Military and smoking

Smoking amongst military personnel has been observed in previous wars, but smoking’s close association with the United States military started in World War I when tobacco companies began to target military personnel through the distribution of cigarettes to servicemen and the eventual inclusion of cigarettes into rations. Although the military has attempted to implement tobacco control initiatives, the association between smoking and military personnel has persisted to the present day as smoking rates remain high, despite declines in civilian rates. Such high rates have led to questions about the effect of smoking from the apparent health risks to troop readiness and training costs.

Smoking in the US military from 1918 to 1975

With the entrance of the United States into World War I in 1918, cigarette use increased dramatically amongst United States military personnel as they were targeted by tobacco companies who touted that cigarettes were a way for soldiers to psychologically escape from their current circumstances, boosting overall troop morale. ^{[1] [2]} Cigarettes became so integrated into life on the battlefield that these symbols of pleasure and comfort were also used as a form of currency. ^[3] Although cigarettes had been regarded as a physical and moral hazard by early anti-tobacco movements around this time, by 1918, previously anti-cigarette organizations and the military began supporting efforts to distribute cigarettes to troops. The New York Times garnered support for these efforts by stating that cigarettes “lighten[ed] the inevitable hardships of war,” and another popular periodical described cigarettes as the “last and only solace of the wounded.” ^[4][5] With the rise of World War II, tobacco companies continued to foster this culture of wartime smoking by sending free cigarettes to troops and supporting the inclusion of cigarettes into the soldiers’ rations. Advertisements also encouraged citizens back home to support the troops by sending cigarettes. ^[6] Despite mounting evidence in the 1950s of the adverse health effects of smoking and tobacco use, the military continued to include cigarettes in rations until 1975. ^[7]

Attempts at Tobacco Control Initiatives

With the scientific data about the health risks of smoking and information about the effect of smoking on troop readiness, in 1975, the Department of Defense discontinued the inclusion of cigarettes in K-rations and C-rations. By 1978, the Department of Defense had implemented basic smoking regulations, including the designation of smoking and nonsmoking areas. ^[8] In 1985, the Department of Defense conducted a study that revealed that smoking rates of military personnel (47%) were significantly higher than that of US civilians (30%) and concluded that smoking had a negative effect on troop readiness. ^[9] The report also cited an estimated tobacco-related healthcare costs as high as $209.9 million, and recommended potential methods to curb smoking in the military, including the elimination of tobacco products from stores, raising tobacco prices to civilian levels, and the implementation of an educational program to discourage smoking. ^[10][11] In 1986, the DoD Directive 1010.10 was issued by Secretary of Defense Caspar Weinberger, who announced, “an intense anti-smoking campaign…at all levels of all Services.” ^[12] It established a policy on smoking and other health risk behaviors such as alcohol consumption. The policy banned the use of tobacco during basic training, increased the number of designated nonsmoking areas, and prohibited health care providers from smoking on duty. The goal of the policy was to reduce all tobacco use rates to below that of civilians, and to reduce personnel and active duty rates from 52% to 25% by 1990. ^[13] In 1992, the DeCA Directive 40-13 policy prohibited commissaries and exchanges from participating with promotions by tobacco manufacturers directed specifically at military personnel, and required commissaries to stock cigarettes in the back. In 1993, the USS Roosevelt became the first smoke free Navy ship. By 1994, the Department of Defense had implemented Directive 1010.15 which banned smoking in workplaces, designated outdoor smoking areas, and created the precursor of an education program that sought to distribute information to new personnel on the health effects of smoking and to encourage smokers to quit. Executive Order 13508 in 1997 banned smoking in all government-owned, rented, or leased interior spaces, but the Department of Defense approved a three year phase-in period for their facilities and eventually implemented the ban on December 7, 2002. ^[14] Despite these attempts, by 1988, the smoking rate had only decreased to 42% and far exceeded the rate of civilians. ^[15] And although prevalence did decrease to 29.9% from 1980 to 1998, it has increased since then and appears to still be increasing. ^[16]

Tobacco Industry’s Response

Realizing the opportunities of a worldwide military market due to the young demographics of military personal and the smoking initiation associated with new recruits, the Tobacco Institute, which served as the tobacco industry’s lobbying organization, and Philip Morris perceived these new tobacco control initiatives as a threat and conceived strategies to circumvent the government policies. Another incentive for the tobacco industry to protect its military market was the recognized phenomenon that consumer product preferences developed during years serving in the military would later translate into civilian market profits as service members left the military or retired. ^[17] After the implementation of Directive 1010.10 in 1986, the Tobacco Institute and Philip Morris immediately began seeking the support of tobacco-friendly politicians against the policy, citing that the policy would have a negative impact on military recruitment, retention, and morale. Furthermore, letters sent to Secretary of Defense Weinberger from politicians invoked rhetoric about the infringement of “personal rights” and “an individual’s right to smoke.” Such political lobbying helped to limit the implementation and the further extension of Directive 1010.10. ^[18]

Although the Department of Defense had discontinued the practice of free distribution of cigarettes during wartime, tobacco companies began campaigns during the Gulf War (1990-1991) to distribute free cigarettes to soldiers stationed in Saudi Arabia, but would eventually be rebuffed by the Department of Defense. Regardless, Philip Morris then began a campaign of sales through direct mail, and extended promotions to deployed troops that included the delivery of branded goods such as playing cards and cup cozies. Curiously enough, the military actually assisted the tobacco companies in delivering shipments to military stores in Saudi Arabia at government expense. Another controversy arose when it was discovered that RJ Reynold’s had placed their company name on the front and a Camel advertisement on the back of donated magazines from Operation Desert News, a civilian project to bring magazines to the troops. In spite of the initial rejection by the Department of Defense due to the advertisement, constant pressure from RJ Reynold’s and politicians allowed the magazines to be delivered with the advertisement at government expense, violating military policy that forbade tobacco-branded promotions directed at military personnel.^[19] In addition, Philip Morris focused on promoting the Marlboro brand with the goal of fostering corporate good will by initiating the "Marlboro holiday voice card" program. ^[20][21] Held on 10 military bases, they invited family of deployed personnel to record a message for onto a chip inserted into a greeting card, and later allowed bases to extend the recording of such messages to the public. Despite being in violation of Department of Defense policy concerning tobacco-branded programs directed at military personnel, Philip Morris had received permission to carry out the program from the Defense Logistics Agency, the Morale, Welfare and Recreation headquarters of the services, and base commanders. Furthermore, after troops were withdrawn from the conflict in 1991, tobacco companies sponsored “Welcome Home” events for returning troops featuring extensive brand promotion. ^[22] Although the Department of Defense had enacted policies to reduce tobacco use amongst personnel, the successful efforts of tobacco companies as well as the cultural factors of smoking in the military have produced a mixed message of tobacco promotion and reduction to military personnel.

Present Day Smoking in the US Military

In 2005, the smoking rate of military personnel was found to be 32.2%, compared to the civilian rate of 21%. ^[23] The higher smoking rate suggests that certain aspects of military may foster smoking. These factors include peer influence, combat stress, boredom, and easy access to cheap tobacco products. ^[24] Another factor that may lead to increased tobacco use is deployment. One study found that among nonsmokers, smoking initiation was observed in 1.3% of nondeployed personnel while 2.3% were observed in deployed personnel. Among past smokers, resumption of smoking occurred in 28.7% of nondeployed personnel and 39.4% of deployed personnel, while smoking increased 44% among the former and 57% among the latter. ^[25] US troops in Iraq and Afghanistan have been reported to smoke at twice the rate of other Americans. 8. ^[26] Even after leaving the service, many veterans continue to smoke as the prevalence of smoking among veterans has been reported to be 27% during 2003 to 2007, and military smoking is strongly associated with increased lifelong cigarette consumption. ^[27] Such high levels of smoking have led to significant costs to the Department of Defense. The costs of smoking among US military health care system beneficiaries have been estimated to be more than $900 million per year in 1995, with $584 million in direct health care costs and $346 million in lost productivity among active duty personnel. ^[28] Suicide, which accounts for 13% of fatalities in the military, has also been tied to smoking, as the risk of suicide among military men was found to increase significantly with the number of cigarettes smoked daily. ^[29] Smoking also affects training costs as smokers are more likely to be discharged during training, and are associated with $18 million per year in excess training costs for the US Air Force, and over $130 million per year for all service branches. ^[30]

Today, the Department of Defense hopes to lower rates of tobacco use to 12% by the end of 2010. ^[31] To achieve their goal, Pentagon health experts have begun to urge the current Defense Secretary Robert Gates to ban the use of tobacco by troops and end its sale on military property. ^[32] More recently, in early April, the Navy implemented a ban on smoking in submarines by the end of 2010 – highlighting one of the last loopholes in the indoor smoking ban imposed in 1994. ^[33] Due to the persistence of tobacco companies and the prevalence of a smoking culture within the military, the Department of Defense may need stronger, and more explicit implementation instructions for policies and stricter enforcement to truly curb smoking rates in the military.

References

1. ^ Brandt, Allan M. 2007. The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America. New York: Basic Books, pp. 50–53
2. ^ Goodman, J. (Ed.). (2005). Tobacco history and culture: An encyclopedia. Detroit, MI: Scribner’s.
3. ^ Goodman, J. (Ed.). (2005). Tobacco history and culture: An encyclopedia. Detroit, MI: Scribner’s.
4. ^ Brandt, Allan M. 2007. The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America. New York: Basic Books, pp. 50–53
5. ^ Smith, Elizabeth A. and Ruth E. Malone. “‘Everywhere the Soldier Will Be’: Wartime Tobacco Promotion in the US Military.” American Journal of Public Health 99 (2009): 1595-1602.
6. ^ Goodman, J. (Ed.). (2005). Tobacco history and culture: An encyclopedia. Detroit, MI: Scribner’s.
7. ^ Joseph, Anne M., et al. “The Cigarette Manufacturers’ Efforts to Promote Tobacco to the U.S. Military.” Military Medicine 170 (2005): 874-880.
8. ^ Joseph, Anne M., et al. “The Cigarette Manufacturers’ Efforts to Promote Tobacco to the U.S. Military.” Military Medicine 170 (2005): 874-880.
9. ^ Arvey, Sarah R. and Ruth E. Malone. “Advance and Retreat: Tobacco Control Policy in the U.S. Military.” Military Medicine 173 (2008): 985-991.
10. ^ Joseph, Anne M., et al. “The Cigarette Manufacturers’ Efforts to Promote Tobacco to the U.S. Military.” Military Medicine 170 (2005): 874-880.
11. ^ Arvey, Sarah R. and Ruth E. Malone. “Advance and Retreat: Tobacco Control Policy in the U.S. Military.” Military Medicine 173 (2008): 985-991.
12. ^ Arvey, Sarah R. and Ruth E. Malone. “Advance and Retreat: Tobacco Control Policy in the U.S. Military.” Military Medicine 173 (2008): 985-991.
13. ^ Arvey, Sarah R. and Ruth E. Malone. “Advance and Retreat: Tobacco Control Policy in the U.S. Military.” Military Medicine 173 (2008): 985-991.
14. ^ Joseph, Anne M., et al. “The Cigarette Manufacturers’ Efforts to Promote Tobacco to the U.S. Military.” Military Medicine 170 (2005): 874-880.
15. ^ Arvey, Sarah R. and Ruth E. Malone. “Advance and Retreat: Tobacco Control Policy in the U.S. Military.” Military Medicine 173 (2008): 985-991.
16. ^ Smith, Elizabeth A. and Ruth E. Malone. “‘Everywhere the Soldier Will Be’: Wartime Tobacco Promotion in the US Military.” American Journal of Public Health 99 (2009): 1595-1602.
17. ^ Joseph, Anne M., et al. “The Cigarette Manufacturers’ Efforts to Promote Tobacco to the U.S. Military.” Military Medicine 170 (2005): 874-880.
18. ^ Arvey, Sarah R. and Ruth E. Malone. “Advance and Retreat: Tobacco Control Policy in the U.S. Military.” Military Medicine 173 (2008): 985-991.
19. ^ Smith, Elizabeth A. and Ruth E. Malone. “‘Everywhere the Soldier Will Be’: Wartime Tobacco Promotion in the US Military.” American Journal of Public Health 99 (2009): 1595-1602.
20. ^ Smith, Elizabeth A. and Ruth E. Malone. “‘Everywhere the Soldier Will Be’: Wartime Tobacco Promotion in the US Military.” American Journal of Public Health 99 (2009): 1595-1602.
21. ^ Joseph, Anne M., et al. “The Cigarette Manufacturers’ Efforts to Promote Tobacco to the U.S. Military.” Military Medicine 170 (2005): 874-880.
22. ^ Smith, Elizabeth A. and Ruth E. Malone. “‘Everywhere the Soldier Will Be’: Wartime Tobacco Promotion in the US Military.” American Journal of Public Health 99 (2009): 1595-1602.
23. ^ Smith, Elizabeth A. and Ruth E. Malone. “‘Everywhere the Soldier Will Be’: Wartime Tobacco Promotion in the US Military.” American Journal of Public Health 99 (2009): 1595-1602.
24. ^ Nelson, Jenenne P. and Linda L. Pederson . “Military tobacco use: A synthesis of the literature on prevalence, factors related to use, and cessation interventions.” Nicotine & Tobacco Research 10 (May 2008): 775-790.
25. ^ Smith, Besa, et al. “Cigarette Smoking and Military Deployment.” American Journal of Preventive Medicine 35 (2008): 539-546.
26. ^ Kirby, A., et al. “Smoking in help-seeking veterans with PTSD returning from Afghanistan and Iraq.” Addict Behav. (2008);33: 1448–53.
27. ^ Brown, David W. “Smoking prevalence among US veterans.” J Gen Int Med 25 (2010): 147-149.
28. ^ Brown, David W. “Smoking prevalence among US veterans.” J Gen Int Med 25 (2010): 147-149.
29. ^ Matthew Miller, et al. “Cigarette Smoking and Suicide: A Prospective Study of 300,000 Male Activeduty Army Soldiers.” American Journal of Epidemiology 151 (2000): 1060-63.
30. ^ Klesges Robert C, Keith C. Haddock, Cyril F. Chang, et al. “The association of smoking and the cost of military training.” Tobacco Control 10 (2001); 43-47.
31. ^ Arvey, Sarah R. and Ruth E. Malone. “Advance and Retreat: Tobacco Control Policy in the U.S. Military.” Military Medicine 173 (2008): 985-991.
32. ^ Zoroya, Greg. “Ban on tobacco urged in military.” USA Today 09 Mar 2009: n. pag. Web. 4/25/2010. <http://www.usatoday.com/news/military/2009-07-09-smoking_N.htm>.
33. ^ Bynum, Russ. “No butts about it: Navy subs to ban smoking.” Washington Post 28 Apr 2010: n. pag. Web. 4/25/2010. http://www.washingtonpost.com/wp-dyn/content/article/2010/04/28/AR2010042800805.html