Educating Air Force Generals About Tobacco Use & Risks

The Military Health System and the Defense Health Agency last November published a grossly misleading article on their website titled, “Quit the spit: Smokeless tobacco no better than lit” (archived article here).  After I educated Air Force officials, the article was removed.  Here is the story. 

The piece wrongly asserted that smokeless tobacco (ST) use is equally harmful as smoking:

“…putting in a dip or a chew can cause as much harm as lighting up cigarettes... ‘A lot of the effects smoking has on the body – causing blood vessels to narrow raising blood pressure and causing several cancers – are the same for smokeless tobacco,’ said Air Force Col. Thomas Moore, a preventive medicine doctor and in charge of health promotions for the Air Force Medical Support Agency... ‘You’re really not gaining anything by giving up cigarettes just to put in a load of chew,’ said Moore.” (emphasis added)

In a November 18 email I advised Colonel Moore of the article’s numerous errors:

“These passages send the clear, unmistakable and completely false message to military personnel that smokeless tobacco use is just as dangerous as smoking.  Numerous scientific studies published over the past twenty years provide indisputable evidence that smokeless tobacco use is vastly safer than smoking.  For example, a 2002 report by the British Royal College of Physicians (here), one of the world’s oldest and most prestigious medical societies, stated ‘As a way of using nicotine, the consumption of non-combustible [smokeless] tobacco is on the order of 10-1,000 times less hazardous than smoking, depending on the product.’

“Your just-as-dangerous message may be considered a breach of medical ethics.  A 2004 study (here) authored by a panel of international tobacco research and policy experts concluded: ‘…[smokeless] products pose a substantially lower risk to the user than do conventional cigarettes.  This finding raises ethical questions concerning whether it is inappropriate and misleading for government officials or public health experts to characterize smokeless tobacco products as comparably dangerous with cigarette smoking.’

“Members of our armed forces put their lives on the line every day.  The Military Health System and the Defense Health Agency should show them respect by giving them truthful information about tobacco use.  There is a lot at stake.  In another 2007 report (here) the Royal College concluded ‘...that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.’

“I urge you to promptly retract the article or issue a substantial revision to reflect the indisputable evidence that smokeless tobacco use is vastly safer than smoking.  Please let me know if I can provide any additional information to facilitate this action.  I appreciate your prompt response to my request.”

In the absence of a response, I sent a similar email to U.S. Air Force Surgeon General Mark Ediger.  This generated a reply from Major General Roosevelt Allen, Jr., Director of Medical Operations & Research in the Office of the Surgeon General.  He wrote that I was “correct in stating that current scientific evidence clearly delineates different levels of health risk associated with the various forms of tobacco use,” and he promised “to see if it is possible to post a clarification of the article on the Health.mil site.”

At General Allen’s request, I supplied a portfolio of published medical articles on ST and tobacco harm reduction. 

Sometime in February, the offending article was removed from the military website.  It is evident that senior Air Force health officials recognized that the Defense Health Agency’s article was indefensible, given the vast difference in risks involved in smoking and ST use.  I am hopeful that this awareness will translate into a rational tobacco policy at the Department of Defense and beyond.

Smokeless Tobacco Helps U.S. Air Force Achieve Low Smoking Rate

“According to the Centers for Disease Control and Prevention, smokeless tobacco is just as harmful as smoking…” 

This egregiously false claim appeared in a June 8 Air Force Times article by Phillip Swarts (here).

A mountain of scientific evidence amassed over two decades attests that smokeless tobacco use is at least 98% safer than smoking (here and here).  Further, while the CDC has been less than forthright in characterizing relative tobacco risks (here), the agency has never asserted that smokeless products are as dangerous as cigarettes.

I emailed Mr. Swarts, requesting a correction: “The CDC has never made such a claim in a public forum.  Please let me know if you have the CDC on record with such a claim.” 

The reporter’s response, void of fact checking, repeats a common misconception, to wit: “A quick Google search will turn up several such statements from the CDC, Mayo Clinic, American Cancer Society, and other health experts.” He is wrong, again.

Seven years ago, I wrote, “Our armed forces put their lives on the line every day; they use tobacco to help manage the resulting stress…It's time for DOD and other agencies to stop the misinformation campaign about tobacco. Show soldiers respect by giving them truthful information about smoking and smokeless tobacco use.” (here) 

Instead, military spokespeople continue to issue ill-informed and misleading pronouncements. Typical is Air Force Colonel John Oh’s 2015 remark (here): “If the Air Force was a state, we would have the second lowest smoking prevalence in the nation — that's the good news.  But we would also have the fourth highest smokeless tobacco use.”

Second lowest and fourth highest: Colonel Oh was complaining, but he should have been bragging.  His rankings are proof that, despite the government’s wrongheaded campaign against smokeless tobacco and the Air Force Times’ sloppy reporting, airmen and women are doing right by using far safer smoke-free products rather than smoking. 


         

Smoking Gun: Manipulating Definitions

A report just published in Nicotine & Tobacco Research (abstract here) draws an obvious conclusion: How surveys define cigarette smokers and smokeless tobacco users influences the prevalence rate of dual use (consumption of both products).

Robert Klesges and colleagues used information obtained from Air Force recruits to show that if dual users are defined as using both products daily (a narrow definition), prevalence of dual use will be low. However, if dual users are defined as using either product once in the past month (a broader definition), prevalence of dual use will be high.

It is not surprising that Dr. Klesges found that defining tobacco use influences survey results. In 2001, he co-authored a study (with first-author C. Keith Haddock, abstract here; hereafter called Haddock-2001) that perfectly demonstrates how definitions can be manipulated to produce desirable results. Haddock-2001 purported to show that smokeless tobacco use is a gateway to smoking among Air Force recruits; it has been widely cited in American prohibitionist attacks on smokeless tobacco. In fact, its results are based on manipulation of definitions.

Haddock-2001 studied 14,340 men (average age, about 20 years) who had never smoked when they reported to Air Force basic training in 1995 and 1996. After one year, Dr. Haddock followed up with 7,865 subjects, finding that 1,099 of them were smoking. That’s a 14% smoking initiation rate among 20-year old men after one year in the Air Force! At one year, Haddock-2001 also found that, compared with recruits who had never used tobacco before basic training, recruits who were current smokeless users were 2.33 (95% Confidence interval = 1.84 – 2.94) times more likely to be smoking.

First, how did 14% of first-year never-smoking Air Force recruits start smoking? It turns out that this number is grossly inflated. In 1999, Drs. Klesges and Haddock had published a study of these same recruits (abstract here; hereafter called Klesges-1999), in which they reported that only 8% of never smokers had started to smoke after one year in the Air Force.

The discrepancy between Haddock-2001 and Klesges-1999 is due to differences in the category definitions of smoking, summarized in this table.

Different Definitions of Smokers in Klesges-1999 and Haddock-2001
Category	Klesges-1999	Haddock-2001(%)
At Enrollment
Never Smoker	Never smoked a cigarette	Never Smoked regularly
Experimental Smoker	Smoked on one or two occasions, never regularly	Not mentioned
Ex-smoker	Smoked regularly, but quit	Smoked regularly, but quit
Current Smoker	Smoked regularly, at least one cigarette per day	Smoked regularly, at least one cigarette per day
At One Year
Current Smoker	Smoked even a puff in last 7 days	Smoked even a puff in last 7 days

At enrollment, Klesges-1999 identified a group of “experimental smokers,” 26% of whom became smokers at the one-year follow-up. But Haddock-2001 never mentioned experimental smokers, which means that they were in the “never-smoking” group at enrollment; that significantly accounts for the 14% initiation rate, instead of the 8% rate found in the Klesges-1999 report.

It is likely that many Haddock-2001 smokeless tobacco users were also experimental smokers. The only apparent reason to eliminate the experimental smoker category and effectively shift those subjects to the never-smoking category was to bolster the case for labeling smokeless tobacco use as a gateway to smoking.

Dr. Haddock also defined current smoking differently at enrollment than after one year of follow-up. Good practice in scientific investigation is to establish definitions and stick with them throughout a research project. As the table shows, Haddock-2001 defined a current smoker at enrollment as smoking at least one cigarette per day, but then defined a current smoker at one-year as someone who smoked even a puff in the last 7 days.

The manipulation of smoking definitions in Haddock-2001 casts considerable doubt on its claim that smokeless tobacco use is a gateway to smoking.

The Consequences of Tobacco Prohibition and Misinformation in the U.S. Air Force

A new study about tobacco use among Air Force recruits, before and one year after basic training, has been published in the American Journal of Public Health (abstract here). The authors include two vocal tobacco opponents, Dr. Robert C. Klesges of the University of Tennessee (Memphis) and Dr. Jon O. Ebbert of the Mayo Clinic.

Dr. Klesges looked at tobacco use among airmen (an Air Force term used for both men and women) who made up a control group in a large study combining universal forced tobacco abstinence during 6 weeks of basic training and an “intervention” consisting of tobacco prevention or cessation. The results from the large study were published in 2006 (I refer to it as Klesges I, the abstract is here; I refer to the current study as Klesges II).

Klesges classified recruits based on their tobacco habits prior to basic training (baseline): nonusers of tobacco, smokers, smokeless users and dual users. In addition, he described tobacco prohibition:

“During basic military training, there is a total tobacco ban…and the prohibition is strictly enforced. At the beginning of basic military training, airmen are searched and all tobacco products are confiscated. Tobacco products are considered ‘‘contraband’’ along with alcohol, drugs, weapons, and chewing gum. The airmen recruits are required to maintain a ‘money list’ (i.e., a list of all serial numbers for all their money), which is checked regularly by basic military training instructors. Airmen are under constant supervision, and there are no tobacco products accessible even during those rare occasions when airmen are not supervised. An honor code is established early in basic training so that if a recruit breaks the rules, fellow airmen are duty bound to report the infraction. Finally, the punishment for tobacco use during basic military training is severe. In virtually all cases, the airman is ‘recycled’ (forced to repeat some or all of basic training), a possible sanction that few airmen dare risk.”

That is serious tobacco prohibition, and perhaps Klesges et al. hoped that none of the 5,225 Air Force recruits would be using tobacco 12 months later. That didn’t happen.

Klesges reported that 11% of recruits who were nonusers at baseline were smoking 12 months afterwards. As he admitted in Klesges I, “the smoking prevention program had no impact on smoking initiation.” So airmen started smoking in large numbers despite boot-camp tobacco prohibition and prevention programs.

In Klesges II, the main focus was on the 6% of smokers at baseline who were dual users afterwards. He classified this transition as harm escalation, which is an appalling misrepresentation of reality. It is scientifically established that smokers who switch to dual use smoke fewer cigarettes and have lower health risks (described here).

Other data in Klesges II were informative. Fewer than 1% of baseline smokers were smokeless users at follow-up, but 15% of baseline smokeless users were dual users and 14% were smokers at follow-up. In addition, 42% of dual users at baseline were smokers at follow-up. Thus, the transition from smokeless to cigarettes was more common than from cigarettes to smokeless. How did this happen? This is strong evidence that tobacco users in the Air Force are not properly informed about the risks of smoking and smokeless use. Unfortunately, they are making very bad decisions based on misinformation.

A big concern with this study is that the numbers don’t add up, compared with Klesges I. That study started with 7,974 airmen, compared with only 5,225 airmen in this study. In Kleges I, there were 312 smokeless users at baseline, but in Klesges II, there were only 193 (38% fewer). In Klesges I dual use was not a tobacco category, so we have no idea how it classified those 249 airmen from Klesges II. In short, reconciliation of different numbers between Klesges I and II is impossible, which is an indicator of low quality and inconsistency.

Klesges concludes that “[harm] escalation is a possible unintended consequence of promoting smokeless tobacco as a harm reduction strategy for smokers.” He is wrong. Harm escalation is the unintended consequence of not telling smokers and smokeless users the truth about the health risks.