Tobacco Cessation and the Department of Defense DoD Department of Veterans Affairs VA Populations

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Tobacco Cessation and the Department of Defense
(DoD) / Department of Veterans Affairs (VA)
Populations

• Larry N. Williams
• Captain, Dental Corps, US Navy
• DoD/VA Primary Care Tobacco Cessation Champion

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DoD/VA Tobacco Cessation

• Issues to be discussed
• Defined DoD/VA tobacco cessation need
• History of tobacco issues in the DoD/VA
• Populations defined
• DoD/VA tobacco use demographics
• DoD/VA tobacco cessation initiatives
• DoD/VA future tobacco cessation issues

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DoD/VA Direction

• As the Secretary of Defense it is my
  responsibility to create and foster leadership
  that will encourage all DoD personnel to choose a
  healthy lifestyle. One imperative is the
  avoidance of all tobacco products. Such products
  are harmful to the individuals who use them and
  can be harmful to their families, friends, and
  their communities.
• SECDEF MEMO 5 Sep 2000
• Tobacco-related diseases together represent
  the single most expensive medical problem treated
  in VA facilities.
• PREVENTIVE MEDICINE PROGRAM, SMOKING CESSATION
• A SPECIAL INITIATIVE FOR 1996/1997

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DoD/VA Tobacco History

• Summary of DoD/VA actions involving tobacco
• 1975- Cigarettes are discontinued in K-rations
  and C-rations given to soldiers and sailors
• 1986- Tobacco use banned during boot camp
• 1989- All VA Acute Care Centers are smoke-free
• 1994- Department of Defense (DoD) bans smoking in
  certain DoD workplaces
• 1995- VA policy for patients using tobacco
• 1996- DoD Commissary prices equal military
  exchange rates
• 1997- President Clinton announces an Executive
  Order to make all federal workplaces smoke-free
• 1999- DoD Smoke-free facilities
• 2001- DoD/VA Tobacco Cessation Clinical Practice
  Guidelines established
• 2001- DoD tobacco prices within 5 of local
  economy

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Department of Veterans Affairs (VA) Population

• 25,497,700 Veterans as of 2001(1)
• A VA-eligible Veteran is defined as any
  prior-Active Duty member honorably discharged
  from Active Duty
• In 2001 there were 4,247,204 Veterans enrolled in
  the VA Healthcare system
• 59.3 percent of veterans using the VA system have
  no private or Medigap insurance and 21 percent
  have no health care coverage
• The veteran population aged 85 and older will
  increase from 154,000 in 1990 to 1.26 million in
  the year 2010. This 720 percent increase is
  expected to increase utilization of VA health
  care by nearly 400 percent for this group in the
  same 20-year time period

(1) VetPop2000, Office of the Actuary (008A2),
Department of Veterans Affairs (2) DEPARTMENT OF
VETERANS AFFAIRS STRATEGIC PLAN Fiscal Years 1998
- 2003
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DoD Populations Active Duty

• As of April  30, 2002
• 481,266 Army
• 381,901 Navy
• 172,741 Marine Corps
• 362,330 Air Force
• Total Active Duty 1,361,324

Military Personnel Statistics Washington
Headquarters Service Active Duty Military
Strength Report for April 30, 2002
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DoD Populations Retirees

• As of September 30, 1998
• All Services 0-19 years of service
• 58,086 (non-disabled)
• 71,833 (disabled)
• 129,919 Total  
• All Services 20 years of service
• 1,262,356 (non-disabled)
• 34,686 (disabled)
• 1,297,042 Total
• Total Retirees 1,462,448

Prepared by Washington Headquarters Services
Directorate forInformation Operations and
Reports
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DoD Populations Active Duty Family Members

• As of September 30, 1998 
• Army 674,516
• Navy 545,529
• Marine Corps 174,356
• Air Force 554,946
• Total 1,949,347

Prepared by  Washington Headquarters Service -
Directorate for Information Operations and
Reports
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Department of Veterans Affairs (VA) Population

• 1999 Health Survey of Veterans
• 845,387 Veterans surveyed
• 77 ever-smoked
• 26.1 still smoking
• Age adjustment shows VHA patients higher than US
  population
• 36.1 vs. 27.6 (males)
• 28.1 vs. 22.1 (females)
• 76 asked about tobacco use 69 advised to quit
  27 referred for cessation 15 received
  cessation help

Miller, DR, et al, Tobacco use and smoking
cessation in the Veterans Health Administration
14 Nov 2000.
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DoD Congressional Mandate

• Senate Appropriations Committee Report 107-109
  that accompanies the FY02 Appropriations
  bill"urges" the Department to expedite the
  availability of tobacco use prevention and
  cessation programs to all DoD personnel

OASD/HA Staff Data
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Why Tobacco Cessation?

• DoD Costs attributable to Smoking in 1995 based
  on limited Inspector General study
• Estimated 584 million for medical care
• Inpatient costs only
• Does not include maternal-child impact,
  secondhand smoke, or outpatient visits
• Estimated 346 million for productivity loss
• Smoking has adverse effects in the short term,
  even in a young AD population (1)
• Over 100 million/year in economic costs
• Equivalent of 1 USAF base worth of work up in
  smoke every year (3,573 lost FTEs)

(1) Cost of smoking among active duty U.S. Air
Force Personnel United States, 1997, 49(20).
MMWR. (May 2000).
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Summary of 1998 Active Duty Tobacco Use Findings

• Findings indicate the Military has made
  considerable progress since 1980
• 2001 Survey delayed due to 9-11
• Military rates of smoking were statistically
  lower than civilian rates, although it should be
  noted that the difference was small and seems
  largely caused by an increase in smoking among
  civilians rather than significant decreases among
  military personnel.
• The rates of any cigarette smoking in the total
  DoD (29.1) and in all four Services (25.7 to
  34.9) were all still well above the Healthy
  People 2000 target of 20.

Source DoD Survey of Health Related Behaviors
Among Military Personnel, 1998
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Comparison of Active Duty/Civilian Cigarette
Smoking

• 32.8 of U.S. Population (1998)
• 33.8 Men
• 26.6 Women
• 29.1 of Active Duty members (1998)
• 29.3 Men
• 25.4 Women
• 37.3 Ages 18-25
• 24.2 Ages 25-55
• Adult prevalence of tobacco use is decreasing.

NHSD 1997/DoDSHRB 1998
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Summary of 1998 DoD Findings

• Smokeless tobacco use in the Military is also
  cause for concern.
• The use of smokeless tobacco ranged from about 9
  to about 19. It was especially prevalent among
  men aged 24 or younger (19).
• Given that one of the Healthy People 2000
  objectives is to reduce the current prevalence of
  smokeless tobacco use to no more than 4 of males
  aged 24 or younger, these findings indicate that
  the DoD and the Services will have to engage in
  considerable effort to reduce smokeless tobacco
  use among young males if this objective is to be
  met within the Military.

Source DoD Survey of Health Related Behaviors
Among Military Personnel, 1998
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Current Tobacco Cessation in the DoD/VA

• 2001 DoD/VA Tobacco Use Cessation (TUC)
  Guidelines established
• Evidence-based using PHS CPG
• Encourages TUC in either a classroom or clinical
  setting
• All DoD and VA beneficiaries should be screened,
  counseled, and offered help
• Various services have different avenues of
  tobacco cessation availability
• Tobacco cessation available at all VA Medical
  Centers
• TUC pharmacotherapy is dependent on the MTF
  budget for all medications
• The VA National Formulary has a full range of
  tobacco cessation medications

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TRICARE Facts

• Total beneficiaries 8.4 Million
• Military hospitals 76
• Clinics 460
• Military Health System Personnel 131,000
• Total budget 24 Billion

2002 TRICARE Stakeholders Report
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TRICARE Facts

• There is currently no defined TRICARE benefit
  for tobacco cessation
• No system-wide funding for tobacco cessation
  medications
• No funding for staffing of tobacco cessation
  programs
• No consensus on cessation programs although the
  DoD/VA TUC Guidelines are being used
• Work is underway for this benefit

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TRICARE and FEHB Program

• Interesting to note
• Premiums in the FEHB rose 26 between 1998 and
  2000
• No premium increases for TRICARE
• Premiums actually decreased in 2001 and benefits
  increased!

2002 TRICARE Stakeholders Report
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The Future of DoD/VA TUC

• Need for defined TRICARE benefit
• Build on the effect of the tobacco-free boot camp
  period
• Look at military-specific lifestyle issues of
  tobacco use
• Currently being researched
• Successfully implement the DoD/VA CPG in all
  populations

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Questions?