Effects of the Wars on Smoking Among Veterans
Lori A. Bastian, MD, MPH
and Scott E. Sherman, MD, MPH
Medical Center, Durham, VA, USA;
Division of General Internal Medicine, Duke University, Durham, NC, USA;
VA New York Harbor
Healthcare System, New York, NY, USA;
Section of Geriatric Medicine, New York University School of Medicine, New York, NY, USA.
KEYWORDS: smoking; veterans; tobacco control efforts.
J Gen Intern Med 25(2):102–3
© Society of General Internal Medicine 2010
lthough smoking rates in the US declined by 50%
between 1965 and 2005, about 21% of adults are current
The prevalence of smoking is estimated to be up to
40% higher in veterans than in the general population.
total burden of Veterans Affairs (VA) health-care costs associ-
ated with smoking range from 8% to 24%.
While the VA has
increased its efforts to fight the “war” on smoking,
in Iraq and Afghanistan are producing veterans who are
smoking at alarming rates. The prevalence of smoking among
veterans returning from recent wars is similar to that of the US
adult population during the late 1960s.
While a minority of veterans use the VA for health care, it
nevertheless provides a useful system in which to look at
tobacco control efforts. Almost 70% of smokers using the VA
want to quit.
In general, most smokers who try to quit do so
without the aid of any smoking cessation treatments and are
Increasing successful quit attempts is an
essential VA health services priority. While almost all VA
smokers are screened for tobacco use and are advised to quit
each year, most veterans do not receive optimal treatment of
combined behavioral counseling and pharmacotherapy.
the VA removed co-payments for smoking cessation care visits
in 2005, other barriers remain, including travel costs, sched-
uling conflicts, and work-related concerns. Only 17% of
smokers in the VA reported receiving desired cessation treat-
although recent efforts to increase treatment rates have
likely increased that number.
In the current issue of JGIM, Brown presents findings from
the 2003–2007 Behavioral Risk Factor Surveillance System
(BRFSS) to estimate and compare the prevalence of smoking
among veterans with non-veterans.
Overall, both male and
female veterans reported higher rates of smoking than non-
veterans. Among veterans, smoking prevalence was highest
among men (40%; 90% CI ¼ 31:7 À 48:2)andwomen(44%;
90% CI ¼ 32:4 À 56:3) born between 1985–1989, i.e., the youn-
gest cohort. Lower smoking prevalence among those from the
earliest birth cohorts may reflect smoking-related mortality
among these older age groups.
Smoking is a major risk factor for heart disease.
Among patients with coronary artery disease, a meta-
analysis reported a 36% reduction in mortality for those
who quit smoking compared to those who continue to
Using BRFSS data, the prevalence of smoking among
male veterans with coronary heart disease (CHD) was
43% 90% CI ¼ 39:0 À 47:6%ðÞ, greater than that for non-veterans
with CHD (31%; 90% CI ¼ 28:6 À 33:1%). Similarly, for women
with CHD, the prevalence of smoking was 30% 90%ð CI ¼
22:9 À 36:1%Þ among veterans and 28% 90%ð CI ¼ 26:1 À 29:5%Þ
The major finding of this report
is higher rates of smoking for
younger veterans, including veterans from recent wars. Smoking
during military service is reported to be associated with lifelong
increased cigarette consumption.
Almost three quarters of
veterans report a history of cigarette use, compared to 48% in the
A report of tobacco use in military
personnel in the first Gulf War showed that 7% initiated smoking
and 56% continued or increased the amount they smoked while
US service members deployed to Iraq and Afghani-
stan smoke at double the rate of other Americans.
Concerns about these higher smoking rates in younger
veterans spurred the VA, in cooperation with the Department
of Defense (DoD), to ask the Institute of Medicine (IOM) to
convene a committee to provide guidance on improving
This IOM report makes both
clinical and research recommendations to improve DoD and
VA smoking initiation and cessation efforts. The IOM commit-
tee also made recommendations to promote a tobacco-free
military. As noted in their report, the US military has set goals
to become tobacco-free several times.
The IOM report notes a
contradiction that although the DoD acknowledges that tobac-
co use impairs military readiness, the military sells tobacco
products at a discount and permits its use in some areas of
The IOM report recommends the DoD set a
specific date by which the military will become tobacco-free and
make compliance in all the armed services mandatory.
military is tobacco-free, the VA would have a manageable number
of smokers to address concerning cessation instead of the
Among the limitations of the study by Brown
on data derived from a telephone-based survey and use of self-
report for both smoking status and heart disease diagnoses.
Another significant limitation is that the data are not adjusted
for education level, and education level is strongly associated
with the prevalence of smoking and likely also with military
service. In other words, the higher rate of smoking may not be
because of military service, but rather simply that people likely
to smoke are more likely to enter the military. Importantly, the
study also raises the issue that clinicians offering smoking
cessation treatments for veterans need to consider co-morbid
mental disorders such as depression and post-traumatic
stress disorder that are associated with smoking.
care physicians and mental-health providers should use a
Published online January 15, 2010