In 2009, an Institute of Medicine report recommended that the Department of Defense and Department of Veterans Affairs prioritize tobacco con¬trol by implementing state-of-the-art programs to achieve a tobacco-free military. This call was rejected by then Secretary of Defense Robert Gates, who defended tobacco use by deployed troops as a means of “stress relief.” However, since then, the Air Force has implemented a new tobacco control policy asserting that its goal is a tobacco-free service; the Navy has also asserted such an aim and has instituted a policy making submarines smoke free. Most recently the secretary of the Navy, supported by the secretary of defense, has called for an end to tobacco sales on Navy and Marine Corps installations. However, this proposal, as with prior attempts by military personnel to implement strong tobacco control policies, has been met by opposition in Congress, often at the behest of the tobacco industry. This policy statement calls on APHA to support the call for a tobacco-free military and the development and implementation of military-specific tobacco control policies and partnerships designed to aid the military in reaching this goal.
Relationship to Existing APHA Policy Statements
• APHA Policy Statement 20075: Agent Orange
• APHA Policy Statement 20076: Tobacco-Free School Environments
• APHA Policy Statement 20082: Discouraging Smoking in Feature Films to Avoid Influencing Youth to Smoke
• APHA Policy Statement 9118: Reducing Smoking in Prisons and Jails
Military personnel are required to be physically fit; however, they have a higher smoking prevalence rate (24%) than do civilians (21.2%). The harms of tobacco use among military personnel include lower levels of military readiness and physical fitness (e.g., decreased muscle endurance, reduced night vision, and increased likelihood of injury);[2–6] longer hospital stays among those who have been injured and double the risk of postsurgical infection relative to nonsmokers;[7,8] retarded wound healing among those who have been injured;[9–11] significantly increased work and life stress, probably owing to chronic nicotine withdrawal; and increased prevalence of posttraumatic stress disorder (PTSD).[13–15] Approximately 18% of enlisted personnel are African American, whereas only 13% of the 18- to 44-year-old labor force is African American. Also, many enlistees are young and just out of high school. These populations have been identified as prime targets for the tobacco industry,[17–21] increasing their vulnerability to pressures to initiate tobacco use and suffer the later consequences.
Economic harms also accrue both to the military as an institution and to individual service members, including Department of Defense (DoD) expenditures of $1.6 billion annually on tobacco-related health care and lost productivity and financial strain among junior enlisted troops who smoke, with tobacco purchases consuming as much as 14.8% of their base pay. The Institute of Medicine (IOM) estimates that, over the next 10 years, the Department of Veterans Affairs (VA) will spend approximately $19 billion on smoking-attributable health care. When military personnel are home, and after they have separated from the service, their smoking may expose their families to second- and third-hand smoke. In addition, both their addiction and its attendant health costs will frequently be borne by their families, as most veterans are not eligible for VA health care services.
Tobacco use by military personnel is contrary to the mission of the armed services. High tobacco use prevalence rates may be attributable to the creation of a culture that supported tobacco use through free distribution (halted in 1975, although discounted prices continue to be offered) and wide availability of “smoke breaks.” However, attempts by military leaders to institute stronger tobacco control policies have frequently been subverted by congressional allies of the tobacco industry, who have prevented efforts to eliminate tobacco sales and restricted the military’s ability to raise tobacco prices in military stores, reversed captains’ attempts to make their ships smoke free, forced the weakening of tobacco control plans in the Army, and promulgated the idea that military personnel have a “right” to use tobacco.
Public health and tobacco control organizations have only rarely responded to these policy struggles, contributing to a gap in civilian support for the tobacco control efforts of military leaders. Furthermore, research shows that public health and tobacco control leaders believe that military personnel have a right to use tobacco, that personnel need tobacco to relieve stress, and that it would be impolitic to engage their organizations in efforts to strengthen military tobacco control. These beliefs have inhibited public health leaders from promoting military tobacco control goals in Congress, where civilian authority over the Department of Defense resides.
The Institute of Medicine, asked by the Department of Defense and the Department of Veterans Affairs to make recommendations to reduce tobacco use among active duty personnel and veterans, came to the conclusion that the DoD should establish a timeline to eliminate all tobacco use on military installations to protect the health of military personnel, civilian employees, family members, and visitors. The IOM specifically suggested that the Department of Defense should stop selling tobacco products in military stores, prohibit tobacco use on military installations, and “treat tobacco use in the same way as other health-related behaviors, such as alcohol abuse and poor physical fitness, which impair military readiness.”
Evidence-Based Strategies to Address the Problem
Numerous policy initiatives have been shown to reduce tobacco use prevalence rates among civilians, and the military has implemented some of these initiatives. For example, military personnel have access to a comprehensive tobacco cessation program, including evidence-based behavioral and pharmacological treatments free of charge. The effectiveness of the cessation program is unknown, as implementation varies from location to location and military personnel move frequently.
The military system of discipline opens up, and sometimes demands, policy approaches that would be impractical and unacceptable in the civilian world. Military personnel are given orders regarding their jobs, clothing, and appearance. In the military, orders create the context and expectations for both military discipline and good physical health. Thus, just as military personnel must meet standards regarding body mass index and physical fitness, they also could reasonably be required to abstain from tobacco use. Currently, for example, recruits must abstain from tobacco during basic training. Extending this rule to their continuing service would be one way to phase in a tobacco-free military. Prohibiting tobacco use while in uniform or while on military installations could also advance the standard of a tobacco-free military. Prohibiting tobacco use among officers, whose prevalence rates are already low, would be another option. Beginning with the Air Force, which already has the lowest tobacco use rates of the service branches, might be easiest in terms of demonstrating feasibility. The proposal by the secretary of the Navy to halt sales of tobacco products on military installations is a promising step as well. Strengthening military tobacco control policies will also require improving the knowledge and understanding of civilian public health professionals about military health issues and their appropriate role in the development, adoption, and implementation of such policies.
No studies exist to support the use of tobacco by military personnel. Opponents of policies requiring military personnel to be tobacco free primarily use two arguments. First, they argue that military personnel, especially when deployed, need tobacco as a way to cope with stress in an environment with limited options. However, studies show that military tobacco users actually experience more stress than either nonusers or ex-users and are more likely to be diagnosed with PTSD.[13,32] There is no evidence to support the contention that tobacco use mitigates the stresses of deployment. Similar arguments have been made about prisoners and psychiatric inpatients, but both of these types of institutions have successfully implemented smoke-free policies.[33,34] There is evidence, however, that recurrent periods of nicotine withdrawal are a source of stress, suggesting that further measures to make the military a tobacco-free organization will decrease stress levels. Second, opponents argue that preventing military personnel from using tobacco would violate their rights; however, no court has ever established such a right. In addition, the military routinely regulates many behaviors for the purpose of maintaining discipline and fitness, including attire, hair style, and tattoos. Allowing and promoting tobacco use may be considered to violate other “rights.” For example, joining the military places young people who are past the usual age of initiation at much higher risk for starting to use tobacco, thus compromising their right to good health. Approximately one third of military personnel who smoke started after joining the military.
Some civilian public health leaders have argued that the military can and will adopt stronger policies when military leadership finds it appropriate. However, this position disregards the long history of such efforts by military leaders being thwarted in Congress, by civilian leaders.
APHA believes that the health and financial consequences of tobacco use significantly impair military readiness and harm individuals serving in the armed forces. Therefore, APHA:
• Urges the Department of Defense to strengthen and systematically evaluate its cessation efforts and adopt the policy recommendations of the Institute of Medicine to ultimately achieve a tobacco-free military.
• Also urges the Department of Defense to enhance its health promotion efforts, including programs focusing on mental health and stress relief, to diminish cultural reliance on tobacco use for these purposes.
• Calls for Congress to support Department of Defense and service efforts to strengthen tobacco control measures designed to forward the goal of a tobacco-free military, including establishing smoke-free installations and raising the price of, and ultimately ending sales of, tobacco in commissaries and exchanges.
1. Barlas FM, Higgins WB, Pflieger JC, Diecker K. 2011 Health Related Behaviors Survey of Active Duty Military Personnel. Washington, DC: US Department of Defense; 2013.
2. Altarac M, Gardner JW, Popovich RM, Potter R, Knapik JJ, Jones BH. Cigarette smoking and exercise-related injuries among young men and women. Am J Prev Med. 2000;18(suppl 3):96–102.
3. Conway T, Cronan T. Smoking, exercise, and physical fitness. Prev Med. 1993;21:723–734.
4. Reynolds KL, Heckel HA, Witt CE, et al. Cigarette smoking, physical fitness, and injuries in infantry soldiers. Am J Prev Med. 1994;10:145–150.
5. Weaver CS. Soldiers who smoke have increased injury risk, reduced muscle endurance. Available at: http://www.drum.amedd.army.mil/news/2012/0112/smoke.htm. Accessed January 19, 2015.
6. Zadoo V, Fengler S, Catterson M. The effects of alcohol and tobacco use on troop readiness. Mil Med. 1993;158:480–484.
7. Handlin DS, Baker T. The effects of smoking on postoperative recovery. Am J Med. 1992;93:32S–37S.
8. Jones RM. Smoking before surgery: the case for stopping. BMJ (Clin Res Ed). 1985;290:1763–1764.
9. Goertz O, Kapalschinski N, Skorzinski T, et al. [Wound healing complications in smokers, non-smokers and after abstinence from smoking]. Chirurg. 2012;83:652–656.
10. Silverstein P. Smoking and wound healing. Am J Med. 1992;93:22S–24S.
11. Sloan A, Hussain I, Maqsood M, Eremin O, El-Sheemy M. The effects of smoking on fracture healing. Surgeon. 2010;8:111–116.
12. Stein RJ, Pyle SA, Haddock CK, Poston WS, Bray R, Williams J. Reported stress and its relationship to tobacco use among U.S. military personnel. Mil Med. 2008;173:271–277.
13. Fu SS, McFall M, Saxon AJ, et al. Post-traumatic stress disorder and smoking: a systematic review. Nicotine Tob Res. 2007;9:1071–1084.
14. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167:476–482.
15. Kirby AC, Hertzberg BP, Collie CF, et al. Smoking in help-seeking veterans with PTSD returning from Afghanistan and Iraq. Addict Behav. 2008;33:1448–1453.
16. Office of the Under Secretary of Defense, Personnel and Readiness. Population representation in the military services. Available at: http://prhome.defense.gov/RFM/MPP/AP/POPREP.aspx. Accessed January 19, 2015.
17. Yerger VB, Przewoznik J, Malone RE. Racialized geography, corporate activity, and health disparities: tobacco industry targeting of inner cities. J Health Care Poor Underserved. 2007;18(suppl):10–38.
18. Fernandez S, Hickman N, Klonoff EA, et al. Cigarette advertising in magazines for Latinas, White women, and men, 1998–2002: a preliminary investigation. J Community Health. 2005;30:141–151.
19. Barbeau EM, Wolin KY, Naumova EN, Balbach E. Tobacco advertising in communities: associations with race and class. Prev Med. 2005;40:16–22.
20. Balbach ED, Gasior RJ, Barbeau EM. R.J. Reynolds’ targeting of African Americans: 1988–2000. Am J Public Health. 2003;93:822–827.
21. Sepe E, Ling PM, Glantz SA. Smooth moves: bar and nightclub tobacco promotions that target young adults. Am J Public Health. 2002;92:414–419.
22. Institute of Medicine. Combating Tobacco Use in Military and Veteran Populations. Washington, DC: National Academies Press; 2009.
23. Pyle SA, Haddock CK, Poston WS, Bray RM, Williams J. Tobacco use and perceived financial strain among junior enlisted in the U.S. military in 2002. Prev Med. 2007;45:460–463.
24. Haddock CK, Hyder ML, Poston WS, Jahnke SA, Williams LN, Lando H. A longitudinal analysis of cigarette prices in military retail outlets. Am J Public Health. 2014;104:e82–e87.
25. Smith EA, Malone RE. Why strong tobacco control measures “can’t” be implemented in the US military: a qualitative analysis. Mil Med. 2012;177:1202–1207.
26. Smith EA, Blackman VS, Malone RE. Death at a discount: how the tobacco industry thwarted tobacco control policies in US military commissaries. Tob Control. 2007;16:38–46.
27. Offen N, Arvey S, Smith EA, Malone RE. Forcing the Navy to sell cigarettes on ships: how the tobacco industry and politicians torpedoed Navy tobacco control. American Journal of Public Health 2011;101(3):404-11.
28. Arvey S, Malone RE. Advance and retreat: tobacco control policy in the U.S. military. Mil Med. 2008;173:985–991.
29. Smith EA, Malone RE. Military exceptionalism or tobacco exceptionalism: how civilian health leaders’ beliefs may impede military tobacco control efforts. Am J Public Health. 2013;103:599–604.
30. Smith EA, Jahnke SA, Poston WS, et al. Is it time for a tobacco-free military? N Engl J Med. 2014;371:589–591.
31. Smoking ban draws fire. 2009. Available at: http://www.washingtontimes.com/news/2009/aug/31/smoking-ban-draws-fire/. Accessed January 19, 2015.
32. Scherrer JF, Xian H, Lyons MJ, et al. Posttraumatic stress disorder; combat exposure; and nicotine dependence, alcohol dependence, and major depression in male twins. Compr Psychiatry. 2008;49:297–304.
33. Foley KL, Proescholdbell S, Herndon Malek S, Johnson J. Implementation and enforcement of tobacco bans in two prisons in North Carolina: a qualitative inquiry. J Correct Health Care. 2010;16:98–105.
34. Williams JM. Eliminating tobacco use in mental health facilities: patients’ rights, public health, and policy issues. JAMA. 2008;299:571–573.
35. Baker TB, Brandon TH, Chassin L. Motivational influences on cigarette smoking. Annu Rev Psychol. 2004;55:463–491.
36. Harrington E. House adopts amendment to protect service members’ right to tobacco. Available at: http://freebeacon.com/issues/house-adopts-amendment-to-protect-service-members-right-to-tobacco/. Accessed January 19, 2015.
37. Bray RM, Hourani LL, Olmsted DLR, et al. Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel: A Component of the Defense Lifestyle Assessment Program (DLAP). Research Triangle Park, NC: RTI International; 2006.