Research articleCigarette Smoking and Military Deployment: A Prospective Evaluation
Introduction
Smoking is the leading preventable cause of death in the U.S. More than 400,000 people die each year due to smoking, with $167 billion spent in annual health-related economic losses.1 The long-term health consequences are well established.2, 3, 4 In the military, where smoking rates are higher than in the general population,5, 6 it is estimated that $130 million is spent annually on excess training alone due to smokers who are prematurely discharged.7 In addition, smoking has implications for military readiness, because service members who smoke have lower fitness levels and are at greater risk for physical injury.8, 9, 10 Understanding the factors that influence smoking among the more than 2 million young adults currently serving in the military is of critical public health importance.
Smoking has been shown as a frequently reported maladaptive coping mechanism among those reporting chronic and acute stress.11, 12 Individuals in stressful occupations have been shown to use tobacco at higher rates than the general population.13, 14 Occupational stress related to serving in the military has also been shown to be a strong predictor for both cigarette smoking and nicotine dependence.15, 16 The stress of military deployment may compound already high occupational stress and manifest in different maladaptive coping behaviors such as increases in the use of tobacco, alcohol, and other drugs. U.S. Navy and Marine Corps personnel exposed to violence prior to the current conflicts were reported to be at twice the risk for nicotine dependence than those not exposed.15 In a cross-sectional survey of U.S. troops deployed to Iraq and Afghanistan, nearly 40% smoked at least one half pack of cigarettes per day, with nearly half of smokers stating that they started or resumed smoking during their deployment.17 A survey of a small group of British military medical professionals reported similar findings of increased smoking rates postdeployment among nonsmokers and increased daily cigarette intake among smokers.18 All past studies have been done prior to the current military conflicts15 or are limited by cross-sectional design,17 the exclusion of nondeployers,17, 18 or small sample sizes.18
To better understand cigarette smoking as a coping mechanism in response to the stress of military deployment, the current study prospectively investigated, among participants in a large, population-based military cohort, changes in cigarette use including smoking initiation among never-smokers, smoking recidivism among past smokers, and changes in daily smoking among smokers. Additionally, cigarette use and its relationship to extreme deployment lengths and multiple deployments were investigated among those deployed to Iraq and Afghanistan while adjusting for potential confounders.
Section snippets
Study Population
The study population consisted of participants in the Millennium Cohort Study. Launched in 2001, this is the largest longitudinal study undertaken by the U.S. Department of Defense (DoD) to evaluate risk factors related to military service that may be associated with long-term health consequences. A detailed description of the methodology has been reported elsewhere.19, 20 In short, invited participants were drawn from a stratified random sample of the 2.2 million U.S. military personnel in
Results
There were 55,021 participants who completed both a baseline and a follow-up questionnaire. Those who completed a baseline questionnaire during or after their first deployment (n=2851); completed their follow-up questionnaire during deployment (n=1986); had missing covariate information (n=58); or were missing smoking information at baseline or follow-up (n=1822) were removed, leaving 48,304 available for analysis. Cumulative length of deployment was highly collinear with deployment frequency
Discussion
Over a period of 3 years, the prevalence of smoking increased 48% in this study population. Smoking increased 44% among nondeployers and 57% among deployers. Among those who never had smoked prior to deployment, the present study found that >2% initiated smoking postdeployment. While initiation rates were relatively low, this represented a 71% increase over the initiation rate in nondeployers. In contrast to initiation, smoking recidivism was high (31%) among all past smokers. In this group,
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