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Although smoking rates in the US declined by 50% between 1965 and 2005, about 21% of adults are current smokers.1,2 The prevalence of smoking is estimated to be up to 40% higher in veterans than in the general population.3,4 The total burden of Veterans Affairs (VA) health-care costs associated with smoking range from 8% to 24%.5 While the VA has increased its efforts to fight the “war” on smoking,6 actual wars 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.7
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.3 In general, most smokers who try to quit do so without the aid of any smoking cessation treatments and are unsuccessful.8 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.3 While the VA removed co-payments for smoking cessation care visits in 2005, other barriers remain, including travel costs, scheduling conflicts, and work-related concerns. Only 17% of smokers in the VA reported receiving desired cessation treatment,3 although recent efforts to increase treatment rates have likely increased that number.6
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.9 Overall, both male and female veterans reported higher rates of smoking than non-veterans. Among veterans, smoking prevalence was highest among men (40%; ) and women (44%; ) born between 1985–1989, i.e., the youngest 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.10 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 smoke.11 Using BRFSS data, the prevalence of smoking among male veterans with coronary heart disease (CHD) was , greater than that for non-veterans with CHD (31%; ). Similarly, for women with CHD, the prevalence of smoking was among veterans and among non-veterans.9
The major finding of this report9 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.12,13 Almost three quarters of veterans report a history of cigarette use, compared to 48% in the non-veteran population.13 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 deployed.14 US service members deployed to Iraq and Afghanistan smoke at double the rate of other Americans.2,15
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 tobacco-control programs.5 This IOM report makes both clinical and research recommendations to improve DoD and VA smoking initiation and cessation efforts. The IOM committee 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.16 The IOM report notes a contradiction that although the DoD acknowledges that tobacco use impairs military readiness, the military sells tobacco products at a discount and permits its use in some areas of military installations.5 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.5 Once the military is tobacco-free, the VA would have a manageable number of smokers to address concerning cessation instead of the ever-expanding numbers of smokers the VA is currently facing.
Among the limitations of the study by Brown9 are reliance 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.17 Primary care physicians and mental-health providers should use a combined approach for treating mental health disorders and tobacco use. More research is needed on how to integrate these treatments effectively.5
Next, steps should include the development of a research database of smokers in the VA to address how veterans quit and follow their long-term abstinence rates, as suggested by IOM report.5 The IOM committee also recommended that DoD and VA consider jointly funding smoking cessation research on veterans who have co-morbid medical and psychiatric conditions. Recently, the VA funded a Smoking Cessation Research Collaborative Group. This group of researchers is well positioned to address the research agenda proposed by the IOM committee. The men and women who serve our country deserve our commitment to improve their health.
Dr. Lori Bastian is supported by grants from the Department of Veterans Affairs, Health Services Research and Development (IIR-05-202) and the NIH/National Cancer Institute (U01 CA92622). Dr. Scott Sherman is supported by grants from the Department of Veterans Affairs, Health Services Research and Development (SDP 07-034 and EDU 08-428). The views expressed in this editorial are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.