1. Smoking Cessation in the Military: Challenges, Solutions, And Issues for Women Smokers Robert C. Klesges, Ph.D. Professor, Department of Preventive Medicine, U. of TN Health Science Center & Department of Cancer Prevention and Control St. Jude Children’s Research Hospital

2. The NIH Revitalization Act (1994) as it Pertains to Women Women shall be included in all human subjects research. Women should be included in sufficient numbers to be able to detect intervention differences. Cost cannot be cited as a reason for exclusion and NIH outreach programs shall be initiated to recruit and retain women in studies.

3. Has The Revitalization Act Worked For Women? Pub Med search from 1995-present. Completed four searches: 1.Smoking cessation/treatment/intervention; 2.Added “women”; 3.Replaced “women” for “military”; and 4.Included both “women” and “military”

4. Results of search Search Phrase # of Articles (%) Smoking cessation25,290 Smoking cessation & women14,932 (59%) Smoking cessation & military 162 (0.6%) Smoking cessation & military & women 108 (0.4%) Of all studies with “smoking cessation & military & women”, our research team accounted for 25% of all citations.

5. Understanding Smoking Within the Context of The Military and Deployment. Want to share the experience that so many of our troops go through. Leaving their loved ones, deployment, and returning home.

6. Conclusions from AF I The smoking ban in BMT produces significant smoking cessation. In short, smoking bans work, particularly for women. Extending the smoking ban to Tech Training is a logical next step. Make smoking a hassle. But what happens to nonsmokers following BMT?

7. One-year initiation rates among nonsmokers

8. Air Force II* Longer interventions Tailored interventions – different interventions dependent on baseline smoking and smokeless status. Three different interventions. AF II was also very large (n = 33,215) *Funded by the National Heart, Lung, and Blood Institute of NIH

9. Results The smoking ban worked again (29% of airmen had not smoked in the past 7 days and 14% had not smoked at all since BMT). Smokers assigned to the cessation intervention were 18% less likely to be smoking. Smokeless users assigned to the smokeless intervention were 24% less likely to be chewing. Marked smoking initiation rate as found previously.

10. Air Force III* While AF I and II addressed maintaining cessation following a smoking ban, the next study addressed those who relapsed following BMT as well as those who initiated smoking in the military. AF III is testing the efficacy of a proactive quit line for domestic and deployed troops. *Funded by the National Heart, Lung, and Blood Institute of NIH

11. Results to date Have enrolled nearly 350 participants all around the globe, including several from as far away as South Korea. Minority recruitment (32%) is much higher than the rates in the Air Force population (21%). Recruitment of females (34%) greatly exceeds the number of females in the Air Force (19.5%).

12. Develop America's Warrior Airmen Today... for Tomorrow Develop and Sustain Warrior Airmen, Train Joint Forces, and Strengthen Coalition Partnerships SAMMC Tobacco Quitline No classes to attend Telephone-based counseling that fits your schedule Free nicotine replacement patches mailed directly to your home Open to active duty and reservists who are 18 years old or older Smoke 5 or more cigarettes per day Call 1-877-SAMMC-11 Sponsored by the University of Tennessee, Wilford Hall Medical Center and the National Heart, Lung and Blood Institute

13. Air Force IV* Funded to understand why military personnel have such a high prevalence of smokeless tobacco and dual use. Tobacco companies are aggressively marketing their new product called snus and several flavors of snus will be targeted to women. “The new (FDA) law…prohibits any cigarette with a characteristic flavor, but does not apply to any other tobacco products.” *Funded by the National Cancer Institute of NIH

16. Conclusions About Smoking and Women in the Military Females in the Military Are Less Likely: –Start smoking after Basic Military Training Females in the Military Are More Likely: –Smoke “light” or “ultralight” cigarettes –Among smoking women, the smoking ban is particularly effective – they are much more likely to remain abstinent following intervention and forced cessation during Basic Military Training. Smoking rates especially high among white women (nearly 1/3 smoked daily prior to BMT). Binge drinking and weight concerns strongly related to smoking in women

17. Conclusion: What can we do to promote a smoke free military? Deployment does not automatically mean high smoking rates. The more we can make using tobacco products a “hassle”, the better (protracted smoking bans, smoking restrictions). Should we sell tobacco in the BX/PX? Cigarette sales in the BX/PX are not in the military’s control.

18. We cannot afford to do face-to-face counseling for tobacco control. Tobacco quit lines, particularly when participants receive free nicotine replacement therapy. Tailored web based programs for the military. I phone/I touch “apps”. Tailored print (or web) communication. Conclusion: What can we do to promote a smoke free military?

19. Officers as role models. Only about 5% of officers smoke. While the IOM recommendation to gradually eliminate smoking in the military may not be completely feasible, having a smoke free officer corps is highly feasible. Targeted programs should address the unique needs of women smokers in the military. Conclusion: What can we do to promote a smoke free military?

20. Significant challenges While not impossible to intervene during deployment, it is still a challenge. Tobacco companies are always a step ahead of us, marketing snus for when smokers are prohibited from smoking. Dual use of smoking and smokeless tobacco is rampant in the military. Tobacco companies are aggressively marketing tobacco to women in general and women in the military in particular.