Epidemiology
Tobacco use, both smoked and smokeless, continues to be a major health behavior problem
in both the Navy and Marine Corps. The most recent available and reliable data indicates
an overall smoking rate of 34.9 percent in the Navy and 35 percent in the Marine Corps,
and military smokers tend to be heavier smokers.
The use of smokeless tobacco products (chew, dip, spit, and snuff) is at 13.2 percent
DoD wide, with the USMC obtaining the highest consumption rates at 24 percent, and the
Navy using at a 12 percent rate. Many observers suspect that the reported data of
smokeless prevalence rates among Marines are low.
The use of cigars and pipes has been surveyed and revealed overall prevalence rates of
28.4 percent among the Marine Corps and 17.1 percent among the Navy. The 1995 DoD survey
data suggests that the Marines and the Navy have higher prevalence tobacco rates of
smoking and smokeless usage than the civilian population; and that the prevalence rates
have been declining since they have been measured in 1980.
Tobacco Hazards
Tobacco contains over 4,000 chemicals that include carcinogens (nitrosamines),
heavy metals (cadmium), poisons (arsenic), and radioactive elements (radium and polonium).
The menthol component of cigarettes adds an additional risk since menthol allows deeper
lung penetration of tobacco smoke leading to a greater risk of deadly small cell lung
cancer.
The nicotine present in tobacco is the addictive component that enhances habit
formation. Studies have shown it to be as addictive as opiates. While its link to cancer
has been fully established, according to the book Nicotine Safety and Toxicity, the
nicotine in tobacco has not been shown to be a carcinogen in any animal based studies.
Nicotine acts as a vasoconstrictor, a stimulant, and an appetite suppressant.
Smokeless tobacco is equally as dangerous as smoked tobacco. It has more nicotine by
weight than smoked tobacco and is therefore considered more addictive. Smokeless tobacco
also produces additional carcinogens when mixed with saliva. Extra care must be taken when
working with smokeless tobacco cessation due to the heavier addiction to nicotine.
The current fad with cigars is considered to be extremely dangerous. The average cigar
is the diameter of an index finger and has 6 times the nicotine of a cigarette. This
increase also pertains to the increase of carbon monoxide, tars, and carcinogens. The risk
of lung cancer is equal to smoking cigarettes but the risk of head and neck cancer is
greatly increased. Cigar smokers generally do not inhale as with cigarettes but the
contents are puffed and held in the oral cavity, thus leading to the increased risk of
head and neck cancers.
Second hand smoke (environmental tobacco smoke, passive smoke, side
stream smoke) has been labeled as a Class A carcinogen by the Environmental Protection
Agency. This action helped lead to the removal of all tobacco use in all Federal
facilities. This smoke has been linked to lung cancer, heart and vascular disease,
respiratory infections, and asthma in non-smokers. Approximately 4 million children each
year are seen in acute care due to middle ear infections, upper respiratory infections,
and asthma, linked to parental / caregiver smoking.
Intervention
The Navy and Marine Corps have encouraged cultural change and cessation efforts by
banning tobacco use during recruit training, prohibiting tobacco use in the workspace,
making tobacco prevention and cessation an integral part of the Health Promotion and
Semper Fit programs, promoting healthy lifestyles, and by offering cessation treatment
programs. Despite progress, some researchers have found that up to 10 percent of
graduating boot camp recruits begin a tobacco habit upon leaving basic training and up to
80 percent previous users return to their tobacco habit.
Most smokers and smokeless users begin during adolescence. The reasons an individual
smokes and or chews/dips are complex and are usually maintained and reinforced by a
combination of behavioral, psychological, and physiological factors. Nicotine is an
addictive drug and nicotine dependence is listed in the psychiatric nomenclature (DSM-IV)
as a substance use disorder.
A one-time message of tobacco use intervention / cessation in a clinical setting has
been shown to have a 5 percent success in getting tobacco users to either quit or to
decrease their tobacco habit. Although this may be a small percentage, each opportunity
needs to be taken to help decrease the use of tobacco. The medical community has a unique
opportunity and the means to help tobacco users quit. In keeping with current Navy
guidelines, the Agency for Health Care Policy and Research (AHCPR) and the National Cancer
Institute (NCI) recommends that the Physician utilize the "Ask, Advise, Assist,
and Arrange" Program.
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Tobacco use intervention should occur at each patient visit. The medical officer asks
about tobacco use at every contact/visit, identifies users and assesses the patients
readiness to quit. Initial questions for each patient could include the following: Do you
use tobacco? What type(s) of tobacco do you use? How much do you use per day
(packs/pouches/cans)? Not every person is ready to change their nicotine habit, and
studies have identified a consistent behavior change pattern, which may be helpful in
understanding and facilitating change. The transtheortical model emphasizes stages of
change: precontemplation, contemplation, preparation, action, maintenance, and
termination. The key features of this model are that an individuals readiness to
change can be assessed; and that specific interventions are tailored to the persons
stage of change, in order to increase the likelihood of success.
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The physician has the influence, as a credible expert in a position of authority, to
suggest and advise patients to quit tobacco use. The medical officer may state, in
a kind, warm, serious and direct manner, for the patient to quit. One often used phrase
is- "As your physician, I must advise you to quit", or another is "I need
you to know that quitting smoking/smokeless tobacco is the most important thing you can do
to protect your current and future health".
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Each tobacco user should be informed of the hazards of tobacco use, the benefits of
quitting, and where to get help in quitting. Additionally, if the patient is pregnant, the
expecting mother must be informed that her tobacco use is harming both herself and her
fetus. This harm could include low birthweight / preterm birth, spontaneous abortion, or
miscarriage. The nicotine of the tobacco product is concentrated in the fetal tissues and
acts as a fetal neurotoxin. Studies also show that the baby born of a tobacco-using mother
will undergo nicotine withdrawal upon birth.
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The physician assists the patient by discussing various quitting strategies (cold
turkey, tapering, nicotine fading), and by reviewing common and specific problem areas
(withdrawal symptoms, tension, cravings, weight gain, psychosocial stressors, and relapse
prevention). The physician also assists by listening to concerns and issues, by
providing self-help materials, and if possible, by establishing a quit date.
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The final and critical step is to arrange follow up supportive care and or other
more intensive interventions such as a referral to a formal tobacco cessation program.
Scheduling follow up supportive appointments or phone calls assists with fostering a
therapeutic relationship, helps with the commitment to quit, offers support and
surveillance, and increases the number of quit attempts and quitters. Each user should
receive a prepared wallet-sized card or paper-slip at each visit with the phone number and
location of the tobacco cessation program.
Any counseling given to patients must be given in an encouraging, empowering manner.
Current studies show that 48 percent of 18 to 24 year old Marines use smokeless tobacco.
This fact coupled with an alarming increase in teen / young adult smoking (1.5 million
start each year), leads to a more difficult group to encourage to quit. Although young
tobacco users have an advantage in that they have spent fewer years forming their tobacco
habit, their young age suggests that they will have greater risk taking behaviors and less
fear of the fatal effects of tobacco use. These youthful tobacco users would best be
reached by appealing to their sense of esthetics and monetary budgeting.
The aging effects of tobacco (wrinkling), yellowing teeth, stained hands, offensive
breath odor, and the monetary costs ($1,100 per year for 1 pack / day) of tobacco use
should be strongly used to effect a decrease or cessation of their tobacco habit. Current
research shows gradual reduction in tobacco use demonstrates to the user that they have
control of their habit and that they can indeed quit. People who have successfully kicked
their tobacco habit have made, on the average, at least 6 serious attempts.
Regardless of the message content, the key is to empower the tobacco user in their
attempt to quit by providing brief, uplifting advice and motivational counseling. The
medical officer may use the patients medical history, presenting complaints,
physical exam, results of the lab tests and non-health reasons (cost, inconvenience, role
model, self esteem) to help personalize the message to quit. The expression of confidence
in the patients ability to quit and accentuating the positives of quitting seem to
be beneficial.
Cessation Medications and Counseling
The benefits of nicotine replacement therapy (NRT), medicinal adjuncts (Bupropion),
herbal replacements (non-tobacco / mint snuff products) and behavior modification should
be considered in any cessation counseling. Numerous studies have established the
effectiveness of NRT, and the AHCPR Clinical Practice Guidelines recommend that NRT should
be offered to every smoker, except when medically contraindicated. Each patient should be
informed that nicotine has not been shown to be a carcinogen. Nicotine is simply the
addictive component of tobacco.
The list of NRT and adjunctive medications / materials is growing daily. Since no one
single product is appropriate or suitable for all patients, the cessation counseling
should include a brief description of materials available to allow patients the
opportunity to select a program that fits their specific needs. Some of the tested,
efficacious medications / adjuncts available include:
Nicotine Replacement Therapy (NRT)
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Transdermal Patch- Nicoderm, Habitrol, Prostep, Nicotrol
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Nicotine Gum- Nicorette 2 and 4 mg. (mint and regular flavor)
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Inhaler: Nicotrol Inhaler
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Nasal Spray: Nicotrol N/S
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Sublingual Tablet: 2 mg Nicotine Sublingual Tablet (awaiting FDA approval)
Psychoactive Medication
Herbal Replacement
The GMO does not have to be the only medical provider involved in the tobacco cessation
process. Studies have found that by use of a systematic, coordinated office plan or a
prevention team approach, such as the national PPIP (Put Prevention Into Practice)
program, increases success, is effective, and is time efficient. This team approach can be
accomplished by screening for tobacco use as a fifth vital sign; asking about tobacco at
every work station; documenting tobacco use; and by encouraging Sailors and Marines to
quit by every member of the health care team. Also helpful is selecting a tobacco
cessation coordinator who trains the team, and sets up, implements, and evaluates the
tobacco clinic program.
The gender differences in nicotine dependence treatment are also very important to
note. Women have been shown to be biologically less sensitive to nicotine levels, more
sensitive to the method of nicotine delivery, more sensitive to non-pharmacological
effects, and less receptive to psychoactive effects. Studies indicate that female hormones
may account for some of these differences. Men have been shown to be more sensitive to
nicotine levels than women. Additionally, women are much more sensitive to issues
regarding weight gain and social factors associated with tobacco use. These differences
have strong implications in the delivery of cessation programs and should be addressed on
an individual basis.
The issue of weight gain is a very important in light of the current military, physical
readiness standards. Studies indicate that quitting tobacco can result in up to a 7
percent decrease in the metabolism of some patients. Nicotine is both a stimulant and an
appetite suppressant. Patients quitting tobacco must be counseled to increase their
exercise routine and to watch their dietary intake. Patients concerned about weight gain
should be referred for dietary / nutritional counseling.
Tobacco cessation programs are offered through the Health Promotion Program at the MTF
or at the Wellness/Semper Fit Center. The program usually offers a variety of self help
materials, as well as a formal behavior modification program, such as the American Cancer
Society Fresh Start Program, or a local program tailored to promote cessation for the
beneficiary population. All Navy/Marine Corps tobacco cessation programs offer some type
of pharmacotherapy (NRT patches/ gum or Zyban/Wellbutrin) along with the behavior change
class. Additional resources may be obtained from the American Lung Association, the Center
for Disease Control and Prevention, the American Heart Association, as well as the
American Cancer Society.
Relapse
Relapse is a frequent occurrence with nicotine cessation and is a natural part of the
change process. Most smokers make four to seven serious attempts to quit before they
succeed. Early relapsers tend to resume tobacco use due to withdrawal symptoms,
weight gain, cravings and habit within 48 hours to one week. Psychosocial factors, such as
interpersonal problems, stress, emotional difficulties, and/or crisis; or due to stimulus
control- such as tobacco with coffee, food or alcohol, are the primary reasons for later
relapse. Most studies have found that relapse occurs within 30 to 60 days.
Former tobacco users should be counseled that relapse is a very real possibility if
their "non-tobacco use guard" is let down. Former users benefit from learning
that a quit is only one day at a time and that one slip does not mean a full return to
tobacco use. Patients returning to tobacco use should be questioned about recent life
changes that may require further evaluation for stress management, relaxation, and / or
coping strategy counseling.
Additional information on tobacco intervention and cessation can be obtained from the
following sources via the Internet:
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http://www.ahcpr.gov/clinic/smokepcc.htm (Current Agency for Health Care Policy and
Research, Clinical guidelines for tobacco cessation)
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http://nmimc-web1.med.navy.mil/MED-06/tobacco\tobacco.htm (Link to various tobacco
hazard and Nicotine Replacement Therapy presentations)
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http://www-nehc.med.navy.mil/hp/tobacco/index.htm (Navy Health Promotion Tobacco
Cessation website, with presentations and information)
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http://www.srnt.org (Society for Research on Nicotine and Tobacco website with links to
worldwide resources)
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http://www.cancer.org/gasp/index.html (Great American Smokeout website, updated each
year)
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http://www.zyban.com/aol2/Pages/zap.htm
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http://www.nicorette.com/
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http://www.nicodermcq.com/
References
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A Review of the New Strategies from the Agency for Health Care Policy and Research,
American Pharmaceutical Association, 1996.
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Fiore, M, et al., The Effectiveness of the Nicotine Patch for Smoking Cessation, A
Meta-analysis, JAMA, 1994.
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National Institute of Health, Internet Source
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NicNet, Internet Source.
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Pomerleau, C. Smoking and Nicotine Replacement Treatment Issues Specific to Women,
American Journal of Health Behavior, 1996; 20(5): 291-299.
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Prochaska, J. In Search of the Structure of Change, NIH Grant CA 27821.
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Society for Research on Nicotine and Tobacco, Internet Source.
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U.S. Navy Manual of the Medical Department, chapter 6.
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Bray, R, et al 1995 Department of Defense Survey of Health Related Behaviors Among
Military Personnel, Research Triangle Institute, December 1995.
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Prochaska, J, Norcross, J, DiClemente, C. Changing For Good. New York: Avon Books, 1994.
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Glynn, T, Manley, M, Solberg, L, Slade, J. Creating and Maintaining an Optimal Medical
Practice Environment for the Treatment of Nicotine Addiction. In Nicotine Addiction
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Principles and Management. Eds. Orleans T, Slade J. New York: Oxford Press, 1993.
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Counseling to Prevent Tobacco Use. In Guide to Clinical Preventive Services, 2nd
ed., Report of the U.S. Preventive Services Task Force. Baltimore: Williams &
Wilkins,1996.
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Glynn,T, Manley, M. How To Help Your Patients Stop Smoking. National Cancer Institute,
U. S. Department of Health and Human Services. NIH PubNo. 97-3064, September, 1997.
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Benowitz, N. Nicotine Safety and Toxicity, New York: Oxford University Press, 1998.
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AHCPR. Smoking Cessation. Clinical Guideline Number 18. AHCPR Publication No. 96- 0692,
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April 1996.
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Hurt, R. et al. A Comparison of Sustained Release Bupropion and Placebo for Smoking
Cessation. NEJM, 1997;337:1195-1202.
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Hughes,J. et al. Recent Advances in the Pharmacotherapy of Smoking. JAMA, 1999;
281:72-76.
Prepared by CDR Larry N. Williams, DC, USN, Advisor to MED-06 on tobacco issues,
Naval Dental Center, Norfolk, VA, and Mark A. D. Long, Ed.D., Tobacco Cessation Program
Manager, Health Promotion/Medical Management, Navy Environmental Health Center, Norfolk,
VA, 23513, DSN 253-5599, Comm 757-462-5599.
Thanks to Navy Environmental Health Center readers Bill Calvert, MS, MPH, MBA, LCDR
Moon H. Jan, MC. USN, and Robert Morrow, M.D., MPH for their helpful comments. (1999).