Predicting cigarette initiation and reinitiation among active duty United States Air Force recruits

Cancer Incidence and Etiology in the Active Duty Population of U.S. Military

INTRODUCTION

As members of the military, all active duty service members (ADS) must meet physical fitness requirements and are provided with equal-access healthcare through the DoD. In addition, 92% of ADS are ≤40 years of age. Together, these characteristics suggest that ADS represent a healthy population that may have a low risk of cancer. Each year, however, >800 ADS are diagnosed with cancer and the resulting in time off for treatment, reassignment, or medical retirement may significantly impact force readiness.

MATERIAL AND METHODS

Relevant literature was identified by searching the PubMed database using search terms ACTIVE DUTY and CANCER. Only articles written in English were included.

RESULTS

Melanoma is the most common cancer in ADS, while testicular cancer is the most common cancer in males and breast cancer is the most common in females. Cancer incidence patterns in ADS differ from those in the general U.S. population and from military veterans. Tumor etiology in ADS may be influenced by military-enriched exposures such as prolonged use of oral contraceptives, suboptimal use of sunscreen, exposure to volatile organic compounds, or germline predisposition/family history.

CONCLUSIONS

The etiology of cancer within ADS remains largely unknown. A number of new research programs may provide the means to improve understanding of the etiology of cancer in ADS. Together, these efforts will improve prevention, early detection, and clinical management, thus improving the outcomes of ADS and preserving force readiness.

The prevalence of smoking among soldiers of the gendarmerie in a provincial center and affecting factors: A cross-sectional study from Turkey. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2023;78:347-356. [PMID: 37788125 DOI: 10.1080/19338244.2023.2262923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Determining the smoking rates and nicotine dependency levels of soldiers can be a guide in smoking cessation interventions and developing a policy for smoking prevention for soldiers serving in military units. The cross-sectional study was conducted with a total of 313 soldiers stationed in gendarmerie units in a city center in the Central Anatolian Region of Turkey. Data were collected between 01.06.2021 and 31.07.2021 by face-to-face interview technique using Personal Information Form and Fagerström Nicotine Addiction Test. It was determined that 54.6% of the participants smoked, 87.1% had low-moderate nicotine addictions, and 94.9% were smokers in their friends' circle. It was revealed that the prevalence of smoking among the participants was high, and the nicotine addiction levels of the participants working in the "Prison" unit were higher.

Motives for using electronic nicotine delivery systems (ENDS) as a cessation tool are associated with tobacco abstinence at 1-year follow-up: A prospective investigation among young adults in the United States Air Force

Introduction

Smokers use electronic nicotine delivery systems (ENDS), including e-cigarettes, as a harm reduction strategy even though the Food and Drug Administration (FDA) has not approved them for tobacco cessation. The limited literature about ENDS use for cigarette cessation is concerning for the U.S. military, which is largely comprised of young adults at increased risk for tobacco use. Thus, the current study aims to evaluate use of ENDS products as a cessation tool in relation to point-prevalence tobacco abstinence at one-year follow-up in a cohort of 8,901 U.S. Air Force personnel attending entry-level job training from March 2016 to April 2019.

Methods

A propensity-score adjusted multinomial logistic regression model was used to assess the association between the baseline motives for ENDS use (i.e., for cigarette cessation versus alternative reasons) and tobacco use at the one-year follow-up (cigarette use, non-cigarette tobacco product use, and tobacco abstinence) among those reporting history of cigarette use at baseline.

Results

Smokers reporting ENDS use for cigarette cessation were more likely to be abstinent at one-year follow-up (Odds Ratio[OR] = 1.62, 95% CI: 1.06-2.49, P =.03) as well as quit using non-cigarette tobacco products (OR = 2.11, 95% CI: 1.65-2.70, P <.001) than those reporting ENDS use for alternative reasons.

Conclusions

Current tobacco users are recommended to use FDA-approved products for smoking cessation, such as nicotine replacement therapy. However, given the high prevalence of cigarette use among military populations, ENDS may provide a useful alternative harm reduction strategy for this high-risk population.

Using the Socio-ecological Model to Explore Facilitators and Deterrents of Tobacco Use Among Airmen in Technical Training

INTRODUCTION

Military personnel have some of the highest rates of tobacco use in the USA. Within the Air Force, a common point of Airmen's (re-)initiation of tobacco use is during technical training once the tobacco ban has been lifted. Unfortunately, little is known about what factors facilitate and deter tobacco use during technical training. The socio-ecological model, which emphasizes multiple levels of influence on behavior (e.g., personal, intrapersonal, and environmental), provides a strong and comprehensive basis for which to explore factors that may impact tobacco use during technical training.

MATERIALS AND METHODS

Twenty-two focus groups were conducted among Airmen (n = 10), Military Training Leaders (MTLs, n = 7), and Technical Training Instructors (TTIs, n = 5). Semi-structured focus group protocols were developed based on the socio-ecological model and included questions intended to elicit factors that facilitated and deterred tobacco use during technical training. Focus groups were transcribed and then coded using a hybrid deductive-inductive process.

RESULTS

At the personal level, five factors were identified that influenced tobacco use: choice, fit with lifestyle, associations with the tobacco experience, association with military job outcomes, and association with health outcomes. Three interpersonal level factors were identified: peer influence, leadership influence, and normative beliefs. There were two influential environmental level factors: pricing and promotion and access to tobacco. Except for normative beliefs, all personal, interpersonal, and environmental-level factors were discussed as having aspects that could either facilitate or deter tobacco use. Normative beliefs, an interpersonal-level factor, were only discussed as a facilitator of tobacco use.

CONCLUSIONS

Taken together, study findings can be used to enhance the effectiveness of tobacco prevention and cessation programs for Air Force Technical Trainees. Specific strategies to support the reduction of tobacco use among Airmen are presented.

Cheaper tobacco product prices at US Air Force Bases compared with surrounding community areas, 2019

INTRODUCTION

In March 2017, the US Department of Defense (DoD) implemented a policy requiring all military stores to set tobacco prices equal to 'prevailing prices' in the 'local community' adjusted for state and local taxes. We compared tobacco product prices in a sample of retailers located on five Air Force Bases (AFBs) in Texas and Mississippi with those sold in nearby off-base stores.

METHODS

We constructed a list of on-base and off-base tobacco retailers. Off-base retailers included stores that were located within a 1.5-mile road network service area from main AFB gates. Between July and September 2019, a trained auditor visited 23 on-base and 50 off-base retailers to confirm tobacco product sales, and documented the price of cigarettes and Copenhagen smokeless tobacco. For each area, the median price for each product, as well as the difference in median prices by on-base versus off-base status, was calculated.

RESULTS

The median price of cigarettes and smokeless products was cheaper at on-base retailers. All products were cheaper at on-base stores in Fort Sam Houston and Lackland AFB. Similarly, all products were cheaper in on-base stores at Keesler AFB, with the exception of Marlboro Red packs ($0.22 more), and at Sheppard AFB with the exception of cheapest cigarette cartons ($6.26 more).

CONCLUSION

Despite the implementation of the new DoD policy, tobacco products are cheaper in on-base retailers compared with off-base retailers. Refining of the definitions used and improved compliance with the new DoD policy are needed.

Efficacy of a group-based brief tobacco intervention among young adults aged 18-20 years in the US Air Force

INTRODUCTION

Most smokers begin using tobacco before the age of 25 years, making it important to reduce tobacco use during adolescence and early adulthood. Rates of use are historically higher among military personnel. While 'Tobacco 21' made it illegal for US retailers to sell tobacco to those aged <21 years, the policy did not address cessation for current youth and young adult tobacco users. Additionally, there is limited research on cessation interventions among young adults under 21 years. The current study evaluated the efficacy of a group-based Brief Tobacco Intervention (BTI) among US Air Force trainees, who are predominantly aged 18-20 years and directly impacted by Tobacco 21 legislation.

METHODS

Participants were 2969 US Air Force Trainees from April 2017 through January 2018 cluster randomized to three conditions: 1) BTI + Airman's Guide to Remaining Tobacco Free (AG), 2) AG alone, and 3) the National Cancer Institute's Clearing the Air (CTA) pamphlet. To assess the efficacy of the interventions among people aged 18-20 years, a domain analysis (<21 years, n=2117; and ≥21 years, n=852) of a multinomial logistic regression model was run.

RESULTS

Mono tobacco users aged <21 years at baseline who received the BTI+AG had higher odds of quitting tobacco at 3 months (OR=2.13; 95% CI: 1.02-4.46). Dual and poly users aged <21 years at baseline who received the BTI+AG intervention had higher odds of reducing the number of tobacco products used at 3 months (OR=2.94; 95% CI: 1.03-8.37).

CONCLUSIONS

The BTI was effective for people aged 18-20 years. The current study offers insight into components of interventions that might be successful in helping this age group decrease tobacco use.

Dual and polytobacco use after a period of enforced tobacco cessation

The current study aimed to assess single product, dual, and polytobacco use in a young adult military population and how an enforced tobacco ban during training impacts these behaviors. Participants were 810 U.S. Airmen who reported tobacco use as civilians. Participants completed baseline and one-year follow-up surveys about their tobacco use from 2016 to 2019. Each product used by a participant was assigned a score based on their frequency of use, which were summed to create a total score. Change scores were calculated by determining the difference between baseline and follow-up frequency scores. Tobacco frequency score and the categorical change (e.g., increased, decreased) were compared between groups using t-tests and Chi-squared tests, respectively, adjusting for clustering effects by squadron and base. Among single product users, 44.58% quit using tobacco products, 47.1% remained single product users, and 8.32% became dual or polytobacco users. Among dual users, 39.1% quit, 43.1% became single product users, 14.2% remained dual users, and 3.7% became polytobacco users. Among polytobacco users, 29.9% quit, 43.4% became single product users, 17.9% became dual users, and 8.8% continued poly-tobacco use. Most participants reduced the number and frequency of tobacco products used. Implementing stringent policies that further restrict tobacco use may decrease tobacco product use or frequency of use.

"Nobody Views It As a Negative Thing to Smoke": A Qualitative Study of the Relationship Between United States Air Force Culture and Tobacco Use

INTRODUCTION

Tobacco use has long been a part of military culture, and rates of tobacco use remain higher among military personnel compared to civilians. The current study examines aspects of Air Force tobacco culture that encourage tobacco use.

MATERIALS AND METHODS

We conducted 7 focus groups among Air Force Military Training Leaders (n=48) and 5 focus groups among Technical Training Instructors (n=33) from July 2018 to February 2019.

RESULTS

Tobacco use was seen as a core part of Air Force culture and a low risk behavior, in contrast to other potential activities. Three themes of Air Force culture that facilitate tobacco use emerged: 1) opportunity for work breaks; 2) finding common ground; and 3) stress management or stress relief during deployment. Smoke pits were seen as serving several functions that were not perceived to occur anywhere else: an opportunity for informal communication with leadership, a source of valuable information, and a space for problem solving.

CONCLUSIONS

Airmen viewed tobacco as serving a functional role, which outweighed its harm. Future programs might try to address the functions fulfilled by tobacco in order to enhance their impact.

Trends in Tobacco Use among Young Adults Presenting for Military Service in the United States Air Force between 2013 and 2018

Background: The US military has historically higher tobacco use compared to civilians, and tobacco use increases following enlistment. While the military is vulnerable to tobacco use, current surveillance of tobacco among this high-risk population is lacking. Methods: Recently enlisted Airmen (N = 43,597) between 2013 and 2018 were asked about tobacco use prior to enlistment across ten products: (1) cigarettes/roll your own tobacco, (2) smokeless tobacco/snus, (3) cigars, cigarillos/little cigars, (4) hookah/pipe, and (5) e-cigarettes. Results: Hookah/pipe use, cigarettes/roll your own, smokeless tobacco/snus, and cigars/little cigars/cigarillos use decreased significantly between 2013 and 2018, while the prevalence of e-cigarette use increased (p's < 0.0001). The relationships between the time and each tobacco product(s) use outcomes were influenced differently by different age, race, education and marital status. Conclusion: While e-cigarette use has increased in the civilian sector, the use of e-cigarettes among new recruits increased much more drastically (i.e. prevalence 15.3% in 2018). Further, demographic characteristics influenced tobacco trends; specifically, recruits of racial minorities increased their use of e-cigarettes over the past five years faster than Whites. Of concern is what impact this dramatic increase in e-cigarette use will have on overall health and later initiation of combustible tobacco products in the military.

Evaluating the Effects of a Brief Tobacco Intervention in the US Air Force

INTRODUCTION

Military personnel have among the highest rates of tobacco use in the United States. Unfortunately, there are few interventions aimed at reducing tobacco use among this vulnerable population. The current study addresses this need by evaluating the short-term effectiveness of a Brief Tobacco Intervention (BTI), a 40-min group-based intervention designed to reduce contemporary patterns of tobacco use among a sample of US military enlistees during an 11-week period of involuntary tobacco abstinence.

AIMS AND METHODS

Participants were 2999 US Air Force Technical Trainees at Joint Base San Antonio-Lackland Air Force Base in San Antonio, Texas from April 2017 through January 2018. Participants were cluster randomized to three conditions: (1) BTI + Airman's Guide to Remaining Tobacco Free (AG), (2) AG intervention, or (3) standard smoking cessation intervention. The primary analysis was a comparison of the interventions' efficacies in preventing tobacco use during Technical Training, conducted using a generalized estimating equations logistic regression model controlling for covariates. Multiple imputation was used to account for loss to follow-up.

RESULTS

There was not a significant difference by condition in the use of tobacco products at follow-up (p = .454). The BTI + AG condition did produce short-term changes in perceived harm, intentions to use tobacco, knowledge about tobacco products, and normative beliefs.

CONCLUSIONS

These findings suggest that while the intervention was effective in the short term, it was not potent enough over a 12-week period to prevent Airmen from initiating tobacco use. Future studies should examine whether adding a booster session or media campaign enhances the effectiveness of the intervention.

IMPLICATIONS

Despite the fact that most Airmen believe they will remain tobacco free following the ban in Technical Training, a large percentage of these Airmen resume and initiate tobacco use during this high-risk period. As a result, there is a need for interventions targeting the range of tobacco available to military trainees during a teachable moment when they report intentions to remain tobacco free. The current study shows that a BTI has promise in reducing long-term tobacco use, when coupled with additional interventions, such as a booster session or a media campaign.

'I Think Smoking's the Same, but the Toys Have Changed.' Understanding Facilitators of E-Cigarette Use among Air Force Personnel

BACKGROUND

The military has stringent anti-tobacco regulations for new recruits. While most tobacco products have declined in recent years, e-cigarette use has tripled among this population. However, little is known about the factors facilitating this inverse relationship.

OBJECTIVES

Examine the facilitators of e-cigarette use during a high risk period following initial enlistment among young adults.

METHODS

Focus groups were conducted with Airmen, Military Training Leaders (MTLs) and Technical Training Instructors (TTIs) to qualitatively explore unique characteristics of e-cigarettes leading to use in Technical Training.

RESULTS

The most commonly used tobacco product across participants was cigarettes (42.7%), followed by e-cigarettes (28.0%) and smokeless tobacco (22.6%). Almost a third (28.7%) of participants reported using more than one tobacco product. E-cigarette use was much more common among Airmen (76.1%), compared to MTLs (10.9%) and TTIs (13.0%).Four main facilitators around e-cigarette use were identified including: 1) There is no reason not to use e-cigarettes; 2) Using e-cigarettes helps with emotion management; 3) Vaping is a way of fitting in; and 4) Existing tobacco control policies don't work for vaping. E-cigarettes were not perceived as harmful to self and others, which could explain why Airmen were much less likely to adhere to existing tobacco control regulations. Subversion was viewed as the healthy option compared to utilizing designated tobacco use areas due to the potential exposure to traditional tobacco smoke. This coupled with a lack of understanding about e-cigarette regulations and difficulties with enforcement, promoted use among this young adult population.

CONCLUSION

Findings suggest that e-cigarettes are used for similar reasons as traditional tobacco products, but their unique ability to be concealed promotes their widespread use and circumvents existing tobacco control policies. In order to see reductions in use, environmental policies may need to be paired with behavioral interventions at the personal and interpersonal level.

When, How, & Where Tobacco Initiation and Relapse Occur During U.S. Air Force Technical Training

INTRODUCTION

Military personnel are at high risk for tobacco use, particularly during the first year of military service. Technical Training follows an 8½ week tobacco ban during basic military training and is a vulnerable time for personnel to both reinitiate and initiate tobacco use. Thus, this can be a crucial time to promote tobacco policies and interventions. However, there is limited research examining when, how, and where personnel access tobacco during the first year of service, particularly among users of newer products (eg, electronic cigarettes[e-cigarettes]). Thus, the purpose of the current study is to explore the timing, source, and location of tobacco use during Technical Training across all types of products. Furthermore, this study will examine differences in demographic characteristics and prior tobacco history in relationship to these tobacco behaviors.

MATERIALS AND METHODS

Participants were U.S. Air Force recruits completing Technical Training (2017-2018). Protocol was approved by the Institutional Review Board at the 59th Medical Wing of the U.S. Air Force. During the first week of Technical Training, Airmen were consented to participate in the study and completed a questionnaire about demographics and tobacco use history. Next, Airmen were randomized to receive one of three tobacco prevention interventions as part of military training. At a 3-month follow-up, during the last week of Technical Training, consented participants completed a questionnaire about current tobacco use. Airmen reported when (ie, first month vs. after), how (ie, "bummed" from another airman, bought on or off base, received from the internet or event), and where (ie, designated smoking areas on base, off base, bar or club, friend's house, cigar lounge, hookah bar, or vape shop) they used tobacco during Technical Training. Descriptive statistics were used to examine these behaviors across all tobacco products. Additionally, Wilcoxon-Mann-Whitney and Kruskal-Wallis tests compared differences in demographic characteristics and baseline tobacco use in relationship to these tobacco behaviors.

RESULTS

No significant differences were found when comparing prior users and first-time users in relationship to tobacco behaviors during Technical Training; however, significant differences in educational background and age were found in regard to the source and location of tobacco use. Additionally, how and where Airmen first used tobacco during Technical Training differed across products. Cigarettes and smokeless tobacco were equally likely to be bought on or off base and most commonly first used at a designated smoking area on base. However, e-cigarettes, cigarillos/little cigars, and hookah were more likely to be bought off base, and first used at a specialty store (ie, vape shop, hookah bar, or cigar lounge).

CONCLUSIONS

Tobacco use behaviors during Technical Training differed depending on the type of product. Specifically, new and emerging products were more likely to be bought off base and first used at a specialty store. Thus, military polices regulating on base tobacco pricing might not reduce the growing prevalence of e-cigarettes. Future policies might consider addressing the density of off-base tobacco retailers to reduce the high rates of tobacco use in this population.

Factors Associated with Cigarette Use During Airmen's First Year of Service in the United States Air Force

INTRODUCTION

Despite declines of cigarette use in the civilian population, military personnel report alarmingly high rates of cigarette use. Enlisted Air Force recruits are required to remain tobacco-free for the first 12 weeks of training, and the majority express confidence they will not use tobacco after the ban; however, most previous smokers return to smoking and many nonsmokers initiate. Understanding the factors associated with cigarette-smoking initiation among non-users and re-initiation among former users is critical for the development of successful tobacco control efforts.

MATERIALS AND METHODS

The current study examines predictors of cigarette smoking among a sample of 2,188 USAF personnel after their first year of service. Logistic regression analyses examined associations between baseline predictors and initiation and re-initiation of cigarette smoking at a one-year follow-up.

RESULTS

Compared to never smokers at both time points, the strongest predictor of smoking initiation over the past 12 months was having owned cigarette-branded merchandise (OR 3.81, 95% CI 1.67, 8.71). Compared to former smokers who remained abstinent, the strongest predictor of re-initiation was intention to use tobacco (OR 2.08, 95% CI 1.53, 2.83). Compared to individuals who initiate, the strongest predictors of re-initiation were prior use of other tobacco products and tobacco use intentions (ORs range 1.85 to 4.63).

CONCLUSIONS

Multiple risk factors are associated with tobacco use. Given that Airmen are tobacco-free for the first 12 weeks of training, tobacco interventions during this period might be more effective. Our findings can be used to tailor interventions to prevent tobacco use in the U.S. military.

Predicting smokeless tobacco initiation and re-initiation in the United States Air Force

INTRODUCTION

Active Duty United States Air Force (USAF) members have substantially higher rates of smokeless tobacco (ST) use than the general population.

METHODS

We longitudinally assessed demographics, tobacco use, intrapersonal factors, and interpersonal factors to determine associations with the initiation or re-initiation of ST in the year following a period of forced abstinence among 2188 newly recruited Airmen. Logistic regression analyses were conducted to examine associations between baseline predictors and ST use at one-year follow-up.

RESULTS

In the final multivariate models compared to never users, the strongest predictors of ST use initiation after BMT were male gender (adjusted OR 8.93, 95% CI 3.82, 20.88), pre-BMT cigarette and cigar use (adjusted OR 1.60, 95% CI 1.00, 2.57; adjusted OR 2.50, 95% CI 1.66, 3.81 respectively). Compared to former ST users, the strongest predictors of re-initiation were male gender (adjusted OR 10.68, 95% CI 2.25, 50.62) and intentions to use ST (adjusted OR 2.10, 95% CI 1.42, 3.12). Compared to initiators of ST, the strongest predictors of re-initiation were intentions to use ST and peer use (adjusted OR 3.26, 95% CI 1.94, 5.49; OR 2.55, 95% CI 1.92, 3.41 respectively).

CONCLUSIONS

Our results suggest that initiators may be exploring and viewing ST as a less harmful alternative to cigarette smoking and ST users reporting intentions to use ST in the future often return to use. The development of interventions able to disrupt the link between intentions to use tobacco and future tobacco use in the USAF is vital.