Skip to main content
PMC home page
Military Medicine logoLink to Military Medicine
. 2020 Feb 15;185(5-6):e609–e615. doi: 10.1093/milmed/usaa016

When, How, & Where Tobacco Initiation and Relapse Occur During U.S. Air Force Technical Training

Margaret Celice Fahey 1, G Wayne Talcott 2,3, Timothy L McMurry 2, Robert C Klesges 2, David Tubman 2, Rebecca A Krukowski 4, Melissa A Little 2,3
PMCID: PMC7282443  PMID: 32060547

Abstract

Introduction

Military personnel are at high risk for tobacco use, particularly during the first year of military service. Technical Training follows an 8½ week tobacco ban during basic military training and is a vulnerable time for personnel to both reinitiate and initiate tobacco use. Thus, this can be a crucial time to promote tobacco policies and interventions. However, there is limited research examining when, how, and where personnel access tobacco during the first year of service, particularly among users of newer products (eg, electronic cigarettes[e-cigarettes]). Thus, the purpose of the current study is to explore the timing, source, and location of tobacco use during Technical Training across all types of products. Furthermore, this study will examine differences in demographic characteristics and prior tobacco history in relationship to these tobacco behaviors.

Materials and Methods

Participants were U.S. Air Force recruits completing Technical Training (2017–2018). Protocol was approved by the Institutional Review Board at the 59th Medical Wing of the U.S. Air Force. During the first week of Technical Training, Airmen were consented to participate in the study and completed a questionnaire about demographics and tobacco use history. Next, Airmen were randomized to receive one of three tobacco prevention interventions as part of military training. At a 3-month follow-up, during the last week of Technical Training, consented participants completed a questionnaire about current tobacco use. Airmen reported when (ie, first month vs. after), how (ie, “bummed” from another airman, bought on or off base, received from the internet or event), and where (ie, designated smoking areas on base, off base, bar or club, friend’s house, cigar lounge, hookah bar, or vape shop) they used tobacco during Technical Training. Descriptive statistics were used to examine these behaviors across all tobacco products. Additionally, Wilcoxon-Mann–Whitney and Kruskal–Wallis tests compared differences in demographic characteristics and baseline tobacco use in relationship to these tobacco behaviors.

Results

No significant differences were found when comparing prior users and first-time users in relationship to tobacco behaviors during Technical Training; however, significant differences in educational background and age were found in regard to the source and location of tobacco use. Additionally, how and where Airmen first used tobacco during Technical Training differed across products. Cigarettes and smokeless tobacco were equally likely to be bought on or off base and most commonly first used at a designated smoking area on base. However, e-cigarettes, cigarillos/little cigars, and hookah were more likely to be bought off base, and first used at a specialty store (ie, vape shop, hookah bar, or cigar lounge).

Conclusions

Tobacco use behaviors during Technical Training differed depending on the type of product. Specifically, new and emerging products were more likely to be bought off base and first used at a specialty store. Thus, military polices regulating on base tobacco pricing might not reduce the growing prevalence of e-cigarettes. Future policies might consider addressing the density of off-base tobacco retailers to reduce the high rates of tobacco use in this population.

1. Introduction

U.S. military personnel are at high risk for tobacco use.1,2 Rates of cigarette and smokeless tobacco use in the military far exceed civilian use 1–3; and this disparity is similarly seen among newer products (ie, electronic cigarettes [e-cigarettes], hookah)4 compared to civilians 5 as well. Given that >170,000 individuals are recruited 6 and 250,000 leave the military annually,7 tobacco prevention in this population can significantly impact both military and civilian sectors. Importantly, the first year of service is a particularly vulnerable time to both initiate and reinitiate tobacco and may offer a critical time for policy and behavioral intervention.8–12

During the Air Force recruitment year, after an 8 ½ week tobacco ban during basic military training (BMT), trainees continue to the second phase (ie, Technical Training) lasting between 2 weeks and 18 months depending on career. Despite forced cessation during BMT and the first 4 weeks of Technical Training,13 most reinitiate tobacco immediately after the ban during Technical Training.8,11,12,14 Additionally, high rates of never users (7.9–12.4%) initiate tobacco products during Technical Training as well.11,12,14

Research supports policy-based interventions, particularly increasing tobacco costs, to reduce smoking among civilians.15 However, military personnel have historically received discounted tobacco products on base,16 perhaps contributing to elevated rates of use.17 In response, a recent military policy18 requires the pricing of tobacco products on base match the prevailing local price in the community including applicable taxes. Yet, it is unclear if this policy will be effective for users of newer products, who might be more likely to buy products off base16 or on the internet.19 Additionally, research on tobacco use during the recruitment year has focused only on cigarette 8–12,20 or smokeless tobacco use.14,21 Given the growing prevalence of e-cigarettes,22,23 and high rates of dual (two products) and poly (three or more products) use among trainees,2,5 it is important to account for all products when informing policy and intervention efforts. More detailed information is needed regarding when, how, and where Airmen use different tobacco during Technical Training.

Thus, to inform future military tobacco interventions and policy, the purpose of this study is to explore when (ie, first month vs. after), how (ie, “bummed” from another airman, bought on or off base, received from the internet or promotional event), and where (ie, smoke pits, on or off base, bar or club, friend’s house, cigar lounge, hookah bar, or vape shop) Airmen use tobacco and nicotine containing products during Technical Training. Furthermore, this study will explore differences across demographic characteristics and prior tobacco history in relationship to these tobacco behaviors.

2. Methods

2.1. Participants

Participants were U.S. Air Force Airmen (called airman regardless of gender or rank) completing Technical Training at Joint Base San Antonio-Lackland Air Force Base (2017–2018). Of Airmen approached (n = 3,347), 89.6% (n = 2,999) consented and 99.0% (n = 2,969) met eligibility (≥18 years of age). Of these, 87.9% (n = 2,611) were retained for 3-month follow-up. Airmen were not retained if they were no longer in the military, had failed all or portions of their Technical Training, or were in the process of being cleared to be stationed overseas (ie, thus, attending a medical exam) at time of follow-up. Protocol was approved by the Institutional Review Board at the 59th Medical Wing of the U.S. Air Force.

2.2. Procedure

During the first week of Technical Training, Airmen provided consent and completed baseline measures. Next, Airmen were randomized to receive one of three tobacco prevention interventions: (1) Brief Tobacco Intervention + Airmen’s Guide to Remaining Tobacco Free, (2) Airmen’s Guide to Remaining Tobacco Free, or the (3) National Cancer Institute’s Clearing the Air pamphlet. All Airmen received one of these interventions as part of training requirements. More information about these interventions can be found elsewhere.24 At 3-month follow-up, consented participants reported current tobacco use.

2.3. Measures

2.3.1. Demographics

Airmen reported age, gender, marital status, educational background, race, and ethnicity.

2.3.2. Tobacco Use

At baseline and follow-up, Airmen responded to how often they used/use tobacco. Responses included: Never, less than monthly, monthly, weekly, and daily. Because of the forced tobacco ban, the assessment measured use before BMT. Regular tobacco use was defined as at least monthly use of that product; given that, this is a common definition among young adults and military personnel.25,26 Reinitiators were Airmen who regularly used at least one product at baseline and subsequently used (either monthly or less than monthly) at least one product at follow-up. Initiators were those who reported using tobacco never or less than monthly at baseline and reported any use of at least one product at follow-up.

2.3.3. Timing of Tobacco Use

At follow-up Airmen were asked, “Remember that tobacco was banned during the first part of Technical Training. When did you start or restart using tobacco since starting Technical Training?”

2.3.4. Source of Tobacco Use

At follow-up Airmen were asked, “If you used tobacco products since staring Technical Training, where did you get the first tobacco product that you used?”

2.3.5. Location of Tobacco Use

At follow-up Airmen were asked, “Where were you when you first used a tobacco product during Technical Training?”

2.4. Analysis

Descriptive statistics were observed to examine prevalence of tobacco use behaviors (ie, timing, location, source) during Technical Training. Wilcoxon-Mann–Whitney and Kruskal–Wallis tests compared differences in demographics and baseline tobacco use (ie, nonusers vs. users) in relationship to these outcomes (ie, timing, location, source). Furthermore, descriptives (ie, counts, percentages) were used to examine differences across all tobacco products in relationship to these tobacco behaviors.

3. Results

Participant demographic characteristics and tobacco use are found in Table I. At baseline, 39.4% (n = 1161) reported regular use of any tobacco product, and during Technical Training, 21.3% (n = 552) used tobacco. Specifically, 37.4% (n = 432) of prior tobacco users reinitiated and 6.4% (n = 116) of prior nonusers initiated. Most commonly during Technical Training, 13.6% used e-cigarettes, 7.7% used cigarettes, 7.1% used smokeless tobacco, 6.7% used cigarillos/little cigars, 5.2% used cigars, 4.9% used hookah, and 0.3% used pipes.

TABLE I.

Sample Characteristics (N = 2,969)

Age M (CI) 19 (18.21)
Sex (male) N (%) 2075 (70.2)
Race N (%)
Black/African American 581 (20.0)
White 1835 (63.2)
Multiple 48 (6.2)
Other 179 (6.2)
Hispanic N (%) 630 (23.1)
Married 271 (9.2)
Education N (%)
High school diploma/GED 1,873 (63.6)
Vocational training 43 (1.5)
Some college/associates 863 (29.3)
Bachelor’s degree or higher 168 (5.7)
Military rank N (%)
Active duty 2,577 (87.4)
Guard 264 (8.9)
Reserve 109 (3.7)
Prior tobacco use N (%)
Any 1,161 (39.4)
Cigarettes 458 (15.5)
E-cigarettes 715 (24.2)
Smokeless tobacco 397 (13.4)
Cigars 336 (11.4)
Cigarillos/little cigars 515 (17.4)
Pipe 55 (1.9)
Hookah 270 (9.1)
Open in a new tab

Note. M, mean; CI, confidence interval; %, percent.

3.1. Timing of Tobacco Use

Of all those using tobacco during Technical Training, across all products, 11.3% initiated before week 4 (despite the tobacco ban during this time), 56.5% initiated after week 4 and 32.2% did not respond. No differences in tobacco use timing were found across demographic characteristics, including gender, and between initiators and reinitiators.

3.1.1. Comparisons Across Tobacco Products

Across all tobacco products, most Airmen reported using after week 4 compared to before week 4 or not responding (Fig. 1). However, a larger majority of smokeless tobacco users (16.7%) initiated in the first month of Technical Training compared to other products, followed by hookah users (16.3%), cigarette users (15.8%), e-cigarette users (11.1%), cigarillo/little cigar users (9.8%), and pipe users (2.9%).

FIGURE 1.

FIGURE 1

Open in a new tab

Timing of tobacco use during Technical Training across products.

3.2. Source of Tobacco Use

Among all tobacco users during Technical Training, Airmen most commonly (33.2%) bought products off base, while 17.0% “bummed” products from another airman, 15.2% bought on base, 1.3% received products from the internet or a promotional event, and 33.3% did not respond. Sources differed by age (p = 0.006); specifically, Airmen who received products from the internet or at a promotional event were younger [Mean (M) = 19.1 (1.2)] compared to other sources. In addition, “bumming” tobacco was significantly more common (22.7%) among those who received more education than a high school education/GED (general educational development) compared to those with less education (13.7%) (p = 0.028). Additionally, buying on base was more common (18.1%) among those with a high school diploma/GED compared to those with more education (10.6%). No other differences in demographics (including gender), as well as previous tobacco history, were found.

3.2.1. Comparisons Across Tobacco Products

Among cigarette users at follow-up, Airmen were most commonly and relatively equally likely to “bum,” buy on base, or buy off base (22.3, 24.8, and 28.7%, respectively) (Fig. 2). For e-cigarette users, buying off base was most common (37.2%). Among smokeless tobacco users, buying on base and off base were the most common sources (28.0 and 28.5%, respectively). Among cigarillo/little cigar users, Airmen were most likely to buy off base (36.3%) and this was also seen among hookah users (40.3%). Pipes were most commonly reported to be “bummed” or bought off base (28.6 and 28.6%, respectively).

FIGURE 2.

FIGURE 2

Open in a new tab

Source of tobacco use during Technical Training across products.

3.3. Location of Tobacco Use at Follow-Up

Among all tobacco users during Technical Training, 18.5% first used at a cigar lounge, hookah bar, or vape shop, 12.3% at a designated smoking area, 5.4% at a bar or club, 4.7% on base (but not a designated smoking area), 2.2% at a friend’s house, and 56.9% reported other location (n = 142) or did not respond (n = 172). Location differed by age (p < 0.001); specifically, the highest mean age was among those who used tobacco at a bar or club [M = 21.8 (2.6)] compared to other locations. Location also differed by education (p = 0.013). Those with more than a high school diploma/GED were more likely to report initiation at a bar or club (8.7%) than those with less education (3.5%). Those with a high school/GED more commonly reported first using at a designated smoking area (14.0%) compared to those with more education (9.2%). No other differences in demographics (including gender) and prior tobacco history were found.

3.3.1. Comparisons Across Tobacco Products

Among cigarette and smokeless tobacco users, most reported first using at other locations or did not respond (48.5 and 55.9%, respectively), which was followed by using at a designated smoking area (24.8 and 16.1%, respectively) (Fig. 3). Among e-cigarette users, cigarillo/little cigar users, and hookah users, Airmen most commonly reported first using at other locations or did not respond (53.5, 56.8, and 42.6%, respectively) followed by using at a cigar lounge, hookah bar, or vape shop (24.2, 18.8, and 36.4%, respectively).

FIGURE 3.

FIGURE 3

Open in a new tab

Location of tobacco use during Technical Training across tobacco products.

4. Discussion

Results extend previous literature by examining when, how, and where Airmen first used tobacco during Technical Training. In this sample, tobacco use was common (21.3%); specifically, 37.4% of prior users reinitiated tobacco use and 6.4% of prior nonusers initiated. However, rates were much lower compared to previous studies.8,9,11,12,14 Perhaps current tobacco use was lower because all Airmen were randomized to receive one of three tobacco prevention interventions. Although the Brief Tobacco Intervention was not more effective than control conditions at reducing tobacco prevalence in the long-term,24 Airmen in this condition had a delayed timing of tobacco use during Technical Training.24 Because this study evaluated tobacco use only at 3 months after BMT, dissimilarly from studies evaluating tobacco at a 1-year follow-up, 8,9,11,12,14 current rates might not represent those who used tobacco later in training.

Regarding the timing of tobacco use, most Airmen who used tobacco, across all products, did so after the first month of Technical Training. However, using tobacco during the ban was most common among users of smokeless tobacco (16.7%) and hookah (16.3%). Perhaps, these products were easier to access and use during periods of forced abstinence. Surprisingly, prior users were not more likely to reinitiate sooner compared to first time users. Previous tobacco history might not help predict which Airmen are more likely to use tobacco when it is prohibited.

How and where Airmen first used tobacco differed across products. Cigarettes and smokeless tobacco were equally likely to be bought on or off base and most commonly first used at a designated smoking area on base. However, e-cigarettes, cigarillos/little cigars, and hookah were more likely to be bought off base, and first used at a specialty store (ie, vape shop, hookah bar, or cigar lounge). These findings suggest the relevance of the tobacco-built environment, off base as well as on base. Extensive literature indicates an association between increased exposure, proximity, and density of retail tobacco marketing and higher likelihood of initiation and continued use.27–29 Although studies more commonly examined cigarettes, some research indicates a link between e-cigarette retailer density and likelihood of use among adolescents.30 Airmen cannot have vehicles during Technical Training; however, many specialty shops remain within walking distance and ride sharing companies provide easily accessible and cheap transportation. Policies regulating the sale of tobacco on base might be insufficient to impact military tobacco rates. Given the unique opportunity of a forced tobacco ban during training, brief tobacco prevention programs might be especially beneficial during this time. Additionally, understanding better how the environment on base promotes tobacco use could be helpful in identifying aspects which perpetuate tobacco culture and policies that might decrease use.

There were no differences between prior tobacco users and nonusers in how and where Airmen first used tobacco. However, there were differences in educational background and age. Those with a high school diploma/GED more commonly bought on base, particularly at designated smoking areas, compared to those with more education. Perhaps, this new policy18 regulating on base tobacco pricing will be more impactful for recruits with less education. Not surprisingly, first using at bar or club was associated with older age, likely given that these individuals were over the age of 21 years. Despite a previous study finding that male air force trainees were more likely to initiate tobacco than females, and females more likely to reinitiate, 11 no gender differences were found in the current study. Perhaps, gender does not influence the timing, location, or source of tobacco use during training.

Although, in the overall sample, a small prevalence of Airmen (1.3%) reported accessing their product from the internet or at a promotional event, receiving tobacco from these sources was associated with younger age. This finding is consistent with trends of increasing online tobacco discounts and advertisements targeting youth.31,32 The internet is an increasingly popular place to buy e-cigarettes, the most common product used by youth and young adults.23,33,34 E-cigarette advertisements are largely unregulated by the FDA33,35; therefore, the FDA and policy makers might consider restricting targeted marketing for the military. There is a long history of tobacco companies promoting a military tobacco culture with targeted advertisements, discounts, and promotional events.36–38 Furthermore, most states with Tobacco 21 laws, restrict tobacco purchases to those under 21 years, but exempt military personnel. 39 Thus, there will be growing opportunity for tobacco companies to target personnel between 18 and 21 years. Given that this population is vulnerable for high rates of tobacco use,1,2 online advertisement regulations and removal of the military exemption from Tobacco 21 laws might help prevent disparities among newer products.

5. Limitations

A high percentage of Airmen did not respond to follow-up questions; perhaps, because of military policy regarding data (ie, commanders have privileges to obtain survey responses). Additionally, time constraints possibly deterred some Airmen from responding. There are likely differences among Airmen who were more likely to respond to all tobacco behavior questions. We also might have missed an important category of response, given that many Airmen reported “other” location. This study was also embedded within a randomized trial. Although there were no differences between interventions and tobacco outcomes,24 it is possible that we observed less tobacco use as a result of the tobacco education Airmen received.

6. Conclusion

How and where Airmen used tobacco during Technical Training was influenced by the product used. For example, users of newer products (ie, e-cigarette and hookah) were more likely to buy off base, specifically at a hookah shop or vape shop. Given the growing popularity of e-cigarettes among young adults, and Tobacco 21 law exemptions of military, current policy regulating on base pricing might be insufficient at decreasing disparities between military and civilian use. Because air force training offers a unique opportunity of forced tobacco abstinence, brief tobacco prevention interventions targeting the use of e-cigarettes can be especially beneficial. The tobacco landscape is vastly changing; thus, future military tobacco policies and interventions need to target and adapt to these behaviors regarding newer products.

ACKNOWLEDGMENTS

The authors gratefully acknowledge the support of Second Air Force, the leadership branch for training in the U.S. Air Force.

The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its components. The voluntary, fully informed consent of the subjects used in this research was obtained as required by 32 CFR 219 and DODI 3216.02_AFI 40–402.

Funding

This work was supported by a grant from the National Institute on Drug Abuse (R21 DA042083). This study is a collaborative endeavor between the U.S. Air Force and the University of Virginia via a Cooperative Research and Development Agreement (CRADA # 17–361-59MDW-C18003).

Conflict of Interest

The authors declare no conflict of interest.

References

  • 1. Department of Defense 2011 health related behaviors survey of active duty military personnel. In: Department of Defense TMA, Defense Health Cost Assessment and Program Evaluation (DHCAPE), and the United States Coast Guard., Fairfax, VA, 2013. [Google Scholar]
  • 2. Little MA, Derefinko KJ, Bursac Z, et al. : Prevalence and correlates of tobacco and nicotine containing product use in a sample of United States air force trainees. Nicotine Tob Res 2015; 49(3): 402–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3. Agaku IT, King BA, Husten CG, et al. : Tobacco product use among adults—United States, 2012-2013. MMWR Morb Mortal W 2014; 63(25): 542–7. [PMC free article] [PubMed] [Google Scholar]
  • 4. Little MA, Derefinko KJ, Colvin L, et al. : The prevalence of E-cigarette use in a sample of U.S. air force recruits. Am J Prev Med 2015; 49(3): 402–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5. King BA, Patel R, Nguyen KH, et al. : Trends in awareness and use of electronic cigarettes among US adults, 2010-2013. Nicotine Tob Res 2015; 17(2): 219–27. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. U.S. Department of Defense website Available at https://dod.defense.gov/News/News-Releases/News-Release-View/Article/1691314/department-of-defense-announces-fiscal-year-2018-recruiting-and-retention-numbe/. November 15, 2018; accessed August 28, 2019.
  • 7. Office of the Chairman of the Joint Chiefs of Staff (2014) Enabling collaborative support to reintegrate the military family. “Active Duty Loss Totals, FY1980—Present”, Defense Manpower and Data Center, September 13, 2012.
  • 8. Haddock CK, O'Byrne KK, Klesges RC, et al. : Relapse to smoking after basic military training in the US air force. Mil Med 2000; 165(11): 884–8. [PubMed] [Google Scholar]
  • 9. Hurtado SL, Conway TL: Changes in smoking prevalence following a strict no-smoking policy in US navy recruit training. Mil Med 1996; 161(10): 571–6. [PubMed] [Google Scholar]
  • 10. Conway TL, Woodruff SI, Edwards CC, et al. : Operation stay quit: evaluation of two smoking relapse prevention strategies for women after involuntary cessation during US navy recruit training. Mil Med 2004; 169(3): 236–42. [DOI] [PubMed] [Google Scholar]
  • 11. Little MA, Ebbert JO, Krukowski RA, et al. : Predicting cigarette initiation and reinitiation among active duty United States air force recruits. Subst Abuse 2019; 1–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12. Little MA, Ebbert J, Krukowski R, et al. : Factors associated with cigarette use during Airmen’s first year of service in the United States air force. Mil Med 2019; usz155. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. AFI 40–102 Tobacco Free Living. DoD announces fiscal year 2018 recruiting and retention numbers—End of year report, 2016
  • 14. Dunkle A, Kalpinski R, Ebbert J, et al. : Predicting smokeless tobacco initiation and re-initiation in the United States air force. Addict Behav Rep 2018; 9: 100142. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Manocci A, Backhaus I, D’Egidio B, Federici A, Villari P, La Torre G: What public health strategies work to reduce tobacco demand among young people? An umbrella review of systematic reviews and meta-analyses. Health Policy 2019; 123(5): 480–91. [DOI] [PubMed] [Google Scholar]
  • 16. Kong AY, Golden SD, Myers AE, et al. : Availability, price and promotions for cigarettes and non-cigarette tobacco products: an observational comparison of US air force bases with nearby tobacco retailers, 2016. Tob Control 2019; 28(2): 189–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Golden SD, Smith MH, Feighery EC, et al. : Beyond excise taxes: a systematic review of literature on non-tax policy approaches to raising tobacco product prices. Tob Control 2016; 25(4): 377–85. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18. Memorandum 16-00 Available at https://www.med.navy.mil/sites/nmcphc/Documents/health-promotion-wellness/tobacco-free-living/INCOMING-CARTER-Tobacco-Policy-Memo.pdf; accessed August 18, 2019.
  • 19. Mackey TK, Miner A, Cuomo RE: Exploring the e-cigarette e-commerce marketplace: identifying internet e-cigarette marketing characteristics and regulatory gaps. Drug Alcohol Depend 2015; 156: 97–103. [DOI] [PubMed] [Google Scholar]
  • 20. Green KJ, Hunter CM, Bray RM, et al. : Peer and role model influences for cigarette smoking in a young adult military population. Nicotine Tob Res 2008; 10(10): 1533–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21. Ebbert JO, Keith Haddock C, Vander Weg M, et al. : Predictors of smokeless tobacco initiation in a young adult military cohort. Am J Health Behav 2006; 30(1): 103–12. [DOI] [PubMed] [Google Scholar]
  • 22. McMillen RC, Gottlieb MA, Shaefer RMW, et al. : Trends in electronic cigarette use among US adults: use is increasing in both smokers and nonsmokers. Nicotine Tob Res 2014; 17(10): 1195–202. [DOI] [PubMed] [Google Scholar]
  • 23. Wang TW, Asman K, Gentzke AS, et al. : Tobacco product use among adults—United States, 2017. MMWR Morb Mortal Wkly Rep 2018; 67: 1225–32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24. Little MA, Fahey MC, Klesges RC,, et al. Evaluating the effects of a brief tobacco intervention in the U.S. air force, 2019Nicotine Tob Res In Press. [DOI] [PMC free article] [PubMed]
  • 25. Little MA, Bursac Z, Derefinko KJ, et al. : Types of dual and poly-tobacco users in the US military. Am J Epidemiol 2016; 184(3): 211–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Ryan H, Trosclair A, Gfroerer J: Adult current smoking: differences in definitions and prevalence estimates–NHIS and NSDUH, 2008. J Environ Public Health 2012; 2012: 11.918368. doi: 10.1155/2012/918368. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27. Novak SP, Reardon SF, Raudenbush SW, et al. : Retail tobacco outlet density and youth cigarette smoking: a propensity-modeling approach. Am J Pub Health 2006; 96(4): 670–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28. Reitzel LR, Cromley EK, Li Y, et al. : The effect of tobacco outlet density and proximity on smoking cessation. Am J Public Health 2011; 101(2): 315–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29. Cantrell J, Pearson JL, Anesetti-Rothermel A, et al. : Tobacco retail outlet density and young adult tobacco initiation. Nicotine Tob Res 2015; 18(2): 130–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30. Giovenco DP, Casseus M, Duncan DT, et al. : Association between electronic cigarette marketing near schools and e-cigarette use among youth. J Adolesc Health 2016; 59(6): 627–34. [DOI] [PubMed] [Google Scholar]
  • 31. Richardson A, Ganz O, Vallone D: Tobacco on the web: surveillance and characterisation of online tobacco and e-cigarette advertising. Tob Control 2015; 24(4): 341–7. [DOI] [PubMed] [Google Scholar]
  • 32. Freeman B: New media and tobacco control. Tob Control 2012; 21(2): 139–44. [DOI] [PubMed] [Google Scholar]
  • 33. Williams RS, Derrick J, Liebman AK, et al. : Content analysis of e-cigarette products, promotions, prices and claims on internet tobacco vendor websites, 2013–2014. Tob Control 2018; 27(e1): e34–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34. Cullen KA, Ambrose BK, Gentzke AS, et al. : Notes from the field: use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011-2018. MMWR Morbid Mortal Wkly Rep 2018; 67: 1276–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35. Food and Drug Administration, HHS Deeming tobacco products to be subject to the federal food, drug, and cosmetic act, as amended by the family smoking prevention and tobacco control act 2016; 81: 289739106 Available at https://www.federalregister.gov/articles/2016/05/10/2016-10685/deeming-tobacco-products-to-be-subject-to-the-federal-food-drug-and-cosmetic-act-as-amended-by-the; accessed August 28, 2019. [Google Scholar]
  • 36. Smith EA, Malone RE: “Everywhere the soldier will be”: wartime tobacco promotion in the US military. Am J Public Health 2009; 99(9): 1595–602. doi: 10.2105/ajph.2008.152983. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37. Smith EA, Malone RE: Tobacco promotion to military personnel: "the plums are here to be plucked". Mil Med 2009; 174(8): 797–806. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38. Fahey MC, Krukowski RAG, Talcott W, et al. : JUUL targets military personnel and veterans. Tob Control In Press. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39. Counter Tobacco Available at https://countertobacco.org/; accessed 19 November, 2019.

Articles from Military Medicine are provided here courtesy of Oxford University Press

RESOURCES