Sot. Sci. Med. Vol. 33. No. 12, pp. 1349-1353. 1991 Printed in Great Britain. All tights reserved
STARTING
TO SMOKE
Copyright
IN THE NAVY: AND WHY
WHEN,
0
0277-9536/91 53.00 + 0.00 1991 Pcrgamon Press plc
WHERE
TERRYA. CRONAN,’TERRYL. CONWAY~and SUZANNE L. KASZA? ‘Psychology Department, San Diego State University, San Diego, CA92182-0350, U.S.A. and *Naval Health Research Center, P.O. Box 85122, San Diego, CA 92138-9174, U.S.A. Abstract-Smoking rates among U.S. military men are much higher than those in the general population. A previous study compared the smoking rates of male recruits coming into the Navy with those of a shipboard sample to find out whether the Navy was attracting or creating smokers. Twenty-eight percent of the incoming recruits were smokers, whereas 50% of the shipboard men were smokers. These findings suggested that the Navy environment somehow encouraged smoking. The present study followed a group of male recruits for one year after they entered the Navy to determine when, where, and why they started smoking during their first year in the service. Two hundred and sixty-two of the original 682 participants returned the one-year follow-up information. Twenty-eight percent of the sample were self-reported smokers upon entry into the Navy. One year later 41% classified themselves as smokers. Of those who started smoking (either for the first time or again after having quit) during their first year, 42% started within their first two months of service (i.e. during recruit training), and another 32% started during their third month in the Navy. In addition to the 42% who started during recruit training, 39% started while attending training school, and 15% started while stationed aboard a ship during their first year in the Navy. The most frequently cited reasons for starting to smoke were: curiosity, friends smoking, calming effect, and wanted to be ‘cool’. Because many individuals begin smoking soon after joining the Navy, effective prevention programs need to be implemented in recruit training and repeated in early training schools. Key words-smoking,
military, prevalence, reasons
INTRODUCTION
METHOD
Since the Surgeon General’s first report on the health consequences of smoking in 1964, smoking rates in the United States have dropped from 42 to 29% [l]. However, a Department of Defense drug and alcohol survey conducted in 1985 showed that 46% of the military smoked [2]. Although historically the rates of smoking among military personnel have been higher than those in the general population, the discrepancy has increased. In an attempt to understand why the military has a higher percentage of smokers, Cronan and Conway [3] compared the smoking rates of recruits coming into the Navy with those of a shipboard sample to find out whether the Navy environment was attracting or creating smokers. Twenty-eight percent of the incoming recruits were smokers, whereas 50% of the shipboard men were smokers. The discrepancy remained even when age-matched comparisons were made between recruits and men aboard ships. Thus, the Navy environment appeared somehow to encourage smoking among its members. However, the Cronan and Conway study was cross-sectional and, thus, did not provide ecological information related to starting to smoke in the Navy. To provide this information, a subset of the recruits in that study was followed for one year after entering the Navy to determine when, where, and why men start smoking during their first year of service.
Subjects
The participants were 682 men entering the Recruit Training Command (RTC). Naval Training Center, San Diego, for Navy basic training during 1986. The mean age of the participants was 18.7 (SD = 2.26). The mean number of years of education was 12.1 (SD = 0.96). Fifty-seven percent were Caucasian, 18% were African-American, 7% were Hispanic, 6% were from other ethnic backgrounds, and 12% did not report race/ethnic background.
Measures Questionnaire. A smoking status questionnaire
was administered to participants at the beginning of recruit training, and a modified version of this questionnaire was mailed to the participants one year later. Participants were asked to classify themselves as nonsmokers, former smokers, or current smokers. Other information collected in the questionnaire included: amount currently smoked, length of time smoked, and duty assignment when started smoking. A checklist of possible reasons for starting to smoke was also included. Participants who had started smoking either for the first time or again after joining the Navy were asked to check the reasons why they started to smoke. This checklist was constructed after conducting a general review of the literature, with a
1349
1350
TERRY
A.
CRONAN
special emphasis on reasons for smoking that might be relevant to the military. Biochemical validation. To assess the validity of the self-reported smoking behavior, saliva samples were collected at the one-year follow-up, and cotinine levels in the samples were assessed. Cotinine levels were measured by gas chromatography using an adaptation of the method described by Verebey, DePace, Mule, Kanzler and Jasse [4]. Analyses were performed by the University of Minnesota Lipid Research Core (BELRC) Laboratory. The methods employed by this laboratory produce a sensitivity of greater than 1 ng/ml. The detector response is linear from at least 10 to 400 ng/ml for cotinine. For making smoker or nonsmoker classifications, a cutoff value of less than 20 ng/ml cotinine was used to categorize nonsmokers (criterion recommended by the BELRC Laboratory). Procedures
Within the first week in recruit training, questionnaires were administered in group settings, with one member of the research team reading all questionnaire items and answering questions asked by the participants. At the end of one year, all recruits who could be located through a Navy locator system were sent (a) a tobacco use questionnaire, (b) instructions for providing a saliva sample, (c) a tube in which to provide the sample, and (d) two pre-addressed, stamped envelopes (one to return the questionnaire to the investigators and one to send the saliva sample directly to the BELRC Laboratory). If the questionnaire was not returned within two months, a followup letter was sent to the locator address. RESULTS
Of the original 682 participants, valid mailing addresses one year later were obtained for 576 individuals; of the latter individuals, 262 (45.5% participation rate) provided follow-up information regarding tobacco use one year after entering the Navy, There were no significant differences in the demographic characteristics or the initial smoking status of participants who returned the one-year follow-up questionnaire and those who did not. Smoking prevalence
At entry into the Navy during 1986, 59.7% of recruits classified themselves as never smokers, 12.8% as former smokers, and 27.6% as current Table 1. Changes in self-reported smoking year Smoking No Smoking
status at entry
Never smoked Former
smoker
Current
smoker
Total group
status during first one year later YCS
%
%
(n)
(n)
87.6 (134) 45.1 (16) 6.8 (5) 59.2 (155)
12.4 (19) 54.3 (19) 93.2 (69) 40.8 (107)
et al.
50 r
46
U.S. men t16-24yrl
Entry into Navy
one yeor later
Men Novywide
Fig. 1. Comparison of smoking rates for young men in the U.S. population (1987), Navy men in the current study (1986 and 1987). and men in the Navy at large (1986).
smokers, which can be compared with 65.1% never smokers, 6.7% former smokers, and 28.1% current smokers among U.S. males 18-24 years old during 1987. Table 1 presents a cross-classification of the smoking status of study participants upon entry into recruit training and one year later. Of the participants who said they had never smoked when they entered recruit training, 12.4% reported that they were smokers at the end of one year. Of those classified as former smokers at entry into the study, 54.3% reported that they were smoking again at the one-year follow-up. Of those who classified themselves as smokers at entry into the study, 6.8% reported that they were not smoking one year later. Overall, 40.8% of the participants classified themselves as smokers at the end of one year. Figure 1 provides a comparison of smoking rates for 18-24 year-old men in the United States during 1987 [ 11,participants in the present study at entry into the Navy (during 1986) and at the one-year followup, and men randomly selected from the Navy at large during 1986 for participation in a study to evaluate the Navy’s Health and Physical Readiness Program [5]. The figure indicates that the smoking rate of men as they enter the Navy (28%) is similar to that of 18-24 year-old men in the U.S. population (28%). However, by the end of their first year in the Navy, the new service members have a substantially higher smoking rate (41%) which is much closer to that observed for men in the Navy at large (46%). Biochemical validation. Two hundred and ten participants provided saliva samples at the one-year follow-up. Analysis of the cotinine levels in the saliva samples indicated 74% agreement between the participants’ self-report of smoking status and the biochemical classification of smoking status; 21% reported that they were nonsmokers but were classified as smokers by the saliva analysis, and 5% reported that they were current smokers but were classified as nonsmokers by the saliva analysis. The latter 5% is not necessarily inconsistent with valid self-reporting if those self-reported smokers simply had not recently had a cigarette prior to providing the saliva sample. However, the 21% who reported that they were nonsmokers but had salivary cotinine levels greater than or equal to 20 ng/ml do represent a concern regarding the validity of self-reported tobacco use among new Navy personnel.
Starting
to smoke
in
the Navy: when, where and why
If one-fifth of survey respondents claim they are nonsmokers but, in fact, actually smoke, the Navy may have a greater smoking problem than is currently believed. However, it should be strongly cautioned that, except for very specific written instructions regarding how to provide the sample, there were essentially no controls in the field when the participant prepared his saliva sample. Unknown confounding or invalidating factors may have been present in some field settings. For example, one issue of particular concern is the effect of passive smoking. In typical Navy environments, a high percentage of personnel smoke-in 1986 about 46%, on the average, and even higher in certain settings such as aboard surface ships, where over 50% smoked [5]. Furthermore, it has been estimated that at least one or more people smoke in almost 85% of Navy members’ work environments [5]. However, the possibility of passive smoking accounting for some of the discrepancy between lab results and self-reports of smoking status is not supported by the results of one study which examined cotinine levels in both the urine and saliva of passive smokers [6]. These researchers detected only very small amounts of cotinine in passive smokers’ urine and found no evidence of cotinine in their saliva. The results, however, were based on only 20 passive smokers. Regardless of any potential effects of passive smoking or any other confounding factors, the biochemical findings in this study should be replicated before any inferences are made regarding under-reporting of tobacco use among Navy personnel. When
All participants who started smoking during their first year in the Navy were asked to indicate the month in which they started smoking. Forty-two percent of the men started smoking within their first two months in the Navy (i.e. during recruit training). Thirty-two percent started during the third month after entering the Navy (i.e. within one month of leaving recruit training). Thus, nearly three-quarters of the participants who started smoking during their first year started within the first three months after entering the Navy. Where
Participants who started smoking during their first year in the Navy were also asked where they were stationed when they started smoking. Forty-two percent were in recruit training; 30% were attending a training school; and 15% were stationed aboard a ship. Of the remaining four percent (n = 3), one participant was stationed aboard a submarine, one was assigned to an air squadron, and one was shorebased overseas. Thus, most men started smoking in recruit training or while going through special training schools immediately following recruit training. However, it should be noted that because all participants had to go through recruit training, and most went to schools afterward, the ‘Where’ variable is necessarily confounded by Navy training and assignment policy. Thus, inferences regarding the impact of training environments per se on smoking behavior should not be made from these data.
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Table 2. Reasons for starting to smoke during tirst year Smoking status
Reason Curiosity Friends smoked To show I wasn’t afraid It was calming Want to lx cool To look like an adult Boredom To lose weight Liked the taste To show I was tough Liked the image To take a dare So I wouldn’t be left out Parents smoked It gave me a kick To be masculine
New’ (n = 19) %
Recidivist@ (n $9)
Total’ (n = 38) %
50.0
62.5 50.0 26.7 35.3 41.2 41.2 23.5 25.0 23.5 23.5 12.5 12.5 II.8 11.8 6.3 6.3
56.7 56.1 37.9 35.5 32.3 32.3 32.3 20.0 19.4 16.1 6.1 13.3 12.9 12.9 6.7 10.0
64.3 50.0 35.7 21.4 21.4 42.9 14.3 14.3 7.1 0 14.3 14.3 14.3 14.3 14.3
‘Those who started smoking for the first time after joining the Navy. bTh0s-c who reported they were former smokers when they entered the Navy but said they were smokers at the end of their first year in the Navy. ‘All who reported starting to smoking during their first year in the Navy (i.e. new smokers and recidivists combined).
Why Table 2 presents the reasons former and new smokers reported for starting to smoke after entering the Navy. The most common reasons for starting to smoke were: friends smoking, calming effects, wanting to be ‘cool’, wanting to look like an adult, and boredom. Marlboro cigarettes were the most popular brand smoked by participants. Marlboros were smoked by 53.8% of men who had smoked at some time in the past and by 75.0% of those who started since entering the Navy. DISCUSSION
The present study showed that after one year in the Navy the overall percentage of smokers increased from 28% to 41%. There was a 12% increase in the number of new smokers, a 54% recidivism rate, and a 7% quit rate. The 12% increase in new smokers is higher than would have been predicted based on findings from the general population. For example, Schoenborn and Boyd [I] found that the prevalence of smoking was lower in the 18-24 year age group than in the 25-64 year-old group. These authors reported that as adolescents have matured into young adults they have maintained lower smoking rates, and this has distinguished them from older cohorts. In the present study, the mean age of recruits entering the Navy was 18.7 years, which was equivalent to the late adolescent/young adult age group in the general population that Schoenbom and Boyd reported maintaining lower smoking rates. Thus, the increase by 12 percentage points in new smokers over the course of one year in the Navy sample would not have been predicted from current trends in the U.S. population of young males. Although 7% of the smokers in the present study quit smoking during their first year in the Navy, this figure is consistent with the 6% ‘spontaneous’ quit rate estimated by others [A. Spontaneous quit rate
1352
TERRYA. CRONAN et al.
refers to the percentage of smokers who, at any given time, report that they are not smoking (this can be contrasted with a ‘continuous’ quit rate which is based on continuous nonsmoking over a given period of time). The smokers at entry into this study who said they were not smoking at the one year follow-up assessment had quit for less than one year. Thus, the percentage of initial smokers who were not smoking one year later is approximately what would have been predicted based on spontaneous quit rates in the general population. Although it may seem high, the 54% recidivism rate of former smokers at entry into the Navy who started to smoke again within their first year in the Navy is probably not atypical. Of the study participants who reported the length of time they had been former smokers (15 of the 19 individuals), all but one had quit smoking for less than one year. According to the National Center for Health Statistics, only 1 in 5 recent smokers (i.e. smoked sometime during the past year) were ‘successful’ (i.e. not smoking at the time of the interview) at quitting [8]. Furthermore, when the same type of analysis was applied in the present study and former smokers and current smokers were grouped together as recent smokers, a ‘quit rate’ of about 19% successful quitters was found. This rate is very similar to the roughly 20% found by Moss [8]. Thus, the relatively high recidivism rate in the present study may be typical for this age group. The smoking prevalence findings in this study suggest that the rates of spontaneous quitting and recidivism of Navy personnel during their first year of service are generally consistent with what would be expected based on rates in the general population. However, the increase in the rate of new smokers would not have been predicted from population trends. Thus, the reasons given for why individuals began to smoke were of interest. The most popular reasons overall for starting to smoke were curiosity and friends smoking. It is interesting that a higher percentage of recidivists than new smokers listed curiosity, wanting to be cool, and to look like an adult, as reasons for starting to smoke. However, more new smokers indicated that they started to smoke because their friends smoked, to show they were not afraid, and because they were bored. Several of the most commonly given reasons for starting to smoke are consistent with the idea that social factors may have a fairly strong influence on the smoking behavior of new Navy personnel. Of the seven reasons given by approximately one-third to one-half of those who started smoking during their first year in the Navy, four were related to social pressures (i.e. friends smoked, to show not afraid, to be cool, and to look adult). Both the smoking prevalence findings and the reasons for starting to smoke have implications for the smoking prevention and cessation programs that the Navy might implement. Because most Navy men who start smoking do so within their first three months in the Navy (i.e. during recruit training or subsequent training schools), effective prevention programs should be implemented in these early training programs. Traditional prevention programs have employed lectures, discussions, films, and pamphlet materials which emphasize the harmful long-term
effects of cigarette smoking. They have had limited success in preventing young people from starting to smoke [9, lo]. More effective interventions have included, along with information about the long-term ill effects of smoking, information about the effects of social influences on starting to smoke and the behavioral skills with which to resist social influences (11, 121. If the Navy is to reduce the number of smokers among its members, it must selectively choose and implement prevention programs which have been shown to be most effective at preventing smoking among young adults who are primarily in their late teens and early twenties and who are just entering the work force. When trying to select which prevention methods might be most effective in the Navy environment, it is important to consider why many young men start smoking, either for the first time or again after having quit, when they join the Navy. One possible environmental influence which could encourage smoking in the Navy might be tobacco industry advertising, which has linked cigarette smoking to patriotism, toughness, and military service [I 31. In the present study, over half of all the men who started smoking for the first time, or who started smoking again, smoked Marlboro cigarettes. The advertisements for Marlboro cigarettes have portrayed a very masculine image: ‘tough guys’ smoke Marlboro cigarettes. This image is consistent with the ‘macho’ image of the hard-charging, hard-drinking, cigarette-smoking military man [13]. Perhaps this advertising image has had an influence on military personnel and is related to why some men in this study began smoking when they entered the Navy, as well as smoking Marlboro cigarettes. It might be useful if the Navy developed an image campaign that clearly dissociated smoking from the image of an attractive Navy man or woman. It is also possible that smoking cigarettes in order to ‘be cool’ and ‘look like an adult’ is related to asserting independence. After entering the Navy, especially while in recruit training, men are given few choices in their schedules or in their behaviors. However, one decision that is left up to each man is whether or not he will start smoking or continue to smoke. To help prevent individuals from smoking as one outlet for asserting independence, a powerful anti-smoking campaign featuring peers engaging in independent, non-smoking, actions could help decrease the number of young men who decide to start smoking during their first year in the Navy. This anti-smoking campaign could emphasize a new image of Navy personnel: “Navy people are healthy men and women who are always working to stay fit. It’s fun and challenging to get fit and stay fit. If you don’t smoke, you are demonstrating high intelligence and an ability to resist pressure.” Previous research has indicated that peer-led smoking prevention programs in which peers provide information about both the short-term and long-term effects of smoking, as well as role-playing methods of resisting pressure to start smoking, have been effective in preventing potential smokers from starting [l 1, 141. Many participants also said that they started smoking because they were curious. An innovative possibility for satisfying this curiosity, yet preventing the smoking habit, might be to give immediate
Starting to smoke in the Navy: when, where and why ‘training’ in smoking. Young men who are curious about smoking could be provided free cigarettes in a controlled, somewhat aversive environment (e.g. excessively smoke-filled room). While the men were smoking, a lecture could be given stressing the negative health effects. Related aversion procedures have sometimes been effective in reducing smoking
USI.
In summary,
many men entering the Navy smoke for the first time; an even greater decide to start smoking again. To combat the smoking problem, tobacco use needs to
start to percent Navy’s
become socially unacceptable for Navy personnel. A strong anti-smoking campaign based on social modeling might help change the current image of the typical Navy member as a smoker. In addition, new Navy personnel should be educated about the serious negative health effects of cigarette smoking. Data from the present study suggest that the Navy’s anti-smoking program should also include information on stress reduction, methods of coping with peer pressure, and breaking the connection between being ‘macho’ and smoking.
1353
Cronan T. A. and Conway T. L. Is the Navy attracting or creating smokers? military Medicine- 153, (4); 175-178. 1988. Verebey K. G., DePace A., Mule S. J., Kanzler M. and Jasse J. H. A rapid quantitative GLC method for the simultaneous determination of nicotine and cotinine. J. Analyr. Toxicol. 6, (6) 294-296,
1982.
Conway T. L.. Trent L. K. and Conwav S. W. Phvsical Readiness and Lvesryle Habirs among *U.S. Navy: Per sonnel During 1985, 1987, and 1988(Report No. 89-24).
Naval Health Research Center, San Diego, 1989. 6. Wall M. A., Johnson J., Jacob P. and Benowitz N. L. Cotinine in the serum, saliva, and urine of nonsmokers, passive smokers, and active smokers. Am. J. Publ. Hlrh 78, 699-701,
1988.
7. Pechacek T. as cited in Flay R. P. Mass media and smoking cessation: A critical review. Am. J. Publ. Hlrh 77, (2), 153-160, 1984. 8. Moss A. J. Changes in cigarette smoking and current smoking practices among adults: United States, 1978. Advance Dara, No. 52, September 19, 1979. Vital and Health Statistics of the National Center for Health Statistics. U.S. Government Printing Office, Washington DC., 1979. 9. Evans R. I. and Borgatta E. F. An experiment in smoking dissuasion among university freshman. J. Hlfh Sot. Behav. 11, 30-36, 1970.
Acknowledgemenfs-Report No. 89-3 1, supported by the Naval Military Personnel Command under Work Order No. N000228OWRWW503 and by the Naval Medical Research and Development Command, Department of the Navy, under Work Unit MR041.01.07-6004. The views presented are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. REFERENCES I. Schoenborn C. A. and Boyd G. M. Smoking and other tobacco use: United States, 1987. In Vital and Health Smtisfics, Series 10, No. 169. DHHS Pub. No. (PHS) 89-1597. National Center for Health Statistics. US Government Printing Office. Washinaton D.C.. 1989. 2. Bray R. M., Marsden M. E., Guess L. L., Wheeless S. C., Pate D. K., Dunteman G. H. and Iannacchione V. G. 1985 Worldwide Survey of Alcohol and Nonmedical Drug use Among Military Personnel. NC Research Triangle Institute, Research Triangle Park, 1986.
SW 11112-0
10. Holland W. W. Cigarette smoking respiratory symptoms and antidepressants-smoking propaganda. Lancer 1, 4143, 1968. Il. Evans R. I., Rozelle R. M., Mittelmark M., Hansen W. B., Bane A. and Havis J. Deterring the onset of smoking in children: Knowledge of immediate physiological effects and coping with peer pressure, media pressure, and parent modeling. J. Appl. Sot. Psychol. 8, (2)
126135,
1978.
12. McAlister A. L., Perry C. and Maccoby N. Adolescent smoking: onset and prevention. Pediatrics 63, 650-658, 1979.
13. Blake G. H. Smoking and the military. NY Slate J. Med. (July), 354356, 1985. 14. Evans R. I., Rozelle R. M., Maxwell S. E., Raines B. E., Dill C. A., Guthrie T. J., Henderson A. H. and Hill P.C. Social modeling films to deter smoking in adolescents: Results of a three-year field investigation. J. Appl. Psychol. 66, 399-414, i981. 15. Grimaldi K. E. and Lichtenstein E. Hot smokv air as an aversive stimulus in the treatment of smoking. Behav. Res. Therapy 7, 275-282,
1969.
STARTING
TO SMOKE
Copyright
IN THE NAVY: AND WHY
WHEN,
0
0277-9536/91 53.00 + 0.00 1991 Pcrgamon Press plc
WHERE
TERRYA. CRONAN,’TERRYL. CONWAY~and SUZANNE L. KASZA? ‘Psychology Department, San Diego State University, San Diego, CA92182-0350, U.S.A. and *Naval Health Research Center, P.O. Box 85122, San Diego, CA 92138-9174, U.S.A. Abstract-Smoking rates among U.S. military men are much higher than those in the general population. A previous study compared the smoking rates of male recruits coming into the Navy with those of a shipboard sample to find out whether the Navy was attracting or creating smokers. Twenty-eight percent of the incoming recruits were smokers, whereas 50% of the shipboard men were smokers. These findings suggested that the Navy environment somehow encouraged smoking. The present study followed a group of male recruits for one year after they entered the Navy to determine when, where, and why they started smoking during their first year in the service. Two hundred and sixty-two of the original 682 participants returned the one-year follow-up information. Twenty-eight percent of the sample were self-reported smokers upon entry into the Navy. One year later 41% classified themselves as smokers. Of those who started smoking (either for the first time or again after having quit) during their first year, 42% started within their first two months of service (i.e. during recruit training), and another 32% started during their third month in the Navy. In addition to the 42% who started during recruit training, 39% started while attending training school, and 15% started while stationed aboard a ship during their first year in the Navy. The most frequently cited reasons for starting to smoke were: curiosity, friends smoking, calming effect, and wanted to be ‘cool’. Because many individuals begin smoking soon after joining the Navy, effective prevention programs need to be implemented in recruit training and repeated in early training schools. Key words-smoking,
military, prevalence, reasons
INTRODUCTION
METHOD
Since the Surgeon General’s first report on the health consequences of smoking in 1964, smoking rates in the United States have dropped from 42 to 29% [l]. However, a Department of Defense drug and alcohol survey conducted in 1985 showed that 46% of the military smoked [2]. Although historically the rates of smoking among military personnel have been higher than those in the general population, the discrepancy has increased. In an attempt to understand why the military has a higher percentage of smokers, Cronan and Conway [3] compared the smoking rates of recruits coming into the Navy with those of a shipboard sample to find out whether the Navy environment was attracting or creating smokers. Twenty-eight percent of the incoming recruits were smokers, whereas 50% of the shipboard men were smokers. The discrepancy remained even when age-matched comparisons were made between recruits and men aboard ships. Thus, the Navy environment appeared somehow to encourage smoking among its members. However, the Cronan and Conway study was cross-sectional and, thus, did not provide ecological information related to starting to smoke in the Navy. To provide this information, a subset of the recruits in that study was followed for one year after entering the Navy to determine when, where, and why men start smoking during their first year of service.
Subjects
The participants were 682 men entering the Recruit Training Command (RTC). Naval Training Center, San Diego, for Navy basic training during 1986. The mean age of the participants was 18.7 (SD = 2.26). The mean number of years of education was 12.1 (SD = 0.96). Fifty-seven percent were Caucasian, 18% were African-American, 7% were Hispanic, 6% were from other ethnic backgrounds, and 12% did not report race/ethnic background.
Measures Questionnaire. A smoking status questionnaire
was administered to participants at the beginning of recruit training, and a modified version of this questionnaire was mailed to the participants one year later. Participants were asked to classify themselves as nonsmokers, former smokers, or current smokers. Other information collected in the questionnaire included: amount currently smoked, length of time smoked, and duty assignment when started smoking. A checklist of possible reasons for starting to smoke was also included. Participants who had started smoking either for the first time or again after joining the Navy were asked to check the reasons why they started to smoke. This checklist was constructed after conducting a general review of the literature, with a
1349
1350
TERRY
A.
CRONAN
special emphasis on reasons for smoking that might be relevant to the military. Biochemical validation. To assess the validity of the self-reported smoking behavior, saliva samples were collected at the one-year follow-up, and cotinine levels in the samples were assessed. Cotinine levels were measured by gas chromatography using an adaptation of the method described by Verebey, DePace, Mule, Kanzler and Jasse [4]. Analyses were performed by the University of Minnesota Lipid Research Core (BELRC) Laboratory. The methods employed by this laboratory produce a sensitivity of greater than 1 ng/ml. The detector response is linear from at least 10 to 400 ng/ml for cotinine. For making smoker or nonsmoker classifications, a cutoff value of less than 20 ng/ml cotinine was used to categorize nonsmokers (criterion recommended by the BELRC Laboratory). Procedures
Within the first week in recruit training, questionnaires were administered in group settings, with one member of the research team reading all questionnaire items and answering questions asked by the participants. At the end of one year, all recruits who could be located through a Navy locator system were sent (a) a tobacco use questionnaire, (b) instructions for providing a saliva sample, (c) a tube in which to provide the sample, and (d) two pre-addressed, stamped envelopes (one to return the questionnaire to the investigators and one to send the saliva sample directly to the BELRC Laboratory). If the questionnaire was not returned within two months, a followup letter was sent to the locator address. RESULTS
Of the original 682 participants, valid mailing addresses one year later were obtained for 576 individuals; of the latter individuals, 262 (45.5% participation rate) provided follow-up information regarding tobacco use one year after entering the Navy, There were no significant differences in the demographic characteristics or the initial smoking status of participants who returned the one-year follow-up questionnaire and those who did not. Smoking prevalence
At entry into the Navy during 1986, 59.7% of recruits classified themselves as never smokers, 12.8% as former smokers, and 27.6% as current Table 1. Changes in self-reported smoking year Smoking No Smoking
status at entry
Never smoked Former
smoker
Current
smoker
Total group
status during first one year later YCS
%
%
(n)
(n)
87.6 (134) 45.1 (16) 6.8 (5) 59.2 (155)
12.4 (19) 54.3 (19) 93.2 (69) 40.8 (107)
et al.
50 r
46
U.S. men t16-24yrl
Entry into Navy
one yeor later
Men Novywide
Fig. 1. Comparison of smoking rates for young men in the U.S. population (1987), Navy men in the current study (1986 and 1987). and men in the Navy at large (1986).
smokers, which can be compared with 65.1% never smokers, 6.7% former smokers, and 28.1% current smokers among U.S. males 18-24 years old during 1987. Table 1 presents a cross-classification of the smoking status of study participants upon entry into recruit training and one year later. Of the participants who said they had never smoked when they entered recruit training, 12.4% reported that they were smokers at the end of one year. Of those classified as former smokers at entry into the study, 54.3% reported that they were smoking again at the one-year follow-up. Of those who classified themselves as smokers at entry into the study, 6.8% reported that they were not smoking one year later. Overall, 40.8% of the participants classified themselves as smokers at the end of one year. Figure 1 provides a comparison of smoking rates for 18-24 year-old men in the United States during 1987 [ 11,participants in the present study at entry into the Navy (during 1986) and at the one-year followup, and men randomly selected from the Navy at large during 1986 for participation in a study to evaluate the Navy’s Health and Physical Readiness Program [5]. The figure indicates that the smoking rate of men as they enter the Navy (28%) is similar to that of 18-24 year-old men in the U.S. population (28%). However, by the end of their first year in the Navy, the new service members have a substantially higher smoking rate (41%) which is much closer to that observed for men in the Navy at large (46%). Biochemical validation. Two hundred and ten participants provided saliva samples at the one-year follow-up. Analysis of the cotinine levels in the saliva samples indicated 74% agreement between the participants’ self-report of smoking status and the biochemical classification of smoking status; 21% reported that they were nonsmokers but were classified as smokers by the saliva analysis, and 5% reported that they were current smokers but were classified as nonsmokers by the saliva analysis. The latter 5% is not necessarily inconsistent with valid self-reporting if those self-reported smokers simply had not recently had a cigarette prior to providing the saliva sample. However, the 21% who reported that they were nonsmokers but had salivary cotinine levels greater than or equal to 20 ng/ml do represent a concern regarding the validity of self-reported tobacco use among new Navy personnel.
Starting
to smoke
in
the Navy: when, where and why
If one-fifth of survey respondents claim they are nonsmokers but, in fact, actually smoke, the Navy may have a greater smoking problem than is currently believed. However, it should be strongly cautioned that, except for very specific written instructions regarding how to provide the sample, there were essentially no controls in the field when the participant prepared his saliva sample. Unknown confounding or invalidating factors may have been present in some field settings. For example, one issue of particular concern is the effect of passive smoking. In typical Navy environments, a high percentage of personnel smoke-in 1986 about 46%, on the average, and even higher in certain settings such as aboard surface ships, where over 50% smoked [5]. Furthermore, it has been estimated that at least one or more people smoke in almost 85% of Navy members’ work environments [5]. However, the possibility of passive smoking accounting for some of the discrepancy between lab results and self-reports of smoking status is not supported by the results of one study which examined cotinine levels in both the urine and saliva of passive smokers [6]. These researchers detected only very small amounts of cotinine in passive smokers’ urine and found no evidence of cotinine in their saliva. The results, however, were based on only 20 passive smokers. Regardless of any potential effects of passive smoking or any other confounding factors, the biochemical findings in this study should be replicated before any inferences are made regarding under-reporting of tobacco use among Navy personnel. When
All participants who started smoking during their first year in the Navy were asked to indicate the month in which they started smoking. Forty-two percent of the men started smoking within their first two months in the Navy (i.e. during recruit training). Thirty-two percent started during the third month after entering the Navy (i.e. within one month of leaving recruit training). Thus, nearly three-quarters of the participants who started smoking during their first year started within the first three months after entering the Navy. Where
Participants who started smoking during their first year in the Navy were also asked where they were stationed when they started smoking. Forty-two percent were in recruit training; 30% were attending a training school; and 15% were stationed aboard a ship. Of the remaining four percent (n = 3), one participant was stationed aboard a submarine, one was assigned to an air squadron, and one was shorebased overseas. Thus, most men started smoking in recruit training or while going through special training schools immediately following recruit training. However, it should be noted that because all participants had to go through recruit training, and most went to schools afterward, the ‘Where’ variable is necessarily confounded by Navy training and assignment policy. Thus, inferences regarding the impact of training environments per se on smoking behavior should not be made from these data.
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Table 2. Reasons for starting to smoke during tirst year Smoking status
Reason Curiosity Friends smoked To show I wasn’t afraid It was calming Want to lx cool To look like an adult Boredom To lose weight Liked the taste To show I was tough Liked the image To take a dare So I wouldn’t be left out Parents smoked It gave me a kick To be masculine
New’ (n = 19) %
Recidivist@ (n $9)
Total’ (n = 38) %
50.0
62.5 50.0 26.7 35.3 41.2 41.2 23.5 25.0 23.5 23.5 12.5 12.5 II.8 11.8 6.3 6.3
56.7 56.1 37.9 35.5 32.3 32.3 32.3 20.0 19.4 16.1 6.1 13.3 12.9 12.9 6.7 10.0
64.3 50.0 35.7 21.4 21.4 42.9 14.3 14.3 7.1 0 14.3 14.3 14.3 14.3 14.3
‘Those who started smoking for the first time after joining the Navy. bTh0s-c who reported they were former smokers when they entered the Navy but said they were smokers at the end of their first year in the Navy. ‘All who reported starting to smoking during their first year in the Navy (i.e. new smokers and recidivists combined).
Why Table 2 presents the reasons former and new smokers reported for starting to smoke after entering the Navy. The most common reasons for starting to smoke were: friends smoking, calming effects, wanting to be ‘cool’, wanting to look like an adult, and boredom. Marlboro cigarettes were the most popular brand smoked by participants. Marlboros were smoked by 53.8% of men who had smoked at some time in the past and by 75.0% of those who started since entering the Navy. DISCUSSION
The present study showed that after one year in the Navy the overall percentage of smokers increased from 28% to 41%. There was a 12% increase in the number of new smokers, a 54% recidivism rate, and a 7% quit rate. The 12% increase in new smokers is higher than would have been predicted based on findings from the general population. For example, Schoenborn and Boyd [I] found that the prevalence of smoking was lower in the 18-24 year age group than in the 25-64 year-old group. These authors reported that as adolescents have matured into young adults they have maintained lower smoking rates, and this has distinguished them from older cohorts. In the present study, the mean age of recruits entering the Navy was 18.7 years, which was equivalent to the late adolescent/young adult age group in the general population that Schoenbom and Boyd reported maintaining lower smoking rates. Thus, the increase by 12 percentage points in new smokers over the course of one year in the Navy sample would not have been predicted from current trends in the U.S. population of young males. Although 7% of the smokers in the present study quit smoking during their first year in the Navy, this figure is consistent with the 6% ‘spontaneous’ quit rate estimated by others [A. Spontaneous quit rate
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TERRYA. CRONAN et al.
refers to the percentage of smokers who, at any given time, report that they are not smoking (this can be contrasted with a ‘continuous’ quit rate which is based on continuous nonsmoking over a given period of time). The smokers at entry into this study who said they were not smoking at the one year follow-up assessment had quit for less than one year. Thus, the percentage of initial smokers who were not smoking one year later is approximately what would have been predicted based on spontaneous quit rates in the general population. Although it may seem high, the 54% recidivism rate of former smokers at entry into the Navy who started to smoke again within their first year in the Navy is probably not atypical. Of the study participants who reported the length of time they had been former smokers (15 of the 19 individuals), all but one had quit smoking for less than one year. According to the National Center for Health Statistics, only 1 in 5 recent smokers (i.e. smoked sometime during the past year) were ‘successful’ (i.e. not smoking at the time of the interview) at quitting [8]. Furthermore, when the same type of analysis was applied in the present study and former smokers and current smokers were grouped together as recent smokers, a ‘quit rate’ of about 19% successful quitters was found. This rate is very similar to the roughly 20% found by Moss [8]. Thus, the relatively high recidivism rate in the present study may be typical for this age group. The smoking prevalence findings in this study suggest that the rates of spontaneous quitting and recidivism of Navy personnel during their first year of service are generally consistent with what would be expected based on rates in the general population. However, the increase in the rate of new smokers would not have been predicted from population trends. Thus, the reasons given for why individuals began to smoke were of interest. The most popular reasons overall for starting to smoke were curiosity and friends smoking. It is interesting that a higher percentage of recidivists than new smokers listed curiosity, wanting to be cool, and to look like an adult, as reasons for starting to smoke. However, more new smokers indicated that they started to smoke because their friends smoked, to show they were not afraid, and because they were bored. Several of the most commonly given reasons for starting to smoke are consistent with the idea that social factors may have a fairly strong influence on the smoking behavior of new Navy personnel. Of the seven reasons given by approximately one-third to one-half of those who started smoking during their first year in the Navy, four were related to social pressures (i.e. friends smoked, to show not afraid, to be cool, and to look adult). Both the smoking prevalence findings and the reasons for starting to smoke have implications for the smoking prevention and cessation programs that the Navy might implement. Because most Navy men who start smoking do so within their first three months in the Navy (i.e. during recruit training or subsequent training schools), effective prevention programs should be implemented in these early training programs. Traditional prevention programs have employed lectures, discussions, films, and pamphlet materials which emphasize the harmful long-term
effects of cigarette smoking. They have had limited success in preventing young people from starting to smoke [9, lo]. More effective interventions have included, along with information about the long-term ill effects of smoking, information about the effects of social influences on starting to smoke and the behavioral skills with which to resist social influences (11, 121. If the Navy is to reduce the number of smokers among its members, it must selectively choose and implement prevention programs which have been shown to be most effective at preventing smoking among young adults who are primarily in their late teens and early twenties and who are just entering the work force. When trying to select which prevention methods might be most effective in the Navy environment, it is important to consider why many young men start smoking, either for the first time or again after having quit, when they join the Navy. One possible environmental influence which could encourage smoking in the Navy might be tobacco industry advertising, which has linked cigarette smoking to patriotism, toughness, and military service [I 31. In the present study, over half of all the men who started smoking for the first time, or who started smoking again, smoked Marlboro cigarettes. The advertisements for Marlboro cigarettes have portrayed a very masculine image: ‘tough guys’ smoke Marlboro cigarettes. This image is consistent with the ‘macho’ image of the hard-charging, hard-drinking, cigarette-smoking military man [13]. Perhaps this advertising image has had an influence on military personnel and is related to why some men in this study began smoking when they entered the Navy, as well as smoking Marlboro cigarettes. It might be useful if the Navy developed an image campaign that clearly dissociated smoking from the image of an attractive Navy man or woman. It is also possible that smoking cigarettes in order to ‘be cool’ and ‘look like an adult’ is related to asserting independence. After entering the Navy, especially while in recruit training, men are given few choices in their schedules or in their behaviors. However, one decision that is left up to each man is whether or not he will start smoking or continue to smoke. To help prevent individuals from smoking as one outlet for asserting independence, a powerful anti-smoking campaign featuring peers engaging in independent, non-smoking, actions could help decrease the number of young men who decide to start smoking during their first year in the Navy. This anti-smoking campaign could emphasize a new image of Navy personnel: “Navy people are healthy men and women who are always working to stay fit. It’s fun and challenging to get fit and stay fit. If you don’t smoke, you are demonstrating high intelligence and an ability to resist pressure.” Previous research has indicated that peer-led smoking prevention programs in which peers provide information about both the short-term and long-term effects of smoking, as well as role-playing methods of resisting pressure to start smoking, have been effective in preventing potential smokers from starting [l 1, 141. Many participants also said that they started smoking because they were curious. An innovative possibility for satisfying this curiosity, yet preventing the smoking habit, might be to give immediate
Starting to smoke in the Navy: when, where and why ‘training’ in smoking. Young men who are curious about smoking could be provided free cigarettes in a controlled, somewhat aversive environment (e.g. excessively smoke-filled room). While the men were smoking, a lecture could be given stressing the negative health effects. Related aversion procedures have sometimes been effective in reducing smoking
USI.
In summary,
many men entering the Navy smoke for the first time; an even greater decide to start smoking again. To combat the smoking problem, tobacco use needs to
start to percent Navy’s
become socially unacceptable for Navy personnel. A strong anti-smoking campaign based on social modeling might help change the current image of the typical Navy member as a smoker. In addition, new Navy personnel should be educated about the serious negative health effects of cigarette smoking. Data from the present study suggest that the Navy’s anti-smoking program should also include information on stress reduction, methods of coping with peer pressure, and breaking the connection between being ‘macho’ and smoking.
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Cronan T. A. and Conway T. L. Is the Navy attracting or creating smokers? military Medicine- 153, (4); 175-178. 1988. Verebey K. G., DePace A., Mule S. J., Kanzler M. and Jasse J. H. A rapid quantitative GLC method for the simultaneous determination of nicotine and cotinine. J. Analyr. Toxicol. 6, (6) 294-296,
1982.
Conway T. L.. Trent L. K. and Conwav S. W. Phvsical Readiness and Lvesryle Habirs among *U.S. Navy: Per sonnel During 1985, 1987, and 1988(Report No. 89-24).
Naval Health Research Center, San Diego, 1989. 6. Wall M. A., Johnson J., Jacob P. and Benowitz N. L. Cotinine in the serum, saliva, and urine of nonsmokers, passive smokers, and active smokers. Am. J. Publ. Hlrh 78, 699-701,
1988.
7. Pechacek T. as cited in Flay R. P. Mass media and smoking cessation: A critical review. Am. J. Publ. Hlrh 77, (2), 153-160, 1984. 8. Moss A. J. Changes in cigarette smoking and current smoking practices among adults: United States, 1978. Advance Dara, No. 52, September 19, 1979. Vital and Health Statistics of the National Center for Health Statistics. U.S. Government Printing Office, Washington DC., 1979. 9. Evans R. I. and Borgatta E. F. An experiment in smoking dissuasion among university freshman. J. Hlfh Sot. Behav. 11, 30-36, 1970.
Acknowledgemenfs-Report No. 89-3 1, supported by the Naval Military Personnel Command under Work Order No. N000228OWRWW503 and by the Naval Medical Research and Development Command, Department of the Navy, under Work Unit MR041.01.07-6004. The views presented are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. REFERENCES I. Schoenborn C. A. and Boyd G. M. Smoking and other tobacco use: United States, 1987. In Vital and Health Smtisfics, Series 10, No. 169. DHHS Pub. No. (PHS) 89-1597. National Center for Health Statistics. US Government Printing Office. Washinaton D.C.. 1989. 2. Bray R. M., Marsden M. E., Guess L. L., Wheeless S. C., Pate D. K., Dunteman G. H. and Iannacchione V. G. 1985 Worldwide Survey of Alcohol and Nonmedical Drug use Among Military Personnel. NC Research Triangle Institute, Research Triangle Park, 1986.
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10. Holland W. W. Cigarette smoking respiratory symptoms and antidepressants-smoking propaganda. Lancer 1, 4143, 1968. Il. Evans R. I., Rozelle R. M., Mittelmark M., Hansen W. B., Bane A. and Havis J. Deterring the onset of smoking in children: Knowledge of immediate physiological effects and coping with peer pressure, media pressure, and parent modeling. J. Appl. Sot. Psychol. 8, (2)
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12. McAlister A. L., Perry C. and Maccoby N. Adolescent smoking: onset and prevention. Pediatrics 63, 650-658, 1979.
13. Blake G. H. Smoking and the military. NY Slate J. Med. (July), 354356, 1985. 14. Evans R. I., Rozelle R. M., Maxwell S. E., Raines B. E., Dill C. A., Guthrie T. J., Henderson A. H. and Hill P.C. Social modeling films to deter smoking in adolescents: Results of a three-year field investigation. J. Appl. Psychol. 66, 399-414, i981. 15. Grimaldi K. E. and Lichtenstein E. Hot smokv air as an aversive stimulus in the treatment of smoking. Behav. Res. Therapy 7, 275-282,
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