Deborah Sherrill-Mittleman

Tobacco Use Harm Reduction, Elimination, and Escalation in a Large Military Cohort

OBJECTIVES We evaluated changing patterns of tobacco use following a period of forced tobacco abstinence in a US military cohort to determine rates of harm elimination (e.g., tobacco cessation), harm reduction (e.g., from smoking to smokeless tobacco use), and harm escalation (e.g., from smoking to dual use or from smokeless tobacco use to smoking or dual use). METHODS Participants were 5225 Air Force airmen assigned to the health education control condition in a smoking cessation and prevention trial. Tobacco use was assessed by self-report at baseline and 12 months. RESULTS Among 114 baseline smokers initiating smokeless tobacco use after basic military training, most demonstrated harm escalation (87%), which was 5.4 times more likely to occur than was harm reduction (e.g., smoking to smokeless tobacco use). Harm reduction was predicted, in part, by higher family income and belief that switching from cigarettes to smokeless tobacco is beneficial to health. Harm escalation predictors included younger age, alcohol use, longer smoking history, and risk-taking. CONCLUSIONS When considering a harm reduction strategy with smokeless tobacco, the tobacco control community should balance anticipated benefits of harm reduction with the risk of harm escalation and the potential for adversely affecting public health.

Tobacco use during military deployment

INTRODUCTION Tobacco use among military personnel is associated with significant health care expenditures, lost productivity, and compromised combat readiness. The prevalence remains high among military personnel and may increase in high-risk situations such as deployment. We assessed the prevalence of tobacco use across the deployment cycle, changes in tobacco use (nonuse, continued use, initiation/harm escalation, cessation/harm reduction) during deployment, and the impact of deployment history on tobacco use. METHOD Cigarette smoking, smokeless tobacco (ST) use, and dual tobacco use were evaluated among 278U.S. Air Force Security Forces personnel undertaking a 1-year deployment to a high-threat combat environment. Multinomial regression was used to examine prediction of tobacco use patterns both cross-sectionally and longitudinally. RESULTS More than half (53%-63%) of all Security Forces used tobacco at all stages of the deployment cycle. Individual tobacco use trajectories showed significant differences in prevalence rates of initiation/harm escalation and cessation/harm reduction when comparing the transition from predeployment to the deployed environment versus returning to postdeployment status. Airmen who had deployed more than once previously had a higher likelihood of using ST use at predeployment and engaging in dual tobacco use during deployment. CONCLUSIONS Findings suggest the potential benefit of targeted or universal interventions at each stage of the deployment cycle to reduce the onset, maintenance, or escalation of tobacco use behaviors in the U.S. military.

Binge Drinking, Drinking and Driving, and Riding with a Driver Who Had Been Drinking Heavily among Air National Guard and Air Force Reserve Personnel

Heavy drinking is associated with significant health problems and increased risk for injury and death. Although several studies have investigated alcohol use among active duty and civilian populations, little is known about the alcohol use patterns of reserve personnel. This study examined the prevalence and correlates of binge drinking, driving after drinking, and riding in a vehicle with a driver who had consumed alcohol among 4,836 guardsmen and reservists who were taking part in basic military training (mean age = 21.3 years; 29.4% female). Forty-six percent reported one or more binge drinking episodes in the month before basic military training. Four percent drove after consuming five or more drinks, while 8.9% rode as a passenger with a driver who had been drinking heavily. Several demographic, behavioral, and attitudinal correlates of risky drinking patterns were identified. Findings have potentially important implications for the health, safety, and military readiness of reserve personnel.

Trial design: The St. Jude Children's Research Hospital Cancer Survivors Tobacco Quit Line study.

Nearly, one-fifth of childhood cancer survivors (CCSs) smoke cigarettes. Because CCSs are already at greater medical smoking-related risks, targeting them for smoking cessation efforts is a high priority. One of the major challenges with smoking cessation in CCSs is how to reach such a geographically dispersed population. This study aims to demonstrate that these challenges can be overcome through the use of telephone-based tobacco quit lines (QLs). This report describes the design of the St. Jude Cancer Survivor Tobacco QL study, which is a randomized controlled clinical trial that will examine the long-term (1-year) efficacy of a counselor initiated vs. participant initiated tobacco QL with adjunctive nicotine replacement therapy (NRT) in both groups. Participants (N=950) will be recruited nationally and randomly assigned to one of the two interventions. The counselor initiated intervention includes six scheduled telephone sessions of a behavioral intervention and provision of 8 weeks of NRT. The participant initiated intervention allows the participant to call the QL at their convenience, but includes the same six telephone sessions and provision of 2 weeks of NRT. Both groups will receive two follow-up phone calls at 8 weeks and 1 year after enrollment to assess their smoking status. The primary outcome measure is cotinine-validated self-reported smoking abstinence at 1-year follow-up. Results from this study will provide the first evidence about the efficacy of intensive QL cessation intervention in this high-risk population. Such evidence can lead as well to the dissemination of this intervention to other medically compromised populations.

Prevalence and Correlates of Lifetime Smokeless Tobacco Use in Female Military Recruits

Although considerable research has been conducted on smokeless tobacco (ST) use in males, much less is known about the characteristics of female ST users. The present study examined the prevalence and correlates of lifetime ST use among female Air Force recruits (N=9,087). Participants were surveyed during Basic Military Training regarding their history of tobacco use and other health risk behaviors. Although the prevalence of current ST use was low (<1%; n=34), 6.6% (n=599) had tried ST. Multivariate logistic regression analysis indicated that lifetime ST use was related to ethnicity, with Native Americans and Whites being most likely to have tried ST. Additional correlates of lifetime ST use included post-high-school education (OR=1.26, 95% CI=1.03-1.55); weekly acts of road rage (OR=1.48, 95% CI=1.06-2.06); frequent arguing (OR=1.71, 95% CI=1.18-2.48); daily or near-daily alcohol consumption (OR=1.71, 95% CI=1.03-2.82); current cigarette use (OR=3.80, 95% CI=2.42-5.94); and experimental use of cigars (OR=4.01, 95% CI=3.22-5.01), pipes (OR=2.23, 95% CI=1.64-3.03), and clove cigarettes (OR=1.23, 95% CI=1.01-1.49), all of which were associated with an increased likelihood of ST use. Results suggest that female recruits who have ever used ST engage in a variety of risk behaviors including use of other tobacco products and alcohol, as well as additional harmful behaviors.

Relationship between smoking status and body weight in a military population of young adults

The purpose of the present study was to determine the association between smoking and body weight in a cohort of young U.S. Air Force recruits (mean age=20 years) enrolled in basic military training (N=35986). Twenty-two percent of recruits smoked daily prior to basic military training (n=8087) and were compared to never smokers, former smokers, and experimental or nondaily smokers. A three-way interaction among smoking status, gender and ethnicity suggested a small effect for daily smoking among White male recruits only and no significant differences for female recruits or members of any other ethnic group. Although there was a statistically significant relationship between smoking and body weight in White males, the effect size was approximately 1 kg. These results suggest that the energy balance differences in body weight between young smokers and nonsmokers are minimal and that it would take decades to accrue the differences typically seen in adult smokers.

Energy Underreporting in African-American Girls: A Longitudinal Analysis

BACKGROUND The objective of this study was to determine the longitudinal prevalence and predictors of dietary underreporting in African-American preadolescent girls and the association of baseline dietary underreporting with changes in BMI over a 2-year period as part of the Girls health Enrichment Multi-site Studies (GEMS). METHODS Energy was summarized at baseline, 12 months, and 24 months and computed as a 3-day average of 24-hour dietary recalls. Physical activity was assessed by accelerometer, basal metabolic rate was estimated using the World Health Organizations prediction equation, and caloric underreporting was based on the Goldberg equation. RESULTS We classified 48% of the girls at baseline as underreporters; with underreporting increasing over time (61% at 12 months; 66% at 24 months). Intervention treatment assignment did not affect the prevalence of underreporting over time. The consistency of underreporting (or not) stayed stable over time. Across all three time points, a higher BMI predicted underreporting. Baseline dietary underreporting and baseline BMI were found to be the major predictors of change in BMI, whereas baseline dietary variables did not predict change in BMI. CONCLUSIONS Dietary underreporting was extremely common in this sample of AA preadolescent girls and predictive of change in BMI. Given the magnitude and consistency of dietary underreporting along with the fact that no dietary variables predicted change in BMI, measurement of dietary intake in preadolescents, even with sophisticated measurement methodologies, appears biased. The best use of dietary recalls may not be to estimate dietary intake but rather to determine underreporting.

Do we believe the tobacco industry lied to us? Association with smoking behavior in a military population

Despite the dangers of smoking, tobacco companies continue to impede tobacco control efforts through deceptive marketing practices. Media campaigns that expose these practices have been effective in advancing anti-industry attitudes and reducing smoking initiation among young people, yet the association between knowledge of industry practices and smoking cessation and relapse has not been studied. In a large military sample entering Air Force Basic Military Training (BMT), where tobacco use is prohibited, we investigated (i) the prevalence of agreement with a statement that tobacco companies have misled the public about the health consequences of smoking and (ii) the association of this acknowledgement with smoking status upon entry into BMT (N = 36 013). At baseline, 56.6% agreed that tobacco companies have been deceptive, and agreement was a strong predictor of smoking status [smokers less likely to agree, odds ratio (OR) = 0.39, P < 0.01]. At 12-month follow-up, we examined the association between industry perception at baseline and current smoking status (N = 20 672). Recruits who had been smoking upon entry into BMT and who had acknowledged industry deception were less likely to report current smoking (OR = 0.84, P = 0.01). These findings suggest that anti-industry attitudes may affect smoking relapse following cessation.

Drinking and driving and riding with an alcohol impaired driver among United States Air Force recruits.

Objective: To identify the prevalence and correlates of binge drinking, driving after drinking, and riding in a vehicle with a driver who had consumed alcohol in US Air Force active duty recruits. Methods: A military cohort (N = 31,108; 25.1% female) was analyzed to identify variables associated with binge drinking, drinking and driving, and riding with a driver who had consumed alcohol. Results: Results indicated that 53 percent (including 45% of those under the legal drinking age) reported alcohol use in the month prior to entering basic military training (BMT). Thirty-eight percent of all active duty recruits reported binge drinking (ie, consuming 5 or more drinks on a single occasion) at least one time in the past 30 days. Nearly 1 in 4 (23%) reported 1 to 3 episodes of binge drinking. Three percent of reported alcohol users drove after consuming five or more drinks, and 9 percent rode as a passenger in a vehicle with a driver who had been drinking heavily. Conclusions: Several demographic, behavioral, and attitudinal correlates of risky drinking patterns were identified. Prevention efforts are needed to address the implications of these findings because they influence the health, safety, and military readiness of active duty personnel.