9A.7 Military personnel and veterans

Last update: November 2022

Suggested citation: Greenhalgh, EM, & Scollo, MM. 9.A.7 Military personnel and veterans. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022.  Available from: https://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/in-depth/9a7_military-personnel-and-veterans  

 

As at June 2021, the Australian Defence Force (ADF) comprised more than 59,500 permanent (47,800 males and 11,700 females) and 29,700 reserve personnel across the Royal Australian Navy, the Australian Army, and the Royal Australian Air Force. The Department of Veterans’ Affairs (DVA) estimated there were about 613,000 living Australian veterans who had ever served in the ADF, either full-time or in the reserves. There were more than 337,000 DVA beneficiaries in receipt of pensions, allowances, and treatment or pharmaceuticals (including approximately 240,000 veterans and 97,200 dependants).1

9A.7.1 Trends in the prevalence of smoking

In 2020–21, the prevalence of current smoking was similar among Australians1 who had and had not ever served in the ADF (12% for both). An estimated 78,200 people who had ever served in the ADF were current smokers; 71,200 were male and 7,000 were female. Males who had served in the ADF were more likely to be current smokers than females (13% compared with 6.7%).2

Examination of this data by age shows that younger men who were currently or had formerly served in the ADF were less likely to be a current smoker than men of the same age who had not served. Among older men, this pattern appeared to be reversed, with those who had served being more likely to be a current or ex-smoker (though the difference was non-significant)2 —see Figure 9A.7.1.  Numbers of women who had served in the ADF were too small to draw comparisons.

 

 

Figure 9A.7.1
Smoking status by age and ADF service status, Australian males aged 18+, 2020–212

 

Source:  : Australian Institute of Health and Welfare

 

The Department of Veterans’ Affairs (DVA) provides support, services and information to various people including veterans and their dependents, serving and ex-serving ADF members, and war widow/ers. DVA clients are typically an older population with greater financial, health, mental and physical support needs.4 Data from the 2017–18 National Health Survey showed that about one in six clients of the DVA were daily smokers, and about one in seven of all people who had served in the ADF—see Figure 9A.7.2.

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Figure 9A.7.2
Proportion of daily smokers by ADF service status, Australians aged 18+, 2017–18
Source: Australian Bureau of Statistics. National Health Survey 2017–18: First results. 2018. 5

 

The prevalence of smoking differs across military populations. Australian research published in 2010 found that the highest prevalence of current smoking in the Australian Defence Force was among individuals with lower levels of education and those serving in the Navy (26%). The percentage of current smokers in the Army was 22% and the lowest prevalence of smokers was in the Air Force (8%).6

Data in the US show that the prevalence of smoking is higher among veterans than the general population, though in contrast to recent Australian data,3 it is particularly high among younger veterans.7, 8 Smokeless tobacco use is also common among military personnel in the US.9, 10 A recent study of US military branch differences found that smoking and smokeless tobacco use was highest in the Marine Force and lowest in the Air Force.11

 

9A.7.2 Contribution of smoking to health outcomes and social inequality

Serving personnel are generally healthier than the overall population, due to screening processes and fitness requirements.12 The health and wellbeing of Australian veterans, however, is influenced by a range of factors that can change over time from enlistment to retirement. Veterans overall report similar health and wellbeing to the broader community. In 2017–18, 21% of men who had ever served in the ADF reported a mental or behavioural condition (for example, anxiety and mood disorders, or problems with alcohol) in the previous year (age-standardised), which was similar to men who had not served (18%). The prevalence of chronic conditions was also similar between men who had and had not served, with the exception of cardiovascular disease which was more common among men who had served in the ADF (24% vs. 18%).13 Some members of the ADF, however, are at a higher risk of developing some cancers and mental disorders than the Australian population.12 In 2017–18, among those who had served, DVA clients were more likely to consider their health as fair or poor than non-DVA clients (34% compared with 20%). DVA clients were also more than twice as likely to report having a mental or behavioural condition (44% versus 17%), including anxiety (37% versus 8%) and depression (26% versus 11%).1 Rates of suicide are also higher among contemporary ex-serving men compared with other Australian men.4 One study examining the use of mental health services found that ADF men were more likely to report poorer health and more likely to be diagnosed with any lifetime mental disorder, any affective disorder, depression, PTSD, and any substance use and alcohol disorder, while DVA women were more likely to report moderate/severe psychological distress and less life satisfaction compared with the overall community.14

Smoking also contributes to poorer health outcomes among both former and current military personnel. Scottish research found an increased risk of smoking-related cancer compared with non-veterans among older veterans,15 and Australian data similarly shows higher incidence of smoking-related cancers among veterans of the Korean War (1950–53).16 One study of Australian Army Vietnam veterans demonstrated increased risk of mortality among these veterans likely attributable to health-risk behaviours such as smoking, inactivity, and poor diet17 A longitudinal study in the US found that among veterans, tobacco users reported poorer physical and mental health and higher rates of substance use compared with non-users.8 Another study found that co-use of cannabis with tobacco was associated with poorer mental health outcomes among veterans.18 Smoking also has short-term harms for young military personnel, including increasing the risk of injuries,19 reducing physical fitness,20 and reduced troop readiness.21

 

9A.7.3 Explanations for higher smoking prevalence

Tobacco use has traditionally been a part of defence force culture, with tobacco being provided and promoted to troops.22-26 The tobacco industry actively targeted the military with marketing, sponsorship, and free cigarettes, which has led to increases in smoking prevalence and the normalisation of tobacco use.22, 23 Military personnel in the US report smoking to fit in with their unit.27 Despite policies that aim to prevent it, in the US, tobacco products are also sold at lower prices on military bases.28, 29 Risk factors that promote smoking among the general population, such as lower income and educational attainment, mental illness, and rurality, have also been shown to increase smoking among veterans.30-33

Stress and trauma associated with war deployment is associated with the uptake of smoking, relapse, and overall high rates of tobacco use compared to the general population.34-39 Australian research among those deployed to the Middle East found that 38% of respondents reported smoking more than usual during deployment, and 17% reporting taking up or re-starting smoking.40 Another Australian study found that trauma exposure in the form of military combat predicted smoking over several decades, and was a more robust predictor than PTSD.41 A study of returned veterans from military conflict in Iraq and Afghanistan indicated an association between heavy daily smoking and emotional numbing, suggesting that veterans suffering post-traumatic stress may smoke in an attempt to manage their trauma.42 US research has found that deployment with combat experience predicted higher smoking initiation and relapse rate among military personnel. Previous mental health disorders, life stressors, and other military and non-military characteristics also predicted initiation and relapse.43 Another US study found an association between smoking and exposure to dead/dying/wounded soldiers during service.31 The misperception that tobacco is effective for stress relief is pervasive among military personnel, including leaders.44, 45 Smoking is also associated with pain46 and alcohol use36 among veterans, and may be perceived as helpful for weight control among young adults in the military.47

 

9A.7.4 Interventions for reducing smoking

Studies of US war veterans have concluded that additional effort is required to support smoking cessation in this community.7, 48, 49 Despite its longstanding role within military culture, there have been increasing efforts in recent years to implement tobacco control policies and cessation programs within the military. In Australia, smoking in all Defence establishments is banned.50 The New Zealand military is also completely smoke-free,51 and the British Army is going smoke-free at all of its sites by the end of 2022.52 Strong, consistent policies and support by leaders appear crucial to the success of such interventions.53-55 Policies may also need to include the use of e-cigarettes, which appears to be growing among military personnel.56, 57

There is limited Australian research on cessation interventions for veteran populations, however a number of US studies have provided evidence as to which strategies may be most effective. A large multi-site study concluded that the Tobacco Tactics program, which comprises nurse counselling, informational materials, pharmaceuticals, and post-discharge telephone calls, has the potential to significantly decrease smoking among veterans.58 Intensive interventions that combine medication with counselling from the tobacco cessation pharmacists also appear promising.59 A small study found that a smartphone-based contingency management intervention may be a useful adjunctive smoking cessation treatment component for reducing smoking among homeless veterans.60 Several studies have provided support for the use of smoking cessation telephone-61 and mobile-phone based interventions tailored for soldiers and veterans who smoke62-64 and who use smokeless tobacco.65, 66 The use of cessation pharmacotherapies may also increase quit rates among veterans,67 and one study has provided support for a group-based brief intervention among young adults in the military.68 Incorporating stress management and mindfulness into interventions may also support quitting among veterans.69

For veterans experiencing posttraumatic stress disorder (PTSD), a systematic review published in 2018 examined integrated, specialised treatments for comorbid smoking—PTSD, including preliminary treatment studies and RCTs in both veteran and general clinical samples. It concluded that mobile technology shows promise for providing effective, lower cost, and wide-reaching PTSD—smoking intervention. There is also evidence to support the integration of smoking cessations aids (e.g., varenicline) and smoking cessation counselling into existing PTSD treatments (i.e., prolonged exposure), particularly for people experiencing elevated PTSD symptom severity.70 Improvements in PTSD symptoms may help to support smoking cessation.71 See Section 9A.3.5.6 for further discussion.

Healthcare providers can also play an important role in promoting quitting and providing evidence-based cessation interventions to veterans,72 and this should be integrated into routine care.73, 74 Proactive outreach may be helpful for engaging veterans in tobacco use interventions.75 Including tobacco cessation education in veterans’ treatment for other substance use disorders can promote quitting,76 but smoking cessation is often not prioritised in these settings.77 A study of the effects of implementing a smoke-free policy within a residential substance use disorder treatment program for veterans found that it increased motivation to quit and use of NRT.78 Chaplains, who provide meaningful physical and mental healthcare support to veterans, have expressed willingness to be involved in cessation efforts, and could represent another avenue for promoting quitting.79 One study found that, among veterans with a history of mental health treatment, smoking abstinence was associated with improvements on a number of behaviour and symptom measures.80

 

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated August 2022)

References

 

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3. Australian Bureau of Statistics. TableBuilder. Available from: http://www.abs.gov.au/websitedbs/d3310114.nsf/home/about+tablebuilder

4. Australian Institute of Health and Welfare. Health of veterans.  2020. Available from: https://www.aihw.gov.au/reports/australias-health/health-of-veterans

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9. Dunkle A, Kalpinski R, Ebbert J, Talcott W, Klesges R, et al. Predicting smokeless tobacco initiation and re-initiation in the United States Air Force. Addictive Behaviors Reports, 2019; 9:100142. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31193918

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11. Schuler MS, Wong EC, and Ramchand R. Military service branch differences in alcohol use, tobacco use, prescription drug misuse, and mental health conditions. Drug and Alcohol Dependence, 2022; 235:109461. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35487079

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15. Bergman BP, Mackay DF, Morrison D, and Pell JP. Smoking-related cancer in military veterans: retrospective cohort study of 57,000 veterans and 173,000 matched non-veterans. BMC Cancer, 2016; 16:311. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27178424

16. Australian Institute of Health and Welfare. Cancer incidence study 2003: Australian veterans of the Korean War. AIHW cat. no. PHE 48.Canberra: AIHW, 2003. Available from: https://www.aihw.gov.au/reports/veterans/cancer-incidence-study-2003-korean-war-veterans/contents/table-of-contents

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18. Fitzke RE, Davis JP, and Pedersen ER. Co-use of tobacco products and cannabis among veterans: A preliminary investigation of prevalence and associations with mental health outcomes. J Psychoactive Drugs, 2021:1–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34334112

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22. Smith EA and Malone RE. "Everywhere the soldier will be": wartime tobacco promotion in the US military. American Journal of Public Health, 2009; 99(9):1595–602. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19608945

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30. Coughlin LN, Wilson SM, Erwin MC, Beckham JC, Workgroup VAM-AM, et al. Cigarette smoking rates among veterans: Association with rurality and psychiatric disorders. Addictive Behaviors, 2019; 90:119–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30388505

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71. Salas J, Gebauer S, Gillis A, van den Berk-Clark C, Schneider FD, et al. Increased smoking cessation among veterans with large decreases in posttraumatic stress disorder severity. Nicotine & Tobacco Research, 2022; 24(2):178–85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34477205

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