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Downloaded from https://academic.oup.com/milmed/article/183/11-12/e402/4999179 by DeepDyve user on 19 July 2022 MILITARY MEDICINE, 183, 11/12:e402, 2018 Sara E. Golden, MPH*†; Sujata Thakurta, MHA*; Christopher G. Slatore, MD*‡§¶; Hyeyoung Woo, PhD‡; Donald R. Sullivan, MD*‡ ABSTRACT Introduction: Given the high prevalence of smoking among Veterans and the economic, social, and clinical implications, it is important to understand the factors that contribute to smoking in order to focus efforts to mit- igate these factors and improve smoking cessation efforts among Veterans. The availability of research on smoking in Veterans compared with civilians is limited given the military-speciﬁc differences in their life course. We aimed to identify military-speciﬁc factors combined with sociodemographic factors for ever smoking and current smoking among Veterans to inform future interventions. Materials and Methods: We used data from the 2010 National Survey of Veterans, the most current, to analyze the association of sociodemographic and military-speciﬁc factors with ever versus never smoking, and current versus past smoking using multiple variable logistic regression models (IRB#4125). Results: Among 8,618 respondents, the proportions of current, past, and never smokers were 17%, 48%, and 34%, respectively. Sociodemographic factors associated with ever smoking were female gender, educational attainment of less than a bachelor’s degree, and being divorced/separated/widowed. Military-speciﬁc factors associated with ever smoking were exposure to dead/dying/wounded soldiers during service, and past, current, and unsure enrollment in Veterans Affairs healthcare. Never smoking was associated with Hispanic ethnicity, income over $75,000, and report- ing fair or poor health. Military factors associated with never smoking were presence of a service-connected disability and military service July 1964 or earlier (i.e., pre-Vietnam). Among 5,652 ever smokers, sociodemographic factors associated with current smoking were age less than 65, being non-Hispanic black, educational attainment of less than a bachelor’s degree, being divorced/separated/widowed, never married, and having no insurance. Factors associated with reduced likelihood of current smoking compared with past smoking included income >$41,000 and reporting fair or poor health. Military-speciﬁc variables associated with reduced likelihood of current smoking were service era of May 1975 or later (i.e., post-Vietnam) and 5 or more years of service. Conclusion: Military-speciﬁc variables are associated with smoking behaviors among Veterans. Findings from this study that exposure to dead/dying/wounded soldiers, ser- vice era, duration of service, service-connected disability status, and enrollment in VA care all inﬂuence smoking in Veterans, can inform prevention and cessation efforts in part by encouraging alternative healthy habits or cessation techniques in subgroups of Veterans with particular military backgrounds. By assessing risk factors in this unique pop- ulation future research can leverage these ﬁndings to determine mechanisms that help explain these associations. Identifying factors associated with smoking offers insights for smoking cessation and prevention interventions given the military experiences and increased smoking incidence among Veterans. INTRODUCTION use. National smoking rates for Veterans have declined Smoking is the leading preventive cause of death in the about 15% from 2010 to 2015 as well, however, Veterans USA as it is associated with increased risk of lung cancer 1,2 are still more likely to be current smokers compared with the and cardiovascular disease, among others. Disparities in civilian population. Despite the availability of tobacco ces- cigarette smoking in demographic subgroups based on eth- sation programs in the Department of Veterans Affairs (VA) nicity, education, and socioeconomic status (SES) have wid- healthcare system, tobacco use remains “accepted, accom- ened in the past decades despite overall decline in tobacco modated, and promoted” during active military service. As a result, almost half (49%) of military service members *Center to Improve Veteran Involvement in Care, VA Portland Health report using nicotine in the past year. This tobacco legacy Care System (R&D66), 3710 SW, US Veterans Hospital Road, Portland, within the military has signiﬁcant consequences as VA has OR 97239. †Department of Sociology, Portland State University, PO Box 751, spent an estimated $2.7 billion on medical consequences of Portland, OR 97207. smoking in 2010. ‡Department of Medicine, Oregon Health & Science University PCCM, Almost one-third of current military members started 3181 SW, Sam Jackson Park Rd, Portland, OR 97239. smoking after joining the military. Reasons for smoking ini- §Section of Pulmonary & Critical Care Medicine, VA Portland Health tiation in the military are multifactorial including stress Care System Portland, 3710 SW, US Veterans Hospital Road, Portland, OR 97239. relief, sanctioned regular smoking breaks, and peer pres- ¶Department of Radiation Medicine, Oregon Health & Science sure. Reasons for initiation may also be related to other University, 3181 SW, Sam Jackson Park Rd, Portland, OR 97239. military-speciﬁc factors such as exposure to traumatic events doi: 10.1093/milmed/usy115 or increased stress of deployment. The Marine Corps has the Published by Oxford University Press on behalf of the Association of highest current smoking rate at 30.8%, while the Air Force Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. has the lowest at 16.7%. A recent poll found that Army e402 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e402/4999179 by DeepDyve user on 19 July 2022 Veteran Factors Associated with Smoking soldiers and Marine Corps members were equally as likely never). In the ﬁrst regression model, we deﬁned ever smokers to serve in combat roles in Iraq or Afghanistan, and these as past or current smokers and compared them to never smo- rates were much higher than other branches. Soldiers and kers. In the second regression model, we compared current Marines were also much more likely to experience a “trau- and past smokers excluding those who were never smokers. matic incident” during combat. These ﬁndings could The following covariates were included in models: age, potentially point to the differing smoking rates among mili- gender, race/ethnicity, educational attainment, income, mari- tary branches if smoking is used to manage stress. Tobacco tal status, health insurance status, and self-reported health deterrence is reported less often in the Army and Marines, status. Additionally, we included military-speciﬁc covariates: which may also contribute to the different smoking rates. exposure to dead/dying/wounded soldiers during service, Associations of social factors with smoking prevalence in branch of service, service era, duration of service (in years), Veterans are less well studied. However, there are several presence of a service-connected disability, service-connected socioeconomic and racial disparities noted in the civilian lit- disability rating (amount of compensation paid for an injury/ erature. Lower socioeconomic status and education, unmar- illness attributed to military service), and enrollment in VA ried marital status, American Indian/Alaska Native race, and care. All military-speciﬁc variables available in the survey poor health are all associated with an increased risk of smok- were included in analyses. We included categories for “don’t 2,3 ing. Non-Hispanic blacks were more likely to be smokers know” in two variables due to the importance of respon- than other racial groups. dents’ misunderstanding of their enrollment in VA care and Similarities exist between Veteran and civilian popula- service-connected disability rating. tions. Veterans who are current smokers are known to have lower incomes and be between the ages of 45–64, similar to Smoking Status civilians. Military-speciﬁc factors that contribute to smok- Smoking status as of 2010 was originally comprised of two ing behaviors in Veterans are unexplored. Given the high questions including the following response categorical options prevalence of current or ever smoking among Veterans and to the questions, “How often do you smoke cigarettes?”:every the economic implications, it is important to understand the day, some days, not at all; and “Have you smoked at least 100 factors that contribute to smoking in order to focus efforts to cigarettes in your lifetime?”: yes, no. For the analysis, we used mitigate these factors and improve smoking cessation efforts the ﬁrstquestiontodeﬁne current smokers and the second among Veterans. questiontodeﬁne ever smokers. There were few missing The aim of this study was to determine factors associated responses (0.9%), to either question, which were excluded. A with ever or current smoking among Veterans using a comparison of respondent demographics based on missing national, comprehensive survey. As social determinants of responses to smoking questions justiﬁed their exclusion, as health are increasingly noted as pathways toward health beha- they were similar to those who completed the smoking viors, the availability of research on smoking in Veterans questions. using such variables is limited given the additional presence of military-speciﬁc differences in their life course. Our results Covariates focus on military-speciﬁc variables to obtain a comprehensive understanding of smoking behaviors in this high-risk popula- The covariates in the analysis were race/ethnicity (originally tion to inform interventions for both current and former ser- categorized into 11 self-report categories but collapsed into vice members. non-Hispanic White, non-Hispanic Black, Hispanic, and Other by the authors), gender (male, female), age category (<65, ≥65), marital status (married or civil union, divorced/sep- METHODS arated/widowed, never married), insurance status (employer/ We conducted this IRB-exempt study (#4125) using data from purchased, Medicare/Medicaid/other government, VA/Tricare, the 2010 National Survey of Veterans (NSV), the most recent Indian/Other, no insurance), income (<$40,000, $40–74,999, available. Survey data collection and weighting methods are ≥$75,000), and educational attainment (high school or less, well established, validated, and have been described previ- some college, BA or higher). In Model 2, we added general ously. In brief, the 2010 NSV is the sixth in a series of self-reported health status (at least good health/fair or poor national surveys for Veterans. The 2010 NSV was conducted health), exposure to dead/dying/wounded (response to the ques- using questionnaires mailed to Veterans regardless of their tion “During your military service, were you ever exposed to afﬁliation with VA healthcare. Data collection occurred from dead, dying, or wounded people?”: yes/no), branch of service October 16, 2009–March 19, 2010. Veterans completed 8,710 (Army/Marines, Navy/Air Force/Coast Guard/Other Service), surveys, with a response rate of 66.7% for the Veteran survey. service era (July 1964 or earlier, August 1964–April 1975 Missing demographic values were imputed using hot deck (Vietnam era), May 1975–present), duration of service (1–4yr, imputation in the original dataset, although nonresponses 5 or more years), presence of a service-connected disability were relatively rare. We included all respondents who (yes, no), service-connected disability rating (0–49%, answered questions about smoking status (past, current, or 50–100%, unsure), and ever enrolled in VA care (yes, no). MILITARY MEDICINE, Vol. 183, November/December 2018 e403 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e402/4999179 by DeepDyve user on 19 July 2022 Veteran Factors Associated with Smoking Service-connected disability rating only includes those who 0.001) or never married marital status (OR 1.92, p < 0.001), responded “yes,” to the prior question about the presence of a and having no insurance (OR 1.92, p < 0.001) were associ- service-connected disability. We dichotomized branch of ser- ated with increased likelihood of current smoking compared vice as such given the higher smoking rates and rates of com- with past smoking. Factors associated with reduced likeli- bat deployment in the Army and Marine Corps. Duration of hood of current smoking compared with past smoking service was dichotomized into less than or greater than 5 yr included income ≥$41,000 ($41,000–74,999, OR 0.78, p < because a standard initial military contract is 1–4yr and dura- 0.05; >$75,000, OR 0.67, p < 0.01), fair/poor health status tion of service longer than this likely connotes a military (OR 0.60, p < 0.001), military service May 1975 or later career. In a sensitivity analysis, we included mental health/ (i.e., post-Vietnam) (OR 0.31, p < 0.001), and 5 or more substance abuse hospitalization in past 6 mo (yes, no), and years of military service (OR 0.76, p < 0.05) (Table II: mental health/substance abuse outpatient counseling in past 6 Model 2). mo (yes, no) to capture information about potential comorbid psychological conditions; results were unchanged. DISCUSSION We performed forward stepwise logistic regression In a large, national cohort of Veterans, smoking behaviors were modeling to determine the relationship between the explana- associated with military-speciﬁc variables that have important tory variables and ever smoking compared with never smok- health implications. We also found that sociodemographic fac- ing status. We utilized the same methods to determine the tors associated with smoking status in Veterans were similar to association with current compared with past smoking status. those observed in civilian populations. Historical tobacco avail- We used SPSS v20 (IBM) for analyses, employing p < 0.05 ability from inclusion of cigarettes in rations from early service criterion for statistical signiﬁcance. eras (until 1975) and current low prices of cigarettes on military bases likely contributes to smoking among Veterans. Over the RESULTS past few decades military culture surrounding tobacco promo- The total number of survey respondents was 8,710 (66.7% tion has improved signiﬁcantly, but smoking remains a signiﬁ- response rate). Among the 8,618 (99%) of included Veterans cant problem among Veterans. Findings from this study that who answered the questions regarding smoking status, 1,485 exposure to dead/dying/wounded soldiers, service era, duration (17%) were current, 4,167 (48%) past, and 2,966 (34%) of service, service-connected disability status, and enrollment in never smokers. Our cohort was largely non-Hispanic white VA care all inﬂuence smoking in Veterans, can inform preven- (83%), male (94%), former Army (46.9%), and the plurality tion and cessation efforts in part by encouraging alternative served in the Vietnam era (35.5%) (Table I). healthy habits or cessation techniques in subgroups of Veterans with a particular military background. Factors Associated With Ever Smoking Factors associated with being an ever smoker were female Ever Smoking gender (odds ratio (OR) 1.71, p < 0.001), educational attain- While the sociodemographic variables included match civil- ment of less than a bachelor’s degree (high school or less, ian population ﬁndings for having ever smoked, four OR 2.02, p < 0.001; some college, OR 1.78, p < 0.001), military-related variables were also signiﬁcant in this analy- divorced/separated/widowed marital status (OR 1.19, p < sis. Military-related stress, as possibly related to our results 0.05), exposure to dead/dying/wounded soldiers (OR 1.24, regarding exposure to dead/dying/wounded soldiers during p < 0.01), and enrollment in VA healthcare (OR 1.20, p < service, is likely a signiﬁcant contributor for ever smoking 0.05) or unsure of enrollment (OR 1.43, p < 0.01). Factors among Veterans. Acute stress during service may lead to ini- signiﬁcantly associated with being a never smoker were tiation of smoking but symptoms of stress generally decrease 13 14 Hispanic ethnicity (OR 0.55, p < 0.001), income >$75,000 over time, especially for those with a positive outlook, (OR 0.79, p < 0.01), fair/poor health status (OR 0.72, p < meaning some military personnel may be more equipped to 0.001), presence of a service-connected disability (OR 0.80, quit smoking after the acute stressors have ended. Indeed, p < 0.05), and military service July 1964 or earlier (i.e., pre- military personnel may use tobacco to cope with stress, Vietnam) compared with Vietnam era (OR 0.67, p < 0.001) and accordingly smoking prevalence is associated with com- (Table II: Model 1). bat deployment where exposure to dead/dying/wounded sol- diers would occur. Veterans have a high incidence of Factors Associated With Current Smoking comorbidities such as post-traumatic stress disorder (PTSD), Among the 5,652 Veterans who were ever smokers (i.e., depression, and traumatic brain injury. In fact, 41% of all past and current), we found that age < 65 (OR 2.37, p < Veterans in care at VA have been diagnosed with either a 0.001), being non-Hispanic black (OR 1.38, p < 0.05), edu- mental health or behavioral adjustment disorder. Although cational attainment of less than a bachelor’s degree (high the limited mental health and substance abuse variables in school or less, OR 1.86, p < 0.001; some college, OR 1.62, our survey were not signiﬁcant in our analyses, we believe p < 0.001), divorced/separated/widowed (OR 1.69, p < military-related stress and the subsequent development of e404 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e402/4999179 by DeepDyve user on 19 July 2022 Veteran Factors Associated with Smoking TABLE I. Descriptive Statistics from the National Survey of Veterans Characteristic All Respondents Current Past Never 8,618 1,485 (17.2) 4,167 (48.4) 2,966 (34.4) Age <65 2,407 (28.5) 405 (27.9) 699 (17.1) 1,034 (35.6) >65 6,027 (71.5) 269 (18.6) 3,383 (82.9) 1,868 (64.4) Gender, male 7,219 (93.6) 1,279 (93.6) 3,611 (96.1) 2,329 (90.0) Race/Ethnicity Non-Hispanic White 6,906 (83.0) 1,136 (78.9) 3,451 (85.5) 2,319 (81.5) Non-Hispanic Black 502 (6.0) 143 (9.9) 167 (4.1) 192 (6.8) Hispanic 373 (4.5) 66 (4.6) 141 (3.5) 166 (5.8) Other/Mixed 540 (6.5) 94 (6.5) 279 (6.9) 167 (5.9) Educational attainment High school or less 2,680 (31.6) 609 (41.6) 1,407 (34.3) 664 (22.8) Some college 3,204 (37.8) 655 (44.8) 1,536 (37.5) 1,013 (34.8) Bachelors or advanced degree 2,589 (30.6) 199 (13.6) 1,154 (28.2) 1,236 (42.4) Annual income, U.S. dollars <41,000 3,242 (40.5) 764 (54.5) 1,574 (40.8) 904 (33.0) 41–74,999 2,567 (32.1) 421 (30.0) 1,295 (33.5) 851 (31.0) >75,000 2,196 (27.4) 217 (15.5) 991 (25.7) 988 (36.0) Marital status Married/Civil union 6,250 (73.7) 873 (60.0) 3,164 (77.0) 2,213 (75.8) Divorced/Separated/Widow 1,741 (20.5) 440 (30.2) 796 (19.4) 505 (17.3) Never married 495 (5.8) 143 (9.8) 149 (3.6) 203 (6.9) Current insurance Medicare/Medicaid/Other government 2,962 (34.8) 330 (22.4) 1,727 (42.0) 905 (30.9) Employer or self-purchase 2,823 (33.2) 506 (34.4) 1,188 (28.9) 1,129 (38.6) VA/Tricare/Military health 1,786 (21.0) 316 (21.5) 866 (21.1) 604 (20.6) Indian health service or other 282 (3.3) 38 (2.6) 152 (3.7) 92 (3.1) None 659 (7.7) 281 (19.1) 181 (4.4) 197 (6.7) Health status At least good 6,054 (71.0) 858 (58.5) 2,875 (69.7) 2,321 (79.1) Fair or poor 2,473 (29.0) 608 (41.5) 1,251 (30.3) 614 (20.9) Exposure to dead/Dying/Wounded soldiers 3,063 (36.3) 608 (42.1) 1,496 (36.5) 959 (33.0) Branch of service Army 3,975 (46.9) 719 (49.5) 1,938 (47.2) 1,318 (45.2) Navy 1,892 (22.3) 290 (20.0) 965 (23.5) 637 (21.8) Air force 1,674 (19.8) 244 (16.8) 781 (19.0) 649 (22.2) Marines 782 (9.2) 182 (12.5) 336 (8.2) 264 (9.1) Coast guard/Other 148 (1.7) 17 (1.2) 82 (2.0) 49 (1.7) Service era Jul 1964 or earlier 2,856 (33.7) 217 (15.0) 1,788 (43.5) 851 (29.2) August 1964–April 1975 (Vietnam) 3,012 (35.5) 623 (42.9) 1,494 (36.4) 895 (30.7) May 1975 or later 2,605 (30.7) 611 (42.1) 826 (20.1) 1,168 (40.1) Duration of service 1–4 yr 5,956 (72.7) 1,016 (72.3) 3,019 (75.9) 1,921 (68.5) ≥5 yr 2,232 (27.3) 390 (27.7) 959 (24.1) 883 (31.5) Service-connected disability, yes 1,406 (16.3) 291 (19.6) 618 (14.8) 497 (16.8) Ever enrolled in VHA care No 5,667 (66.4) 824 (55.8) 2,784 (67.4) 2,059 (70.2) Yes 2,300 (26.9) 516 (35.0) 1,095 (26.5) 689 (23.5) Don’t know 574 (6.7) 136 (9.2) 251 (6.1) 187 (6.4) Note. Expressed as N (%); percents are of non-missing data; all variables had <5% missing, except duration of service (5.1%); BA, bachelor of arts degree; VA, Department of Veteran’s Affairs; NA, not applicable; some variables included a “don’t know” category of <1% and were not included. mental illness likely contribute to the high smoking rates Veterans in regard to the unique combat conditions and among Veterans. Exposure to combat trauma is likely a much higher prevalence of PTSD and other psychological strong indicator of development of psychological conditions problems. Therefore, they may have not felt the need to 18 19,20 like PTSD which are associated with tobacco use. initiate smoking. However, this ﬁnding may also be a relic Those in earlier eras of service (pre-Vietnam) are also of immortality bias, as discussed in the limitations below. less likely to have ever smoked. Those from earlier eras may With the prevalence of psychological disorders like PTSD in not have experienced the same challenges as Vietnam era the service, especially for Vietnam era Veterans, military MILITARY MEDICINE, Vol. 183, November/December 2018 e405 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e402/4999179 by DeepDyve user on 19 July 2022 Veteran Factors Associated with Smoking TABLE II. Logistic Regression of Ever and Current Smoking Status in Veterans Ever vs. Never Smoking (n = 8,618) Current vs. Past Smoking (n = 5,652) Characteristic Exp(B) (95% CI) Exp(B) (95% CI) Age >65 —— — — <65 1.01 (0.82, 1.24) 2.37 (1.83, 3.06) Gender Male (ref) —— — — Female 1.71 (1.36, 2.15) 1.16 (0.82, 1.66) Race/Ethnicity Non-Hispanic White (ref) —— — — Non-Hispanic Black 0.98 (0.76, 1.25) 1.38 (1.01, 1.87) Hispanic 0.55 (0.42, 0.72) 0.99 (0.67, 1.47) Other/Mixed 0.85 (0.65, 1.10) 0.94 (0.66, 1.32) Educational attainment High school or less 2.02 (1.73, 2.37) 1.86 (1.46, 2.38) Some college 1.78 (1.55, 2.04) 1.62 (1.29, 2.04) BA or advanced degree (ref) —— — — Annual income, U.S. dollars <41,000 (ref) —— — — 41,000–74,999 0.98 (0.85, 1.14) 0.78 (0.64, 0.95) >75,000 0.79 (0.67, 0.93) 0.67 (0.52, 0.86) Marital status Married/Civil union (ref) —— — — Divorced/Separated/Widow 1.19 (1.02, 1.38) 1.69 (1.40, 2.04) Never married 0.86 (0.67, 1.09) 1.92 (1.39, 2.66) Current Insurance Medicare/Medicaid/Gov’t (ref) —— — — Employer or self-purchase 0.86 (0.72, 1.02) 1.05 (0.82, 1.35) VA/Tricare/Military health 0.91 (0.75, 1.11) 0.96 (0.74, 1.22) Indian health service or other 0.93 (0.67, 1.28) 0.73 (0.44, 1.21) No insurance 1.07 (0.81, 1.41) 1.92 (1.40, 2.63) Self-reported health status At least good (ref) —— — — Fair or poor 0.72 (0.63, 0.83) 0.60 (0.50, 0.71) Exposed to dead/Dying/Wounded soldiers Yes 1.24 (1.10, 1.41) 1.12 (0.94, 1.32) Branch of service Army/Marines (ref) —— — — Navy/Air Force/Coast Guard/Other 1.04 (0.92, 1.61) 0.92 (0.78, 1.08) Service era Jul 1964 or earlier 0.67 (0.54, 0.82) 1.16 (0.88, 1.52) Aug 1964–April 1975 (Vietnam) (ref) —— — — May 1975 or later 0.93 (0.78, 1.10) 0.31 (0.25, 0.40) Duration of service 1–4 yr (ref) —— — — ≥5 yr 0.98 (0.85, 1.14) 0.76 (0.62, 0.94) Service-connected disability Yes 0.80 (0.67, 0.95) 0.91 (0.72, 1.15) Ever enrolled in VA care No (ref) —— — — Yes 1.20 (1.02, 1.40) 1.19 (0.97, 1.46) Don’t Know 1.43 (1.12, 1.82) 1.17 (0.86, 1.58) Note: Expressed as N (%); percents are of non-missing data; all variables had <5% missing, except duration of service (5.1%). All boldfaced values are sig- niﬁcant at p <0.05. culture and VA could be modiﬁed to provide and encourage rather than upon military discharge given the heightened risk healthy, alternative ways to manage stress and avoid the of symptoms of stress (like smoking) immediately after or desire to start (or continue) smoking, as other military factors during a stressful event. When taking military histories, are largely unmodiﬁable. Interventions to prevent or stop healthcare providers can request more information on poten- smoking may be more helpful at the time of stressful events tial risks for smoking like duration of service and service e406 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e402/4999179 by DeepDyve user on 19 July 2022 Veteran Factors Associated with Smoking era, or cessation resources may be tied in more closely with healthcare have lower SES and other important social factors mental health consults. contributing both to their ever smoking behavior and need for VA care. This study has limitations. Female and non-white Veterans Current Smoking are under-represented in the cohort; however, survey data Our ﬁndings regarding Veterans’ sociodemographic factors were weighted per Veteran population demographics. There are similar to previous research identifying risk factors for were no data on time since military service or on pack-years current smokers in the civilian population. For example, available, possibly inﬂuencing smoking persistence. Self- Veteran age was signiﬁcant for current smoking where youn- reported survey data are subject to recall and response bias. ger Veterans are more likely to currently smoke. These We also acknowledge a potential immortality bias since many results support previous ﬁndings that current cigarette smok- of the responders are older than 65 and smoking-related mor- ing is more common among those under 65. Additionally, tality may inﬂuence results in older populations. Additionally, smoking rates among older Veterans have been found to be secular changes in smoking and military make-up such as similar to the general senior population, and 68% of military availability and price of cigarettes, presence combat expo- retirees reported they were former smokers, perhaps imply- sures, and increasing numbers of females are not accounted ing Veterans are incorporating healthier behaviors as they for. age. We also found that marital status (i.e., married or hav- Military-speciﬁc variables are associated with smoking ing a partner) was an important characteristic for successful behaviors among Veterans. These descriptive results offer cessation as unmarried individuals may lack the support or important insights into factors that contribute to ever and motivation needed to quit. current smoking among Veterans, which may enhance the Importantly, two military-speciﬁc factors were associated development of targeted interventions to both active military with past (service era and service duration), but not current personnel as well as Veterans. By assessing risk factors in smoking which may indicate that Veterans are more pre- this unique population, future research can leverage these pared to quit smoking after the day-to-day stress of a mili- ﬁndings to determine mechanisms that help explain these tary career has ended. Service era was a signiﬁcant risk associations. Smoking remains a signiﬁcant public health factor with more recent eras being less likely to currently issue in the US, especially among Veterans, that contributes smoke, possibly due to the removal of cigarettes from rations to substantial morbidity and mortality. These ﬁndings have or initiatives by the military for smoking cessation. Career important future implications for the health of Veterans. military members may have favorable sociodemographic variables, like higher SES, that contribute to smoking cessa- CONFLICT OF INTEREST STATEMENT tion since they may have higher incomes, better education, All authors declare no conﬂicts of interest with the work presented in this more prestigious military or civilian occupations, more sta- manuscript. ble access to healthcare, or are required to sustain a more active lifestyle. Military personnel on shorter contracts can be more closely monitored during their tour for presence of FUNDING continued or increased smoking behaviors. Incorporating This material is the result of work supported with resources and the use of sociodemographic as well as military-speciﬁc information facilities at the VA Portland Health Care System, Portland, Oregon, USA. gathered at annual primary care visits may provide more sights into current and past smoking behaviors and inform REFERENCES smoking cessation interventions at VA facilities. This infor- 1. Carter BD, Abnet CC, Feskanich D, et al: Smoking and mortality – mation can also be gleaned from medical or service records beyond established causes. N Engl J Med 2015; 372(7): 631–40. to help identify Veterans most in need of cessation 2. Centers for Disease Control and Prevention. Tobacco-related disparities. resources, even those not enrolled in VA healthcare. Available at https://www.cdc.gov/tobacco/disparities/. Published December Treatment of comorbid conditions like PTSD, depression, 1, 2016; accessed January 6, 2017. or pain, can aid in smoking cessation. 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Military Medicine – Oxford University Press
Published: Nov 5, 2018
Keywords: smoking; military personnel; veterans
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