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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Mil Med. Author manuscript; available in PMC Oct 1, 2013.
Published in final edited form as:
Mil Med. Oct 2012; 177(10): 1202–1207.
PMCID: PMC3572716
NIHMSID: NIHMS436924
Why Strong Tobacco Control Measures “Can’t” Be Implemented in the U.S. Military: A Qualitative Analysis
Elizabeth A. Smith, PhD and Ruth E. Malone, RN, PhD, FAAN
Department of Social & Behavioral Sciences, University of California, San Francisco, 3333 California Street, Suite 455, San Francisco, CA 94118
The Institute of Medicine recently called for a tobacco-free military, citing evidence that high rates of tobacco use harm readiness and create enormous costs for the Department of Defense and the Veterans Administration. The pro-tobacco activities of the tobacco industry and others, sometimes supported by military authorities even when prohibited by policy, have created a culture highly hospitable to smoking. Through qualitative secondary analysis of data from interviews and focus groups, this article explores the reasons enlisted personnel and their supervisors, installation tobacco control managers, and service policy leaders give for why tobacco control policy change “cannot” effectively be achieved. Three primary reasons were given: policies would impinge on the “right to smoke,” policies would be unenforceable and lead to disciplinary breakdown, and the rights of civilian workers on military installations precluded policy enforcement. Yet evidence suggests that these reasons are not only invalid, but inconsistent with military policies addressing other threats to the health of personnel. This pervasive tobacco “exceptionalism” is a significant barrier to achieving a tobacco-free military. The military, Congress, and the President should re-evaluate the “can’ts” that have prevented effective action, and act to regulate and eventually abolish tobacco use in the armed forces.
The pro-tobacco activities of the tobacco industry and others, sometimes supported by military authorities even when prohibited by policy,1 have created a culture highly hospitable to smoking. A 2005 survey found that 42% of military personnel agreed that the number of places to buy cigarettes on base or post made it easy to smoke, and a similar percentage reported that most of their military friends smoked.2 Other military practices also encourage smoking. A focus group study found that “smoke breaks” were one of the only sanctioned reasons for taking a break from duty.3 The same study also found that “smoking pits” were valued as places to socialize, and some subjects noted that senior personnel sometimes encouraged or pressured junior personnel to join them there.3 A similar study found that service members believed that the environment on deployment encouraged smoking and that rules about tobacco use were inconsistently enforced.4 The comparatively low cigarette prices military outlets offer also imply that the military still encourages smoking.5
The military is characterized by its multiplicity of rules that control what in the civilian world are considered personal choices. Examples include attire, hair length, fitness level, and weight, and enforcement of such policies is considered part of military discipline. However, tobacco control (TC) policies are regarded differently, considered a threat to smokers’ “rights”. This language is widely used by the tobacco industry and its allies6; for example, “rights” rhetoric figured in efforts to prevent price increases on tobacco products in military stores,7 rescind a strong Army TC program,8 weaken an initiative by the (then) Strategic Air Command,8 and undermine a smoke-free policy at Fort Dix.8 An Institute of Medicine (IOM) report9 recently recommended that tobacco be phased out of the military because of its substantial negative impact on troop health and combat readiness; that recommendation was almost immediately rejected publicly by the Department of Defense (DoD). Troops were assured from the highest level of the military hierarchy that their “right to smoke” would not be taken away.10
This article explores how enlisted personnel, installation TC managers, and service-level policy leaders characterize proposed policy changes, emphasizing their reasons why effective tobacco policy change “cannot” be achieved, and analyzes what is needed to effect change in the military culture of tobacco “exceptionalism.”
This study is a secondary analysis of data from two prior projects. The first involved focus groups (N = 20) on four Air Force and two Army installations with enlisted service members and supervisors. These groups explored themes and messages about smoking that might be effective in promoting tobacco use prevention or cessation among junior enlisted personnel. Details of instrument development, recruitment, and procedures have been previously described11; Table I outlines group characteristics.
TABLE I
TABLE I
Focus Groups (n = 20)
The second study involved interviews with a purposive sample of military installation-level TC managers and service-level policy leaders (N = 52), located on installations across the country and overseas, about TC efforts, policies, and challenges within the DoD. Instrument development, sample selection, and procedures have been previously described.12 Table II outlines respondent characteristics.
TABLE II
TABLE II
Interviews (n = 52)
For secondary analysis of these data, transcripts of interviews and focus groups were imported into NVivo, a qualitative analysis software package. Iterative readings by both authors were used to inductively identify themes; all texts were then coded for these themes and clusters of coded text analyzed for meaning, using an interpretive approach involving repeated readings of text, examination of the overall data for contrasts and comparisons, and discussion by the authors.13,14 Because this is a secondary analysis of qualitative data not originally gathered to focus explicitly on this topic, the themes arose in a variety of different contexts, and follow-up questions to further elucidate themes were not possible. Because of space limitations, not all identified themes are reported here; however, other themes were consistent with these findings.
Legality and Rights
The belief that smoking was a “right” was widespread among all types of respondents—junior enlisted, supervisors, and TC managers and policy leaders from all services. This belief appeared to contribute to the idea that there were few enforceable policy options the military could use to reduce or eliminate tobacco use. The most basic statement of this belief was the simple assertion that tobacco was “legal” or “not illegal.” For instance, asked about the possibility of restricting sales, a policy leader responded, “You can’t restrict something that’s legal. You just can’t do that, so I’m going to say that’s unlikely”. A TC manager thought his/her commanders would support banning smoking in military uniform, “but legally, I don’t know if they can do that.” This suggests that respondents regarded legality as equating with permissibility, despite numerous existing military policies restricting otherwise legal activities and practices.
Others specifically identified tobacco use as a “right” or a “freedom,” which should not be impinged upon. An enlisted smoker asserted, “it’s like we’re here fighting for our freedom and you’re not going to allow me my freedom to smoke?” Another expressed the idea that “military personnel have earned the right to be able to smoke.” A TC manager thought it unlikely that his/her service would make smoking status a part of fitness evaluation scores because it was “getting into personal rights.”
During basic and technical school training, troops are required to refrain from tobacco use. This policy was mentioned several times. One enlisted smoker noted that in basic training, “you don’t have many rights,” which gave the service a chance to “get their point across” that tobacco use was discouraged. However, another smoker was concerned that this policy was spreading to make all training installations completely tobacco-free for everyone, which “concerns a lot of people, like, that’s their right, if they want to smoke, they shouldn’t be told if they can or can’t.” Yet another asserted that many enlistees smoked at their first opportunity once they left technical school: “I’m allowed to do it now and it’s my God-given right.” A policy leader echoed this idea, suggesting that trainees had “their rights restricted or what they perceive as their rights restricted. So when they get the opportunity to make some of their own choices about what they do, we may be getting a rebound effect for tobacco use.”
There were also more elaborate theories regarding “rights” to use tobacco. A TC manager asserted: “You can’t ban smoking in military housing – that’s probably something in the Constitution.” A policy leader said that family military housing could not be made smoke free because “there’s people who are in there that have constitutional rights that aren’t service members”. This policy leader also believed that the number of designated smoking areas provided was determined by “federal law under the Discrimination Act.” If TC policies became too onerous, a nonsmoking enlisted person thought, smokers would fight them collectively, because “we have a zero-tolerance on discrimination and that would be a big discrimination against smokers.” Another policy leader claimed that base newspapers could not ban tobacco ads because “you’ve still got freedom of speech.” One TC manager thought it might be illegal for the service to make smoking status a part of fitness evaluation.
Many TC managers and policy leaders’ comments were ambiguous as to whether they themselves believed that tobacco use was a right; however, they clearly believed that others did and would use this argument to combat proposed TC regulations. “Retirees think it’s their God-given right to buy cigarettes cheap at the commissary,” remarked a TC manager. A policy leader feared “a mass uprising from a hard core group of smokers who say, ‘hey, you’re taking away my rights. How dare you?’” A TC manager said that declaring a tobacco-free installation would be “very difficult because of individual rights, union rights, workers’ rights, all that type of thing.”
The tobacco industry also would bring political pressure to bear on this basis, argued a policy leader. S/he suggested that such action might result in “being called to testify in front of Congress and hav[ing] to defend why you banned smoking from a base and why you’re keeping Johnny from his legal right to smoke.” Another policy leader painted a similar scenario, with an aggrieved service member bringing the issue to government attention, saying, “I think that is one of the biggest barriers” to policy change; “they can get Congressional, if you will.” This fear was not unjustified. Attempts at establishing strong tobacco policies in the military have resulted in Congressional pressure being brought to bear upon policy advocates, including demanding testimony before a hostile House Armed Services Committee.7,8
The belief that tobacco use was a “right” justified seeming inconsistencies in policy, even when the examples given did not support the argument. For example, a policy leader and TC manager both remarked that, like sex, tobacco use could not be regulated because of the primacy of “choice” and “privacy,” although at the time, the “don’t ask, don’t tell” policy prohibiting openly gay people from serving was in effect. As with promoting healthy eating “in a society of choice,” argued a policy leader, the task was balancing encouragement and enforcement, although s/he also acknowledged that the only “right balance” with tobacco was abstinence. In contrast, others pointed out that the services had “kicked people out for becoming obese,” suggesting that food-related policy could be implemented in such a “society of choice.”
A few respondents resisted formulating tobacco use as a “right.” A supervisor observed: “a lot of our rights as military people that we enjoy can be taken from us and supervisors are hesitant to talk about some of these other things because they feel like, ‘I don’t want to get into their business or infringe on their rights,’ but as supervisors that’s part of your job, to make sure that your soldiers are safe and squared away.” The difference between civilian rights and military discipline was noted by a policy leader: “The length of your hair, how you wear it. You have to wear the uniform a certain way. There are all kinds of inalienable rights that we control. This is just another one.” Consideration of the comparative value and difficulty of enforcing policies restricting behaviors and activities much less damaging to health and military fitness was rare, however.
Discipline
A number of respondents suggested that strong TC policies were unworkable in the military context. Numerous enlisted personnel, asked to assess what approaches might most effectively encourage quitting, offered comments expressing a sense that such efforts would be futile: “you really can’t force anybody to do anything unless they want to.” Enlisted personnel and policy leaders also noted that tobacco use was an addiction, and “you can’t order somebody not to do it.” More vaguely, a TC manager declared that some policies, such as prohibiting smoking in housing, in uniform, or on the installation, were unlikely to be supported by leadership because “I don’t think the troops would go for it at all.”
Some respondents cited enforcement issues as seemingly insurmountable. Policy proposals that were declared unlikely to be supported because of enforcement issues included smoke-free military housing, making smoking status a part of fitness score, smoke-free installations, and limiting employees to two daily smoke breaks a day.15
All types of respondents predicted widespread and sometimes elaborate resistance to strong TC measures, such as prohibiting smoking in uniform or on base or post. A supervisor said, “If they tell us no more smoking in uniforms somebody would just walk down by a tree and have a cigarette.” Enlisted smokers also asserted that they would “find somewhere else to smoke,” such as their houses or cars. Respondents suggested that both discipline and productivity would suffer as service members attempted to change out of their uniforms or drive off base for smoking breaks. An enlisted member thought that smokers would “get hostile” and “get themselves in trouble by going underground” to smoke. Enforcement of a tobacco-free military, a few suggested, would harm recruitment and retention: “when you push soldiers that smoke to the point that they are not able to smoke, it’s time to get out.” An enlisted nonsmoker agreed, predicting that with such policies, “25 to 30% of the military is going to be gone.”
Other policies were described as failures because they did not achieve 100% compliance, justifying a similar prediction of “failure” for TC policies. For example, one enlisted person reported: “they tried to illegalize [sic] alcohol, and that did not work at all.” A supervisor noted that “drugs are illegal [but] there are still soldiers doing drugs,” and a TC manager cited the example of people smoking during basic training, even though it was prohibited.
Despite these gloomy predictions, some thought policy changes were possible because of the tradition of military discipline. “In the military,” noted a supervisor, “you’re trained to follow orders and if someone said, ‘no, you can’t take a smoke break,’ then that would eliminate smoking throughout the day and people would really cut down.” Similarly, a policy leader thought that the biggest strength the military had was that “they’re in uniform and you set guidance, set policy and set roles. Because you could say ‘Guess what? No tobacco in uniform.’ It’s hard to say that to the civilian population.”
Policy leaders more frequently endorsed the idea that strong TC policy implementation was possible, but emphasized that orders had to come from the top echelon of command at service or DoD levels. One commented that in an era of budget cuts, senior staff should prioritize making the most of available resources, including the health of service members. “Part of that is banning tobacco use in any form while in uniform and while on installations,” s/he said. “While that won’t completely eradicate tobacco use, it will tremendously change the environmental piece and the outlook.” Another suggested that what was needed was “a wonderfully explicit and to the point – one page – briefing package that goes out to all leaders that says, ‘this is how the military … will benefit from tobacco use going away … this is what’s going to happen, folks, get with the program.’” If such a directive were sent from “the senior leadership of the [service], then it flows downhill from there.”
The Civilian Problem
Even if military discipline could address tobacco among enlistees, TC managers and policy leaders suggested that a stumbling block to effective TC was the presence of civilians on military installations. Several civilian populations were mentioned, including retirees, clinic patients, and families of service members, but most frequently civil service employees and their unions.
Enforcement
Policy leaders and TC managers asserted that there was no authority that could compel civilian employee compliance with TC policies. A policy leader said that current installation policies were enforced for active duty members, but not for civilians because “There’s no leverage. Somebody might say something, but so what if they do?” A TC manager said there was “debate on who should be the one to go out there” and tell smoking civilians to go to smoking areas. Others also cited a lack of control over civilian behavior. A TC manager said that “contractors and civilians feel that it’s their right to smoke, and they’re not [service members], so why should they have to follow the same rules as active duty would?” However, another TC manager said that if rules about smoking were not followed, “normally our Inspector General department or Staff Judge Advocate get involved. We have done things to the point of even doing the formal reprimand to individuals who will not abide by the policy, whether it be an active duty or civilian individual,” suggesting variation in how the issue of civilian discipline was addressed.
Policy Development
On an institutional level, respondents said that employee unions had either bargained for smoke breaks or smoking areas, or that they would object to any changes in that regard. A policy leader said that it was the line leadership and the unions that “ultimately have the influence over what’s in our policy.” Another agreed: “for every person in uniform, there are ten civilians in our military now. So your unions are a hell of a lot more powerful than the common perception.” This situation, said a TC manager, made the idea of a tobacco-free base “something a lot of commanders don’t want to touch.”
In this context, restricting the number of smoke breaks in the duty day often was considered unachievable. A policy leader explained that “for most places, it’s written in the contract that they will have a morning and afternoon break,” but s/he also noted that it was normal for many more than two to be taken. To restrict active duty personnel more than these contractual obligations required would mean having two sets of rules. A TC manager explained that “when the union gets involved and says that civilians can [take breaks], then it’s hard to tell the active duty that they can’t do it.” However, another TC manager thought that even if civilians’ breaks were restricted, it was “pretty unlikely” that active duty personnel would be similarly constrained. This suggests that it was not the union rules or the complications of having two sets of rules that were interfering with change.
The findings of this study suggest that the military’s apparent inability to implement strong TC policies is sustained by a kind of “tobacco exceptionalism”16 that dominated discussions, even when it clearly contradicted military principles. For instance, the idea that “you can’t force someone” to do something they don’t want to do is difficult to reconcile with an institution in which people routinely receive orders to perform difficult or dangerous tasks, which they are expected to obey even if they disagree with or do not understand the rationale for them. “Wanting” to smoke is apparently of a different order than, say, wanting to chew gum (which is forbidden in uniform), grow one’s hair long, or stay in a place of relative safety.
Similarly, talk of tobacco policy provoked many mentions of the “rights” such policies would supposedly violate. Courts have consistently ruled that there is no right to smoke17; even if there were, military discipline routinely eliminates many “rights” taken for granted in civilian life, as a few respondents noted. “Regulating private behavior” also came up as a problematic aspect of TC policy, although the military regulates members’ weight and, until very recently, the gender of their sexual partners.
Tobacco use also superseded other normative ideas about discipline. Respondents predicted that attempts to prevent tobacco use would lead to widespread flouting of rules, such as leaving the post or base in order to smoke. (Similar arguments were used by tobacco industry supporters in Congress when the Navy attempted to establish smoke-free ships.18) Discipline also came into play when discussing civilians; respondents frequently believed that the military had little authority over civilian employees. However, widespread resistance has not been a problem at the numerous institutions (e.g., workplaces, hospitals, and universities) that have gone entirely smoke-free, despite the presence of many unionized employees. Numerous Navy Medical Treatment Facilities now have tobacco-free campuses, including NH 29 Palms, USNH Rota (Spain), and NHC Great Lakes.19 Some unions now support TC policies to protect members’ health.20,21 Respondents also suggested that it would be problematic to have different rules for military personnel and civilians, although there are already at least some rules (e.g., wearing uniforms) that are different for military and civilian personnel. In addition, in civilian life, employers routinely limit the number and length of workers’ breaks without widespread disciplinary issues.
Tobacco use is embedded in some military traditions, including the “smoke break.” In this study, respondents asserted that “smoke breaks” could not be limited, although some said the problem was enforcing such a rule for military personnel and others said it was enforcement for civilians. Civilian unions also were said to have bargained for smoke breaks, which therefore could not be denied. Labor contracts guarantee the breaks, not the smoking (although contracts may specify the location of smoking areas); the association between the two is emphasized by their conceptual elision by respondents.
There are many different arguments against any policy change; whether those arguments are considered valid is a matter of perspective. For instance, an opponent may argue that the problem being addressed by the policy is unimportant, or that the policy would be unfair, ineffective, too expensive, or prone to producing unintended consequences. Participants in this study did not make these arguments. A few participants mentioned past experience and future likelihood of Congressional objection to stronger military TC. However, most did not refer to such specific problems. Rather, they essentially argued that the military had no authority to implement strong TC policies or prohibit the use of tobacco altogether, and that if it tried to do so, the very character and discipline of the military would be put at risk. This belief, suggesting that tobacco use is essential to the military, is fundamentally at odds with both the health impact of tobacco use on military personnel and the reality of military discipline.
In bringing up the “right” to smoke, participants invoked the Constitution (or God), suggesting a lack of legal authority by the military or any other individual or body, except under the most extraordinary circumstances. References to civilians essentially asserted that the military was contractually obligated to accommodate smoking. Remarks about discipline claimed that service members “could not” be ordered not to use tobacco, and that they “would not” obey such regulations. Yet the military controls, or attempts to control, nearly every aspect of its members’ lives, often for health reasons (Table III). That tobacco remains an exception to ordinary military discipline and regulation suggests that reaching the IOM goal of a tobacco-free military will require exposing these contradictions and reasserting the military’s legitimate authority to regulate behaviors that affect troop performance and discipline.
TABLE III
TABLE III
Summary of Conclusions
In the civilian world, there have been great changes in attitudes toward tobacco use in the last 25 years, as people come to understand it as an addiction and a health hazard, not a “freedom” or a “right.” These shifts have not largely permeated the military approach to TC. Tobacco use is a waste of resources, a detriment to readiness, and a disservice to those in uniform, no more “special” than drunk driving.
No further research is required to establish that tobacco use impairs military readiness and increases costs,2225 that tobacco use damages health in both short- and long-term contexts,2629 or that tobacco has long been a difficult issue for the military because of industry lobbying and political pressures.1,7,18,30,31 What is lacking is political will and the belief among military authorities that something can and must be done. Research is needed, therefore, on how to move military TC beyond tobacco “exceptionalism” toward policies more consistent with the military’s approach to other threats to the health and readiness of its personnel.
Every TC policy ever achieved was first thought to be impossible, and was initially met with similar reasons why it “couldn’t” be done. Few would have dreamed only a few years back, for example, that pubs in Ireland would ever be smoke-free.32 The military, Congress, and the President should re-evaluate the “can’ts” that have prevented effective action, and act to regulate and eventually abolish tobacco use in the armed forces. The civilian public health sector should actively support this reasonable goal, which would prevent suffering, save lives and tax dollars, and increase the readiness of military forces.
Acknowledgments
This research was supported by NIH grant CA109153 (R.E. Malone, PhD, Principal Investigator) and the American Legacy Foundation (C. Keith Haddock, PhD, Principal Investigator).
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