Effect of an eight week smoking ban on women at US navy recruit training command

The Impact of Military Tobacco Control Policy: A Systematic Review

INTRODUCTION

Tobacco use is synonymous with the military. Despite that military personnel are trained to follow commands, opportunities exist to implement various tobacco control strategies. We conducted a systematic review to evaluate the impact of tobacco control policy employed in military settings.

MATERIALS AND METHODS

We searched for published English articles in Medline, Web of Science, Scopus, and Google Scholar databases using relevant subject headings without year restriction. We included randomized controlled trials, nonrandomized controlled trials, case-control, cohort, controlled before and after, and uncontrolled before and after studies evaluating the impact of tobacco control policy in the military population. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, three independent reviewers independently screened initially identified articles, reviewed the full text, and extracted the data and any disagreements resolved by consensus after data recheck. Five reviewers used a validated tool to assess the quality of the included studies. The primary outcome was the reduction of any tobacco or nicotine-contained products (TNCPs) use among the troops. The impacts of the tobacco control policy were synthesized and analyzed qualitatively. This study is registered with the International Prospective Register of Systematic Review (CRD42022314117).

RESULTS

Fourteen studies were included in the analysis from 5372 studies screened. Most of the studies were from the USA, and fractions were from Thailand, France, and Taiwan. These studies were methodologically heterogeneous. Most studies employed a total ban policy on TNCP use during basic military training or operational deployment as the primary strategy. Other methods utilized were the brief tobacco intervention, targeted treatment, support, and counseling provided through telephone or mailing systems, the adjunctive behavioral intervention, providing free nicotine gum, the "Pharsai clinic", active and regular smoking restriction, and interventions aimed at intrapersonal, interpersonal, and organizational levels. There is a moderate quality of evidence that the tobacco control policies effectively reduced the prevalence of TNCP use, increased the cessation rate, reduced the intake, and lowered the dependency. The adjunctive interventions provided after the total ban on TNCP use may increase its effectiveness. However, findings from this review need to be carefully considered as the definition of TNCP use status was not universal between studies and lacked a biochemical validation procedure.

CONCLUSIONS

There is reasonable evidence to support that the tobacco control policy employed in the military population has multiple positive impacts in reducing the prevalence of TNCP use, increasing the cessation rates, reducing the intake, and lowering dependency. Other evidence-based strategies need to be fully utilized to materialize the tobacco endgame.

Effect of smoke-free policies in military settings on tobacco smoke exposure and smoking behaviour: a systematic review

INTRODUCTION

Smoke-free legislation has been instrumental in reducing secondhand smoke (SHS) exposure in public places. However, the evidence of the impact of institutional smoke-free policies in settings such as healthcare and defence is weaker. Specifically, the literature on the effect of smoke-free policies in military settings has not yet been synthesised.

METHODS

This review aimed to identify, critically appraise and synthesise the available evidence to evaluate the effect of defence smoke-free policies on SHS exposure. Eight electronic databases (eg, EMBASE, MEDLINE) were searched from inception to June 2020. We included English-language studies on smoke-free policies introduced in a defence setting, assessing their impact on SHS exposure (primary outcome) and healthcare utilisation, smoking behaviours and defence efficiency (secondary outcomes). Risk of bias was assessed using ROBINS-I. Synthesis without meta-analysis was conducted using vote counting of direction of effect.

RESULTS

The search retrieved 4503 citations of which eight met inclusion criteria; two controlled and six uncontrolled before-and-after studies. The evidence, although low-quality, from one study indicated reduced SHS exposure following the introduction of a defence smoke-free policy. For secondary outcomes the review found mixed results, with the quit rate being the one outcome favouring smoke-free policies. The cumulative confidence of evidence is uncertain and therefore reliable conclusions cannot be drawn from these studies.

CONCLUSIONS

A research gap exists for high-quality studies on the impact of defence smoke-free policies which should use comparators and, if possible, randomisation. Policy-makers should introduce institutional smoke-free policies in defence settings within an evaluative framework to generate such evidence.

Implementation of a community-based secondhand smoke reduction intervention for caregivers of urban children with asthma: process evaluation, successes and challenges

Many children, including those with asthma, remain exposed to secondhand smoke. This manuscript evaluates the process of implementing a secondhand smoke reduction counseling intervention using motivational interviewing (MI) for caregivers of urban children with asthma, including reach, dose delivered, dose received and fidelity. Challenges, strategies and successes in applying MI are highlighted. Data for 140 children (3-10 years) enrolled in the School Based Asthma Therapy trial, randomized to the treatment condition and living with one or more smoker, were analyzed. Summary statistics describe the sample, process measures related to intervention implementation, and primary caregiver (PCG) satisfaction with the intervention. The full intervention was completed by 79% of PCGs, but only 17% of other smoking caregivers. Nearly all (98%) PCGs were satisfied with the care study nurses provided and felt the program might be helpful to others. Despite challenges, this intervention was feasible and well received reaching caregivers who were not actively seeking treatment for smoking cessation or secondhand smoke reduction. Anticipating the strategies required to implement such an intervention may help promote participant engagement and retention to enhance the program's ultimate success.

Development, design, and conceptual issues of project zero exposure: A program to protect young children from tobacco smoke exposure

BACKGROUND

Tobacco smoke exposure (TSE) is a serious threat to child health. Roughly 40% of children worldwide are exposed to tobacco smoke, and the very young are often "captive smokers" in homes in which others smoke.The goal of this research project is to develop and evaluate an intervention to reduce young child tobacco smoke exposure. The objective of this paper is to document our approach to building the intervention, to describe the planned intervention, and to explore the conceptual issues regarding the intervention and its evaluation.

METHODS/DESIGN

This project is being developed using an iterative approach. We are currently in the middle of Stage 1. In this first stage, Intervention Development, we have already conducted a comprehensive search of the professional literature and internet resources, consulted with experts in the field, and conducted several Design Workshops. The planned intervention consists of parental group support therapy, a website to allow use of an "online/offline" approach, involvement of pediatricians, use of a video simulation game ("Dr. Cruz") to teach parents about child TSE, and personalized biochemical feedback on exposure levels. As part of this stage we will draw on a social marketing approach. We plan to use in-depth interviews and focus groups in order to identify barriers for behavior change, and to test the acceptability of program components.In Stage II, we plan to pilot the planned intervention with 5-10 groups of 10 parents each.In Stage III, we plan to implement and evaluate the intervention using a cluster randomized controlled trial with an estimated 540 participants.

DISCUSSION

The major challenges in this research are twofold: building an effective intervention and measuring the effects of the intervention. Creation of an effective intervention to protect children from TSE is a challenging but sorely needed public health endeavor. We hope that our approach will contribute to building a stronger evidence base for control of child exposure to tobacco smoke.

Cigarette smoking and subsequent hospitalization in a cohort of young U.S. Navy female recruits

INTRODUCTION

Tobacco use is of particular concern to the U.S. Department of Defense because the military historically has had higher and heavier rates of tobacco use than civilians. Few prospective studies have examined the association of cigarette smoking with medical outcomes, particularly among initially healthy female military personnel.

METHODS

This prospective cohort study followed over 5,000 young U.S. Navy female recruits varying in their smoking status at entry into the Navy and collected their subsequent hospitalization data (i.e., International Classification of Diseases, Ninth Revision codes) for up to 7-8 years of service.

RESULTS

Results indicated that after adjusting for differences in time at risk and sociodemographic variables, daily smokers (compared with never-and other smokers) had higher rates of hospitalization for any reason and for musculoskeletal conditions. Daily smokers also had higher rates than never- and other smokers for non-pregnancy-related hospitalizations and for mental disorders, although only the daily/other differences reached statistical significance. Daily smokers' average number of days hospitalized was significantly longer than that of never- and other smokers.

DISCUSSION

Results suggest that young women do not have to wait decades to experience the harmful effects of smoking. A recent history of cigarette smoking is an important determinant of hospitalization risk for even young healthy women in the U.S. Navy.

Resumption of smoking after release from a tobacco-free correctional facility

Approximately 70% of incarcerated people smoke tobacco, and an estimated 12% of all smokers in the United States leave correctional facilities annually. Many facilities prohibit smoking, but no published study has measured the relapse to tobacco after release. In a study of 200 people with chronic health conditions reentering the community from jail, 165 (83%) were cigarette smokers. Of these, 129 were interviewed at 1 and/or 6 months after release. Self-reported sustained abstinence rates were 37.3% at the end of the first day, 17.7% for the first week, 13.7% for 1 month, and 3.1% for 6 months. These abstinence rates are lower than those reported after military basic training and medical hospitalization but similar to rates after inpatient psychiatric and addiction programs. More efforts and resources are needed to determine successful tobacco cessation interventions during incarceration and after release.

Action to achieve smoke-free homes: an exploration of experts' views

Background

Smoking in the home is the major cause of exposure to second-hand smoke in children in the UK, particularly those living in low income households which have fewer restrictions on smoking in the home. Reducing children's exposure to second-hand smoke is an important public health and inequalities issue. Drawing on findings from a qualitative Scottish study, this paper identifies key issues and challenges that need to be considered when developing action to promote smoke-free homes at the national and local level.

Methods

Two panels of tobacco control experts (local and national) from Scotland considered the implications of the findings from a qualitative study of smokers and non-smokers (who were interviewed about smoking in the home), for future action on reducing smoking in the home.

Results

Several key themes emerged through the expert panel discussions. These related to: improving knowledge about SHS among carers and professionals; the goal and approach of future interventions (incremental/harm reduction or total restrictions); the complexity of the interventions; and issues around protecting children.

Conclusion

The expert panels were very aware of the sensitivities around the boundary between the 'private' home and public health interventions; but also the lack of evidence on the relative effectiveness of specific individual and community approaches on increasing restrictions on smoking in the home. Future action on smoke-free homes needs to consider and address these complexities. In particular health professionals and other key stakeholders need appropriate training on the issues around smoking in the home and how to address these, as well as for more research to evaluate interventions and develop a more robust evidence base to inform effective action on this issue.

Binge drinking among U.S. active-duty military personnel

BACKGROUND

Binge drinking (drinking on a single occasion >or=5 drinks for men or >or=4 drinks for women) is a common risk behavior among U.S. adults that is associated with many adverse health and social consequences. However, little is known about binge drinking among active-duty military personnel (ADMP). The objectives of this study were to quantify episodes of binge drinking, to characterize ADMP who binge-drink, and to examine the relationship between binge drinking and related harms.

METHODS

The prevalence of binge drinking and related harms was assessed from responses to the 2005 Department of Defense Survey of Health Related Behaviors Among Military Personnel (n=16,037), an anonymous, self-administered survey. The data were analyzed in 2007 after the release of the public-use data.

RESULTS

In 2005, a total of 43.2% of ADMP reported past-month binge drinking, resulting in 29.7 episodes per person per year. In all, 67.1% of binge episodes were reported by personnel aged 17-25 years (46.7% of ADMP), and 25.1% of these episodes were reported by underage youth (aged 17-20 years). Heavy drinkers (19.8% of ADMP) were responsible for 71.5% of the binge-drinking episodes and had the highest number of annual per-capita episodes of binge drinking (112.6 episodes). Compared to nonbinge drinkers, binge drinkers were more likely to report alcohol-related harms, including job performance problems (AOR=6.5; 95% CI=4.65, 9.15); alcohol-impaired driving (AOR=4.9; 95% CI=3.68, 6.49); and criminal justice problems (AOR=6.2; 95% CI=4.00, 9.72).

CONCLUSIONS

Binge drinking is common among ADMP and is strongly associated with adverse health and social consequences. Effective interventions (e.g., the enforcement and retainment of the minimum legal drinking age) to prevent binge drinking should be implemented across the military and in conjunction with military communities to discourage binge drinking.

Formative research on creating smoke-free homes in rural communities

The home is a significant place for exposure to secondhand smoke for children and non-smoking adults. This study explored factors that would convince families to adopt household smoking bans and actions to create and maintain smoke-free homes. Interviews were conducted with adults in 102 households in rural Georgia. Participating families had a young adolescent and included households with a mix of smokers and non-smokers and smoking ban status. Families reported they would consider a total ban to protect children from secondhand smoke and protect family members if they got sick. Few described difficulties in enforcement with over half of smokers accepting the rules. Situations that made it hard to enforce restrictions were if there was a visitor who smoked, a smoker who had cravings, and bad weather outside when the smoker desired to smoke. Smokers explained that family members could assist them in quitting by talking to them, not purchasing cigarettes for them, not smoking around them, and supporting them. Ideas for promoting smoke-free homes were having a no smoking sign, saying no to visitors who want to smoke, removing ashtrays, and creating a place outside for smokers. These findings can inform interventions designed to create and maintain smoke-free households.

Nonpharmacologic therapy for smoking cessation: characteristics and efficacy of current approaches

This article reviews the most common nonpharmacologic approaches used to support smoking cessation and, where possible, provides estimates of their efficacy in controlled clinical trials. Virtually all of the approaches that have been systematically evaluated to date have demonstrated modest efficacy in increasing quit rates. A cornerstone of effective treatment is tobacco dependence counseling, for which there is a dose-response relation between the intensity of counseling (total minutes of contact) and its effectiveness. New approaches in which treatment is tailored to individual patient characteristics appear promising for the future but require further study. Also, new technologies that permit delivery of smoking interventions to a wider range of patients could have a significant impact on reducing smoking prevalence worldwide in the future. Overall, the clinical literature strongly endorses combining nonpharmacologic interventions with pharmacotherapy to optimize support for smokers who are trying to quit.

Biomedical Research on Health and Performance of Military Women: Accomplishments of the Defense Women's Health Research Program (DWHRP)

In 1994, Congress provided dollar 40 M for biomedical research on issues of importance for military women. This supported 104 intramural and 30 extramural studies and launched an era of research to narrow the knowledge gap on protection and enhancement of health and performance of military women. Projects addressed issues specific to female physiology (e.g., gynecological health in the field, maternal malaria), problems with higher prevalence for women (e.g., marginal iron deficiency, stress fracture), and issues of drug and materiel safety that had only been extrapolated from studies of men (e.g., chemical agent prophylaxis, fatigue countermeasures). Several important assumptions about female physiology and occupational risks were found to be astoundingly wrong. Hormonal changes through the menstrual cycle were less important to acute health risks and performance than predicted, exercise did not increase risk for amenorrhea and consequent bone mineral loss, and women tolerated G-forces and could be as safe as men in the cockpit if their equipment was designed for normal size and strength ranges. Data on personal readiness issues, such as body fat, physical fitness, nutrition, and postpartum return to duty, allowed reconsideration of standards that were gender appropriate and not simply disconnected adjustments to existing male standards. Other discoveries directly benefited men as well as women, including development of medical surveillance databases, identification of task strength demands jeopardizing safety and performance, and greater understanding of the effects of psychosocial stress on health and performance. This surge of research has translated into advances for the welfare of service women and the readiness of the entire force; relevant gender issues are now routine considerations for researchers and equipment developers, and some key remaining research gaps of special importance to military women continue to be investigated.

Engineering clinician leadership and success in tobacco control: recommendations for policy and practice in Hungary and Central Europe

Decades of research and advocacy to control tobacco use and related public-health harm have not counterbalanced the tobacco industry's successful stronghold, which is ever-increasing in countries with weaker anti-tobacco leadership. Current rates of tobacco use and harm in Hungary and other Central European countries mark them as some of the industry's greater successes. Following the Behavioural Ecological Model, a framework for behavioural and cultural change, this paper reviews important ways that dentists, physicians and other healthcare providers can counter the tobacco industry's influence on patients, communities, and the nation. The analysis includes policies and practices shown to be effective in controlling and undermining the tobacco industry, and outlines new policies and practices that show promise based on the behavioural change framework. The components of an all-encompassing tobacco-control programme are described through explicit recommendations for research, practice and policy that are necessary to establish a professional and societal culture that extinguishes the influence and harm of the tobacco industry in Hungary, Central Europe and developing countries worldwide.