Advance and Retreat: Tobacco Control Policy in the U.S. Military

INTRODUCTION

On April 29, 2007, Stars and Stripes reported that the Air Force would ban tobacco products, becoming tobacco-free by 2010.1 On May 6, Air Force officials recanted, stating that while such a program was possible, it was "not imminent."2 Why the Air Force retreated from the plan is unknown, but the episode follows an established pattern of advance and retreat in military tobacco control efforts.

Under Department of Defense (DoD) Health Promotion policy Directive 1010.10 initiated in 1986,3 individual military services and commanders have had authority to implement their own tobacco control programs with the goal of lowering military smoking rates below civilian rates. The DoD today seeks to lower rates to a maximum of 12% by 2010.4 Certainly, nothing would lower smoking rates more effectively than simply banning tobacco use, and the Air Force has long had an interest in achieving a smoke-free force. Under the authority granted to individual services, the Air Force and the Navy have each implemented previous plans for a smoke-free force: in 1993, the Air Force set a smoke-free goal for 1998 and in 1992 the Navy set one for 2000.5,6 However, these goals have not been achieved.

Military smoking is an increasingly important issue because smoking impairs troop readiness and productivity, and increases medical and training costs.78 Additionally, tobacco, use by junior enlisted members is related to reported financial strain and stress.9 Currently, the military smoking rate is well above civilian rates and may be rising, from 29.9% in 1998 to 33.8% in 2002.10,11 Service-specific smoking rates for 18- to 25-year-olds can be as high as 33% to 45%.12,13 Problematically, while the DoD orders the services to discourage tobacco use and promote cessation, it simultaneously sells its personnel tobacco products tax-free.14

This set of case studies based on internal tobacco company documents and other materials related to U.S. military tobacco control policy sought to explore reasons for the pattern of advance and retreat in U.S. military tobacco control. We describe four failed attempts by the U.S. military to implement strong tobacco control measures, showing how in all cases, various political actors effectively thwarted or weakened service-level tobacco control efforts. Our findings have implications for future tobacco control initiatives.

BACKGROUND

The tobacco industry has "unmatched economic and political lobbying" power in the United States.15,16 Its lobbying and campaign contributions influence both federal and state policymaking.17,18 The tobacco industry's front groups pressure politicians,19 and the tobacco industry fosters relations with specialty groups such as unions that pressure policymakers to hinder or pass legislation favoring the tobacco industry's positions.20 Previously published research has also shown how the tobacco industry successfully exploited relationships among Congress, the DoD, and private industry to stop efforts to raise tobacco prices in military commissaries.14 Globally, the tobacco industry has coordinated efforts across multiple companies to thwart national and international public health initiatives.21,22

METHODS

We analyzed internal tobacco industry documents made public through litigation and selected tobacco control policies obtained from the U.S. military.23 We searched the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) and Tobacco Documents Online (http://tobaccodocuments.org), using keywords (e.g., military, Army, DoD) and then employed a snowball strategy to generate additional search terms. We identified over 5,000 documents, narrowing them to 600 of the most relevant. Based upon preliminary findings, we requested additional documents from the military services via the Freedom of Information Act.24 We searched for additional documents on the Lexis-Nexis database. We analyzed data by looking for evidence from multiple sources, identifying patterns across chronologically assembled cases.

This study has limitations. The document set is not comprehensive, but is a selection of litigation-related material. To date, there has been no litigation that concerns the tobacco industry and the military. Therefore, there may exist additional relevant documents that we were unable to access. Military documents were not readily available; many of those cited were retrieved from the archives of tobacco industry documents. Our study is not a comprehensive analysis of all military tobacco control measures: the cases described here are limited to those from 1986 to 1993 that were connected to the implementation of Directive 1010.10, a seminal event in military tobacco control efforts. It is possible that there exist cases that occurred beyond 1993, and that examples of successful initiatives at individual bases exist.

RESULTS

Directive 1010.10

In 1985, the DoD conducted a study on military smoking that revealed that smoking rates among military personnel were significantly higher than U.S. civilian smoking rates (47% of reported active duty personnel smoked versus 30% of the civilian population).8 Additionally, it concluded that smoking impaired military readiness, and estimated DoD tobacco-related annual health care costs as high as $209.9 million.8 On March 10, 1986, Secretary of Defense (1986-88) Caspar Weinberger announced "an intense anti-smoking campaign. . . at all levels of all Services."25 This was unprecedented for a U.S. federal institution.

Directive 1010.10 went further than mere educational programs, detailing restrictions concerning tobacco use. It specified where individuals could smoke on military installations and when smoking would be permitted. Smoking was prohibited in auditoriums, elevators, conference rooms, classrooms, hospital public areas, schools for military dependents, and official busses and vans.3 Smoking was still permitted inside buildings, but "only to the extent that it does not endanger life or property, or risk impairing nonsmokers' health."3

Directive 1010.10 also included provisions to educate personnel about the risks of smoking, to prevent personnel from taking up smoking, and to help personnel quit.3 The policy established that upon entry into the military, personnel would be "encouraged" to stop smoking or to refrain from smoking if they did not already smoke.3 During routine health examinations, practitioners were instructed to advise people of "the risks associated with [tobacco] use, the health benefits of abstinence, and of where to obtain help to quit."3 Occupational health clinics were ordered to "consider the feasibility" of smoking cessation programs for civilian employees, or offer referrals to such programs.3

With Directive 1010.10, DoD set a baseline, not a ceiling, for military tobacco control policy. Each service was ordered to design and implement its own "comprehensive" health promotion plan that included, but was not limited to, the measures set out in the DoD policy.3 The directive, while establishing goals, left design and implementation of specific measures to service-level military officials. Authority for implementing Directive 1010.10 devolved to individual base or unit commanders within each service, who exercised considerable "street-level" discretion to initiate policy and programs.26

On November 12, 1986, after all four services had announced their initial compliance plans, DoD health authorities further strengthened the directive, setting a goal of reducing the military smoking rate by at least 10% per year until it reached 25%, below the civilian rate of 30% at that time. Assistant Secretary of Defense-Health Affairs John Mayer issued a memo to the Assistant Secretaries of the Army, Navy/Marines, and Air Force asserting that "we must be more aggressive in eliminating this serious hazard to health and military readiness."27 Mayer ordered the Secretaries to revise their programs to reflect this new goal.

Although Directive 1010.10 was extended in 1994 by Directive 1010.15, which formalized prohibitions of smoking in indoor facilities, DoD tobacco control policy has changed little since 1986. In the 1994 policy, DoD prohibited smoking in workplaces but granted many exceptions, including ships, indoor smoking areas, housing, and Morale, Welfare, and Recreation (MWR) facilities.28 DoD continues to delegate tobacco control policy design, implementation, and enforcement to service-level officials.

Case Study 1

The Army responded first to Directive 1010.10, issuing a detailed tobacco control plan in April 1986, to be implemented in full by July 7, 1986. The Army Tobacco Control Plan (ATCP) had three goals: "deglamorizing" smoking, implementing education and cessation programs, and lowering the smoking rate from 52% to 25% by 1990.29,30

The ATCP included all the measures of Directive 1010.10, plus other innovations. It prohibited smoking in all military vehicles and aircraft, not just busses and vans, and it promised administrative punishment of personnel and civilian employees who did not comply.29 It instituted periodic assessments of tobacco cessation and appointed tobacco cessation coordinators.29 Finally, its focus on "deglamorization" was an innovation.29

As soon as Directive 1010.10 and the ATCP were issued, the Tobacco Institute (TI)-the tobacco industry's lobbying organization-and tobacco company Philip Morris (PM) initiated plans to obstruct them. The TI claimed that the ATCP went "well beyond" an education program, which it had assumed would be the limited effect of the directive.31,32 According to the TI, the ATCP was a "somewhat draconian" interpretation of the directive, and needed to be cut back, if not fully rescinded.33

The TI assigned four staff members to the issue and hired independent consultants, including Jim Juliana (described as a "retired DoD insider") and David Satterfield (a former Congressman and retired Navy officer).34 A public relations firm was contracted to "gather signatures of military-oriented groups for [a] letter sent to Secretary Weinberger."34 Additionally, the TI arranged for position papers to be written arguing against the new policies, hoping to publish them in military journals.34

Behind the scenes, the tobacco industry coordinated and motivated tobacco-friendly politicians to confront the DoD about the ATCP. PM officials visited various members of the House and Senate Armed Services Committees (HASC and SASC) and the Defense Appropriations Subcommittees and asked them to "call Secretary Weinberger's office and Army Secretary John Marsh's office to ask that the Army program be withdrawn" before it started.35 TI President Samuel Chilcote urged tobacco industry executives to call Senator John Warner (Republican-Virginia) and Congressman Dan Daniel (Republican-Virginia), both members of the Armed Services Committees.31 Representative Daniel served as head of the HASC Morale, Welfare, and Recreation Panel and was TI's "key contact" and "chief supporter on Capitol Hill."34

Tobacco-friendly politicians complied. In letters to Secretary of Defense Weinberger and HASC Chair Les Aspin (Democrat-Wisconsin), politicians used language similar to that of position papers TI had distributed to them, invoking rhetoric about infringements on "personal freedom" and "individuals' right to smoke."36-38 Daniel and Senator John East (Republican-North Carolina) circulated letters among Congress members, seeking up to 60 supporting signatures.39,40 Many signers were members of the HASC and SASC.41 North Carolina representatives wrote Secretary Weinberger, arguing that the policy would have a negative effect on military recruitment, retention, and morale and that it intimated that "no smokers need apply" to the military.36

Ultimately, the Army backed down from fully implementing the ATCP. On July 2, 1986, 5 days before the ATCP was to take effect, Army Chief of Staff General John Wickham released a revised directive that cut the plan into two phases. Army Major Commanders would implement only phase I, limited to the regulations of Directive 1010.10. Phase II, which could "extend beyond baseline guidance of DoD Directive 1010.10," would only be implemented if it was later deemed necessary.42

The revised ATCP and the official public announcement about it also incorporated language suggesting that the Army recognized "smokers' rights."43 General Wickham emphasized that Army Commanders would "ensure that the individual rights of all personnel, smokers and nonsmokers" were protected.42 Assessing the revised ATCP, a PM administrator noted that it had been "altered to be more favorable to the industry's position."44

The TI chalked up the Army's decision to "trim" the ATCP as a definite win.45 The TI's Chilcote saw it as "a major victory for the industry and the industry's friends in Congress."45 PM officials regarded their efforts with tobaccofriendly politicians as pivotal, crediting Congressional pressure as being "instrumental in forcing the Army to make . . . changes."44 PM USA President Frank Resnick noted to other PM executives: "the Warner visit paid off."45

Case Study 2

In March 1987, Air Force General and Commander of the Strategic Air Command (SAC) John T. Chain initiated a ban on smoking in all SAC-controlled buildings at Offutt Air Force Base. To "set an example," Chain also announced that he and all SAC senior staff had stopped smoking.46 As part of his efforts, Chain required SAC staff to submit a "Monthly Anti-Smoking Campaign Report," counting smokers by rank in their sections, and reporting on cessation efforts.47 Smokers would be identified not by name but by position symbol.

The tobacco industry became aware of Chain's policies when a SAC officer wrote to Senator Jesse Helms (Republican-North Carolina), complaining that from the information included in the SAC monthly report, individual smokers could be easily identified.48 He argued that Air Force members were willing to die "to preserve this great nation's freedom, but if some of our fighters choose to smoke, they should be allowed that choice. ... it's one of the few rights they have left as a military member."48 The officer begged Helms to inform the "American Public of the dilemma faced by smokers in the Strategic Air Command."48

By late November 1987, the SAC officer's letter reached PM executives, one of whom suggested that Helms release the letter to the public and demand an explanation from the DoD.49 The executive noted that PM was "prepared, once the issue is public, to mobilize smokers throughout the country against the Armed Services committees on this issue."49 The tobacco industry rallied Congressional allies to protest. Representative Daniel confronted General Chain directly in letters also copied to Chain's military superiors, including Secretary Weinberger, the Secretary of the Air Force, and the HASC chair.50,51 Daniel suggested that Chain's policy went "beyond persuasion, to coercion."50 He pointedly reminded Chain (as well as the other copied officials) that "each year our Committee authorizes billions of dollars to protect freedom not only of our own people but around the world, yet your action will deny that same freedom to those who have volunteered to protect us all . . . ."50

We could not locate Chain's response to Daniel, but it apparently did not assuage Daniel, who wrote Chain a second time, asserting that Chain's "use of such phrases as 'to encourage,' 'to motivate,' and 'to lead,' fly in the face of your fascist tactics."51 Accusing Chain of "excessive nannyism," Daniel "strongly" recommended "that you [Chain] bring your actions in harmony with the department policy of education as agreed to by the Secretary of Defense."51

Helms also approached Chain's superiors, complaining to Secretary of Defense Frank Carlucci (who succeeded Weinberger in 1987-89).52 Helms's letter reproduced almost word for word Daniel's first letter, arguing that SAC policy went "beyond the bounds dictated by Secretary Weinberger" and was "not motivating the men to quit smoking of their own accord, but rather coercing them . . . ."52 Helms asked Carlucci to do "something" about Chain's policy.52

Sometime between December 1987 and May 1988, Chain's SAC policy was modified to accommodate the tobacco industry's concerns. In late May 1988, Helms asked the Air Force about the policy's status and the Chief of the Air Force Legislation Division assured him that "all Strategic Air Command members retain the freedom to choose whether or not to smoke."53 The practice of collecting the monthly reports "was not used to coerce or intimidate any individual" and it had been modified "to eliminate any possible concern that an individual might be identified . . . ".53 Although the Air Force and General Chain did not entirely rescind the policy, it was revised after political pressures were applied.

Case Study 3

In September 1988, Major General James Wurman of New Jersey's Fort Dix Army Base issued "Fort Dix Policy Memorandum 43," banning tobacco use in all indoor areas and in military vehicles and aircraft.54 Newly enlisted personnel were by this time prohibited from smoking during basic training, and Wurman further prohibited all personnel inside the training areas from using tobacco products in trainees' presence.54 He also prohibited those undergoing Advanced Individual Training from using, possessing, or distributing tobacco products.54 Administrative action was promised against those who failed to comply.54

The policy extended to civilian employees, whose smoking was to be permitted only on designated breaks outside. American Federal Government Employees Union representative Vincent L. Pesini protested. In an interview, Pesini implied that Wurman had set the policy "hoping for a third star," arguing: "The nonsmoker has rights but the smoker has rights, too. We are not in favor of a smoke-free atmosphere."55

By October 7, the TI reported that following Congressional protest, the Pentagon had ordered Wurman to suspend his policy "indefinitely."55,56 Army Chief of Human Resources Colonel Walter Stowell wrote to HASC staff on October 13, assuring them that "all future considerations for change in tobacco use policy" would be coordinated with Army Headquarters and union representatives.57

Despite these setbacks, the policy was still under negotiation between base officials and union leaders in December 1988.55 Wurman told reporters: "A lot of our civilians aren't on my team yet."55 Fort Dix spokesperson Richard Dowling noted that although Wurman could "issue a command" at any time, he was "continuing to negotiate with the civilian units in a spirit of cooperation," with the aim of "hav[ing] a smoke-free work force in 1989."55 Once negotiated with the unions, the policy would be subject to review by the Department of the Army.

While we could locate no further evidence regarding the Fort Dix policy, the base did not institute a smoke-free policy. Fort Dix apparently has no site-specific tobacco control regulations at this time (K. M. Hoffman, personal communication). Instead, it follows 1996 Army health promotion regulations (under Army Regulation 600-63) issued to fulfill Directives 1010.10 and 1010.15.58

Case Study 4

On October 3, 1990, the Army/Air Force Exchange Service (AAFES) announced, in Marketing Bulletin 90-127 (MB 90-127), a ban on all advertising and promotion of tobacco products with the exception of vendor-issued coupons in exchange stores. Directive 1010.10 had not included restrictions on the marketing of tobacco products in military exchange stores, only in commissaries.14 Nevertheless, AAFES officials claimed that they wanted to "support DoD's policy to deglamorize" tobacco use.59

Alerted to MB 90-127 by DoD sources, ? counsel Juliana spearheaded industry efforts to rescind it.60 Throughout 1991, representatives from RJ Reynolds, PM, the Liggett Group, Brown and Williamson, and the TI met to review strategies.61,62 Industry executives later met with AAFES officials at least twice and lobbied HASC and SASC members with jurisdiction over AAFES.63

After one meeting, Juliana reported that AAFES Commander and Major General Jeffery D. Kahla and AAFES Deputy Commander of Operations Paul Fromm had indicated that they were tired of the "clutter" caused by promotional goods such as free lighters, playing cards, sports bags, etc., as well as "overzealous" tobacco company salesmen who approached store owners and customers.59,64 They claimed that the policy's goal was to "get the junk out of the stores."59

Tobacco industry representatives warned AAFES representatives that the policy could result in losses of $3 to 5 million yearly, largely in funds designated for military MWR programs (two-thirds of AAFES earnings fund MWR programs).64 They also contended that the policy would result in lost employment opportunities for military dependents and retirees, and loss of exchange customers to commissaries or other retail stores.62,64,65

Kahla and Fromm reportedly admitted that DoD health programs were not "the principal driving force" behind their decision to limit tobacco promotions.64 When faced with the industry's projections of MB 90-127's economic impact, they agreed to "reconsider the effective date" of implementation. They also agreed to cooperate with the tobacco industry so as to "meet patron demands, keep AAFES profitable, and continue industry's participation in the military marketplace."64

AAFES also agreed to allow the industry to conduct tests on promotional activities and sales in 8 to 10 exchange stores,64 to "capture sales data" for 4 months on sales, inventory, carton conversions, marketing information, etc.63 AAFES agreed to delay implementing MB 90-127 until the economic impact of tobacco product promotions could be determined. Yet, even before testing was to begin, on April 26, AAFES rescinded MB 90-127.66 Fromm' s memo indicated that AAFES would continue to allow tobacco companies to distribute free goods and use other types of promotions in exchanges. AAFES officials apparently assured the tobacco industry that they would not make a public announcement of its decision but would quietly advise the chair of the HASC MWR Committee.67 At this point, TI counsel Juliana reassured companies that they could "continue to market their products" just as before.68

DISCUSSION

Since 1985, the DoD has known that if it were to enforce nonsmoking regulations and stop selling tobacco products to its personnel and their dependents, it would positively affect the health of service members and their families, improve military readiness, and dramatically reduce immediate and future health care expenditures.8 However, DoD still sells discounted tobacco products, remains vulnerable to outside pressures, and allows perverse incentives to persist. These circumstances, given the political pressures, have hindered the military from reaching its goal. In 1988, the 42% smoking rate among military personnel still far exceeded that of the U.S. civilian population, despite DoD's stated desire to decrease it to 25%.27,69 Today, this pattern persists and overall military smoking rates appear to be increasing.10,11

These cases illustrate a pattern of advance and retreat, in which various actors with different interests have weakened service-level military tobacco control initiatives (Table I). The tobacco industry often had an unseen hand in influencing policy, motivating Congress members who held real power over the DoD to protest military policy. Yet other actors, such as lower level personnel and civilian union leaders, have also hindered military tobacco control efforts.

There are few incentives for service-level military personnel to implement innovative tobacco control measures. For example, AAFES officials' job is to sell products and collect revenue for MWR programs. They are not rewarded for reducing consumption, and may even be punished for attempting to do so.14 Furthermore, when faced with controversy and pressure, the DoD has not supported innovations.

It is clear that the DoD and individual military services and commanders have made genuine and repeated efforts to lower military smoking rates through incremental measures. However, they have been thwarted repeatedly. This study suggests that they must become more sophisticated and determined in anticipating, exposing publicly, and countering political pressures aimed at scaling back effective policies. Identifying political champions in Congress and policy entrepreneurs within the military is essential. Furthermore, the larger public health community should help to create public awareness of the way in which our country's military is damaged by tobacco use and manipulated by the tobacco industry and its allies, building a constituency in support of strong tobacco control measures.

Given the documented effects of tobacco use on troop readiness, health care and training costs, productivity, and financial strain among troops, banning smoking within the military would be both militarily and fiscally prudent. Given a reasonable transition period within which smoking cessation resources were made available for current users and cultural norm changes initiated, such a policy could also be the most simple and practical solution. Military personnel are, after all, bound to follow rules set by superiors. Upon enlistment, personnel formally relinquish many aspects of personal privacy that would be protected or at least assumed in most civilian workplaces.70 They are subject to routine and compulsory medical testing, evaluation, and vaccination, and to formal punishment for committing adultery, an act not considered a crime for civilians and not, in general, affecting troop health costs and readiness. They can also be discharged from service for exceeding set weight limits.

Nevertheless, personnel are still permitted to use cigarettes, products that when used as intended addict and kill. Due to heavy lobbying and political influence, the tobacco industry's mythology that military personnel have a "right" to smoke has superseded soldiers' rights to belong to a cohesive, healthy unit and the U.S. public's right to be protected by a prepared and healthy military. However, this mythology need not continue. Recent research shows that military personnel see themselves as role models for others; thus a smoke-free military could be a point of pride and cohesion.71

Advocacy groups that address tobacco use in the military such as Project Uniform, a state-funded California-based advocacy group, do exist. Partnerships between military health promoters and public health advocacy groups should be fostered and expanded to include funders who could help identify replacements for the MWR resources generated by tobacco sales. It is ironic that as troops fight military enemies in other countries, those who would maintain a healthy military workforce must also fight government and tobacco industry enemies in their own country. This public health battle requires many more committed allies.

ACKNOWLEDGMENTS

This work was supported by the National Cancer Institute (Grant CA109153). We thank Elizabeth A. Smith, Patricia A. McDaniel, C. Keith Haddock, Kevin M. Hoffman, and Colleen Haydon for their help and comments.

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