Tobacco use has been a part of military culture since World War I, when cigarettes became widely available; service members were issued cigarettes with their rations to help them escape the tedium of war, boost morale, and offer pleasure, comfort, and currency (16
). Our results show that smoking is still perceived as endemic in military service by the newest cohort of veterans. Moreover, we found that OEF/OIF veterans felt smoking was an encouraged and normalized part of life during deployment. Our results are consistent with previous findings among active-duty service members. Deployed troops have higher rates of smoking initiation and smoking relapse compared with nondeployed troops (6
Prior research shows that smoking is a way to manage stress, boredom, anxiety, and sleep deprivation among active-duty military personnel (17
). Our results extend this research. Veterans described additional perceived benefits of smoking during their deployment, including creating a sense of camaraderie, facilitating communication outside one's work area, being able to take approved work breaks to smoke, and improving job performance. Instead of smoking, military service members should be offered access to healthy activities that foster a sense of troop cohesion while alleviating stress and boredom. To counter perceptions that tobacco use improves job performance, efforts should be made to increase soldiers' awareness of the association between smoking and risk of injury during physical training (19
) and reinforce their beliefs that smokers present a risk to other service members during deployment because of reduced levels of readiness caused by withdrawal symptoms and lit cigarettes revealing locations (18
Our findings suggest that veterans continue to use tobacco to modulate depressed mood, anxiety, and boredom after returning home. Feelings of stress related to interpersonal relationships (eg, family, community) are also prevalent among returning combat veterans (21
). Smokers in our study reported using cigarette breaks as a way to deal with anger, by stepping away from escalating situations with others. When asked why quitting smoking was so difficult for them, many veterans listed symptoms consistent with depressive disorders and posttraumatic stress disorder (PTSD) (eg, irritability, uncontrolled anger, sleeplessness). Our findings align with other research; 37% of all OEF/OIF veterans seen in VA health care facilities received mental health diagnoses (23
). People with mental health issues are more likely to smoke and may experience more difficulty when trying to quit (24
). For example, people with PTSD are more likely to be smokers and smoke more heavily than smokers without PTSD (26
). The VA successfully integrated tobacco use cessation treatment into PTSD mental health services (27
). Further efforts should be made to integrate smoking cessation treatments into other health care services accessed by veterans.
Despite the multiple challenges OEF/OIF veterans expressed, our results indicate that these veterans have a strong desire to quit using tobacco. This finding is consistent with other research; almost 70% of veteran smokers want to quit (12
). Since 2002, the VA health care system has implemented an array of systemwide evidence-based policies and programs to facilitate smoking cessation efforts (4
). These included such changes as increased access to smoking cessation pharmacotherapies and elimination of copayments for outpatient smoking cessation counseling; these positive changes contributed to an increase of approximately 60% in NRT and buproprion prescriptions from 2004 to 2008 (28
). Moreover, virtually all VAs offer some form of a tobacco control program, and most veterans seen in the VA for care are screened for tobacco use and provided with brief cessation counseling (11
). Although empirically based smoking cessations services are available free at the VA, many of the participants in our study reported not knowing services were available, suggesting an opportunity to improve marketing of existing VA smoking cessation services.
Our findings should be interpreted with caution. A regional cohort limits the generalizability of our findings; the results may not represent the needs and preferences of veterans living outside the southeastern US region or veterans not seeking VA care. Furthermore, OEF/OIF veterans may have unique smoking needs and preferences that may not translate to other veteran cohorts. Also, we were not able to directly assess psychiatric diagnoses in this cohort. Future studies should include full mental health history and include more geographically diverse samples.
Smoking is prevalent in military service and is a behavior that carries over into civilian life. We found that OEF/OIF veterans want to quit smoking but have multiple behavioral, situational, and environmental triggers that make smoking cessation complex. In addition, these veterans are younger overall than past cohorts of veterans seeking VA care (23
). Thus, these veterans often have young families and are engaged in school and work. Future smoking cessation strategies for OEF/OIF veterans may need to promote themes that have not been used for previous cohorts (eg, quit for the sake of children, increase physical stamina). This younger cohort may also be more likely to use new technologies to get help. The Department of Defense website, Quit Tobacco — Make Everyone Proud (www.ucanquit2.org
), provides online assistance with live chat services and individualized quit plans. The Department of Defense and the VA have partnered to extend access for this online resource to veterans enrolled for care in the VA to target the smoking cessation needs of OEF/OIF veterans. Themes from our analysis may help serve as a foundation to reach, engage, and facilitate successful quit attempts in this unique veteran population.