Availability of smoking cessation resources for U.S. Army general medical officers

Adequate resources are a necessity in providing effective smoking cessation interventions to active duty soldiers. The availability of smoking cessation resources was measured by a survey of Army general medical officers (GMOs). Questionnaires were successfully mailed to 232 Army GMOs, which was the entire population of this group in 1997. One hundred fifty GMOs (65%) returned the questionnaire voluntarily and anonymously. Fifty-three percent of GMOs identified the nicotine patch as a formulary item. All responders indicated that some form of nicotine replacement was available on formulary or for purchase in the area. Eighty-two percent of GMOs reported that group smoking cessation programs were available. The widespread availability of group smoking cessation programs may reflect an emphasis on this strategy by the Army's health promotion program. Additional attention needs to address the availability of nicotine replacement items and other adjunctive medications without cost to the beneficiary at military installations.     

The clinical implications of a smoking ban on submarines in the U.S. Navy

By the end of calendar year 2010, a total smoking ban on submarines is expected to be implemented throughout the submarine force because of the negative health effects of environmental tobacco smoke and the recently demonstrated exposure of nonsmoking submariners to measurable levels of nicotine during submarine deployments. Historically, smoking has been highly prevalent in the military, but new data on the negative health effects of tobacco have led the military to change its policies, restricting its use in certain environments. A number of research studies have examined the effect of smoking on the military, cessation and prevention interventions, effect of environmental tobacco smoke onboard the submarine, and treatment modalities aimed at smokers attempting to quit. With the potential for considerable physical and psychological effects, a mass tobacco cessation program is being implemented to support the prohibition onboard the submarine. Recommendations for a successful implementation program are included.     

Controlled trial for smoking cessation in a Navy shipboard population using nicotine patch, sustained-release buproprion, or both

This study reports an experimental, randomized controlled clinical trial comparing three treatments for smoking cessation: sustained-release bupropion, nicotine patch, and combination nicotine and bupropion, to a counseling-only control group (N = 140), for smoking sailors aboard seven Navy ships. The purpose was to determine the effectiveness of different pharmcotherapies used in smoking cessation programs. Continuous abstinence was defined as the percentage of subjects who did not smoke since the quit date assessed at 6 and 12 months and having an expired carbon monoxide concentration of <10 ppm at educational sessions 2, 3, and 4. Nine subjects dropped out of the study, and 40 subjects were lost to follow-up. Eleven percent (15/140 subjects) had continuous abstinence at 12 months. The abstinence rates at 12 months were 47% in the control group, as compared with 27% in the nicotine patch/bupropion group, 20% in the nicotine patch group, and 7% in the bupropion group.     

Assessing the institutional approach to implementing smoking cessation practice guidelines in veterans health administration facilities

National smoking cessation guidelines include recommended strategies for providers and health care organizations, but they offer little guidance on how to structure care. We conducted a cross-sectional survey at 40 Veterans Health Administration facilities, to describe the structure of smoking cessation care, to assess adherence to national guidelines, and to assess facilities' preferred approach to providing smoking cessation treatment. We categorized sites as those using a primary care approach (most smokers treated by the primary care provider) versus a specialty approach (medication restricted to smoking cessation clinics, to which most patients were referred). Nearly all sites reported systematic screening for smoking and counseling of smokers, usually by both nursing staff members and the primary care provider. Most sites used a specialty approach, restricting medication access to smokers attending a cessation program. Future research should evaluate whether this approach provides adequate access and responsiveness to patient preferences for the full population of smokers in primary care.     

Military tobacco policies: the good, the bad, and the ugly

The United States military has the legacy of a pro-tobacco culture and still has prevalence rates of tobacco use that are higher than their civilian counterparts. One tactic for decreasing use and the subsequent health problems is through effective tobacco control policies. We collected available tobacco control policies from all four branches of the military and, through qualitative analysis, identified policies that were unique either as providing more or less detail and restriction than peer group policies. Best and worst practice policies in the areas of enforcement, smoking cessation, smokeless tobacco use, environmental tobacco smoke, framing tobacco as non-normative, designated tobacco use areas, and monitoring of tobacco use are presented. Because policy making can be an effective tool for improving the health of military members, understanding what policy components are comparatively positive or negative is an important tool for health advocates both in the military and civilian settings.     

Clinical competence in myocardial perfusion scintigraphic stress testing: general training guidelines and assessment

The suggestion by the National Institute for Clinical Excellence (NICE) to more than triple the number of myocardial perfusion scintigraphy (MPS) procedures carried out by the NHS each year is a challenge both in terms of numbers of gamma cameras available to carry out the scans and qualified staff to supervise stress tests. In the past, exercise and pharmacological stress testing have been supervised only by doctors but, increasingly, this is taken on by suitably trained non-medical professionals such as nurses, radiographers and clinical technologists. The expansion of the numbers of non-medical professionals qualified to supervise stress testing will be key to meeting NICE's recommendations. This paper sets out how potential new stressors should be identified, what their training should cover and discusses the standards of competence they should meet. It provides guidelines for training non-medical stressors to perform a safe and efficient stress test during MPS and advice for maintaining competency.     

The use of unit watch or command interest profile in the management of suicide and homicide risk: rationale and guidelines for the military mental health professional

Military mental health care professionals have, for decades, recommended that commanders implement a unit watch (now called a "command interest profile" at most Army posts) as a tool for enhancing the safety of personnel in the unit when a soldier presents with suicidal or homicidal ideation. Although these procedures are used extensively in garrison and in operational settings, there exists no specific body of literature or Army publication to offer either a rationale or a set of guidelines for their use. We have successfully used unit watch protocols for years both in the deployment setting and in garrison. This article provides both a rationale and a set of guidelines for their use based on fundamental military psychiatric principles, review of the relevant literature, and anecdotal experience with this intervention. Although further research is indicated, this article provides support for the use of unit watch in military settings.     

A theoretical model for the study of active and passive smoking in military women: an at-risk population.

This paper presents a model designed for the study of active and passive smoking in military women with children. Some constructs have been adapted from a transtheoretical model of behavior change. Transtheoretical model constructs of relevance to this model include (1) stages of behavior change, (2) decisional balance, and (3) self-efficacy. Other model constructs include (1) personal and situational factors, (2) a mother's self-efficacy to reduce the child's smoke exposure, (3) a mother's expectation for the child's smoke exposure, (4) smoke avoidance, (5) nicotine dependence, and (6) social support for quitting smoking. The occurrence of health problems associated with smoking is the outcome variable. The results of a study under way at present may support the use of this model and may make data available to substantiate the need for behavior-specific interventions designed to prevent and reduce active and passive smoking among military personnel.     

A submarine shipboard smoking cessation program

The discouragement of tobacco abuse in the military requires effective smoking cessation assistance for all active duty and dependent personnel. Specifically tailoring this assistance to the unique features of the various military communities will help to make it more effective. The program presented herein was designed for use in the submarine fleet. It combines basic proven workplace smoking cessation techniques with lessons learned from experience in submarines. It is believed that other military populations can benefit from similar efforts. This paper is an abridged version of the author's Submarine Medical Officer qualification thesis.     

International survey of military mental health professionals

This paper reports on data from a survey of international military mental health professionals. In a series of open-ended questions, respondents were asked to describe their country in terms of the field of military psychology, the role of mental health professionals on deployment, the degree to which the field of mental health is accepted in the military, and their contact with their international counterparts. The survey was mailed to 44 different countries from July 1995 through July 1996. The data are based on 30 individual responses from 23 different countries. Cultural differences included the role of psychologists in the military and on deployment, the degree of professional isolation, and specific services provided by psychologists. Cultural similarities included the ambivalent response to the mental health field by military leaders, the use of psychology as a prevention tool, and the degree of interest in international contact and exchange. The discussion focuses on three obstacles to the acceptance of the mental health field and possible avenues for greater exchange of information among military professionals working in psychology-related fields.     

Attitudes of oncology healthcare practitioners towards smoking cessation: A systematic review of the facilitators,barriers and recommendations for delivery of advice and support to cancer patients

ObjectivesA systematic review of the literature was conducted. The review was conducted using a search of the literature for all years up to October 2016. Statements that identified facilitators, barriers or recommendations surrounding smoking cessation delivery were extracted and analogous statements aggregated to enable thematic analysis. After searching multiple databases and the application of exclusion and inclusion criteria, a total of 19 acceptable studies were identified.Key findingsDelivery of cessation by oncology professionals was impacted by their own knowledge and views, their perception of the benefits to patient health and by the workplace procedures within their institution.ConclusionOncology practitioners worldwide face similar issues in delivering smoking cessation advice. By improving training programs that address the attitudes and beliefs which facilitate or block delivery of smoking cessation and by implementing systemic changes within cancer centres, delivery of smoking cessation should be enabled.     

Effectiveness of revised fluid replacement guidelines for military training in hot weather

BACKGROUND: This study compared the revised U.S. Army fluid replacement guidelines (REV) with the old guidelines (OLD) on daily changes in serum sodium concentration (Na+) and body mass (BM) during Basic Combat Training at Fort Benning, GA during two successive summers. METHODS: Recruits (n = 550; OLD = 277, REV = 273) were evaluated before and after 8-12 h of outdoor military combat training in hot weather. The WBGT (mean +/- SD) averaged 26.6 +/- 1.7 degrees C for OLD and 27.4 +/- 0.9 degrees C for REV (NS). RESULTS: Serum Na+ decreased from 137.5 +/- 1.6 mEq x L(-1) to 137.0 +/- 2.1 mEq x L(-1) after outdoor military training in OLD (p < 0.05). Twenty-two recruits (8%) had serum sodium fall to below 135 mEq x L(-1) during OLD. Serum Na+ increased from 139.0 +/- 1.7 mEq x L(-1) to 139.4 +/- 2.1 mEq x L(-1) after outdoor military training in REV (p < 0.05). Only two recruits (1%) had serum Na+ fall to below 135 mEq x L(-1) during REV. BM increased an average of 1.3 +/- 1.4 kg (p < 0.05) in OLD and an average of 0.4 +/- 1.7 kg in REV (p < 0.05). CONCLUSIONS: The revised guidelines effectively reversed the decrease in serum sodium, reduced the increase in body mass, maintained hydration and minimized overdrinking during hot weather military training compared with the old fluid replacement guidelines.     

Multiple-role dilemmas for military mental health care providers

Military psychologists and psychiatrists frequently face ethical quandaries involving boundary crossings, or extratherapy contact, and multiple relationships. A multiple relationship is defined as necessarily engaging psychotherapy patients in nonclinical roles, such as coworker, superior officer, neighbor, or friend. In contrast to their civilian counterparts, military mental health professionals must often engage patients in many different contexts and roles. In this article, we consider the distinctive features of mental health practice in the military and offer military providers several practice guidelines for avoiding harm to patients in military settings. This article is also designed to enhance sensitivity to multiple-role risks among nonpsychiatric providers.     

Screening tools to prioritize routine dental care in an institutional environment

OBJECTIVE: This study examines whether self-rated oral health is a suitable screening tool to detect dental caries and periodontal pockets, by itself and in combination with other self-reported health indicators, at the entry point of an institutional system for routine dental care. METHODS: Eight dentists recorded the clinical oral health status of a diverse adult sample (#n = 483) demanding routine dental examinations from a military health maintenance organization in South Africa (July 1999 to December 2000). Additionally, subjects reported their smoking status and rated their general and oral health by using a 4-point Likert scale (excellent, good, fair, or poor). RESULTS: Self-rated oral health in combination with self-reported smoking and self-rated general health were associated with the majority of decayed teeth and periodontal pockets in subjects demanding routine dental examinations. CONCLUSION: This study indicates that self-rated oral health in combination with self-reported smoking can be a useful screening tool to prioritize routine dental care in an institutional environment.     

Clinical effectiveness of sustained-release bupropion and behavior therapy for tobacco dependence in a clinical setting

Despite decades of public education, cigarette smoking remains a serious health problem. The treatment approach at Tripler Army Medical Center is a unique collaboration of family practice physicians and health psychologists providing combination therapy to patients attempting to quit smoking. This article discusses a program evaluation of the Tripler Army Medical Center smoking cessation program. Patients attempting to quit smoking were assisted with a combination of cognitive-behavioral group therapy and sustained-release bupropion hydrochloride. At 6 months postintervention, patients who attended the smoking cessation programs were contacted via telephone and asked to complete a survey regarding their smoking status. One hundred forty-four participants completed the survey. Thirty-five percent of all contacted attendees remained abstinent from smoking at 6 months after intervention. A significantly greater percentage of men quit than women. There were no significant differences of abstinence rates by any other demographic characteristic or smoking history variable. Family practice physicians and health psychologists providing a combination of pharmacological and group cognitive-behavior therapy for nicotine dependence are effective in promoting abstinence from smoking.     

Procedure guidelines for radionuclide myocardial perfusion imaging

Radionuclide myocardial perfusion imaging (MPI) is an established and non-invasive imaging technique with diagnostic and prognostic efficacy in the investigation of coronary artery disease. It is the only widely available test for assessing myocardial perfusion directly but there are variations in the way it is performed in different centres. Harmonization of practice, at least at a national level, is therefore essential, and clinical governance now makes it mandatory for practice to be based upon evidence whenever possible [ 1]. This is best achieved by expert analysis of the evidence and to this end the British Nuclear Cardiology Society (BNCS) in association with the British Cardiac Society (BCS) and the British Nuclear Medicine Society (BNMS) have developed procedure guidelines for tomographic myocardial perfusion imaging. A systematic literature search was performed and every effort was made to conform with the AGREE recommendations [ 2]. All recommendations are therefore based on either evidence from clinical studies, previous published guidelines or expert consensus of the writing and advisory groups. The guidelines cover the clinical indications of MPI, the methods used for stress testing, the radiopharmaceuticals and the injected activities and also issues related to acquisition, processing and interpretation of images. They do not cover the benefits or drawbacks of the technique in specific circumstances; neither do they address its cost effectiveness in clinical diagnosis and management nor its potential impact on clinical outcomes. The guidelines aim to assist medical practitioners and other health care professionals in recommending, performing, interpreting and reporting single photon emission computed tomography (SPECT) of myocardial perfusion.     

Fluid replacement recommendations for training in hot weather.

The U.S. Army's fluid replacement guidelines emphasize fluid replacement during hot weather training to prevent degradation of performance and minimize the risk of heat injury. Little consideration has been given, however, to possible overhydration and development of water intoxication. Sufficient epidemiological evidence is available to demonstrate an increasing incidence of water intoxication during military training. This article summarizes the development and validation of revised fluid replacement guidelines for hot weather training. The end product is an easy-to-read table that provides the user with the appropriate hourly work time and fluid intake to support work during hot weather training. The guidelines include the range of hot weather conditions likely to be encountered during military training and cover a broad range of military activities. It is expected that the revised guidelines will sustain hydration and minimize the number of heat injuries during military training while protecting the soldier from becoming sick from overdrinking.     

Temporal change in human nicotinic acetylcholine receptor after smoking cessation: 5IA SPECT study.

Nicotinic acetylcholine receptors (nAChRs) are of great interest because they are implicated in various brain functions. They also are thought to play an important role in nicotine addiction of smokers. Chronic (-)-nicotine, a nAChR agonist, treatment in mice and rats elicits a dose-dependent increase in nAChRs in the brain. Upregulation of nAChRs in postmortem human brains of smokers has also been reported. However, changes in nAChRs after cigarette smoking cessation in humans are poorly understood. The aim of this study was to detect the dynamic changes of nAChRs after smoking and smoking cessation in the brains of living subjects. METHODS: We performed 5-(123)I-iodo-A-85380 ((123)I-5IA) SPECT on nonsmokers and smokers (n = 16) who had quit smoking for 4 h, 10 d, and 21 d and calculated and compared distribution volumes (Vt) of (123)I-5IA. RESULTS: The binding potential of nAChRs (Vt of (123)I-5IA) in the brains of smokers decreased by 33.5% +/- 10.5% after 4 h of smoking cessation, increased by 25.7% +/- 9.2% after 10 d of smoking cessation, and decreased to the level of nonsmokers after 21 d of smoking cessation. CONCLUSION: Because the upregulation of the nAChRs of the smokers after chronic exposure of the nicotine was downregulated to the nonsmokers' level by around 21 d after smoking cessation, the upregulation is a temporary effect. The decrease in nicotinic receptors to nonsmoker levels may be the breaking point during the nicotine withdrawal period.     

Smoking cessation therapy and the return of aviators to flying duty

Smoking cessation is an important part of every primary care physician's work. The importance of smoking cessation in the reduction of cardiovascular morbidity and mortality and the reduction of cancer incidence cannot be overstated. Various treatments have been established to encourage smoking cessation; these include group and individual psychological therapy, nicotine replacement in various forms, and drug therapy. The best-known drug used for smoking cessation is bupropion SR (Zyban). Smoking in aviators is not different than in the general population in terms of prevalence. Thus it is important for flight surgeons worldwide to be familiar with the magnitude of the problem and the available treatment options. Yet, it is also important for this community to become familiar with the relevance of this treatment to aviation and to recognize the limitations pertinent to flying personnel who are attempting to quit smoking. We present treatment options for smoking cessations and their limitations on flying personnel.