Editoials

It may simply be an impossible task to write a coherent report on the future of public health because the field is so vast, its practitioners so varied, and the problems it addresses so sweeping in scope. The solutions to the problems of air pollution, hazardous waste disposal, substance abuse, and health care for the uninsured have little, if anything, in common. To pretend that restructuring the bureaucracy is a significant part of the answer overlooks the political and economic barriers to the solution of these problems. There are many players who must come to the table, and their agendas

are very different. Perhaps it is the very magnitude and scope of public health problems and their solutions that cause the field to appear to be in disarray. Much of the report is commendable, but it does not address the future of public health. That report is still to be written, and we urge the public health community and those who support it not to facilely rely on what has been done but rather to develop their own vision of the future. O

George J. Annas, JD, MPH

Leonard H. Glantz, JD Norman A. Scotch, PhD George J. Annas, JD, MPH, is Chairman and Professor in the Health Law Department at the Boston University School of Public Health. Leonard H. Glantz, JD, is a Professor in the Health Law Department as well as Associate Director at the Boston University School of Public Health. Norman A. Scotch, PhD, MSHyg, is Director of the Boston University School of Public Health.

Reference 1. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988.

Substance Abuse in Military Personnel: Better or Worse? With stooping of weary shoulders, in garments tattered and frayed, They shambled into his [Tennyson's] presence, the last of the Light Brigade. The old Troop-Sergeant was spokesman, and "Beggin' your pardon" he said, "You wrote o' the Light Brigade sir. Here's all that isn't dead. "An' its all come true what you wrote, sir, regardin' the mouth of hell; For we're all of us nigh to the workhouse, an' we thought we'd call an' tell. "No thank you, we don't want food, sir; but couldn't you take an' write A sort of 'to be continued' and 'see next page' o' the fight? We think that someone has blundered, an' couldn't you tell 'em how? You wrote we were heroes once, sir. Please write we are starving now. (Kipling, "The Last of the Light Brigade")'

Kipling's 1891 poem reminds us that yesterday's war heroes may become tomorrow's homeless and jobless; and as such they will share in the special plagues visited upon those groups-cigarettes and alcohol abuse. The burden of disease due to cigarette and alcohol consumption by US veterans is enormous. For veterans attending Veterans Administration (VA) hospitals between 1970 and 1982, the agespecific incidence rates for cancers of the lung, bronchus, larynx, oral cavity, and esophagus were consistently higher than rates for similar age intervals for the popJuly 1991, Vol. 81, No. 7

ulation described in the 1973-1977 Surveillance Epidemiology and End Results (SEER) Cancer Registry.2 These excesses projected over a lifetime of 18 to 74 years resulted in an average relative risk for the VA population compared with the SEER population of 2.0 for these five malignancies.3 A visit to any Veterans Administration hospital will confirm these observations. It's undeniable that high rates of heavy alcohol use and cigarette smoking have also been characteristic of soldiers while they were soldiers. This fact has been amply documented over the years, and Bray and Marsden's analysis in this issue of the journal calls attention to the fact that this was still true in 1985.4 However, in many ways the decade of the 1980s was entirely different from previous decades in the military because attitudes toward cigarette smoking and alcohol abuse had begun to shift and a number of new policies and programs were implemented. In 1984, "happy hours" were discontinued at Army officer and enlisted clubs. Since 1986, any soldier convicted of driving while intoxicated has had a letter of reprimand placed in his official personnel folder and has been given a mandatory referral to the alcohol and drug abuse prevention and control program. Such letters have a decidedly negative impact on promotions and thus may bring about an early end to a career. Base military police have conducted random stops of motorists to administer Breathalyzer tests. A significant event of the decade was the publication in 1987 ofthe Army Health Promotion regulation, which prohibits smoking in buildings controlled by the Army. The

scope of the Health Promotion regulation and a brief description of its 10 components has been published.5 This regulation requires that building occupants be protected from second-hand smoke. In many of the Army's old buildings with inadequate and poorly maintained ventilation systems smoking is now prohibited. Smoking is also prohibited during basic and combined basic/advanced training. Smoking at advanced training schools is controlled and limited to certain times of the day. Cigarette vending machines have been removed from Army medical centers. Tobacco use is further discouraged by the incorporation of tobacco screening into routine dental examinations. Previously published data from the 1985 Worldwide Survey in the Department of Defense (DOD) have suggested some improvement in the rates of cigarette smoking. The lowest ranking enlisted grades (E1-E3) and the 20 to 29 year age group showed declines in cigarette smoking rates of approximately 8% between 1982 and 1985. It is too early to tell if these small differences are part of a significant trend, and we cannot yet separate the impact ofthe general societal trend from programs and policies adopted in the military in the 1980s. Recreational drug use policies directed at marijuana, cocaine, and opiates have taken a very tough line against users; the DOD program by all estimates has been highly successful and achieved its goals at a modest cost. But curtailing the use of legal controlled substances can be far more expensive than curtailing illegal controlled substances, and the use of legislative remedies to control smoking and eliminate alcohol abuse can be justified on

American Journal of Public Health 837

Editorials

cost grounds alone. The legislative remedies, along with local commander's sponsored health promotion programs, will certainly reduce institutional encouragement and perpetuation of these behaviors. The Bray article's comparison of military and civilian surveys is useful, but one should keep in mind that these surveys were not designed to answer the questions of how and when smoking and drinking behaviors began. The authors conclude that the differences in rates between the surveys suggest that "certain aspects of military life may foster use" (p. 866). There is nothing in the data they cite to help them arrive at this conclusion. Identifying the causes of behavior and of changes in behavior in the cohorts of young Americans who have passed through the military will require some separate studies. Questions concerning the determinants of smoking and drinking behavior could be addressed in a casecontrol design, in which persons with these behaviors from veterans hospitals or veterans' associations are paired with control subjects from comparable community hospitals or from other appropriate sources in the community. Such a study could determine if the military services are part of the problem rather than part of the solution. But if the military services have been selecting individuals who are predisposed to smoke and

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drink, the differences between civilian and military surveys in smoking and drinking rates may never be reduced to zero, even with highly successful programs and policies. Temporal trends in the demographics of the armed services will make long-term comparisons of these behaviors a challenge. The demographics of the US military are a moving target, so to speak. As the Army has begun to require more applicants to have technical skills and a high school diploma at the time they enlist, persons with substantial smoking and drinking habits have been excluded. (The relationship between socioeconomic factors and smoking and drinking behaviors is well documented.7) Much of this shift has occurred recently. The percentage of persons entering the armed services with high school diplomas has climbed from 68% in 1980 to 91% in 1983.8 Analyses of the 1985 and 1988 Worldwide Surveys will provide important measures of the extent of alcohol abuse and smoking in persons on active duty in the US Armed Forces. To make sense of the temporal trend in the gap between civilian and military rates in comparable surveys, additional studies will have to be done, studies designed to uncover the context within which these behaviors developed. Such data will help to determine what changes, if any, need

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Lytt I. Gardner is with the Department of the Army, Walter Reed Army Institute of Research, Walter Reed Army Medical Center, Washington, DC 20307.

References 1. Rudyard Kipling's Verse. Definitive Edition. Garden City, NY: Doubleday and Co., Inc., 1940; 200-201. 2. Young YL, Percy CL, Assir AJ. Swavedlance Epidemiology and End Results: Incidence and Mortality Data 1973-1977. Bethesda, MD: Public Health Service; 1981. NIH publication 81-0332. 3. Harris RE, Hebert JR, Wynder EL. Cancer risk in male veterans utilizing the Veterans Administration medical system. Cancer. 1989; 64:1160-1168. 4. Bray RM, Marsden ME, Peterson, MR. Standardized comparisons of the use of alcohol, drugs and cigarettes among military personnel and civilians.AmJPublicHealth. 1991; 81:866-870. 5. Rothberg JM. Some thoughts on health promotion in the United States Army. Milit Med. 1989; 154:457-461. 6. Ballweg JA, Bray RM. Smoking and tobacco use by US military personnel. Milit Med. 1989; 154:165-168. 7. Health Promotion and Disease Prevention, United States 1985. Hyattsville, Md: National Center for Health Statistics; 1988. Data from the National Health Survey, Series 10, No. 163, DHHS publication 88-1591. 8. Defense 84. Publication of the Department of Defense, September, 1984. Available from: Superintendent of Documents, Washington, DC.

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Substance abuse in military personnel: better or worse?

Editoials It may simply be an impossible task to write a coherent report on the future of public health because the field is so vast, its practitione...
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