Effect of the Alcohol Misconduct Prevention Program (AMPP) in air force technical training

Developing a Text Messaging Intervention to Prevent Binge and Heavy Drinking in a Military Population: Mixed Methods Development Study

BACKGROUND

Alcohol misuse is the fourth leading cause of death in the United States and a significant problem in the US military. Brief alcohol interventions can reduce negative alcohol outcomes in civilian and military populations, but additional scalable interventions are needed to reduce binge and heavy drinking. SMS text messaging interventions could address this need, but to date, no programs exist for military populations.

OBJECTIVE

We aimed to develop an SMS text messaging intervention to address binge and heavy drinking among Airmen in Technical Training in the US Air Force.

METHODS

We implemented a 2-phase, mixed methods study to develop the SMS text messaging intervention. In phase 1, a total of 149 respondents provided feedback about the persuasiveness of 49 expert-developed messages, preferences regarding message frequency, timing and days to receive messages, and suggested messages, which were qualitatively coded. In phase 2, a total of 283 respondents provided feedback about the persuasiveness of 77 new messages, including those developed through the refinement of messages from phase 1, which were coded and assessed based on the Behavior Change Technique Taxonomy (BCTT). For both phases, mean persuasiveness scores (range 1-5) were calculated and compared according to age (aged <21 or ≥21 years) and gender. Top-ranking messages from phase 2 were considered for inclusion in the final message library.

RESULTS

In phase 1, top-rated message themes were about warnings about adverse outcomes (eg, impaired judgment and financial costs), recommendations to reduce drinking, and invoking values and goals. Through qualitative coding of suggested messages, we identified themes related to warnings about adverse outcomes, recommendations, prioritizing long-term goals, team and belonging, and invoking values and goals. Respondents preferred to receive 1 to 3 messages per week (124/137, 90.5%) and to be sent messages on Friday, Saturday, and Sunday (65/142, 45.8%). In phase 2, mean scores for messages in the final message library ranged from 3.31 (SD 1.29) to 4.21 (SD 0.90). Of the top 5 highest-rated messages, 4 were categorized into 2 behavior change techniques (BCTs): valued self-identity and information about health consequences. The final message library includes 28 BCTT-informed messages across 13 BCTs, with messages having similar scores across genders. More than one-fourth (8/28, 29%) of the final messages were informed by the suggested messages from phase 1. As Airmen aged <21 years face harsher disciplinary action for alcohol consumption, the program is tailored based on the US legal drinking age.

CONCLUSIONS

This study involved members from the target population throughout 2 formative stages of intervention development to design a BCTT-informed SMS text messaging intervention to reduce binge and heavy drinking, which is now being tested in an efficacy trial. The results will determine the impact of the intervention on binge drinking and alcohol consumption in the US Air Force.

Decreasing alcohol use among young adults presenting for service in the U.S. Air Force: An epidemiological surveillance study

U.S. surveys demonstrate recent decreases in the prevalence of alcohol use and binge drinking among young adults. The current study aims to determine whether similar trends are evident in a similarly aged cohort of service members in the US Air Force to inform ongoing prevention efforts. Participants were 103,240 Air Force personnel in entry-level training between 2016 and 2019. Participants anonymously completed the AUDIT (Alcohol Use Disorder Identification Test) regarding their pre-service drinking. Logistic regression analyses and the Cochran-Armitage test were conducted to measure population trends over the study duration with stratification by age (<21 vs. ≥21) and evaluation of specific alcohol behaviors. Between 2016 and 2019, the proportion of young service members endorsing any alcohol use significantly decreased for both the <21 group (i.e. from 38.9% to 32.6%) and the ≥21 group (i.e. from 80.6% to 77.5%). Among those who endorsed drinking, a decrease over time in binge use was also observed from 46.6% to 37.8% for the <21 group and from 34.2% to 27.5% for the ≥21 group. Responses to other specific alcohol risk items and total AUDIT scores also demonstrated decreases. Binge use and risky drinking remained disproportionately common among those under the legal drinking age. It is encouraging to observe a shift toward abstinence and decreased binge use among this population of young military recruits. However, given the risk for many adverse health and legal consequences in this population, more work is needed to prevent problematic drinking, especially among those under the legal drinking age.

Where, When, and How Alcohol Use Occurs During Air Force Technical Training

INTRODUCTION

Alcohol use is prevalent among military personnel, with many engaging in binge drinking behaviors. Military trainees are unique, in that they experience an enforced alcohol ban for 8 weeks while in Basic Military Training. However, they are also typically young adults, who consume alcohol at higher rates than any other age group. The current study aimed to describe alcohol consumption among trainees, determine when, where, and with whom Airmen drank for the first time during Technical Training, and if these patterns were significantly different based on descriptive norms (i.e., beliefs about how many other individuals engage in a certain behavior) related to alcohol use, given that most military members consume alcohol. Last, we aimed to determine if alcohol consumption or potential alcohol use disorders were significantly different based on descriptive norms.

MATERIALS AND METHODS

Airmen (n = 599) were recruited at Joint Base San Antonio-Fort Sam Houston during their last week of Technical Training to complete a survey. Study procedures were approved by the 59th Medical Wing Institutional Review Board. Participants were asked about their beliefs related to how many other Airmen drink alcohol (i.e., less than 50%, 50%, or greater), their own experiences with alcohol (e.g., how much they drink compared with consumption before military service, blackouts after drinking during Technical Training), and when, where, and with whom they consumed alcohol for the first time after beginning military training.

RESULTS

Over half of the Airmen reported not engaging in drinking behaviors during Technical Training. Among those who reported drinking one or more drinks during Technical Training, most reported drinking the same amount or less than they did prior to Basic Military Training. The majority of Airmen reported that they had "maybe" experienced blackouts from drinking since Technical Training. Most Airmen drank for the first time with another someone who was not an Airman, at a restaurant, home, or other place off base, and while they were on leave. Results indicated no significant differences between groups related to beliefs about how many Airmen drink during Technical Training and where, when, and with whom Airmen drank for the first time since joining the Air Force. There were also no differences in Alcohol Use Disorders Identification Test scores or drinks per week between these normative belief groups.

CONCLUSIONS

Almost half of Airmen resume drinking after alcohol restrictions are lifted during Technical Training but maintain low numbers of drinks consumed per week and low risk for alcohol use disorders, which may indicate that this is an opportune time for intervention to prevent alcohol consumption from escalating over time. Airmen reported drinking for the first time with another Airman off base during leave. Focusing on how Airmen navigate alcohol-related decision-making while their responsibilities are reduced, or how other Airmen influence their decisions to engage in risky drinking, may help prevent alcohol use rates from increasing post-enforced ban.

The Feasibility of Using Self-Generated Identification Codes in Longitudinal Research With Military Personnel

Self-generated identification codes (SGICs) are strings of information based on stable participant characteristics. They are often used in longitudinal research to match data between time points while protecting participant anonymity. However, the use of SGICs with military personnel has been infrequent, even though military personnel do not have the same privacy protections as civilians. The current paper reports results from two studies that tested the feasibility, reliability, and validity of using a SGIC to collect sensitive longitudinal data among military personnel. In study one, a team of 105 participants was tracked three times over a period of 12 weeks. The 10-item SGIC produced optimal matching over the 12-weeks. In study two, 1,844 participants were randomly assigned to a SGIC group or an anonymous control group, and then were asked to provide information about their alcohol use. Although match rates declined over time, there were no observed differences between study groups in participants' beliefs about the use of a SGIC. However, differences were identified in reported alcohol use behaviors between the groups, with controls reporting significantly more drinks per week and higher AUDIT-10 scores. While these findings raise potential concerns about using SGICs for epidemiological assessments of highly sensitive problem behaviors, these codes may still be useful in determining group differences in behavior change in randomized studies.

Prevention of Alcohol-related Incidents in the U.S. Air Force: Results From a Cluster Randomized Trial

BACKGROUND

Alcohol misuse poses significant public health concerns in the U.S. Military. An Alcohol Misconduct Prevention Program (AMPP), which includes a brief alcohol intervention (BAI) session, plus random breathalyzer program, has been shown to reduce alcohol-related incidents (ARIs) among Airmen undergoing training.

PURPOSE

The current study sought to examine whether a booster BAI administered at the end of Airmen's training reduced ARIs out to a 1-year follow-up.

METHODS

Participants were 26,231 U.S. Air Force Technical Trainees recruited between March 2016 and July 2018. Participants were cluster randomized by cohort to two conditions: AMPP + BAI Booster or AMPP + Bystander Intervention. The primary analysis was a comparison of the interventions' efficacies in preventing Article 15 ARIs at a 1-year follow-up, conducted using a generalized estimating equations logistic regression model controlling for covariates.

RESULTS

There was no significant difference by condition in Article 15 ARIs at the 1-year follow-up (P = .912).

CONCLUSIONS

Findings suggest that a booster may not be necessary to produce maximum effects beyond the initial AMPP intervention. It is also possible that alcohol behaviors changed as a result of the intervention but were not captured by our outcome measures. Future research should consider alternative outcomes or participant-tracking measures to determine whether a different or more intensive BAI booster is effective. The majority of Article 15 ARIs were for underage drinking; therefore, developing an intervention focused on this problem behavior could lead to large reductions in training costs in the military.

Dissemination of a Universally Delivered Brief Alcohol Intervention in United States Air Force Technical Training

OBJECTIVES

Heavy alcohol use is a particular problem in the US military, prompting the Institute of Medicine to identify it as a public health crisis. Developing prevention programs aimed at reducing problematic drinking during military service would be useful. Thus, the purpose of the current study, was to broadly disseminate and assess the effectiveness of a brief alcohol intervention (BAI) + random breathalyzer (RB) intervention to reduce alcohol related incidents (ARIs), to all incoming Air Force trainees.

METHODS

The BAI was administered to all incoming Airmen (N = 15,898) across 4 major training Air Force bases. Additionally, underage Airmen were subject to RB tests. A quasi-experimental pre-test post-test design compared the rate of ARIs, per 100,000 training days, during the year prior and the year after the intervention was delivered.

RESULTS

A Poisson model indicated that the BAI + RB intervention was associated with a decrease in ARIs across all bases. Overall, the intervention lowered the ARI rate by 16% (β = -0.178, standard error  = 0.0742, P = 0.016). For every 100,000 training days, annual ARIs decreased from 30.8 to 25.5 after implementation.

CONCLUSIONS

A universally administered brief alcohol intervention, coupled with RB targeting underage drinkers, was associated with a reduction in the rate of ARIs. Results of this large-scale prevention study indicate that a brief alcohol intervention can be widely disseminated during US Air Force training and can perhaps reduce costs and make a public health contribution by decreasing alcohol related incidents.

Workplace intervention programmes for decreasing alcohol use in military personnel: a systematic review

INTRODUCTION

Harmful or risky-single occasion drinking (RSOD) alcohol use in the military is a significant problem. However, most studies of interventions have focused on veterans, representing a missed opportunity for intervention with active military personnel. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, the aim of this systematic review was to analyse and synthesise the evidence related to workplace-based interventions for reducing alcohol use in active-duty military personnel.

METHODS

Four electronic databases and reference lists of relevant articles were searched from database inception until 20 January 2020. This review focused on experimental and quasi-experimental studies of active-duty military personnel. Data extraction and methodological quality assessment were independently performed by two reviewers using a standardised checklist. A third reviewer was used to arbitrate the disputed studies for final selection.

RESULTS

The search yielded seven studies from an initial 1582 records identified. A range of interventions were used in these studies (four randomised controlled trials, two non-randomised trials and one before and after cohort study), including web-based approaches, telephone-delivered interventions and individual and group-based face-to-face interventions. Seven studies found decreased drinking, measured using a range of outcomes, following the intervention. However, this was not sustained in the longer term in any of the studies.

CONCLUSIONS

The low methodological rigour of most studies limited the capacity to demonstrate the efficacy of the interventions studied. Given the importance of reducing harmful or RSOD use of alcohol in the military, future studies would benefit from improved methodological rigour including ensuring adequate study power, randomisation, selection of validated outcome measures, including measures other than consumption (eg, attitudinal measures), and longer-term follow-up. There is also a need to develop methods that ensure participant loss to follow-up is minimised.

Substance Use and Psychological Distress Before and After the Military to Civilian Transition

Background

Those currently serving in the military constitute a vulnerable population given their high-risk status for substance use, and population data suggest that veterans continue to engage in significant substance use long after their military service ends. Recent research suggests that the separation transition from active duty to civilian life may be critical in terms of the future functioning of the veteran.

Methods

We sought to explore substance use prevalence, as well as potential emotional distress among veterans by retrospectively assessing substance use during active duty and following separation to examine possible changes in use over this period. This study assessed substance use and emotional distress in veterans (N = 80; 90% male) across the military to civilian transition.

Findings

Repeated measures tests indicated that endorsement of alcohol use, cigarette use, and prescription drug misuse was similar during active duty and post-separation, and marijuana and hard drug use endorsement increased significantly in the 6-mo period post-separation. Further, comorbid use of different substances was common. Active duty levels of anxiety/depression and aggressive feelings were maintained from active duty to post-separation, and feeling alone and military-based trauma symptoms increased significantly. Finally, participants indicated that only a minority of the veterans they knew were doing emotionally well or did not have alcohol/substance use issues.

Discussion

These findings indicate a clear need for substance use and psychological intervention availability before and after transition to enable veterans to transition to civilian life effectively. Based on the many issues at work during the transition process, programs may do well to focus more specifically on identification of problems and raising awareness, rather than awaiting more severe issues in the future. Validation of the difficulties of the separation transition, veterans' feelings of isolation, and the importance of veteran community support may help newly transitioning veterans find advocates who may help them navigate existing assistance programs.

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

Background: The first year of military service in the United States Air Force (USAF) is a high-risk time for tobacco use. Previous studies have demonstrated the effectiveness of a tobacco ban during Basic Military Training (BMT). However, no studies have examined the effect of increasing the protracted ban for an additional 4 weeks. Understanding the patterns of initiation and reinitiation following the protracted ban will inform future intervention and policy efforts. Methods: The current study examines patterns of cigarette smoking among a sample of 2188 USAF personnel at baseline and after their first year of service. Results: One year after BMT, we observed that 65.0% of USAF enlistees remained never smokers, 9.6% remained abstinence from cigarettes, 9.3% initiated cigarette smoking, and 16.1% reinitiated cigarette smoking. Despite the extended tobacco ban in BMT and Technical Training, 12.6% of individual who never smoked initiated cigarette smoking and 62.6% of individuals who formerly smoked reinitiated. Over half (54.2%) of Airmen who reported smoking cigarettes at follow-up reported initiating or reinitiating during Technical Training. Conclusions: Our findings indicate that although the increased ban prevents additional individuals who smoked cigarettes prior to joining the Air Force from reinitiating, it has no effect on initiation among individuals who report never using prior to military service. Additional research is needed to understand what may be leading to these high rates of initiation and reinitiation in Technical Training following the ban.

Brief Motivational Intervention for Underage Young Adult Drinkers: Results from a Randomized Clinical Trial

BACKGROUND

While there is a substantial literature on the efficacy of brief motivational intervention (BMI) for college student drinkers, research has focused less on young adults who do not attend a 4-year college, despite their elevated risk for excessive alcohol use and associated harmful consequences.

METHODS

This randomized controlled trial (NCT01546025) compared the efficacy of BMI to a time-matched attention control intervention (relaxation training [REL]) for reducing alcohol consumption and related negative consequences in an underage young adult sample. BMI was tailored to the developmental transition out of high school for young adults who were not immediately planning to enroll in a 4-year college. Non-treatment-seeking underage drinkers who reported past-month heavy drinking (N = 167; ages 17 to 20; 42% female; 59% non-Hispanic White) were randomly assigned to receive a single session of BMI or REL. Outcomes were evaluated 6 weeks and 3 months postintervention via in-person assessments.

RESULTS

Generalized estimating equation models provided strong support for the efficacy of BMI for reducing harmful drinking in these young adults. Compared to REL, and after controlling for baseline covariates including gender, those who received BMI subsequently reported significantly fewer average drinks per week, percent drinking days, percent heavy drinking days, lower peak and typical estimated blood alcohol concentration on drinking days, and fewer adverse consequences of drinking (all ps < 0.05). These between-group effects did not weaken over the course of the 3-month follow-up period.

CONCLUSIONS

These findings demonstrate an efficacious approach to tailoring BMI for non-college-attending young adults. Future research should replicate and extend these findings over a longer follow-up period.

Types of Dual and Poly-Tobacco Users in the US Military

The present investigation was designed to determine the prevalence and types of dual and poly-use of tobacco products in the US Air Force, as well as characteristics and factors associated with these types. We conducted a cross-sectional assessment of tobacco-product use among 13,873 Air Force trainees from 2013 to 2014. The assessment included prevalence of the use of 10 different tobacco products and demographic and environmental factors, such as risk perceptions of tobacco use, peer use, and tobacco-company influences. Latent class analysis was carried out to determine types of poly-tobacco users. Tobacco-product use was reported by 27.1% of participants, and of those, over half reported using more than 1 tobacco product. Latent class analysis indicated 5 classes of poly-tobacco use. Factors associated with poly-tobacco (vs. mono-tobacco) use included lower confidence to remain tobacco-free, low harm perceptions, and receiving tobacco products free at bars or social events. Rates of dual and poly-tobacco use are high among trainees, and while these groups are similar to mono users in some ways, there are a number of differences that need to be considered when developing targeted interventions to address use of multiple tobacco products.

Alcohol issues prior to training in the United States Air Force

The negative impact of alcohol is a significant concern to the US military given the costs associated with alcohol-related offenses. Despite considerable research in active duty personnel, relatively little is known about the current extent of alcohol use among incoming recruits. We examined the history of alcohol use and harmful patterns of alcohol consumption among recruits entering the United States Air Force (USAF; N=50,549) over the span of 4 years (2010-2014). Across all years, drinking rates reflected national average trends for those aged 18-24 (NIDA, 2014). However, when abstainers were excluded, those under 21 (n=10,568) reported an average of 18.4 drinks per week, whereas those age 21 and over (n=14,188) reported an average of 14.1 drinks per week, suggesting that for those who drink, those under 21 are exhibiting more risky drinking rates. Alcohol Use Disorders Identification Task (AUDIT) scores for drinkers reflected these same trends. For those under 21, 58% scored in risk categories of 2 or higher (risky drinking warranting attention), compared with 40% for those age 21 and over. These scores indicate that for recruits in the USAF, approximately half report alcohol use immediately prior to basic training, resulting in the inheritance of these potential alcohol related issues for those conducting training of these recruits. Based upon these numbers, brief alcohol interventions could have a potential positive impact on individuals in their initial training stages of the USAF to prevent these baseline issues from resulting in problems later in their military careers.

Prevalence and Correlates of Tobacco and Nicotine Containing Product Use in a Sample of United States Air Force Trainees

INTRODUCTION

Although there is increasing attention to the prevalence of new and emerging tobacco products in the civilian population, remarkably little is known about the current prevalence of these products in a military population.

METHODS

The current investigation was designed to determine the prevalence of tobacco and nicotine containing products (TNCP) and correlates of use across multiple cohorts of trainees undergoing Technical Training in the US Air Force between April 2013 and December 2014. Chi-square test, Cochran-Armitage test for linear trend, and logistic regression models were applied to test differences and linear trends across time for TNCP use as well as correlates of use in a cross-sectional sample of 13 685 Airmen (final analytic sample).

RESULTS

Over a quarter (26.9%) of Airmen reported regular use of a TNCP. The two most prevalent products were cigarettes (11.2%) and hookah (10.5%). Among correlates of use, Airmen that regularly use TNCPs were more likely to be male, younger, non-Hispanic white, and single with a high school degree or General Education Development. Hookah was the most endorsed for intentions to use, and along with e-cigarettes, had the lowest perception of harm. While prevalence of most products remained constant across entering cohorts, the prevalence of e-cigarettes showed significant linear increase.

CONCLUSIONS

The prevalence of TNCP use is high across cohorts of Airmen. Remarkably high estimates of future intentions to use and low perceptions of harm for emerging products suggest that intervention efforts should be directed at multiple forms of TNCP use to address this important public health issue.

The Prevalence of E-cigarette Use in a Sample of U.S. Air Force Recruits

INTRODUCTION

The prevalence of electronic cigarette (e-cigarette) use is increasing markedly in the general population. Yet, remarkably little research exists to examine these ongoing trends in at-risk populations, and nothing is known about the prevalence of e-cigarette use among military personnel. The purpose of the current study is to provide recent (2013-2014) data on the prevalence of regular e-cigarette use in a population of recruits prior to their entry into the U.S. military.

METHODS

The study utilized a cross-sectional assessment of e-cigarette and other tobacco and nicotine-containing product (TNCP) use in 2013-2014 among 10,043 U.S. Air Force (USAF) recruits in Technical Training. Chi-square tests, the Cochran-Armitage test for trend, and logistic regression models tested differences and trends across time for e-cigarette use.

RESULTS

The rate of e-cigarette use among recruits was 5.2%, which doubled (3% to 6.5%, p<0.0001) across a 1-year period. E-cigarette use was associated with increased odds of all measured TNCPs, as well as dual and poly use (all p<0.0001).

CONCLUSIONS

Rates of e-cigarette use are slightly higher in young USAF recruits than in the general population, and e-cigarette users are likely to be using other TNCPs in tandem. Although additional work is needed to understand the reasons for this concomitant use, this is a necessary first step to understanding e-cigarette use prevalence in military populations. Historic trends suggest that, like general populations, e-cigarette use is on the rise for those entering the USAF and should be monitored to inform future prevention programming.