U.S. troops in Iraq are heavy smokers*

American sailors and Marines stationed in Iraq are more than twice as likely to use tobacco products as the average American, according to a study presented today at the annual meeting of the American College of Chest Physicians.

In a survey of 408 Marines and sailors, Dr. Michael A. Wilson found 64% used some form of tobacco: 52% smoked cigarettes, 36% used smokeless tobacco and 24% used both. In contrast, the national average for tobacco use is 29.6%. Wilson found the rate of tobacco use is higher now among U.S. troops in Iraq than was found in a 2004 survey of troops returning from the war.

Tobacco use was clearly linked to military service. About half of those surveyed said they had never used tobacco products before joining the military. Eighty percent of the smokers said that being in the military had increased their use while 72% stated that being deployed to Iraq had increased their smoking. Smokeless-tobacco users also said being in the military and being in Iraq increased their usage. Overall, 74% of the troops who use tobacco said they wanted to quit.

Some controversy has surrounded the military's efforts to discourage tobacco use. Smoking among the troops has always been linked with deployment to foreign lands, but much more is known today about the health hazards of smoking, said Wilson, who is stationed with the U.S. Navy, 3rd Battalion, 23rd Marine Regiment, 4th Marine Division, New Orleans.

"There is a culture of acceptance about tobacco in the military. It's embraced by the leadership. A lot of the leadership use tobacco. They learned it from the people they trained with, and it gets passed on."

Wilson conducted the survey while stationed in Iraq and said that troops told him they used tobacco for a variety of reasons: peer pressure, to emulate leaders they admire, boredom, stress relief and to help them stay awake. But, he said, tobacco use is likely to have a greater negative impact to the long-term health of Iraq War veterans than combat-related injuries. The cost of care for troops with tobacco-related health problems will also soar for both the VA and U.S. healthcare systems.

The Defense Department recently launched a virtual anti-smoking campaign targeting enlisted personnel between ages 18 and 25 called "Quit Tobacco, Make Everyone Proud." The Department of Veterans Affairs also has a website on smoking cessation. But more effort should be spent to discourage tobacco use among newly enlisted troops and to discourage smoking in the war zone, Wilson said in an interview with The Times.

"My point is that we have to get them ready to survive Iraq and survive beyond Iraq. Everyone realizes this is a problem. But you need the leadership on a macro level, from the general on down, to the micro level, to get on board because that is who the kids really look up to."

* In a follow-up interview and e-mail, Dr. Wilson said he wanted to make clear that he conducted this study on his own and that the views expressed regarding this study are his own opinions. He is not a spokesman for the U.S. Navy, the U.S. Marine Corps, nor the Department of Defense and his views and opinions do not represent theirs. He is speaking only for himself and his study as a pulmonary and critical care physician and fellow in the American College of Chest Physicians and not as a Lt. Commander in the U.S. Navy Reserve.

-- Shari Roan

Photo credit: Roslan Rahman/AFP/Getty Images

Comments

[bill]

Zila, Inc. (NASDAQ:ZILA) was recently awarded a contract by the U.S. Department of Veterans Affairs to market its oral cancer screening product ViziLite Plus to VA and Department of Defense dental clinics. ViziLite helps dentists and hygienists identify oral abnormalities that can lead to oral cancer. There are 7.9 million veterans enrolled in the VA Health Care System and more than 1.3 million men and women in active military service - a population that is clearly at increased risk for oral cancer.

[Brad Rodu, Professor, University of Louisville]

I am a professor of medicine and I hold an endowed chair in tobacco harm reduction research at the University of Louisville. I read with interest this blog post about the prevalence of tobacco use in US troops in Iraq, as reported by Dr. Michael Wilson at the recent American College of Chest Physicians meeting.

Conditions of war have been associated with increased use of tobacco for centuries. The post alluded to this but added Dr. Wilson's comment that much more is known today about the health hazards of smoking. That may be true, but for these troops 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 of us who have never seen combat cannot comprehend the psychological toll it exacts. But we can understand, and have sympathy with, how these soldiers deal with the stress. Tobacco and nicotine are powerful psychoactive agents that help our troops manage stress, grief, boredom, and suffering that the rest of us can only imagine.

Dr. Wilson concluded that "tobacco abuse in combat units deployed to Iraq... will likely cause a greater negative impact on the long term health of US Veterans than combat related injuries and will have great financial consequences for both VA and US healthcare systems." Not only is that comment inappropriately moralistic in tone, it incorrectly assumes that smoking and smokeless tobacco use have equal health consequences. Nothing could be further from the truth.

In fact, smokeless tobacco 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 by officials in other government agencies about the relative safety of smokeless products. Unlike cigarettes, smokeless tobacco does not cause lung cancer, heart disease or emphysema. Smokers rightfully worry about mouth cancer, but they should take comfort in the fact that the risk for mouth cancer with smokeless is far lower than it is with cigarettes. Statistically, smokeless users have about the same risk of dying from mouth cancer as automobile users have of dying in an automobile accident.

In 2004 Valerie Reitman wrote about this subject in the LA Times (http://www.smokersonly.org/others/is_smokeless_safer.html ). Since then 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 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…"

Dr. Wilson's comments about the "culture" of tobacco use in the military are a thinly veiled plea for complete tobacco abstinence. Such pronouncements, which ignore the immediate benefits of tobacco use and disregard knowledge of the long term health consequences, are disrepectful of American military personnel. They should not be castigated for tobacco use, but properly informed.

Brad Rodu
Professor, Department of Medicine
Endowed Chair, Tobacco Harm Reduction Research
University of Louisville

[Michael Wilson]

Professor Rodu,
Sir, you seem to have an ax to grind with my research and comments. Naturally, I appreciate your feedback. As a Veteran and someone who has actually served in Iraq, there are great psychological stressors not to mention significant boredom faced by our brave men and women in uniform, as you alluded to in your comment. However, I am confused as it seem that you are actually advocating acceptance of high levels of tobacco usage to help with the stress of being in Iraq. Surely you must agree that we can find more healthy ways to deal with stress and boredom in Iraq then by use of a substance that has been shown to cause more preventable health related disease then any other drug currently unregulated by the FDA. Can we not at least search for options to greatly reduce its usage?
I apologize if my tone seemed moralistic to you. I have a great deal of respect and concern for the Marines and Sailors that I served with in Iraq and was simply trying to point out that tobacco usage in Iraq has a very high prevalence and I speculated as to why that is the case. It is my opinion, based on direct experience in the military and not based on "imaging" what it must be like, that the development of nicotine dependence while in Iraq is a real issue that many of these great men and women in the military will have to contend with for years to come. My point, born out of my respect and concern for my fellow veterans, is that if we can effect a change in the military culture that will find HEALTHY ways to deal with the stress and boredom of being in Iraq or Afghanistan then we will save many from the difficult task of trying to kick nicotine dependence.
As for the other, I think few would argue that once nicotine dependence develops that if one continues to smoke OR CHEW TOBACCO that their risk of developing a tobacco related illness IS SUBSTANIALLY HIGHER then if they never developed the habit to begin with. You might have mentioned that trauma related to automobile accidents is the number one killer of young adults aged 15-24.This does not mean I advocate no one driving, by the way, it just points out how deadly both can be when you are the one if effects.
I was very generous in supposing that only 1/4 of tobacco users would someday develop tobacco related disease in my speculation of cost estimates. I realize that smokeless tobacco use carries less risk then cigarettes and their toxins, however, most of the tobacco users were smokers. I have always found your research advocating replacement of cigarettes with smokeless tobacco interesting, but, as a Dentist, surely you will admit that smokeless tobacco is not w/o some health concerns and dependence on nicotine with use of smokeless tobacco is a real consequence. That is what my wife has always told me and I trust her opinion on the matter as she is my Dentist (DMD). Why not try and reduce that risk before it develops?
Also, I am NOT AN ADVOCATE FOR ABSTIENCE IN TOBACCO USAGE in any form. Quite to the contrary, I am an avid believer in freedom of choice, hence my decision to serve in the military in defense of my country. By being a medical officer I am charged with looking out for the health and well being of the Marines and Sailors with whom I serve. As such, and as a board certified Pulmonary and Critical Care Physician, I am naturally concerned when I see young men and women picking up a nicotine dependence habbit at such a young age. My goal was only to quantify the issue and to support the Department of Defense in its ongoing push to reduce the usage by getting more Marines and Sailors to choose either NOT TO USE IT IN THE FIRST PLACE or to help them quit once they have become dependent on nicotine.
I hope none of the above seems veiled in anyway.
I appreciate you taking an interest in my abstract and using it as a chance to push your own agenda. I wish you nothing but the best in your research and career. I can assure I was not looking for any of the attention this article has gained, I was simply trying to help quantify an issue as a concerned physician.
I guess its true that for every idea or project there is always a critic.
Very Respectfully,
Michael Wilson, M.D., F.C.C.P

[Michael Wilson]

Addendum:
For those that have read the comment by Dr. Rodu and the answer by me please note that disagreements between medical professionals occur. Please understand I have the utmost respect for Dr. Rodu and his research, I just happen to disagree with his opinions on my research and the tone in which it was delivered. As for the "relative safety" of smokeless tobacco products, I refer readers to the National Cancer Institutes web-page for the cancer experts discussion on the risk of smokeless tobacco and its carciongic containing product:

http://www.cancer.gov/cancertopics/factsheet/Tobacco/smokeless

I agree that is you must use a form of tobacco product that smokeless seems to be the lesser of 2 evils, but it is NOT W/O risk and avoidance, if possible, is the current recommendation of most health professionals.
Respectfully,
Michael Wilson, MD, FCCP

[Herman Heyn]

I am a Korean war vet. I remember being deluged with free cigarettes
back then. I've often wondered what's going on cigarettewise in the
army these days. Dr. Wilson's article partially answered the question...
at least in Iraq, the cigarette smoking rate among soldiers is alot higher than among civilians at home. What I'm left wondering is how the Iraq soldiers
obtains their smokes. Is it through PX's (maybe at near cost prices?),
and are they still being deluged with free samples?

[Mike Wilson]

Sir (Korean War Vet)
Excellent question. It is still very easy to get from PX and, overall, the cost is lower at the PX then elsewhere, but not a low as it use to be. They have a mobile PX in Iraq that makes it to the base about every 2 weeks when I was there. They also get it from home via family.
v/r
Mike Wilson

[Linda Friedman]

This disclosure, made at the end of Dr. Rodu's papers on smokeless tobacco, tells the story. "This study was supported by unrestricted grants from smokeless tobacco manufacturers to the University of Louisville (US Smokeless Tobacco Company and Swedish Match AB)."

Smokeless is not harmless. Smokeless is deadly. Smokeless destroys lips, faces, gums, chins, tongues, cheeks, teeth, and it kills. To make a statement that it is 98 percent safer than cigaretters is perposterous.

Dr. Wilson, thank you for your work!

[Michel Wilson, MD, FCCP]

Mrs. Friedman,
Thanks for you kind words. Dr. Rodu does interesting, albeit controversial reserach. It is a shame he takes such exception with others research and launches personal attacks when it disagrees with his research. I particularly enjoyed his "speculation" of what it must be like to be in the military and in Iraq. I don't have to speculate, I was there for 7 months in Hadithat, Al Anbar, a fact that likely makes me far more qualified to discuss tobacco and its effects in combat then does Dr. Rodu's "imagination". As for his own research funding, I will let him speak for himself.
This is from a 2003 CBC artilce outlining Alberta's plan to try and reduce smokless tobacco use in Alberta. Dr. Rodu is quoted again preaching is agenda and the reporter called him on what you pointed out:

"I think once consumers are aware of the differential risks between smoking and smokeless tobacco, the transition will be overwhelmingly from smoking to smokeless," says Rodu who is part of a campaign of "harm reduction."

Since 1999, Rodu's research has been partly funded by U.S. Tobacco, the company that makes Copenhagen and Skoal. Rodu points out much of his research was done before that and insists the company has no influence on his results.

Enough said on his research funding and his comments above.
Thanks again,
Michael Wilson