Military Tobacco Policies: The Good, The Bad, and The Ugly

Abstract

The United States military has the legacy of a pro-tobacco culture and still has prevalence rates of tobacco use that are higher than their civilian counterparts. One tactic for decreasing use and the subsequent health problems is through effective tobacco control policies. We collected available tobacco control policies from all four branches of the military and, through qualitative analysis, identified policies that were unique either as providing more or less detail and restriction than peer group policies. Best and worst practice policies in the areas of enforcement, smoking cessation, smokeless tobacco use, environmental tobacco smoke, framing tobacco as non-normative, designated tobacco use areas, and monitoring of tobacco use are presented. Because policy making can be an effective tool for improving the health of military members, understanding what policy components are comparatively positive or negative is an important tool for health advocates both in the military and civilian settings.

INTRODUCTION

Tobacco use in the U.S. military is more prevalent than among gender- and age-matched civilians and this has been attributed to aspects of military culture that promote it.^1–6 For example, Bray et al¹ reported that 15% of Department of Defense (DoD) personnel started smoking after joining the military and that 30% of current smokers reported initiating tobacco use after joining the military. The DoD has estimated in 1996 that the cost of tobacco to the military is approximately $1 billion a year.⁷

One challenge to addressing tobacco use among military members is the long history of pro-tobacco culture.^8,9 However, as the negative health and readiness effects of tobacco use have become better known, the military, through policy initiatives, has substantially reduced tobacco use. One of the policy initiatives that the military adopted to discourage smoking among its personnel is a comprehensive ban on tobacco use during basic military training (BMT).¹⁰ For example, a longitudinal study involving 449 U.S. Navy recruits¹¹ found that the prohibitions on smoking during BMT assisted more recruits to stop their tobacco use than would be expected without the ban. In their study, 40% and 19% of those reporting that they were current smokers changed their classification to either former smoker at the end of BMT and or former smokers at the 1-year follow-up, respectively.¹¹

Other policy initiatives that have been enacted to reduce tobacco use include the Air Force implementing tobacco bans during technical school training (AETC Instruction 36-2216, June 16, 2004) and the Defense Department implementing DoD Instruction 1010.15 Smoke-Free Workplace (DoD 1010.15, 1994). This instruction became effective on March 7, 1994 and prohibits smoking worldwide in all DoD workplaces. This ban includes all buildings and vehicles owned by the DoD. However, it still allowed, in some instances, smoking in military barracks, family housing, prison quarters, clubs, recreational areas, and restaurants. Regardless, the implementation of DoD 1010.15 essentially gave the DoD the “distinction of being the largest employer in the United States with a worksite ban on tobacco use that prohibits smoking within all its buildings.”⁸ Despite these progressive policy attempts to limit when and where DoD personnel can smoke, other policies exist that seem to contradict the discouraging messages.

Tobacco control policies can have the beneficial effects of encouraging cessation and reducing consumption among current smokers and reducing exposure to environmental tobacco smoke (ETS) among non-smokers. For the present study, we conducted a comprehensive examination of current U.S. military tobacco control policies. Given the high rates of use among military members when compared to civilians, the long and notorious history of tobacco propaganda in the military^5,6 and the unique characteristic of being a population that has to follow orders in the form of directives, regulations, and instructions, the military is an ideal group for policy interventions. By identifying the strengths and, more importantly, the weaknesses of current military tobacco control policies, the results of this study can assist the military in further reducing tobacco consumption among its ranks.

METHODS

This study used a mixed methods approach involving both qualitative and quantitative components to evaluate tobacco policy documents from all four service branches of the U.S. military and the DoD. This research was approved by the Institutional Review Boards from all investigator institutions and by the TRICARE Management Activity Institutional Review Board Program Office. We collected a total of 305 documents from 162 different military sources across all four military branches and the DoD and 218 qualified as a policy (i.e., they addressed a topic relevant to tobacco control) (see Hoffman et al¹² for details). This included each of the overarching policies as well as all supplements at Command and installation levels.

NVivo was used for text coding and to facilitate organization, retrieval, and systemic comparison of the data.¹³ Policies were coded by two different members of the investigative team and audited by a third member to ensure coding accuracy.¹⁴ Policies were highlighted that were exceptional or unusual in any way and flagged as either “best practices” or “worst practices.” A precedent, such as a policy with a total prohibition on tobacco use, is important to evaluate and to make available to other installations to assist them in the development of similar policies. Specific areas examined for this study were clean indoor air, smoking areas, smokeless tobacco, and prevention and cessation programs. For example, when a policy was found that addressed any one of these domains when all other policies did not, that became an example of a “best practice.” On the other hand, if all policies addressed one of these domains and then there was one that did not, that was an example of a “worst practice.” Policies were identified both during the coding process and through conversations with military personnel. Detailed description of the data collected and coding is available in Hoffman et al¹² and copies of policies are catalogued and available in searchable form (http://www.ndri.org/ctrs/ibhr/index.html).

RESULTS

Best Practice Examples

Several policies stood out as exceptional or unusual in certain ways (Table I). Of all the overarching policies, the Department of the Navy SECNAV 5100.13E serves as an example of “best practice” for a service-level policy. The SECNAV 5100.13E is its own freestanding independent, 10-page policy with detailed information about expectations around tobacco, as opposed to the Army’s overarching policy which is embedded in a much larger Health Promotion policy.

TABLE I.

Best Practice Policy Examples

Location	Policy	Strength
Navy/Marine	SECNAV 5100.13E	Independent, detailed policy about expectations related to tobacco
Fort Lewis	Regulation No. 1–4	Addressed enforcement
Tinker AFB	Installation Tobacco Use Policy	Addressed enforcement and negative effects of excessive smoke breaks
Altus AFB	Tobacco Use Policy	Designates unit tobacco cessation representatives
Buckley AFB	Tobacco Use Policy	Comprehensive, mandates tobacco cessation classes
Navy/Marine	SECNAV 5100.13E	Addresses smokeless tobacco use
Army Garrison Heidelberg	Smoking Common Areas, Government Quarters	Addresses ETS, supports non-smokers’ rights
Air Force	AFI 40–102	Rights of non-smokers
AFMC	Review and Enforcement Tobacco Control Policies	Standardizes tobacco policies, intent to make tobacco use non-normative
FE Warren AFB	Instruction 40-1	Describes tobacco use as non-normative
Malmstrom AFB	Tobacco Use Policy, SW 00–008	Describes tobacco use as non-normative, base-specific prevalence, adverse health effects, goal of reducing tobacco use
Dover AFB	Supplement to AFI 40–102	Designates all areas as non-tobacco use areas unless designated as a smoking area
Kessler AFB	Supplement to AFI 40–102	Designates Health Promotion Manager as chair of the Tobacco Ad Hoc Committee to provide review and recommend policy

Enforcement

Although few policies addressed the issue of enforcement, Fort Lewis (U.S. Army) stood out by detailing how both Army and civilian personnel employed on its jurisdiction were subject to disciplinary action:

4. ENFORCEMENT. Failure to comply with the provisions of this regulation may subject the military offender to adverse administrative action, and/or criminal punishment under the UCMJ. Violation of these same provisions by civilian employees will be considered as “failure to observe written regulations, orders, rules or procedures” and disciplinary actions will be administered (Department of the Army, Fort Lewis Regulation No. 1–4 (2003); pgs. 2–3)

The tobacco control policy for Tinker Air Force Base also provides an example of a “best practice” on the issue of enforcement. Not only does it address enforcement in a detailed manner and cover civilians and military personnel, but it also is unique in that it cites excessive numbers of smoke breaks during the work day as “driving up the cost of doing business” and “not acceptable.”

Supervisors are responsible for administering/approving smoke breaks prudently. An excessive number of smoke breaks in a work day and smoke breaks of unreasonable duration drive up our cost of doing business and are not acceptable. Supervisors are required to enforce these rules and employees must use self-control in this regard. (Department of the Air Force, Tinker Air Force Base Memorandum For All Supervisors, Installation Tobacco Use Policy (n.d.); pgs. 1–2)

Smoking Cessation Services

Although several policies referenced smoking cessation services, Altus Air Force Base Tobacco Use Policy is unique as it highly encourages each unit commander to designate two smoke-free individuals to become Unit Tobacco Cessation Representatives:

Unit commanders are highly encouraged to provide a minimum of 2 smoke free individuals to become Unit Tobacco Cessation Representatives. These individuals will be trained in tobacco cessation classes offered by Health and Wellness Center and be able to assist those within their unit who are trying to quit and may be requested at times to assist Health and Wellness Center with tobacco cessation classes. (Department of the Air Force, AETC Memorandum For Category “A”, Tobacco Use Policy on Altus Air Force Base (2004); pg. 2)

Another tobacco use policy that serves as an example of a “best practice” is the Buckley Air Force Base Tobacco Use Policy. In addition to its comprehensiveness, it mandates tobacco cessation classes for its members:

All Buckley Air Force in-processing personnel will be briefed on Buckley AFB tobacco policy during their mandatory Total Fitness Enhancement (TFE) briefing. Tobacco users assigned to the 460 ABW and participating tenant units will be identified during the TFE briefing and scheduled to attend a mandatory one-hour “Getting Ready to Quit” tobacco education class. (Department of the Air Force, 460th Air Force Base Wing Memorandum, Buckley Air Force Base Tobacco Use Policy (2003); pg. 2)

Smokeless Tobacco

A policy that serves as a “best practice” for smokeless tobacco is the Navy and Marine Corps SECNAV 5100.13E. This policy is detailed and specifically addresses the negative health consequences of using smokeless tobacco. The policy states:

Tobacco Products. Includes the use of smoking (e.g., cigarettes, cigars, pipes) and smokeless tobacco (e.g., spit, plug, leaf, snuff, dip, chew) …. Additionally, smokeless tobacco residue (from spitting into open containers, waste baskets, or on the ground) presents an unsanitary condition. As saliva is a culture medium for infectious organisms, it poses a risk to those nearby …. Tobacco use in any form is addictive; and no form of tobacco other than cigarettes, including smokeless tobacco, are safe alternatives to cigarettes. The use of smokeless tobacco may cause a number of serious oral health conditions and problems, including cancer of the mouth and gums, periodontitis, tooth loss, and thus loss of medical readiness …. Smokeless Tobacco. Smokeless tobacco is not a safe alternative to smoking. It is no more or less acceptable than smoking. Smokeless tobacco use is only permitted in designated tobacco use areas. (Department of the Navy, Office of the Secretary, SECNAV Instruction 5100.13E, Navy and Marine Corps Tobacco Policy (2008); pgs. 2–4).

Environmental Tobacco Smoke

Policies exist across the services addressing non-smoker rights. For example, Army Garrison Heidelberg submitted a tobacco use policy that opens with a strong statement supporting the rights of the non-smoker over those of the smoker:

To smoke tobacco products is a personal decision, but with the rising concern over secondhand smoke and the impacts on public health, the personal decision to smoke cannot unduly infringe on another’s right to live in a tobacco-free atmosphere. (Department of the Army, U.S. Army Garrison Heidelberg Memorandum for Residents of Government-Controlled Quarters, United States Army Garrison Heidelberg Community Memorandum #10C, Smoking in Common Areas of Government Quarters, (2006); pg. 1)

Further, Air Force Instruction (AFI) 40–102 also offers a clear statement stating the rights of the non-smoker shall prevail when in conflict with those of a smoker:

If the smoke or odor from tobacco seeps from a smoking room into common areas or non smoking rooms, the rights of the nonsmoker will prevail. (Department of the Air Force, Air Force Instruction 40–102, Tobacco Use in the Air Force, pg. 3)

Tobacco Use as Non-normative

The headquarters for the Air Force Material Command (AFMC) in June of 2004 issued a memorandum to all of its bases with the intent of standardizing tobacco use policies. This memorandum states:

Lieutenant General Tex Brown, AF/CVA, requests a review of your tobacco control policies to ensure your policies encourage a tobacco-free lifestyle. This review is due to the continued high tobacco use among our junior airmen. This rate has not declined significantly over the years; and the use of tobacco impacts readiness, productivity, and health …. The main reason junior airmen use tobacco are: (1) they see their mentors, instructors and peers using tobacco, and (2) inconsistent enforcement of rules. The message should be clear at every AFMC base; tobacco use is not the norm in the Air Force and is unhealthy. (Department of the Air Force, Headquarters AFMC Memorandum for ALHQCTR/CC, AFMC WING/CC, ALHQSTAFF, Review and Enforcement of Tobacco Control Policies (2004); pgs. 1–2)

Another example of a policy describing tobacco use as non-normative is found in the FE Warren Air Force Base tobacco control policy. It states “defending America with the most powerful combat ready ICMB force requires this unit to take active steps to limit, decrease, and eventually eliminate tobacco use by its members.” (Department of the Air Force, 90th Space Wing Instruction 40-1, 90th Space Wing Tobacco Use Policy (2003); pg. 1)

An installation-level policy that did an exceptional job portraying the message that tobacco is non-normative is the Malmstrom Air Force Base Tobacco Use Policy which states:

1. Forty years have passed since the first Surgeon General’s report in 1964, the list of diseases and other adverse effects caused by tobacco use continues to expand. Yet, smoking remains the leading preventable cause of death in the USA. Currently, 33% of our team members at Malmstrom AFB use tobacco products. This is the highest percentage in AF Space Command. The 2004 Surgeon General’s report illustrates the harmful impact of smoking on nearly every organ of the body. Smoking causes heart disease, stroke, multiple cancers, respiratory diseases, and other costly illnesses. Non-smokers are subject to similar health problems when exposed to second hand smoke. Smokers who quit will, on average, live longer and enjoy more years of living without a disability. Scientific evidence provides a strong argument for action at all levels of society. We need to motivate Team Malmstrom’s addicted tobacco users to quit. 2. My goal is to reduce tobacco use on this installation by 5 percent each year. Tobacco cessation treatments have been found to be effective and safe. The 341st Medical Group, Health and Wellness Center (HAWC) offers counseling, medication, or a combination of both to inspire and assist all beneficiaries in achieving their tobacco free goals. We want to help you quit. Furthermore, we intend to protect the health of non-tobacco using members by instituting the following policy throughout Malmstrom AFB and the missile complex: (Department of the Air Force, Memorandum For All Team Malmstrom Members, Malmstrom AFB Tobacco Use Policy—SW 00-008, (2004); pg. 1).

This policy provides base-specific prevalence data, states adverse health effects of smoking for both smokers and non-smokers and, and is one of the few documents with a stated goal submitted to our study, provides in writing a goal of reducing tobacco use by 5% each year among its members.

Designated Tobacco Use Areas

An example of a tobacco use policy that serves as a “best practice” in the area of designated tobacco use areas is the Dover Air Force Base Supplement to the AFI 40–102. This policy states:

The Air Force will no longer designate non-tobacco use areas. All areas will be considered tobacco free with the exception of “Designated Tobacco Use Areas.” (Department of the Air Force, Dover Air Force Base Supplement 1 to AFI 40–102, Tobacco Use in the Air Force (2003); pg. 2)

Installation-Level Monitoring of Tobacco Use

Keesler Air Force Base provided an installation-level supplement to the AFI 40–102 that stands out as a “best practice” for placing the Health Promotion Manager in the position of chair to the Tobacco Ad Hoc Committee. This document states:

The Health Promotion Manager will report as a standard agenda item the 81 TRW tobacco use rates at the quarterly Health Promotion Council. The Health Promotion Manager will chair a Tobacco Ad Hoc Committee in order to provide an ongoing review of base-wide tobacco use activity and to recommend policy. (Department of the Air Force, Keesler Air Force Base Supplement 1 to AFI 40–102, Tobacco Use in the Air Force (2002); pg. 2)

Worst Practices

The examination of policies identified several that were unique in their limited tobacco-control impact. Names of individual bases were redacted.

Smoking Cessation Services

An example of a policy that stands out as unique in a negative way is the Smoking Policy of one Army installation where the policy specifically limits access to and treatment options for those wishing to quit use:

Management will offer each Federal employee who smokes and desires to quit a one time smoking cessation class. The Federal employee’s personal physician will determine the course that is most advantageous for successful smoking cessation and will determine if the prescription medication, Welbutrin, is medically sound. This examination is at the employee’s own expense. Occupational Health must authorize the private sector prescriptions for Welbutrin before medication is filled by the WAMC pharmacy. Management will determine the size and length of the class. This one-time class may be during duty time. There will be no charge for the class. Any additional smoking cessation/classes; etc. will be the employee’s personal responsibility.

Smokeless Tobacco

Military tobacco use policies were inconsistent in whether they allowed smokeless tobacco use outside of designated areas. For example, one Marine Corps Base’s Tobacco Use Policy allows smokeless tobacco use inside except in certain situations:

(1) Use of smokeless tobacco is prohibited during briefings, meetings, classes, formations, inspections, and while on watch. (2) Where smokeless tobacco use is permitted, tobacco spit shall be held in containers with sealing lids to prevent odor and accidental spills. Tobacco spit and residue shall be disposed of in sanitary manner that prevents public exposure.

Another policy from a Marine Corps Base also has no clear prohibition on using smokeless tobacco inside as it appears to allow its use inside bathrooms:

(5) Use of smokeless tobacco is prohibited during briefings, meetings, classes, formations, inspections, and while on watch. (6) The expectoration of smokeless tobacco waste is confined to heads within government buildings aboard this installation. The expectoration of smokeless tobacco waste within or from government vehicles is not permitted.

Environmental Tobacco Smoke

Several policies make it clear that smokers will be accommodated to allow them to smoke inside installation buildings. For example, the overarching tobacco use policy in the Army, the AR600-63, states:

When individual living quarters are not required or are not available, and two or more individuals are assigned to one room, smoking preferences will be a determining factor during the assignment of rooms. The installation commander will provide affirmative procedures to reassign nonsmokers to living space that is not occupied by a smoker and if necessary, reassign smokers to living space where they may smoke without inflicting harm or inconveniencing those who do not smoke. (Department of the Army, Army Regulation 600-63, Army Health Promotion (2007); pgs. 20–21)

It is apparent from this policy that the non-smoker is reassigned, therefore inconveniencing and arguably punishing the non-smoker in these situations. An Army installation’s tobacco use policy similarly states:

When individual living quarters (BOQs, EEQs) are not required or are not available, and two or more individuals are assigned to one room, smoking and nonsmoking preferences will be a determining factor during the assignment of rooms. Nonsmokers will be assigned to living space not occupied by a smoker; and smokers will be assigned to living space where they may smoke.

In addition to clearly allowing smoking inside living quarters, these policies do not provide a procedure for what to do when a non-smoker and smoker are not able to be moved and must share living quarters.

DISCUSSION

Strong policies that we identified often had detailed information about the prevalence of tobacco use as well as information about the adverse health effects for both users and those exposed to ETS. The Department of the Navy’s policy SECNAV 5100.13E was identified as the most comprehensive and strongest overarching tobacco control policy in that it was both an independent policy and had the most components of any service.¹² Comprehensive and high-level policies provide clear and unambiguous guidance and background about the negative impact of tobacco use and how it should be best approached with regard to prevention and treatment.¹⁵ This is important because Jahnke et al¹⁶ found that lack of direction from leadership about tobacco control and lack of understanding among commanders about the impact of tobacco use on readiness was one of the more important harriers to tobacco control efforts noted by tobacco control managers and military tobacco policy makers.

Several policies were identified as particularly strong in various areas. Enforcement policies that addressed both military and civilian use of tobacco were identified as the strongest as use of tobacco by civilians on military installations has been cited as a challenge to tobacco control efforts.¹⁶ In addition, lack of enforcement and inconsistency in policies across commands has been identified as factors (hat undermine tobacco control efforts.^3,15,16

Strong smoking cessation policies were ones that devoted manpower to the tobacco control and enforcement efforts and those that required users to attend tobacco training to provide information about cessation. Smokeless tobacco policies that were identified as particularly strong often described the specific health consequences of smokeless tobacco products. This is particularly important given the disproportionately high rates of smokeless tobacco use in some branches of the military and because the health effects often are not treated as seriously in policies, as evidenced by the stronger restrictions on use of cigarettes when compared to smokeless tobacco products.^1,15

Although there were several strengths evident in military tobacco policies, there also were policies that were poorly constructed and are not like to improve the tobacco climate among military members. For instance, some policies limited resources available to tobacco users to help with quitting. Given the addictive nature of tobacco, repeated quit attempts often are necessary to result in permanent cessation. Limiting the availability of treatment sends the message that tobacco cessation is not a priority. Further, cessation planning needs to be based on empirically validated methods and protocols rather than the discretion of management as highlighted in referenced policy.

Some policies that addressed smokeless tobacco allow use in a variety of situations which clearly sends the message that cessation from these products is not a priority for the military. Although the health dangers associated with smokeless tobacco use are not as numerous or deleterious when compared to cigarette use, it still is associated with negative outcomes that make it a threat to the overall health of military members. Evidence suggests that the tobacco industry is specifically targeting smokeless tobacco advertising toward military members as its use is more difficult to detect and regulate.^16,17 It is important that tobacco control efforts and policies address all types of tobacco use.

Policies on ETS that allow smoking in some facilities and that give priority to smokers exist and likely limit the strength of the message that tobacco use is not consistent with readiness. Not only do these types of policies put the burden of inconvenience on the non-smokers, but the underlying message reinforces the idea that smoking is an acceptable part of the military culture.¹⁶

Military tobacco policies continue to evolve and new policies developed and implemented on a regular basis (see for instance the AF Surgeon General’s newly revised AFI 40–102 that decreases the number of designated smoking areas and makes medical treatment facilities tobacco free). As policies are developed, it is important for leadership to understand what constitutes strong messages and continued research into the evolving policies is warranted. In order to maximize the benefit of tobacco control policies in the military, it is important that they send strong and consistent messages to service members and, if possible, provide comprehensive guidance at the highest level possible.^15,16 This would improve the likelihood that commanders are clear about the negative impacts of tobacco on their personnel and provide them guidance on how to best approach tobacco control efforts. In addition, strong policies should address issues such as methods of enforcement and be clear that tobacco use is non-normative.^13,14 Best practice policies such as those identified above can be used as models for other installations and commands.