Mediatory myths in the U.S. military: tobacco use as “stress relief”

Abstract

Purpose

To examine perceptions of military personnel about tobacco use.

Design

Secondary analysis of a) focus group and b) interview data.

Setting

U.S. Military

Subjects

Total participants (n= 241): Enlisted personnel, supervisors (n=189 individuals participating in 23 focus groups), tobacco control managers, and policy leaders (n=52 interview participants).

Intervention

Not applicable.

Measures

Not applicable.

Analysis

Inductive, iterative coding for salient themes using an interpretive approach. Application of the concept of mediatory myths, used by institutions to cover over internal contradictions.

Results

All types of participants endorsed the idea that tobacco was needed in the military for stress relief. Types of stress identified included fitting in, (relationships with co-workers and superiors) and control of workflow (taking breaks). Participants also discussed beliefs about the impact of tobacco on the military mission, and institutional sanction of tobacco use.

Conclusions

Despite tobacco's well-documented negative effects on fitness, the myth that tobacco relieves stress serves several institutional functions in the military. It serves to minimize perceptions of stress on the fitness of personnel, suggests that stress can be managed solely by individuals, and institutionalizes tobacco use. Growing recognition among military leadership that countering stress is essential to fitness offers an opportunity to challenge this myth.

Introduction

The US military is among the largest and most complex organizations in the world, within which many subgroups are concerned with health and health promotion. Peak physical health is highly valued in the military, with personnel required to pass periodic fitness tests. Yet military activities can be inherently contrary to good health. In recent years, the military has attempted to address both stress and tobacco use as important health promotion and health policy issues.

Stress is an acknowledged problem in the military, with personnel subject to difficult and dangerous jobs, exposure to trauma in combat, and lengthy deployments necessitating separation from family and friends. In addition, military personnel are subject to the ordinary stresses of handling interpersonal relationships with peers and authorities and managing workload.¹ The psychological health of military personnel returning from combat in Iraq and Afghanistan is an important concern, with as many as 19% returning with post-traumatic stress disorder or other mental health issues.² Furthermore, many personnel do not seek out care because of the stigma associated with mental illness.³

Such stigma may contribute to military personnel attempting to manage stress with tobacco,¹ although available evidence suggests that smokers actually experience more stress than do non- or ex-users.⁴ Tobacco use prevalence among military personnel remains high; 24% are current smokers and nearly 20% use smokeless tobacco.¹ Basic military training may itself be a risk factor for smoking initiation.⁵ Deployment has been found to increase the risk of initiating smoking; relapse by ex-smokers is even more common.⁶

Tests of ways to ameliorate stress for military personnel have focused on techniques derived from meditation practices (such as breathing exercises), mindfulness or cognitive behavioral therapy, and good sleep and nutrition practices. Efforts have been made to frame these practices in ways that might make acknowledging and addressing stress compatible with a military mindset more traditionally marked by stoicism. For example, the “One Shot-One Kill” program frames stress management techniques as ways to increase a warrior's effectiveness.⁷ However, none of these techniques has been integrated into military training or made routine. Few have been thoroughly evaluated and none has been positioned as an alternative to or replacement for tobacco use.

Policy changes, such as increased cigarette taxes and clean indoor air laws, are more effective at reducing smoking rates than education or individual intervention.⁸ However, although numerous military tobacco control policies have been issued or proposed since the 1980s, their adoption or implementation has been thwarted by structural, cultural, and political barriers. ^9-15 In practice, tobacco use is often condoned and promoted. Cigarettes are sold cheaply in base commissaries and exchanges, frequently in violation of pricing regulations;^{16, 17} smoke breaks are common;¹⁴ and using tobacco is perceived to be a “right” which cannot be abridged.¹⁸ Anecdotal evidence suggests that tobacco-related regulations are infrequently enforced.¹⁹ A recent survey found that 73% of active duty personnel reported that some or most of their friends used cigarettes, but only 50% thought that their superiors discouraged smoking.¹

Both tobacco use and the mental health problems associated with stress are incongruent with the requirement that military personnel be at peak fitness. Maladaptive responses to stress are associated with poor performance, less perceived social support and sense of belonging, and early separation from service.²⁰ Smokers in the military have lower levels of physical fitness than nonsmokers,^{21, 22} limiting their ability to fulfill their duties. Exposure to primary^{23, 24} and secondhand²⁵ smoke impairs wound healing.²⁶ Smokers are at increased risk for training injury^{27, 28} and are more likely to be discharged prematurely.²⁹ In addition, high smoking prevalence rates among military personnel contribute to increased costs for the Department of Veterans Affairs.³⁰ An Institute of Medicine (IOM) report recently recommended ending tobacco use in the military due to its negative impact on troop health and readiness.³⁰ Yet the IOM recommendation to phase out tobacco from the military was quickly rejected by the Department of Defense (DoD), with Defense Secretary Robert Gates emphasizing that tobacco use was one of few outlets service members had to relieve stress while deployed.³¹ Thus, contradictory notions and practices concerning tobacco are simultaneously sustained within the military organization, most notably that tobacco use is inimical to the fitness necessary for deployment, but its use is tolerated and even facilitated; and that although some policies are aimed to discourage tobacco use, it is also seen as a necessity to relieve the stresses inherent in military life.

Organizational contributions to health

Organizations, such as the military, and their practices and rules play important roles in health promotion. Yet organizations, as functional systems, are not wholly rational, but may sustain competing, contradictory or conflicting practices, goals and ideologies such as those mentioned above.³² Organizational cultures, as systems of “publicly and collectively accepted meanings,”³³ enable people within the organizations to manage conflicts, by giving activities and relationships their specific significance. These cultures have numerous aspects, including language, ritual, and myth.³³

The concept of “mediatory myths” has been proposed as a way to explain how organizations reconcile apparently contradictory practices with institutional goals and ideologies.³⁴ For example, a study of “outpatient commitment” (i.e., a system allowing mental health patients to live at home, but requiring them to take medication) identified an inherent contradiction between the ideal of the “least restrictive environment” for patients and the practice of forcing them to take medication regardless of their wishes. The reconciling mediatory myth was that the medication would enable patients to achieve insight into their condition, allowing for productive psychotherapy. This was true in some cases; however, it achieved the status of “myth” because it was unquestioned, and became the underlying belief supporting the system overall.³⁵

In the US military, tobacco use is widely understood to be part of military culture and an important—if not essential--stress reliever,^{14, 15} despite the harm it does to personnel. Such contradictions are endemic to organizations, which must function in ways that do not always conform to their fundamental ideologies. Mediatory myths help organizations ignore contradictions between their formal organizational ideologies and actual practice. However, they can also serve as obstacles to more effective organizational functioning or create problems in themselves. This paper reports the findings from a secondary analysis of focus group and interview data obtained from military personnel which sought to better understand how these contradictory ideas about tobacco coexist within the military context. Following the summary of results, the concept of mediatory myths is applied to illustrate how tobacco use functions at the individual and organizational levels in the US military and how it addresses organizational gaps related to stress management.

Methods

This study is a secondary analysis of data from two prior projects, both conducted by several researchers, some of whom had a military background. The first involved focus groups (N=189 participants in 23 groups) with enlisted service members and supervisors and explored themes and messages about smoking that might be effective in promoting tobacco use prevention or cessation among junior enlisted personnel. Group topics included how the military encouraged or discouraged tobacco use, the availability of cessation help, and perceptions of the effects of tobacco use on mission readiness. Participants were recruited through posting flyers and announcements at staff meetings. Details of instrument development, recruitment, and procedures have been previously described; ³⁶ institutional review board approval for the original data collection was obtained from the University of Missouri—Kansas City. Table 1 outlines group characteristics. Key findings of the primary analysis were that participants perceived smoking to be a way to manage stress, especially on deployment; the risks of deployment to outweigh the potential harms of smoking, and the military environment to encourage smoking.¹⁵

Table 1. Focus group demographics (n=189 participants in 23 focus groups).

	Air Force	Army	Total Across Both Services
Smokers (Total 7 Groups)	n=35	n=23	Total n=58
Gender
Male	25 (71.4%)	18 (78.3%)	43 (74.1%)
Female	10 (28.6%)	5 (21.7%)	15 (25.9%)
Race
Black/African American	3 (8.6%)	3 (13%)	6 (10.3%)
White	19 (54.3%)	19 (82.6%)	38 (65.5%)
Asian	7 (20%)	0 (0%)	7 (12.1%)
Other	6 (17.1%)	1 (4.3%)	7 (12.1%)
Age
Mean	22.7	23.9	23.21
Median	23	23	23
Mode	24	21	23
Years in military
Mean	3.2	3.2	3.2
Median	2.5	2	2.25
Mode	1	1	1
Rank
Enlisted	35 (100%)	23 (100%)	58 (100%)
Non-smokers (Total 9 Groups)	n=47	n=20	Total n=67
Gender
Male	32 (68.1%)	12 (60%)	44 (65.7%)
Female	15 (31.9%)	8 (40%)	23 (34.3)
Race
Black/African American	6 (12.8%)	4 (20%)	10 (14.9%)
White	28 (59.6%)	11 (55%)	39 (58.2%)
Asian	3 (6.4%)	2 (10%)	5 (7.5%)
Native Hawaiian/Pacific Islander	0 (0%)	1 (5%)	1 (1.5%)
American Indian/Alaskan Native	0 (0%)	1 (5%)	1 (1.5%)
Other	10 (21.3%)	1 (5%)	11 (16.4%)
Age
Mean	22.68	24.4	23.19
Median	21	22	21
Mode	20	20	20
Years in military
Mean	3.26	3.1	3.2
Median	2	2	2
Mode	2	2	2
Rank
Enlisted	47 (100%)	20 (100%)	67 (100%)
Supervisors (Total 7 Groups)	n=32	n=32	Total n = 64
Gender
Male	19 (59.4%)	20 (62.5%)	39 (60.9%)
Female	13 (40.6%)	12 (37.5%)	25 (39.1)
Race
Black/African American	3 (9.4%)	14 (43.8%)	17 (26.6%)
White	23 (71.9%)	14 (43.8%)	37 (57.8%)
Asian	2 (6.3%)	1 (3.1%)	3 (4.7%)
American Indian/Alaskan Native	1 (3.1%)	0 (0%)	1 (1.6%)
Other	3 (9.4%)	3 (9.4%)	6 (9.4%)
Age
Mean	33.94	34.4	34.8
Median	35.5	35	35
Mode	37	35	35
Years in military
Mean	13.5	12.7	13.1
Median	15.9	13.5	14
Mode	19	14	17
Rank
Enlisted	30 (94%)	28 (88%)	58 (91%)
Officers	2 (6%)	4 (12%)	6 (9%)

The second study involved interviews with a purposive sample of military installation-level tobacco control managers (TC managers) and service-level policy leaders (N=52) about tobacco control efforts, policies, and challenges within the DoD. Policy leaders are individuals involved in the development or implementation of health policy at the service level. Tobacco control managers handle the tobacco control programs at their military installation.³⁷ Respondents of both types included personnel from all four branches of the service (Air Force, Army, Marine Corps, Navy); a majority were civilian employees, and a majority had more than 5 years of experience in their positions. Instrument development, sample selection, and procedures have been previously described; ³⁷ institutional review board approval for the original data collection was obtained from the University of Missouri—Kansas City, the University of California, San Francisco, and the Tricare Management Activity Institutional Review Board Program Office. Question domains included strengths and weaknesses of military tobacco control efforts, barriers to tobacco control and how to overcome them, and tobacco industry influence on military tobacco issues.³⁷ Key findings of the primary analysis included that respondents believed that service level commanders saw tobacco control as a low priority, numerous aspects of military culture promote tobacco use (e.g., low cost of tobacco, the custom of “smoke breaks”), and tobacco control policies were unevenly enforced.³⁸

In an effort to further understand the meanings of and reasons for these findings and how they reflected or sustained organizational priorities, a secondary analysis of these data was conducted. Previous analysis focused on the direct answers to specific questions posed (denotation); this analysis explored themes and ideas that emerged across questions and topics (connotation), revealing underlying beliefs and understandings about tobacco use. Transcripts of interviews and focus groups were imported into NVivo, a qualitative analysis software package. This program permits the clustering and sorting of segments of text that appear to have thematic or semantic similarities or patterns of difference. Concepts or language recurring across data sources can thus be identified and analyzed. 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.^{39, 40} In this type of analysis, one does not specify in advance an analytic or theoretical schema, but tries to remain open to noticing patterns of language, meanings, and comparisons within the data. The assumption is that in addition to the concrete particulars reported in language, individuals also convey taken-for-granted meanings in their responses that reflect cultural practices within social worlds.

In contrast to grounded theory, which aims to generate theoretical or conceptual models to explain human activity, the interpretive approach used seeks to create a more “experience-near”⁴¹ account that will help readers grasp the lived meanings of the phenomena under study. The descriptive account below was developed by re-reading the coded data and summarizing the key themes, contrasts and similarities. After summarizing key findings, the concept of mediatory myths was utilized to help describe and explain the organizational contradictions the data revealed.

Results

Military life has many inherent stresses, including little control over work assignments and pacing, adaptation to a highly structured social system, and exposure to physical hazards. Respondents associated tobacco use with all of these. Tobacco was used to control work pace by taking “smoking breaks,” to bond with peers and to socialize with superiors. Many respondents saw few downsides to tobacco use, denying any impact on mission readiness.

Stress as a risk factor for tobacco use

Smoking was frequently attributed to “stress,” exacerbated by the demands of war. An enlisted smoker asserted: “Either you are going to slow down on the stress or you're gonna increase the stress and there is gonna be more smokers.” A nonsmoker described the “hurry up and wait” aspect of military life as particularly stressful: “you're sitting there and you're supposed to be getting off work early and all of a sudden something breaks, so now you have to go right now right now right now right now, and everybody's supposed to go faster and you can't do anything, you're just waiting on someone else.”

Smoking also was described as a way to pass the time or a response to boredom. For example, one enlisted nonsmoker said that people “start smoking because there's nothing else to do.” Thus, smoking was regarded as a normal way to cope with the stresses of both sides of the “hurry up and wait” condition. It was an excuse to “take a break,” (i.e., pause when there is too much to do); it was also a way to “pass the time” (i.e., occupy oneself when there is not enough to do). In both instances, smoking was experienced as a way to manage workflow.

In this context, tobacco use was regarded as necessary, or even medicinal. A TC manager thought that it was unlikely his/her commander would support restricting cigarette sales in a deployed setting, “because they are very adamant about making sure that their soldiers have that, so that they are not stressed out, to be able to do their mission.” Another TC manager reported hearing “from several people” that commanders would “encourage whatever they need to, to calm their nerves … If smoking is going to help them, or dip … then they're going to encourage the habit.” Some had heard “rumors” that tobacco use was used by deployed service members as “self-medication” for depression and combat stress.

Some respondents took this connection at face value. A TC manager said that the stress of working long shifts was a barrier to reducing tobacco use. Another compared two types of assignments, asserting that one had higher stress levels, which accounted for the relatively higher smoking rates among troops thus assigned. Deployment and other increased demands of the military during wartime also were mentioned. A policy leader thought that deployment increased tobacco use because it was “acceptable activity that someone could do to relieve that stress – certainly pounding two beers out in a combat zone is not going to happen.” Given the inherent demands of military life, one TC manager thought, little could be done to improve the situation: “Obviously, I don't think there is a way to overcome that in our environment, aside from changing working hours and things like that.”

A sense of belonging

Smokers, compared to non- or ex-smokers, have reported elevated levels of stress relating to problems with peers and supervisors.⁴ Such stresses may be exacerbated in the military context, requiring adaptation to a new group of people upon whom one's life may depend. Respondents noted that tobacco was often used to facilitate relationships.

Peer groups

Tobacco use was a way for service members to bond with one another and gain confidence. A supervisor said that s/he “started smoking right out of basic training because I saw others doing it and felt comfortable doing it.” Another supervisor agreed, saying, “when you've got a bunch of young 18 year-olds coming in who've never left momma's side, and you shove them into this group of people yelling at them all the time, then they're going to look for the group strength, and if the group is smoking … that's why they're taking it up.”

A policy leader said that in his/her service there were some units in which, “almost everyone in the unit” used smokeless tobacco, the understanding being, “if you want to be one of us … you have the dip in your back pocket.” A TC manager agreed, saying that taking smoke breaks “is very much for the young enlisted [service members] a social bonding thing … They don't want to break up with their friends … and they don't see another way to bond with each other.” In a setting where unit cohesion can be life-saving, tobacco thus functions to reinforce social ties, essential to organizational cohesion.

Using tobacco for social bonding and identity formation also may be encouraged by the policy making tobacco use a privilege granted only after tobacco-free basic training. This had the unintended consequence of creating a “rebound effect for tobacco use”. In the opinion of some respondents, this was exacerbated by a recent change that allowed tobacco use at the end of Advanced Individual Training. Respondents noted that in some respects, the services had created a “nicotine reward system,” in which tobacco use signified achievement and belonging.

Role models

Although it is rare among civilians for adults to initiate tobacco use, one interviewee noted that it was common in the military. Many respondents observed that tobacco-using role models encouraged use; this was especially true for young recruits. A policy leader noted: “Those Training Instructors are looked up to as … the ultimate [service members]. … And when … many of them smoke themselves, I think it just sets the message like, ‘Hey, I want to be like him.’” Tobacco use among officers is less prevalent, with as few as 5% of the most senior being smokers ⁴², but the direct influences on recruits are frequently senior enlisted personnel. A policy leader noted that “the drill sergeants are very young personnel, but they're in the age of heavy use of tobacco,” and they were the ones recruits looked up to.

This influence sometimes went beyond behavior modeling; a group of supervisors remarked that a few senior people, “may grab a buddy to pull out for a smoke break; that kid may not want a break but … it's very challenging when they say, ‘come smoke with me.’” A policy leader confirmed this: “enlisted personnel see [smoke breaks] as an opportunity to get to rub elbows with somebody senior – their immediate boss.” Tobacco use is thus positioned as a route to acceptance by superiors and successful advancement.

Some respondents disagreed with this perception, noting that tobacco use was becoming less acceptable. The fact that fewer officers than enlisted members smoked was frequently commented upon, as was the impression that officers who smoked were secretive about it,³⁷ suggesting that tobacco use was becoming contested as a normal military practice. Senior leaders who smoked, said a supervisor, “hide it. They'll find a nook or cranny or they'll go somewhere the younger people can't see it.” An ex-smoker said s/he quit because s/he was “trying to apply for officer training, so it's not conducive to my career.”

Managing workload

Work breaks are an institutionalized form of stress management common to many work settings. In the military context, all types of respondents thought smoking was the most acceptable excuse to take a break. A supervisor noted: “you can't get a break to go outside to use the phone … but … if you tell us … ‘I'm going out to have a cigarette,’ they[‘ll] be like, ‘oh, all right’.” An ex-smoker said that before s/he quit, “every hour you would go outside for 5 minutes … now … you have no excuse to get away. [If you say] ‘I'm just gonna go outside,’ [the response is] ‘No, no, you're working.’” Unlike the response when asking for a smoke break, a policy leader observed, “If someone says, ‘I need a stretch break,’ then people think you're slacking.”

Smoking also was a way to get extra breaks. Although only two daily breaks were officially prescribed, a TC manager said, “It's perfectly all right for somebody to get up and take a smoke break three times in the morning and three times in the afternoon.” A supervisor believed that “most soldiers who don't smoke will not take their 15 minute break … Smokers will go out and have a smoke break. So [they are] getting rewarded for being a smoker.”

This system encouraged people to start smoking. One smoker claimed, “I've been out to the smoke pit all the time, and two or three people that don't normally smoke bum a cigarette so they can stay.” A supervisor noted that he had “a troop that says, ‘Oh, I only smoke when I'm at work,’ so she can get the breaks.” A long term service member recalled that “guys [who] didn't smoke when they came in … they knew they could have a smoke [break] … . I can't imagine how many people that were in my group started smoking back then.” Another remarked, “Yeah, you don't get a break unless you're freaking smoking. Figure it out.”

Smoking areas were themselves identified by some participants as contributing to tobacco use. Although segregating smoking to minimize second-hand smoke exposure is promoted by tobacco control, it may also institutionalize smoking. A supervisor noted, “We even got signs to tell you, ‘You can smoke; you just got to be 50 feet away to do it.’” A TC manager also thought the ubiquity of these areas contributed to “the message that tobacco use is acceptable.” Another TC manager reported that smoking areas also had “beautiful new smoking gazebos.”

Numerous policy leaders and TC managers noted that there were no equivalent places for non-smokers. For example, a TC manager reported the existence of smoking rooms, but no smoke-free break rooms. Another remarked that there was “a nice place to go smoke, and there's not a nice place to just go sit outside and eat your lunch.” In some cases, the designated smoking area eliminated what was formerly an option for non-smokers: “a gathering place for a picnic.”

Some saw “smoke breaks” as having elements of more sensible stress management strategies. For example, a TC manager remarked that although smoking itself was unhealthy, smokers, “take breaks, they socialize, and they take deep breaths when they're inhaling the smoke. So those are three very good stress management tools.” An enlisted ex-smoker had a similar perspective, saying that smoking had been a “time where you stopped, removed yourself from a stressful situation … So it's the same thing as a non-smoker stepping away, taking a breather.” However, if smoking is the only acceptable reason to take a break, service members cannot utilize these techniques in a healthy way.

Mission and institutional sanction

Numerous policy leaders and TC managers thought that their leadership did not believe that tobacco use affected the ability of service members to perform their mission.³⁸ Several felt that, to the contrary, those leaders believed tobacco use was necessary. A policy leader said that most commanders “believe that any impact is pretty minimal, and that the impact of, say, banning smoking at one of the deployed locations would be even worse. You know, you would have bunch of nicotine addicted people – I mean, who knows what would happen?”

Enlisted smokers almost universally rejected the idea that smoking made one less physically fit for active duty. One said that if someone was chasing him “with an AK-47, I'm going to take off running. I'm not going to care if I need a cigarette or not, or if I'm in shape or not.” Smokers rejected concerns that the need to satisfy addiction might compromise missions. The problem of drawing enemy fire could be resolved by using smokeless tobacco. On deployment, one claimed, withdrawal “never affected our job … but once we got the situation calm …then we would go, ‘Hey, you got a cigarette?’ … It might give some motivation to end that mission so you can have that cigarette.” Policy leaders and TC managers believed their leadership shared these views. According to a TC manager, deployed service members used smokeless tobacco “as a stimulant.” A policy leader noted that, “unfortunately, there are a couple of studies out there that seem to state that nicotine increases clarity, alertness. If there's anything positive in the literature, that's what folks pick up on.”

However, others realized that tobacco use posed particular problems in the military context. Some supervisors thought nicotine addiction disrupted teamwork: “Because… if … you got [service member] Joe Blow over here having a cigarette and then five minutes later this one over here got to have a cigarette, you can't work as a team.” Another pointed out that tobacco addiction could create risks for an entire unit because enemy forces watch convoys, “and they … know that this convoy is going to have to stop at some point … to take a smoke break.” In addition to enemy behavior, nicotine withdrawal in combat situations could make someone “anxious and irritable and less able to concentrate; [if] you can't concentrate on your job you can get somebody killed,” a supervisor noted.

Discussion

Previous analysis of these data demonstrated that military personnel perceived tobacco use to relieve stress. This analysis extends that finding by delineating the many ways in which this belief is enacted and placing it in the larger context of organizational culture. Mediatory myths help organizations reconcile conflicts between ideology and practice. In this case, the widespread tobacco use among a population institutionally required to be healthy and fit was justified by its purported ability to “relieve stress.” In this study, all types of respondents endorsed this myth. Policy leaders and TC managers thought that leadership opposed stricter tobacco control because it was believed to have this property. It also was referenced by the Secretary of Defense in his rejection of a tobacco-free military. Few respondents suggested alternatives and many seemed to believe that smoking was a natural consequence of a stressful condition. As others pointed out, however, tobacco use is a socially constructed response to military rules and customs that encourage tobacco use, and also actively discourage other, healthier ways of coping with stresses. In fact, most people in the military do not use tobacco, despite undergoing the same stresses as their fellow service members. Tobacco users report experiencing more stress than never or former smokers, supporting the theory that tobacco use only relieves the stress of nicotine addiction.⁴

If people believe (or are told) that smoking is the best or only reason for taking a break, they may be less likely to use healthier techniques, such as deep breathing, socializing, meditation, or exercise to relieve daily stresses. Even if alternative stress management tools are taught or facilitated, unless and until they are socially integrated into military life as tobacco has been, tobacco will likely continue to be the fallback. Yet we also found emerging evidence that the mediatory myth is fraying. Tobacco use was not seen as appropriate role modeling for young recruits, and was perceived by some as not being conducive to career advancement.

Qualitative research is exploratory. These methods are particularly useful for describing how research participants experience a particular phenomenon, and what meanings they ascribe to it. It is best approached without predetermined categories of analysis, in order to allow the participants’ own meanings to emerge. Thus, findings are not precisely replicable. This study has a limited sample size. Undetermined factors may have biased participant recruitment. Furthermore, focus groups were held only with Army and Air Force personnel, excluding those in the Navy and Marine Corps. The ability to generalize from these data is unknown. While the original data collection team included members with military experience, the authors of this secondary analysis have no such experience; this may have limited our comprehension or biased our analysis in unknown ways. Still, these data are, to our knowledge, unique in that very few such studies have been conducted among active duty military personnel, and elucidating the organizational dynamics of these phenomena is a new contribution. Further research should explore these dynamics, particularly in the as yet unstudied service branches.

Conclusion

Mediatory myths reconcile the fundamental with the operative.³⁴ That is, they allow daily necessary operations to continue even when those operations contradict institutional ideology. Such myths need not be explicitly articulated or endorsed by institutional authority; rather, unstated belief in such myths often resides in the background of daily life. The myth that tobacco use relieves stress operates on two levels; the individual and the institutional. That is, individuals believe that tobacco use serves to reduce their own stress, and the institution endorses that idea. The myth also serves two purposes at the institutional level. First, it justifies a lack of action, or lack of success, in effective military tobacco control. Tobacco use has a long history of association with the military, beginning before most of its harms were known. That association is maintained through both custom and the continuing efforts of the tobacco industry.^{9-12, 43} Attempts to disrupt it would likely meet opposition from within the military and from Congress.³¹ The stress myth justifies taking the path of least resistance and continuing to support tobacco use despite the harms it causes, contrary to the military ideology demanding fit personnel.

Second, the belief that tobacco use helps service members allows the military to neglect the need for institutionalizing more effective, healthy stress management tools and techniques. Although tobacco use does not appear to actually relieve stress (except for the cravings of nicotine addiction), culturally it serves an available resource to deal with the problem. Furthermore, this conceptualization implicitly minimizes the issue of stress by defining it as a problem the individual can address through tobacco use. Fully acknowledging the magnitude and severity of the psychological pressures military personnel experience might directly threaten the ideology of a fit fighting force. The myth of tobacco use as stress relief thus resolves the contradictions of a tobacco using force by mitigating both ends of the equation: tobacco use is necessary, and “stress” is not an institutional threat.

Maintaining tobacco use has several practical advantages. Tobacco is adopted voluntarily by, paid for, and distributed by individual service members. Military systems need only attend to distribution at the wholesale level. Although in the long run tobacco costs the DoD, in the immediate sense it does not appear as a line item expense. The expenses are now scattered invisibly throughout the system as training costs, absenteeism, medical costs, and reduced productivity, mostly not explicitly linked to tobacco use. Instituting stress reduction training or other programs would have an obvious upfront cost, as well as requiring time and attention. The ultimate savings – and lives saved – would be far less visible, and only in the longer term.

Replacing tobacco use with healthier stress management techniques also risks failure. Because tobacco use is not an official response to stress, its failures are invisible. If tobacco were to be replaced by something else (e.g., meditation training), it would likely be explicitly and stringently evaluated. However effective it might be, it would not always work, and those failures would be noted and could be used to criticize the change.

Eliminating tobacco use in the military would mean confronting the myth of tobacco as a necessary stress reliever. Although such myths are important for organizational stability, they are not necessarily static.³² When they become detrimental to the organization, myths can change or be replaced. Current understanding of both the harms of tobacco use and the necessity of effective stress management for military personnel may provide an opportunity for this shift, as the justification for tobacco use looks increasingly inadequate and the need for its replacement becomes clear.³² The reduction in use among officers, and the perception that tobacco use is a detriment to advancement, adds salience to the new idea that tobacco use is becoming “not military.” A replacement myth might reinforce some recent efforts to address the contradiction between fitness and susceptibility to stress by defining stress management training and tools as “military,”^{7, 20, 44, 45} as, for example, in the “One Shot – One Kill” program. Such a change would likely meet resistance; however, the military has recently demonstrated its ability to implement widespread cultural change with the repeal of “don't ask don't tell” and the open acceptance of lesbian and gay members. Desire for improvements in the mental and physical health of service members should provide motivation to make the shift to a tobacco free military.

So What? Implications for Health Promotion Practitioners and Researchers.

What is already known on this topic?

Military personnel have high tobacco use prevalence rates, despite the impact of tobacco use on mission readiness, health consequences, and costs to the U.S. military and the Department of Veterans Affairs.

What does this article add?

The myth that tobacco use helps military personnel cope with stress supports continuing tobacco use and justifies the absence of institutionalizing more effective, healthy stress management tools.

What are the implications for health promotion practice or research?

The increasingly evident harms of both stress and tobacco use to military personnel offer an opportunity for policy makers to challenge this myth and begin to make the shift to a tobacco free military.