The Impact of Military Tobacco Control Policy: A Systematic Review

INTRODUCTION

Tobacco use is synonymous with the military. Despite that military personnel are trained to follow commands, opportunities exist to implement various tobacco control strategies. We conducted a systematic review to evaluate the impact of tobacco control policy employed in military settings.

MATERIALS AND METHODS

We searched for published English articles in Medline, Web of Science, Scopus, and Google Scholar databases using relevant subject headings without year restriction. We included randomized controlled trials, nonrandomized controlled trials, case-control, cohort, controlled before and after, and uncontrolled before and after studies evaluating the impact of tobacco control policy in the military population. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, three independent reviewers independently screened initially identified articles, reviewed the full text, and extracted the data and any disagreements resolved by consensus after data recheck. Five reviewers used a validated tool to assess the quality of the included studies. The primary outcome was the reduction of any tobacco or nicotine-contained products (TNCPs) use among the troops. The impacts of the tobacco control policy were synthesized and analyzed qualitatively. This study is registered with the International Prospective Register of Systematic Review (CRD42022314117).

RESULTS

Fourteen studies were included in the analysis from 5372 studies screened. Most of the studies were from the USA, and fractions were from Thailand, France, and Taiwan. These studies were methodologically heterogeneous. Most studies employed a total ban policy on TNCP use during basic military training or operational deployment as the primary strategy. Other methods utilized were the brief tobacco intervention, targeted treatment, support, and counseling provided through telephone or mailing systems, the adjunctive behavioral intervention, providing free nicotine gum, the "Pharsai clinic", active and regular smoking restriction, and interventions aimed at intrapersonal, interpersonal, and organizational levels. There is a moderate quality of evidence that the tobacco control policies effectively reduced the prevalence of TNCP use, increased the cessation rate, reduced the intake, and lowered the dependency. The adjunctive interventions provided after the total ban on TNCP use may increase its effectiveness. However, findings from this review need to be carefully considered as the definition of TNCP use status was not universal between studies and lacked a biochemical validation procedure.

CONCLUSIONS

There is reasonable evidence to support that the tobacco control policy employed in the military population has multiple positive impacts in reducing the prevalence of TNCP use, increasing the cessation rates, reducing the intake, and lowering dependency. Other evidence-based strategies need to be fully utilized to materialize the tobacco endgame.

"We're tough, but so is quitting." Barriers to Smoking Cessation: The Royal Malaysian Navy Perspective

INTRODUCTION

Tobacco kills half of its users. Despite this, there are over 1.1 billion smokers worldwide. Its harmful effects impair performance and readiness. Unfortunately, smoking has deeply ingrained in the military culture, as evidenced by the high prevalence. Hence, this study aims to identify the barriers to smoking cessation among this population.

METHODS

A study involving two groups of current smokers (commissioned officers and non-commissioned officers) was conducted using the modified nominal group technique (mNGT), a qualitative research method of judgmental decision-making involving four phases: Generating ideas, recording, evaluation, and prioritization. The mNGT was used to solicit respondents' barriers to smoking cessation.

RESULTS

The mNGT yielded seven main barriers to smoking cessation: (1) Addiction, (2) difficulty in staying focused without the usage of cigarettes, (3) smoking has been incorporated into an individual's lifestyle, (4) environmental influence, (5) coping mechanism, (6) the long-interval period between orders and duties exacerbates the desire to smoke, and (7) smoking has evolved into a permanent habit. Although nicotine addiction and habit were ranked as the most important barriers, the military working environment and nature of the job exposed them physically and mentally to unfavorable situations, complicating the quitting attempt. Furthermore, the acceptance of smoking in military culture leads to a positive smoker identity, further hindering cessation.

CONCLUSIONS

The findings indicate that in addition to barriers affecting the general population, military-specific barriers related to the nature of the job exist, complicating cessation. Hence, any intervention program should address these barriers to achieve positive outcomes.

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.

"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.

I smoke to cope with pain: patients' perspectives on the link between cigarette smoking and pain

BACKGROUND

For people with chronic pain, cigarette smoking is associated with greater pain intensity and impairment. Researchers have hypothesized a reciprocal relationship in which pain and smoking exacerbate each other, resulting in greater pain and increased smoking. This study aimed to qualitatively examine patient perspectives on this association.

METHODS

A retrospective thematic analysis of smoking cessation counseling notes for 136 veterans in the Pain and Smoking Study, a tailored smoking cessation trial, was conducted. A validated codebook was applied to each counseling note by four independent coders using Atlas.ti (Atlas.ti, Berlin, Germany). Coders participated in a consensus-forming exercise with salient themes validated among the wider research team.

KEY RESULTS

Participants averaged 60 years of age (range 28-77 years) and were 9% female. The median number of cigarettes smoked per day was 15, with a mean pain intensity score in the last week (from 0-10) of 5.1. While not all patients acknowledged a connection between pain and smoking, we found that (1) pain motivates smoking and helps manage pain-related distress, as a coping strategy and through cognitive distraction, and (2) pain motivates smoking but smoking does not offer pain relief. Concerns about managing pain without smoking was identified as a notable barrier to cessation.

CONCLUSION

Many patients with chronic pain who smoke readily identified pain as a motivator of their smoking behavior and are reluctant to quit for this reason. Integrated interventions for smokers with pain should address these perceptions and expectancies and promote uptake of more adaptive self-management strategies for pain.

Role of procedural intervention and acute illness in veterans affairs smoking cessation program referrals: A retrospective study

INTRODUCTION

Tobacco use remains pervasive amongst veterans. Unfortunately, the negative impact on postoperative outcomes may preclude surgeons from offering operative intervention to veterans who smoke. As such, a major health event may provide added incentive to quit. We sought to describe the role of acute illness and interventional specialist involvement in Veterans Affairs Smoking Cessation Program referrals compared to primary care wellness initiatives.

METHODS

We retrospectively reviewed consultations to the pharmacy-led Smoking Cessation Program (SCP) at the Middleton Memorial VA Hospital from 2017 to 2019. Consultations placed during the last three months were categorized based on the source of referral: primary care, acute care, and interventional specialties. Descriptive statistics were used to assess rates of veteran engagement based on referral source. Consultation completion was used as a proxy for veteran engagement.

RESULTS

A total of 2993 new SCP consultations were placed during the study period. Overall, veteran engagement rose from 43% in 2017 to 53% in 2019. In recent months, there were 282 SCP referrals. While only 19 (7%) of these referrals were placed by interventional specialties - primarily cardiology and thoracic surgery - the rate of veteran engagement was 63%. The majority of referrals (65%) were placed by primary care providers with an engagement rate of 68%. In contrast, only 42% of consultations placed in the context of an acute illness were completed.

CONCLUSIONS

In our study, primary care directed smoking cessation referrals were most prevalent and resulted in the highest completion rates. The presence of an acute illness in isolation failed to impact program success. However, while surgeon-initiated referrals were meager in number, the engagement rate approached that of primary care. This finding suggests that surgeons play a powerful role in influencing patient behavior that may be harnessed to augment success of existing smoking cessation programs.