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Smoking impairs the readiness and performance of military personnel, yet congressional opposition has thwarted military tobacco control initiatives. Involvement of civilian organizations might alter this political dynamic.
We interviewed 13 leaders of national civilian public health and tobacco control organizations to explore their perspectives on military tobacco control, inductively analyzing data for themes. Leaders believed that military tobacco use was problematic but lacked specific knowledge. Most supported smoke-free policies and prohibiting smoking in uniform; however, they opposed banning tobacco use, arguing that it would violate smokers’ rights. Most leaders inappropriately applied civilian models of policy development to the military context.
A tobacco-free military is unlikely to be achieved without military–civilian partnerships that include educating civilian health leaders about military policy development and implementation.
As of July 2011, There Were 1 434 312 active-duty United States military personnel.1 In 2008, 34% of personnel surveyed had smoked cigarettes in the past 30 days,2 a smoking rate that exceeds the overall US civilian population rate (20.6%).3 Smokeless and polytobacco use are common.4
Smokers in the military have lower levels of physical fitness than nonsmokers,5, 6 limiting their ability to fulfill their duties. Exposure to primary7, 8 and secondhand9 smoke impairs wound healing.10 Smokers are at increased risk for training injuries11, 12 and are more likely to be discharged prematurely. 13 Approximately $346 million is lost annually to productivity decrements associated with smoking in the military, and smoking-related medical care costs the Department of Defense $584 million annually.14 A recent Institute of Medicine review of the impact of tobacco use on military personnel and veterans recommended eliminating tobacco use in the armed forces.15
In the civilian world, reduced smoking prevalence has accompanied aggressive policy change. In the military, however, cigarettes are sold tax-free,16 tobacco use is prohibited only during basic training,17 and ships are required to have smoking areas.18 Proposed military tobacco control policies have been withdrawn or weakened as a result of political pressure. For example, after tobacco industry lobbying of Congress, the US Army’s first tobacco control plan was weakened.19 Members of Congress and the Department of Defense attempted to raise commissary cigarette prices for more than a decade, partially succeeding only over the objections of members of the House Armed Services Committee.16 These findings suggest that industry-instigated political opposition is a primary obstacle to effective tobacco control in the military.
Although military personnel cannot lobby for change, civilian public health organizations could promote military tobacco control by countering tobacco industry influence in Congress. However, few civilian groups have been active in this area. We explored public health and tobacco control leaders’ perspectives on tobacco use among military personnel and military tobacco control policy.
Drawing on personal knowledge and Internet searches, we identified a purposive sample of 17 major national public health and tobacco control organizations: 6 national tobacco control---focused (TC) organizations and networks, 4 national public health (PH) organizations, 2 organizations of government officials, and 5 physician medical specialty (MS) organizations. Two of these organizations focused on minority populations. Organization leaders were contacted by letter and then via follow-up telephone calls. Three health care specialty professional organizations and 2 organizations of government officials declined to participate.
The 13 interviewees (from 12 different organizations) were 7 executive directors, 4 other directors, and 2 program administrators. Participants’ organizational tenure was 2 to 30 years (average = 12.5 years). Semistructured telephone interviews 15 to 30 minutes in duration were conducted by the first author (E. A. S.); interviews were recorded and transcribed. Interviews explored participants’ general knowledge of and thoughts about tobacco and the military; participants were then asked whether they agreed or disagreed with 4 specific policy options. Data were analyzed qualitatively by coding for recurrent themes and iteratively reviewing clusters of coded text. In order to maintain anonymity, participants are hereafter referred to by organization type and number (PH1, PH2, TC1, TC2, etc.).
Themes that arose from the interviews included ideas about the “right” to smoke, tobacco use as a stress management tool, spontaneous policy suggestions, and comparisons between the military and other tobacco control arenas.
Most participants believed that military tobacco use was a problem, but many felt, as one respondent put it, that they lacked “real knowledge” about it (PH3). Most noted that tobacco use prevalence was higher among military than civilian populations. Several respondents remarked on changes in military policy, recalling when cigarettes were distributed free, physical training was interrupted for smoking breaks, and military hospitals sold cigarettes. They also described tobacco use as a continuing “part of military culture” (TC6).
Many respondents had not considered how tobacco use affected the military. Asked whether tobacco use impaired the ability of the military to achieve its mission, most leaders extrapolated from knowledge about the consequences of tobacco use. One respondent commented:
even smoking for healthy people degrades your performance. I don’t necessarily know that I can quote the evidence for that, but I believe that to be true (PH2).
Another respondent said, “It would stand to reason that … use of tobacco [in the military means that] folks will not be able to perform optimally” (TC3). Only 2 of the respondents mentioned consequences of smoking particularly significant for service members: impaired wound healing (TC5), propensity for musculoskeletal injuries, and premature discharge from service (TC1). Public health advocates do not “have the science yet to know how [badly tobacco use] degrades your performance,” one leader asserted (PH2).
Most respondents knew little about existing military tobacco control policies. The most common policy improvements mentioned were increased cessation services (MS1, PH3, PH4, TC3, TC5, TC6) and expanded smoke-free policies, such as for barracks and submarines (TC3, TC4). Respondents also mentioned continued sale of cigarettes at discounted prices in military stores (PH4, TC1, TC4). Many interviewees believed that adherence to policies depended on local command (PH2, PH3, PH4, TC1, TC4, TC5).
Most leaders supported strengthening military tobacco control policies but viewed policy change as internal to the military, invoking the authority of the Joint Chiefs of Staff (TC1, TC4), the secretary of defense (PH3), or military senior leadership (MS2). Two of the TC respondents suggested that the president, as commander-in-chief, should be involved (TC2, TC4). The role of Congress was rarely mentioned, although one leader thought that Congress could counter the “people in the military … opposed to change” (PH4). This respondent continued with an analogy to the repeal of the “don’t ask, don’t tell” policy (prohibiting service by gay people) that explicitly referenced the political nature of military policymaking:
the military was … against it while the public was more in favor…. And then over time they were forced to change…. May be we need something like that
Most of the respondents had no specific ideas about civilian involvement in military policy, although 2 respondents thought that the Department of Veterans Affairs and veterans’ groups could educate the public (TC5, TC6). Organizations could offer expert advice, such as providing “the rationale, the education, the experience” about policy proposals (PH3, TC3). But some seemed reluctant; one leader thought that the military should “champion that effort themselves,” because that “would be the most effective” strategy (TC3). Civilian involvement might be rejected, another respondent suggested, because “the hard-nosed military people would just dismiss them as nannies” (PH3). Another believed that the military was capable of determining its own course, saying that
if something degrades performance, boy, they hop on it like a laser … so I’m comfortable and confident that should they choose to do that, it will get done (PH2).
Some of the civilian health leaders regarded taking up military tobacco control issues as risky. Their lack of knowledge about the impact of tobacco use on military readiness contributed to this feeling. One respondent remarked that supporting some of the specific policies on which leaders were asked to comment might endanger the organization’s credibility without “evidence that this will really help people stop smoking” (PH1). According to 2 respondents, being perceived as “non---evidence-based” would reduce the organization’s ability to achieve its goals (PH1, PH2). One respondent mentioned a law prohibiting tobacco products from being sent to deployed military personnel. In discussions with other organizations, the respondent said, it was “decided that this was not the place to take a stand”; “definite backlash” would result if an organization were perceived to be saying that “our boys in combat shouldn’t get tobacco” (PH3).
Leaders frequently reified the notion of a “right to smoke.” Two suggested that prohibiting smoking would be “a violation of people’s rights” (MS2, TC2). Another asserted, “I never want to get into a situation where you’re trying to dictate the rights of a person” (TC3). Using tobacco was “legal, so I don’t think you can prohibit them from smoking,” another respondent observed (PH2). Several referenced the “choice” to use tobacco in this context, with one respondent saying that “individuals have to make their own decisions” (PH1). Only a few explicitly rejected this construction, with one making reference to “the tobacco industry seeking to cloak themselves in the flag” by having veterans oppose clean indoor air laws with the claim that they “fought … for our right to choose” (TC5).
Interviewees recognized that military enlistment was a risk factor for tobacco use initiation; almost half noted without prompting that many people started smoking after enlistment. One respondent commented on the “subtle encouragement” of low tobacco prices and the example set by leaders smoking (PH4). Another remarked that the military “facilitated addiction to nicotine” (PH1). One leader mentioned the “right to quit” (TC5), but none of the respondents discussed young recruits’ right not to be influenced to start using tobacco.
Leaders were concerned about depriving service members of the stress relief tobacco presumably provided, particularly in combat, which one thought “probably results in more people smoking” (PH2). Tobacco use was described by another respondent as “a coping mechanism” used to “calm the nerves” (TC3). Nicotine was also used by personnel to help them stay awake, according to another interviewee, who suggested that “the nature of the work of the military promotes smoking” (TC1). Two other respondents noted that cessation would be harder amid the stresses of deployment (PH1, PH3).
Prohibiting tobacco use in a combat zone might “degrade performance,” one leader worried (PH2). Several respondents believed that even if tobacco use were otherwise banned, it might be allowed during deployment. Hesitancy to support strong tobacco control in combat situations also came from a sense that civilians were not in a position to dictate; as one interviewee remarked, “if troops are out there facing death … who’s going to tell them not to [smoke]?” (TC1). Another respondent suggested, “you don’t want someone backing you up in a life and death situation who is going through withdrawal” (PH3). However, one interviewee noted the irony of this position:
the commanders in the field feel that encouraging people to [quit] will … affect military readiness negatively, as opposed [to] never having them start in the first place (PH4).
When asked about performance, several respondents applied different criteria than when they discussed combat (which we did not specifically ask about). Discussing combat evoked emotional responses, rendering the performance issue secondary. Because secondhand smoke “creates environmental hazards to others,” one leader said, it “absolutely degrades performance, and therefore it degrades the military mission” (PH2). This respondent then wondered whether “cessation in a combat zone, does that degrade performance, [when] the greater risk is … getting shot?” Another respondent noted that military personnel needed “all of their physical abilities,” which, for smokers, would be “impaired” (TC1).
In discussions of combat, however, the focus was on tobacco use as “a way of bonding” (TC1). Tobacco use was “counter to physical readiness, there’s no question,” noted one respondent (PH3), but this respondent also conjectured that deployed troops might be saying “I can’t … ride a Humvee in Afghanistan if I don’t have my nicotine” and that combat put them in a position to “make the argument that I have to have the nicotine to perform well.” Consideration of the combat situation led leaders to shift the focus from tobacco to nicotine, from the physical to the psychological, whether about smoking’s perceived benefits or problems associated with deprivation.
Although respondents generally supported smoke-free rules, the approaches they most often suggested were cessation, education, and raising prices in military stores. According to one respondent, lower prices created a “subtle encouragement to smoke” (PH4); another said they sent a “terribly mixed message” about tobacco use (PH3). One respondent said that low prices meant “the tobacco industry is using the US military as a drug purveyor, and that seems unconscionable” (PH1). No one suggested that raising prices might be desirable but infeasible. Rather, such a policy was described as a “more subtle way” (PH2) to address tobacco, or a “first step,” in that smoke-free policies “might be harder to [implement" (PH4). Leaders assumed that changing prices was within the military’s power; no one mentioned the necessity of obtaining congressional approval.
Respondents also suggested improving education about tobacco and access to cessation help, policies that would “persuad[e] the individuals” (PH1). Leaders acknowledged military authority but suggested only that it be used for persuasion. One noted, “You can tell a soldier, you will not smoke with your kids in the car. You can’t do that in the civilian world” (PH2) Yet this same respondent believed that the military could not prohibit service members from using tobacco, describing the military’s ability to implement policy “by fiat” but proposing only “educational activities.”
Military personnel were compared with others in highly structured institutions. For instance, one leader compared a combat zone exception for using tobacco to a hospital going smoke-free, “except in the mental health ward” (PH2). Another compared the regimented atmosphere of military bases with prisons: “they have to provide other means to let off steam” (TC1).
Leaders supported a democratic, nonhierarchical approach to tobacco control. One rejected the idea of mandating smoke-free ships and bases because it would not be “a democratic approach” (PH1). This respondent also believed that such policies would fail because “grownups don’t like to be told what to do,” comparing them with a wife who “nags her husband about eating that next piece of pie.” Another respondent felt that strong smoke-free policies would require “a collaborative process … so it’s not a top-down thing … which can lead to resentment” (TC5).
Asked about 4 specific policy measures, most leaders were supportive of 3: prohibiting smoking on ships, smoking on military bases, and smoking while in uniform.
Many respondents who supported smoke-free ships (12 of the 13 respondents overall) justified this policy by describing ships as enclosed spaces. Smoking on ships was thus “like smoking indoors” (PH2), threatening the health of nonsmokers. Two respondents also said that ships’ outdoor areas should be smoke-free (TC2, TC4). A few respondents suggested that smoke-free ships would encourage cessation (PH4, TC1, TC4). Other justifications included reducing maintenance costs (TC3) and eliminating fire hazards (MS2). One respondent argued that “if soldiers [sic] can go off to work on [smoke-free] submarines for months at a time, then there’s no reason they can’t … on ships” (TC4). Some leaders were concerned about implementing policy “precipitously,” wishing to avoid resistance (PH3) and minimize withdrawal problems (TC6). One respondent was reluctant to state a position, saying “if it were possible on ships to [keep] smoke away from all the other individuals … we wouldn’t necessarily take a position against that” (PH1).
The idea of smoke-free bases (supported by 11 of the 13 respondents) was more problematic for some. Although numerous interviewees thought bases definitely should be smoke-free, including outdoors, more hesitation and caveats were expressed. One leader commented that making a base smoke-free was “like saying there shouldn’t be smoking in a city,” which was “not a realistic position” (PH1). For others, the “most sensitive” issue was requiring single-family homes on bases to be smoke-free (TC2, TC4).
Prohibiting smoking in uniform was supported by 7 of the 13 interviewees. Of these 7 respondents, 6 (along with 3 respondents who did not support the policy) referenced the image military smokers projected. Smoking in uniform was a “bad example” (TC1, TC3) that would “detract from the general feeling of the populace about military individuals” (MS1) and “ruins the whole look” (PH4). Only 3 respondents (including one who did not support the policy) mentioned readiness in this context (PH2, TC1, TC5).
Those not supporting the policy found it unfeasible for 2 reasons. A pair of respondents noted that smoking was “a legal activity” that could not be prohibited (PH2, TC4). The others found the policy extreme. One was concerned about service members who “are in uniform, practically speaking, for … months at a time” and would have no opportunity to smoke (PH1). Another rejected it because “we haven’t made the politicians do that, even our president” (MS2) suggesting that the policy might be unfair.
Asked whether they supported the proposal that “service members should not be allowed to smoke at all,” most of the leaders (8 of 13) did not. Several thought it impossible or unenforceable. Some believed that “prohibitions tend not to work” (PH1) or that such a policy could cause “overreaction” that might threaten other tobacco control policies (PH4, TC3). Several leaders explicitly invoked service members’ “right” to smoke. For example, one said that “smoker-free workplaces [violate] people’s rights” (TC2). Another cited “the free will to do whatever you want” (TC3). Two respondents who opposed the policy were concerned that it could impair recruitment (PH1, PH3).
Tobacco’s impact on military readiness did not affect leaders’ evaluation of the available solutions. For instance, one leader said that smoking would “affect [service members’] ability to do their job at even a young age” yet rejected its prohibition as “too Big Brother” (MS2). Another remarked that “some people … may actually have their heart attack in close proximity” to smoke exposure but rejected prohibiting smoking: “I don’t think that we have that kind of control over the activities of people in the military” (PH2).
Such a policy was too sweeping, leaders thought. One believed “strongly that smoking inhibits combat readiness, but I don’t know of any evidence that prohibiting soldiers from smoking altogether is necessary” (TC4). Another leader tempered rejection of a smoking ban by adding that if “it degrades their performance it ought to be a factor in their performance evaluation” (PH2). For these respondents, knowledge that tobacco use impaired military readiness did not justify a general solution; rather, each individual would have to be evaluated.
The military is a highly regimented institution that controls many things (e.g., haircut, weight, physical fitness) civilians choose for themselves. Being reminded of this did not change respondents’ minds. For example, one respondent conceded that military personnel had fewer rights than civilians but disagreed with even those restrictions, essentially dismissing the system of military discipline. Another said that the difference between a policy forbidding smoking and existing restrictions on military personnel was that individuals had chosen to accept the status quo, but “you do not make a choice to join the military to choose if you smoke or not” (TC3) That is, personnel had enlisted with knowledge of current rules, but prohibition of tobacco use was not one of them. This logic would prevent many military policy changes.
A few leaders supported the idea of a tobacco-free military; one suggested that “smokers should not be recruited” (MS1). Others thought that such a policy could be implemented gradually; as one TC leader said: “it would take time to get there, but … that’s what it [should mean] to be in the military, that you’re not a smoker” (TC6).
Public health and tobacco control leaders we interviewed had many gaps in their understanding of military systems and policies. Until these gaps are addressed, civilian leaders are unlikely to become effective advocates for stronger military tobacco control. Civilian leaders’ failure to account for the special circumstances of the military led them to adopt an approach of “tobacco exceptionalism” 20 in which tobacco could not be regulated in the same way as other harmful products. This approach, questionable in the civilian world, has led to the acceptance of continued promotion of a product that, were it newly introduced today, would likely be prohibited.21 In the regimented military context, however, this stance is even more inappropriate. The military takes strong action to protect personnel; for example, the sale of ephedra on military bases was prohibited years before the Food and Drug Administration acted to ban it.22
Leaders had little knowledge of the impact of military tobacco use; they had only a vague belief that it harmed the military mission. They also endorsed the idea of tobacco as a “stress reliever,” although it likely primarily relieves the stress of nicotine withdrawal.23–25 This inhibited them from conceptualizing smoking as a systemic problem for the military.
The shaping of military policy through tobacco industry influence on Congress was not well understood. Consequently, leaders regarded the military as independent, immune from or resistant to efforts of civilian organizations. Only a few mentioned that authorities such as Congress and the president might be significant influencers. Contrary to history,16, 19 some believed that Congress was more progressive on tobacco control than the military itself.
Leaders did not understand military discipline. Some recognized the military’s authoritarian nature, but few considered how it affected policy development and implementation. Leaders extrapolated from civilian examples of policy adoption, in which multiple constituencies must be persuaded to support new regulations. Few acknowledged that, in the military, policy change is implemented through orders rather than negotiation.
In addition, leaders did not consider the military’s mission. In evaluating policies, they focused on the harm secondhand smoke posed to nonsmokers. However, in the military, smokers’ reduced physical fitness also may pose a threat to others who must depend on them. Some made comparisons with populations in other controlled institutions, such as prisoners or psychiatric patients, but firefighters represent a better comparison. As is the case with military personnel, firefighters must maintain peak physical fitness for their own and their fellow workers’ safety. In addition, many states have “presumption” laws according to which diseases contracted by firefighters, such as lung cancer, are presumed to be job-related for insurance and compensation purposes. For all of these reasons, firefighters are often prohibited from smoking at all. (To the dismay of many veterans’ organizations, smoking-related disability is not considered “service related” for purposes of defining pension benefits, even if the veteran began smoking during service.26)
Contrary to basic public health tenets, leaders focused on individuals, rather than the population, when contemplating military tobacco policy. Although admitting that smoking impairs performance, leaders suggested individual assessments rather than population-level preventive measures. This focus also emerged in leaders’ preference for education and cessation over policies mandating behavior.
Most surprisingly, many leaders invoked a right to use tobacco. Banning tobacco use among service members was rejected, with about half of the leaders concerned that this would contravene service members’ rights. The “right to smoke” is a formulation that the tobacco industry has frequently promoted27, 28; however, courts have consistently ruled that there is no such right.29
Few civilian leaders could envision a tobacco-free military because they viewed tobacco use as a coping mechanism for the stresses of military life. Banning smoking altogether was unacceptable, yet it was permissible to place nonsmokers at increased risks of initiation as well as risks resulting from smokers’ reduced fitness. Although leaders likely would support the goal of a tobacco-free military in principle, they hesitated to endorse the necessary policies.
Finally, leaders saw military tobacco control as a problematic issue for their organizations; involvement might result in criticism from both the military (for being “nannies”) and the public (for seeking to “deprive” service members). Partnerships with military tobacco control proponents and veterans’ groups might help in addressing civilian public health leaders’ knowledge gaps regarding tobacco control in the military and the political risks involved in tackling it.
Probably on the basis of their own experiences, public health and tobacco control leaders applied civilian assumptions about policy development to the military context. Banning tobacco use evoked the tobacco control mantra that the problem is “the smoke, not the smoker,” and the conviction that policies should protect nonsmokers rather than compel abstention. Leaders disregarded the fact that, in the military, peak physical health is crucial, and members are accustomed to following orders.
Leaders also adopted the approach, favored by the tobacco industry, of focusing on harm to individuals rather than justifying universal policy to prevent harm. However, the military often makes policy on the latter basis: the services have regulations about weight, even though individuals with similar body mass indices might have different physical abilities.
If civilian public health groups are to aid in improving military tobacco control, they should replace tobacco exceptionalism with “military exceptionalism”—that is, understanding that the regulatory apparatus and mission of the military mean that stricter policy is both possible and justified. In the military context, both the smoke and the smoker are problematic for the lives and health of those around them. The budgetary consequences for the Department of Defense and the Department of Veterans Affairs, which ultimately provide health care for many tobacco-sickened veterans, are considerable. The military’s authority over its personnel obligates minimizing unnecessary health risks and providing optimal solutions for problems such as the stress of combat. Tobacco control policies should be evaluated with standards appropriate to the policy context, aiming for a tobacco-free military.
This study was supported by the National Cancer Institute (study R01 CA157014). Ruth E. Malone owns 1 share each of Philip Morris USA, Philip Morris International, and Reynolds American stock for research and advocacy purposes.
Human Participant Protection This study was approved by the Committee on Human Research of the University of California, San Francisco.
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ContributorsE. A. Smith conducted interviews, analyzed the data, and drafted the article. R. E. Malone originated the study, reviewed the data, and contributed to subsequent drafts of the article.