional Barriers in VA
• Requirement for smoking shelters at medical care facilities
• Lack of sufficient staff trained in tobacco-cessation
interventions (including mental health providers)
• Lack of prescribing privileges for tobacco-cessation
medications among health-care providers
• No documentation effectiveness of tobacco cessation
interventions
• Lack of forceful advocacy for tobacco control and promotion
of the most effective tobacco cessation tools
Barriers to Care for Military Personnel
• Counseling not offered at convenient times
• Need to coordinate two sources for
tobacco-cessation treatment: medical staff
for medications and health promotion staff
for counseling
• Senior staff and role models who use
tobacco
• Perception that tobacco use is acceptable
• Used to relieve stress and boredom of
deployment
Institutional Barriers in DoD
• Congressional and tobacco industry
influence
• Tobacco control not perceived as a
high priority for DoD leadership
• Tobacco use is not considered to
impact readiness
• Discounted price of tobacco products
Overcoming Barriers in VA
• National quitline to reach more
veterans
• Train all health care providers in
tobacco cessation
• Consider including spouses in
tobacco-cessation programs
• Close smoking shelters at VA
facilities
Overcoming Barriers in DoD
• National DoD quitline
• Train all health promotion/health care
personnel to provide tobacco cessation
interventions
• Eliminate sale of tobacco products on
military installations
• Eliminate designated tobacco-use areas
• Establish tobacco use as a military
readiness and safety issue
• Treat smokeless tobacco as equal to
smoked tobacco
Bottom line:
• Set a timeline for all services to be tobacco-free
• Close the pipeline of tobacco users entering the
military using a phased approach
• Ban tobacco use during technical/advanced
training
• Stop selling tobacco products on military
installations
• Assess effectiveness of tobacco-cessation
programs
• Foster VA and DoD coordination for tobacco
control
Leadership
An engaged leadership, that believes
that tobacco-control is a high priority
for military readiness and the health
of military personnel and veterans, is
critical for reducing tobacco use in
those populations.
Research Agenda
• Assessment projects for improving interventions
• Effective prevention and cessation interventions
for smokeless tobacco
• Evaluation of long-term abstinence rates for
tobacco-cessation programs
• Specific interventions for patients with mental
illnesses and comorbidities
• Need for alternatives to tobacco to relieve stress
and boredom during deployments