U.S. Military’s Misbegotten Message to Troops: Cigarettes Are Safer Than Vape Products

With regard to tobacco products, the U.S. Department of Defense isn’t serving the health interests of those who serve.

As I have documented many times (here, here, here and here), in pursuing a tobacco-free fighting force, DOD has grossly misinformed American service members about the relative safety of smokeless tobacco and e-cigarettes. 

David Sweanor recently posted the photo at left from an Army and Air Force Exchange Service store. 

Even worse is this Military Times article from September 24,

about the removal of vaping products from Army, Air Force and Navy exchanges by October 1, owing to “the outbreak of mysterious vaping-related lung injuries.” 

Actually, that mystery has been solved.  CDC Principle Deputy Director Dr. Anne Schuchat said on October 25, “The vast majority of patients with [lung injuries] including those who died…, had a history of use of e-cigarette, or vaping, products that contained THC.”

DOD removed products that we now know did not kill 34 Americans who were instead vaping contaminated marijuana liquids, yet DOD continues to sell cigarettes, which have, in fact, killed 380,000 Americans so far this year.

In this case, military intelligence is an attribute of our proud troops, but not of their health officers or administrators.  The Military Times notes:

“Vaping now appears to be more common in the military than smoking regular cigarettes, according to results of the most recent Defense Department Health-Related Behaviors Survey of Active-Duty Service Members. The results of that survey, conducted in 2015, showed 11.1 percent of troops said they were daily e-cigarette users, compared to 7.4 percent who said they smoked cigarettes daily.  In the junior enlisted ranks, nearly 20 percent said they were current e-cigarette smokers.”

The troops have made the switch to vastly safer smoke-free tobacco at far higher rates of use than are seen in the general U.S. population. 

So far, the Marine Corps, which at 16% has the highest prevalence of vaping among the military branches, continues to permit the sale of vaping products, signalling semper fidelis to harm reduction. 

The Army, Air Force and Navy exchanges should immediately reverse their egregious decision and return e-cigarettes and vaping products to their shelves.

Indefensible Action By the U.S. Army Public Health Command

On February 28, I saw the “Great American Spit Out/ Tobacco Cessation” webpage (from my archive here), published by the Army Public Health Command (APHC) to “raise awareness of the dangers associated with smokeless tobacco.” The site was inaccurate and unprofessional with regard to smokeless tobacco use among army personnel.

After the ironic introductory statement, “Unfortunately, the myths concerning smokeless tobacco are still in existence,” the webpage contained this egregious claim: “Smokeless tobacco is as harmful as smoking tobacco.”

I contacted two APHC staffers and explained that this statement was factually incorrect and indefensible. A 2004 National Cancer Institute study 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.” (abstract here).

To its credit, the APHC responded quickly. Less than 24 hours later, on February 29, the just-as-dangerous myth was removed from the website (here).

I also explained to the APHC that the word “spit” is demeaning, disrespectful and deplorable, as I pointed out in a previous post (here). Two years ago, I wrote to federal officials, strongly objecting to use of this term (here). The Centers for Disease Control, the Food and Drug Administration and the National Institute for Dental and Craniofacial Research responded by removing the offensive term from websites and other publicly available materials (here).

It’s time for the Department of Defense and the U.S. Army Medical Command to abandon this offensive language, treat smokeless tobacco users with respect, and provide accurate medical information, particularly on the subject of tobacco harm reduction.

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.

Tobacco Prohibition in the U.S. Military

A newly released report from the Institute of Medicine (IOM) provides more evidence that the federal government is steadily moving toward prohibition of tobacco. The report, requested by the Department of Defense (DOD), calls for implementation of “state-of-the-art programs to achieve tobacco-free military and veteran populations.” Some of the draconian measures include:

• Stop selling tobacco products in military commissaries and exchanges.
• Prohibit tobacco use anywhere on military installations.
• Treat tobacco use in the same way as …alcohol abuse and poor physical fitness, which impair military readiness.

The report acknowledges that deployment of military forces is a primary factor in high prevalence of tobacco use. War has been associated with increased use of tobacco for centuries. During the Revolutionary War, George Washington pleaded to the Continental Congress: “If you can't send money, send tobacco.”

Cigarettes were considered to be effective for dealing with the stress of trench warfare in the First World War; they were given to soldiers in 1917 and 1918. General Pershing said at the time, “Tobacco is as indispensable as the daily ration; we must have thousands of tons without delay.” In World War II, cigarettes were included in soldiers’ rations.

For deployed soldiers, the health hazards of smoking are far in the future. In stark contrast, the hazards of combat, both physical and mental, are endured each and every day they are deployed. Those who have never seen combat cannot comprehend the psychological toll it exacts, but we can appreciate how soldiers deal with the stress. Tobacco and nicotine are powerful psychoactive agents that help our troops manage extreme stress, grief, boredom and suffering.

There is one scientific fact that the IOM report completely ignores: The adverse health effects and long-term financial impact of soldiers’ tobacco use are almost exclusively the result of smoking, not smokeless tobacco use. The report suggests that smokeless tobacco use as risky, but it cannot refute the scientific evidence that smokeless use is 98% safer than smoking.

While no tobacco product is completely safe, cigarette smokers in the military are routinely misinformed by health professionals and government officials about the relative safety of smokeless products. As discussed in earlier posts, smokeless tobacco does not cause lung cancer, heart disease or emphysema. The risk for mouth cancer with smokeless is far lower than it is with cigarettes. In fact, the risk is vanishingly small; nine epidemiologic studies published in the last decade, including one from the American Cancer Society, have concluded that smokeless tobacco use is not associated with mouth cancer.

A growing number of health care and policy experts have endorsed the concept of encouraging smokers to use tobacco in a far safer way. For example, a 2007 report by Britain's Royal College of Physicians, one of the most prestigious medical societies in the world, 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.” In 2008, the American Association of Public Health Physicians officially endorsed this strategy.

Smokeless tobacco is a satisfying and far safer substitute for cigarettes. So why is the military moving toward total tobacco prohibition? Perhaps it is because DOD’s stop-smoking programs have been unsuccessful. In desperation, the agency awarded a researcher $3.7 million to develop a video game for smoking cessation.

Our armed forces put their lives on the line every day; they use tobacco to help manage the resulting stress. The answer isn’t video games and tobacco prohibition. 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.