Cigarettes were part of the routine kit for soldiers in every war through Vietnam, but just as the nation has become increasingly non-smoking, so has the military. Smoking is now banned just about everywhere except in combat – including, as of next year, aboard U.S. submarines. And chronic obstructive pulmonary diseases (COPD), many smoking-related, have become one of the largest health care issues for the VA.

While somewhat slower to react than the general population after the 1964 Surgeon General’s report linking smoking to cancer, smoking in the military had seen a steady decline in the past two or three decades, according to Dr. Jack Smith, the Military Health System’s (MHS) acting chief medical officer and acting deputy assistant secretary of Defense for Clinical & Program Policy.

A decade of war and repeated combat tours in Iraq and Afghanistan, however, appear to have sent those numbers into what MHS and VA healthcare officials hope will be a temporary rebound.

“We now know tobacco is a hazardous substance and the No. 1 cause of preventable death in the U.S., so we do our very best in the MHS to discourage people from taking up tobacco use and support tobacco users in quitting, if they are motivated to do so,” Smith said. “We view tobacco use as a readiness issue and certainly it has an adverse impact on not only health but physical conditioning, makes people more prone to respiratory illnesses, slows down wound healing, and affects night vision.”

Smoking was banned in military facilities as part of a presidential order in the 1990s that made all federal workplaces smoke-free. Effective Jan. 1, 2011, that will extend to submarines, the result of an April 2010 report that the scrubbers that recycle air within the boats while submerged are insufficient to prevent the exposure of non-smokers to secondhand smoke.

“Our sailors are our most important asset to accomplishing our missions,” Vice Adm. John J. Donnelly, Commander, Submarine Forces (COMSUBFOR), said in issuing the ban. “Recent testing has proven that, despite our atmosphere purification technology, there are unacceptable levels of secondhand smoke in the atmosphere of a submerged submarine. The only way to eliminate risk to our non-smoking sailors is to stop smoking aboard our submarines.”

The study was spurred by a new Surgeon General’s report in 2006 that said there is no risk-free level of exposure and even non-smokers have an increased risk of heart and lung disease when exposed to secondhand smoke.

With estimates of smoking among submariners as high as 40 percent, additional programs to help sailors quit were put into place aboard every submarine, using both education and nicotine replacement therapy.

“While submarine duty is a dynamic and demanding job, the Submarine Force is dedicated to mitigating unnecessary risks to our sailors. Exposure to a harmful substance that is avoidable, such as secondhand smoke, is unfair to those who choose not to smoke,” Capt. Mark Michaud, Submarine Force-Atlantic surgeon, said, adding the program is aimed at all forms of tobacco use, not just smoking. “What we want to discourage is smokers turning to alternative methods of tobacco use, such as chewing tobacco.”

About the same time the Navy was conducting its submarine study, the National Academy of Sciences Institute of Medicine, responding to a request from the Department of Defense (DoD) and the VA, issued a report urging the U.S. military to “assign high priority to tobacco control.” In addition to military readiness issues, the report cited “the short- and long-term health and financial burden of tobacco use on military personnel, retirees, families, and veterans.” The long-term goal, the report concluded, should be a completely smoke-free military by no later than 2030.

“Fewer than one in five Americans uses tobacco, but more than 30 percent of active-duty military personnel and about 22 percent of veterans use tobacco. Of greater concern, the rate of tobacco use in the military has increased since 1998, threatening to reverse the steady decline of the last several decades. Furthermore, smoking rates among military personnel returning from Iraq and Afghanistan may be 50 percent higher than rates among non-deployed military personnel,” the report stated.

“The Department of Defense and the Department of Veterans Affairs bear the heavy costs of treating tobacco-related diseases. DoD spends more than $1.6 billion per year on tobacco-related medical care, increased hospitalizations and lost days of work. In 2008, VA spent more than $5 billion to treat veterans with COPD, which is strongly associated with tobacco use.”

The most recent DoD study of smoking in the military, conducted in 2005, found reported rates of 32 percent in the Army, 32.4 percent in the Navy, 23.3 percent in the Air Force, and 36.3 percent among Marines. Smith said MHS surveys conducted every three or four years had shown a steady decline from 1980 through 1998, then an increase through 2005, when they began a new anti-smoking education campaign. In addition to pointing out the health hazards to the smoker, the campaign also focused on the negative influence warfighters who smoke might have on their children or younger siblings.

“Between 2005 and 2008, there was a slight decline in self-reported use of tobacco and we think we may be having some impact with our counter-marketing campaign. We do have a Web site at http://YouCanQuit2.org that has a lot of information about the hazards of smoking and how to design a quit smoking effort for themselves,” he said. We also need to combat some cultural aspects, where tobacco use is portrayed on TV and in the movies as part of the military lifestyle.

“The use of smokeless tobacco in DoD also is higher than the averages in the civilian community, with the prevalence of tobacco use highest in the 18 to 24 age group. That is a large part of our armed forces and, I think, [they] tend to be risk-takers focused less on the long-term health impact. Having been 18 once myself, it was hard to imagine I would ever have any health problems or vulnerabilities related to my behavior. Smoking among officers, who tend to be a little older, is lower than the enlisted ranks, but the 18 to 24 age group is our highest among both groups.”

The survey of health-related behaviors is only administered to service members in the United States, he added, so there are no data available on smoking among those deployed to Iraq and Afghanistan or how the number of deployments factor into tobacco use. However, there is anecdotal evidence relating combat duty to increased rates of smoking.

“That suggests to me some people may be using tobacco as one way of coping with stress, which certainly is a concern. Just as we would with alcohol use, we want to propose they adopt other methods of stress management,” Smith said.

“In our surveys of active duty, Guard, and Reserve, we find the overall prevalence of tobacco use is somewhat higher in active duty members, but the Reserve and Guard average age also is somewhat older. If you look at CDC data on tobacco use by state, you see a lot of variability, from a low of 9 percent in Utah up to 26 percent in West Virginia. I would expect Guard and Reserve percentages would vary by state, as well.”

All military treatment facilities now offer smoking cessation programs. In addition, a smoking cessation benefit has been established under TRICARE, the health care program covering all military personnel, veterans, and their families. That includes a Web-based “quit line” and counseling.

“A couple of the elements there require regulatory changes that are in the works – the provision of pharmaceuticals has not yet been approved, for example. Regulatory change is a lengthy process that involves publication in the Federal Register and approval at multiple levels, with a period of comment and response to the comments before a final rule is published,” he said, but added those and other efforts will continue.

“The Navy, for example, is going even further, with two trained tobacco cessation facilitators now assigned to each submarine to help the sailors with a quit plan. In addition, there is a tobacco cessation program aboard each boat, connected to programs ashore.”

Part of the Web-based anti-smoking effort is an educational campaign launched in 2007 called “Quit Tobacco – Make Everyone Proud.” The program provides information about how to quit smoking and develop a personalized plan, including creating a personal or public blog. The Web site also includes a live private help feature, with trained cessation counselors available 24 hours a day, seven days a week for confidential online conversations.

The newest addition to that is Train2Quit, a customizable step-by-step training system with interactive tools and activities to help service members and their families quit tobacco use.

“[Airmen], soldiers, sailors, and Marines are used to training,” Capt. David Arday, a U.S. Public Health Service officer and chairman of the DoD Alcohol and Tobacco Advisory Committee, said. “And although quitting tobacco is tough, we know members of the armed forces are even tougher. They can get through this unique and easy-to use online training to quit – and stay quit.

“Train2Quit doesn’t take eight weeks or even eight hours. Receiving support whenever it’s convenient in their busy and changing schedules gives them a real advantage to succeed in becoming tobacco-free, particularly used as an adjunct to counseling and medications available on their installations.”

At present, aside from bans on smoking by location, the decision to quit – or not to start – is entirely up to the individual, with counseling and treatment available for those who request it. Nor are there specific efforts under way to identify those in uniform considered to be at early risk for COPD.

“That is something handled at the individual provider level. Certainly whenever a patient comes in contact with a provider, we ask about the use of tobacco. And if somebody has clinical problems we feel may be associated with tobacco use, they would be counseled and advised to stop smoking,” Smith said. “As a physician, I hope we will see a continued decline in tobacco use. If it becomes unfashionable to be a smoker, we may one day become tobacco-free.

“Right now, however, tobacco is a legal substance and DoD recruits from the population at large, where the prevalence of tobacco use is still around 20 percent – even higher among the 18 to 24 age group. Tobacco is a very potent, addictive substance and it is very difficult for many people to quit. About a quarter of smokers tell us they intend to quit within 30 days and up to 40 percent within the next six months, yet we know that does not happen. They may have some practice quits, but it is a difficult thing to kick that habit once it starts. So what we want to do is discourage them from starting.”

Even so, tobacco products are still sold in military base stores, although without the substantial discounts they once had. And while generally supporting the Institute of Medicine recommendations, Secretary of Defense Robert M. Gates has said he has no plans to ban smoking in combat zones.

Meanwhile, DoD and the VA will continue their efforts to help service members and veterans quit smoking and using other tobacco products as they deal with related health issues.

“We’ve certainly been comparing notes with the VA, which has some different challenges than DoD. We are dealing with people in the early part of their lives and careers, while the VA deals with those who have gone farther in life and often have more health problems than we see. So our strategies are a bit different,” Smith concluded. “But we are sharing information about the effectiveness of smoking cessation approaches and how we might do education programs together. We also have been in contact with the Department of Health and Human Services, which has its own campaign focused on encouraging people to quit or not start in the first place.

“The Military Health System wants to assist our service members to be as healthy as they need to be to carry out their missions. To that end, we are working to educate them about the hazards of smoking and other tobacco use. We stand ready to assist those already [trying] to quit, while applauding those who do quit, as well as those who do never start, and encourage them to continue that healthy lifestyle.”

This article was first published in The Year in Veterans Affairs and Military Medicine: 2010-2011 Edition.