Tackling The Smoking Menace In The Army

Dear Editor, World wide, tobacco use is the single most important preventable risk to human health, and probably is the single largest cause of premature death in adults [1]. Tobacco kills more than four million people every year, and is estimated to kill 8.4 million people every year by 2020 [2]. It is perceived that tobacco usage in the Army has not been adequately addressed or quantified. Hence, a cross sectional descriptive study aimed at eliciting information about usage and attitudes towards tobacco was carried out using a structured semi open ended questionnaire, based on standardized formats prepared by the World Health Organization [3], among officers attending training courses in a large cantonment (N = 50) in 1999. The study was intended to be a rapid epidemiological assessment to serve as a pointer for action in advocacy for change. The aim was to highlight the tobacco problem, and invoke introspection and debate on the actions that need to be taken by all responsible individuals to deal with the onslaught of tobacco. 26 officers (52%) were identified as ‘ever smokers’; of them tobacco was currently being smoked daily or used only occasionally by 7 (26.92%) and 9 (34.62%) participants respectively. All ‘ever smokers’ named cancers of various organs in the digestive and respiratory tract as the major disease caused by smoking. Despite this high level of awareness among the participants, continued usage of tobacco illustrates the gap between knowledge, attitude and practice. Most health consequences of smoking are not manifested until three to four decades after the onset of persistent smoking. Hence, efforts need to be made to encourage cessation activity irrespective of the age of the individual. Smoking cessation has immediate and substantial health benefits and dramatically reduces the risk of most smoking-related diseases [4]. More smokers in the younger service bracket were interested in quitting than those senior. While not statistically significant, it revealed the amenability to efforts directed at encouraging cessation of smoking. Of the participants in the study, those who smoked had invariably not been advised at any point of their service, by an AMC doctor to quit or cut down on use of tobacco. This is despite easy accessibility of health care facilities and an established system of compulsory Annual and Periodic Medical Examinations. This reveals an area where proactive efforts need to be initiated vigorously. Hence it is recommended that Authorized Medical Attendants must specifically screen all ranks for tobacco usage and provide advice to quit. Medical Officers must ask each of their patients whether they smoke, and provide proper information and counselling based on that history. Patients who are non-smokers should receive positive reinforcement for decreasing their risk of smoking-related disease. A smoking patient requires a more detailed history of why and how much he smokes, whether there have been efforts to quit, any respiratory symptoms or disease from smoking and a search for other risk factors which might increase the chance for that patient to develop cardiovascular disease, obstructive lung disease or lung cancer. Doctors should explain to every smoking patient the medical risks associated with smoking and the reduction in risk associated with smoking cessation [4]. Those who start to smoke in the teenage years are the most likely candidates for eventual nicotine dependence. Disease prevention thus may begin by educating soldiers and young officers in their formative years of service, before their views and outlook becomes well entrenched and rigid. On the issue of banning of usage / sale of tobacco products within the Army environment, 39 (78%) participants were of the opinion that a ban was justified. It was found that the younger officers were more favourably inclined to this ban. This identifies a target group which can be motivated to influence others behaviour, especially that of their subordinates. As a step in the correct direction from the public health perspective, all hospitals and medical establishments may be declared as ‘Non Smoking Zones’. A complete ban on smoking in other offices and workplaces may subsequently be enforced in the Army. This would need an enhanced effort at advocacy, targeting the officer cadre primarily. Smoking may further be banned in all air conditioned areas as also in common areas where other non smokers including those from the clerical staff are present. Awareness creation and encouraging social non acceptability are thus considered to be the keystones in the crusade against tobacco.