A recent Department of Defense survey of health-related behaviors found 31% of U.S. naval personnel smoke cigarettes (www.tricare.osd.mil/ analysis/surveys/98survey/survey.html). Although this might appear to be a significant decline in cigarette use from the more than 50% reported in 1980, it falls significantly short of the Healthy People 2000 objective of 20%. Even more alarming is the high rate of smokeless tobacco use of 9.2% and the almost doubling of cigar and pipe use—31% compared to 17% in 1980. Sailors continue to use tobacco products, even though most are aware of the significant adverse health effects.
Tobacco dependence should be viewed as a chronic disease with remissions and relapses. Continued therapy and surveillance are necessary to maximize good outcomes, and a formal cessation program has been shown to increase long-term abstinence. Most such programs use behavior, cognitive, and educational therapy combined with replacement products to target the multilayered aspects of addiction. The Tripler tobacco cessation program has a 27% success rate at one year, which compares favorably to an average 20% success rate among similar programs. The main predictor of abstinence from a treatment program among active-duty military was found to be class attendance.
A recent review of physical fitness assessment questionnaires of 1,416 Trident submariners at Bangor, Washington, demonstrated overall tobacco use to be 27%. There may be several reasons for the lower usage rate among these submariners. The two-crew structure affords individuals more opportunities to participate in cessation programs. The local military treatment facility, Naval Hospital Bremerton, also has one of the Navy's most active programs, with 20 group classes offered per month at various times and locations. Recently, Commander Submarine Group Nine, Rear Admiral Charles Griffiths, initiated a quit tobacco campaign. Once every three months a classroom is reserved and a message is put out to all area commands requesting mandatory attendance for tobacco users. Admiral Griffiths addresses the audience, and the program director then discusses how to start quitting.
By the end of a tobacco cessation program more than 50% of people have quit. Unfortunately, about half of these individuals return to tobacco usage. Nicotine craving and habit are cited as the primary motivators for relapses and continuation of smoking, but are we doing enough to encourage and support smoking cessation? Do we reward smokers with smoking breaks?
In addition to the quarterly address by the admiral and the tobacco cessation program director, Submarine Group Nine recently initiated an onboard tobacco cessation program. Such a group requires minimal resources (i.e., an individual designated as moderator) and can be incorporated into the plan of the day to meet once a week. Volunteers from each crew are trained by the hospital's program director. Training involves one four-hour indoctrination course followed by participation in several group and individual treatment sessions. Total training time does not exceed 12 hours. All of the necessary information to start and maintain a group can be found at the Surgeon General's web site (www.surgeongeneral.gov/tobacco/tobarqrg.htm).
The Healthy People 2010 objectives set a target of 12% for cigarette smoking, 0.4% smokeless tobacco, and 1.2% for cigar smoking. As a community with easy access to clinical resources dedicated to tobacco cessation, it should be relatively easy for us to decrease the number of tobacco users on board the fleet's submarines. Our goal should be to provide an environment that is conducive to quitting and to remaining tobacco free. In the present climate of health promotion, where every individual is an essential player needed to carry out the mission, we no longer can afford to take a passive stance. A concerted and active approach from the top down is required to stop this epidemic.
Lieutenant Escobar is the undersea medical officer of Submarine Group Nine.