Smoking Cessation in the Military: Challenges, Solutions, And Issues for Women Smokers

1. Smoking Cessation in the Military: Challenges, Solutions, And Issues for Women Smokers Robert C. Klesges, Ph.D. Professor, Department of Preventive Medicine, U. of TN Health Science Center & Department of Cancer Prevention and Control St. Jude Children’s Research Hospital

2. The NIH Revitalization Act (1994) as it Pertains to Women • Women shall be included in all human subjects research. • Women should be included in sufficient numbers to be able to detect intervention differences. • Cost cannot be cited as a reason for exclusion and NIH outreach programs shall be initiated to recruit and retain women in studies.

3. Has The Revitalization Act Worked For Women? • Pub Med search from 1995-present. • Completed four searches: • Smoking cessation/treatment/intervention; • Added “women”; • Replaced “women” for “military”; and • Included both “women” and “military”

4. Results of search Search Phrase# of Articles (%) Smoking cessation 25,290 Smoking cessation & women 14,932 (59%) Smoking cessation & military 162 (0.6%) Smoking cessation & military & women 108 (0.4%) Of all studies with “smoking cessation & military & women”, our research team accounted for 25% of all citations.

5. Understanding Smoking Within the Context of The Military and Deployment. • Want to share the experience that so many of our troops go through. • Leaving their loved ones, deployment, and returning home.

6. Conclusions from AF I • The smoking ban in BMT produces significant smoking cessation. In short, smoking bans work, particularly for women. • Extending the smoking ban to Tech Training is a logical next step. • Make smoking a hassle. • But what happens to nonsmokers following BMT?

7. One-year initiation ratesamong nonsmokers

8. Air Force II* • Longer interventions • Tailored interventions – different interventions dependent on baseline smoking and smokeless status. Three different interventions. • AF II was also very large (n = 33,215) *Funded by the National Heart, Lung, and Blood Institute of NIH

9. Results • The smoking ban worked again (29% of airmen had not smoked in the past 7 days and 14% had not smoked at all since BMT). • Smokers assigned to the cessation intervention were 18% less likely to be smoking. • Smokeless users assigned to the smokeless intervention were 24% less likely to be chewing. • Marked smoking initiation rate as found previously.

10. Air Force III* • While AF I and II addressed maintaining cessation following a smoking ban, the next study addressed those who relapsed following BMT as well as those who initiated smoking in the military. • AF III is testing the efficacy of a proactive quit line for domestic and deployed troops. *Funded by the National Heart, Lung, and Blood Institute of NIH

11. Results to date • Have enrolled nearly 350 participants all around the globe, including several from as far away as South Korea. • Minority recruitment (32%) is much higher than the rates in the Air Force population (21%). • Recruitment of females (34%) greatly exceeds the number of females in the Air Force (19.5%).

12. SAMMC Tobacco Quitline • No classes to attend • Telephone-based counseling that fits your schedule • Free nicotine replacement patches mailed directly to your home • Open to active duty and reservists who are • 18 years old or older • Smoke 5 or more cigarettes per day • Call 1-877-SAMMC-11 • Sponsored by the University of Tennessee, Wilford Hall Medical Center and the National Heart, Lung and Blood Institute

13. Air Force IV* • Funded to understand why military personnel have such a high prevalence of smokeless tobacco and dual use. • Tobacco companies are aggressively marketing their new product called snus and several flavors of snus will be targeted to women. • “The new (FDA) law…prohibits any cigarette with a characteristic flavor, but does not apply to any other tobacco products.” *Funded by the National Cancer Institute of NIH

16. Conclusions About Smoking and Women in the Military • Females in the Military Are Less Likely: • Start smoking after Basic Military Training • Females in the Military Are More Likely: • Smoke “light” or “ultralight” cigarettes • Among smoking women, the smoking ban is particularly effective – they are much more likely to remain abstinent following intervention and forced cessation during Basic Military Training. • Smoking rates especially high among white women (nearly 1/3 smoked daily prior to BMT). • Binge drinking and weight concerns strongly related to smoking in women

17. Conclusion: What can we do to promote a smoke free military? • Deployment does not automatically mean high smoking rates. • The more we can make using tobacco products a “hassle”, the better (protracted smoking bans, smoking restrictions). • Should we sell tobacco in the BX/PX? • Cigarette sales in the BX/PX are not in the military’s control.

18. Conclusion: What can we do to promote a smoke free military? • We cannot afford to do face-to-face counseling for tobacco control. • Tobacco quit lines, particularly when participants receive free nicotine replacement therapy. • Tailored web based programs for the military. • I phone/I touch “apps”. • Tailored print (or web) communication.

19. Conclusion: What can we do to promote a smoke free military? • Officers as role models. Only about 5% of officers smoke. • While the IOM recommendation to gradually eliminate smoking in the military may not be completely feasible, having a smoke free officer corps is highly feasible. • Targeted programs should address the unique needs of women smokers in the military.

20. Significant challenges • While not impossible to intervene during deployment, it is still a challenge. • Tobacco companies are always a step ahead of us, marketing snus for when smokers are prohibited from smoking. • Dual use of smoking and smokeless tobacco is rampant in the military. • Tobacco companies are aggressively marketing tobacco to women in general and women in the military in particular.