Reported Stress and Its Relationship to Tobacco Use among U.S. Military Personnel

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1 MILITARY MEDICINE, 173, 3:271, 2008 Reported Stress and Its Relationship to Tobacco Use among U.S. Military Personnel Risa J. Stein, PhD*; Sara A. Pyle, PhD ; C. Keith Haddock, PhD ; W. S. Carlos Poston, PhD ; Robert Bray, PhD ; Jason Williams, PhD ABSTRACT In addition to common stressors, members of the U.S. Armed Forces experience a high level of stress unique to their status as service members. In an effort to combat stress, many military personnel report high levels of nicotine use. This study investigated the relationship between tobacco use and perceived stress among military members in all four armed services. Results indicate that those who use tobacco products specifically to reduce stress report significantly higher stress levels than those who do not use tobacco. Moreover, current users and those who both smoked and used smokeless tobacco were far more likely to report experiencing a lot of stress from a variety of sources than former or never users. Tobacco users also engaged more frequently in negative coping behaviors and relied less on the positive coping strategies used more often by former or never smokers. These findings are consistent with the larger body of literature suggesting that tobacco is not only an ineffective stress-reducing strategy, it also likely perpetuates a stress response in users. It is, therefore, critical that the military improve effective means of coping among nicotine-using troops. INTRODUCTION Members of the U.S. Armed Forces face stressors unique to their occupations and lifestyle. According to a recent survey of U.S. military personnel, one-third reported experiencing a lot of work-related stress, with the most frequently cited sources of stress being time away from home, deployment, and a heavy workload. 1 To combat the negative impact of stress on troops, the military has implemented a broad range of stress-management tools, from providing recreational venues to treating traumatic stressors with critical-incident stressdebriefing interventions. Historically, smoking breaks also were offered to military members as a mode of stress reduction. Although formally sanctioned smoke breaks are no longer condoned, a high proportion of military members continue to smoke and use other tobacco products. 1 Among the reasons often reported for continued nicotine use is the distinctively stressful military environment. 1 Smokers frequently make the assumption that smoking reduces their perceived levels of stress. 2 4 Consistent with this belief, Perkins and Grobe 5 reported that during an acute stressful task, the desire to smoke increases, thus reinforcing *Department of Psychology, Rockhurst University, 1100 Rockhurst Road, Kansas City, MO Departments of Preventive Medicine and Family Medicine, Kansas City University of Medicine and Biosciences, 1750 Independence Avenue, Kansas City, MO Department of Basic Medical Science, University of Missouri Kansas City, 1000 East 24th Street, 5th Floor, Kansas City, MO Substance Abuse Epidemiology and Military Behavioral Health Program, Research Triangle Institute, 3040 Cornwallis Road, Research Triangle Park, NC Risk Behavior and Family Research Program, Research Triangle Institute, 3040 Cornwallis Road, Research Triangle Park, NC This manuscript was received for review in February The revised manuscript was accepted for publication in December Reprint & Copyright by Association of Military Surgeons of U.S., the notion that stress causes the addicted individual to smoke and, in turn, smoking reduces the experience of stress. Similarly, Niaura et al. 6 found that when put in an anxietyprovoking situation, participants reported a stronger urge to smoke. In reality, smoking has been demonstrated to increase stress levels. Parrot 7 and Baker et al. 4 in their reviews of literature on the impact of smoking on health note that the apparent stress-modulating effect of smoking simply reflects the reversal of tension developed during nicotine depletion. In other words, addicted smokers need nicotine to feel normal and to combat the stress caused by smoking. 8 Research with smokeless tobacco (SLT) users have produced similar results. Coffey and Lombardo 9 found that SLT users reported an increased urge to use SLT when faced with stress-producing tasks or when guided through procedures meant to induce negative affect. Poly users, smokers who also use SLT, have been found to report even less healthy lifestyle habits than those who use only one of the products. 10 Research with adolescents suggests that those who are poly users report both a higher rate of risky behaviors and a higher prevalence of risk indicators than their smoking and SLT-using peers. 11 The constitutional, physiological, and emotional changes developed as a result of nicotine addiction serve to increase stress levels and render addicted individuals even more vulnerable to the stress response while under duress. 5 Moreover, a peak in the reported experience of stress occurs during cessation attempts, rendering those who endeavor to quit even more anxious and agitated, 12,13 often resulting in a return to smoking in an effort to reduce physical and emotional discomfort. 14 Reversal of negative mood state is a primary motivating force behind why smokers consistently report needing each consecutive cigarette. 7 Thus, tobacco use results in a self-perpetuating cycle of propagating stress and providing relief for the stress that is subsequently produced. 271

2 Despite data which demonstrates that cigarette smoking is a significant source of stress, many military smokers and commanders continue to believe that tobacco is an effective method of managing stress endemic to military life. 15 Tobacco use tends to increase during war and periods of high operations tempo and the tobacco industry has been praised for ensuring that military personnel have access to an unlimited supply of tobacco. 19 Forgas, Meyer, and Cohen 17 found that, during Operation Desert Storm, a high rate of military members began using both SLT and cigarettes and a large number who were already users increased their use while deployed, citing stress and boredom as the primary reasons. Although the literature would suggest that tobacco use is not an effective method for managing the stress of military service, no study to date has examined the relationship between smoking status (e.g., never, former, and current smoking, and poly use) and perceived stress among military personnel, the focus of the current study. METHODS Data collection was part of the larger 2002 Department of Defense (DoD) Survey of Health-Related Behaviors among Military Personnel that was administered September 2002 February The target population of the study was all active duty military personnel (i.e., Army, Navy, Air Force, and Marine Corps). Two hundred forty installations that met the selection criteria of employing a minimum of 1,000 active duty personnel were identified. Only installations that met this size requirement were included in the survey pool with a purpose of facilitating data collection with a minimum of 800 individuals. Thirty of those military installations were randomly selected as data collection sites. Participants from each installation were selected at random from the May 2002 Defense Manpower Data Center files. Personnel considered eligible were those who were not absent without leave, recruits, academy cadets, incarcerated, or in the process of a permanent change of station. Data collection took place onsite in 90-minute sessions. Those who did not attend one of the data collection sessions were sent surveys via U.S. mail. The overall response rate among those who were deemed eligible was 55.6%. An in-depth explanation of methodological procedures is available from Bray et al. 1 Participants Participants were military members in all four services (25.6% Army, 22.4% Air Force, 23.6% Marines, 28.4% Navy) and in all pay ranges (19.7% E1 E3, 40.6% E4 E6, 20.0% E7 E9, 3.0% W1 W5, 9.3% O1 O3, 7.4% O4 O10) who were randomly selected (N 12,149). The sample was 24.7% female and diverse in terms of reported ethnic status (67.9% non-hispanic Caucasian, 20.1% Non-Hispanic African American, 7.0% Hispanic, 5.0% Other). Tobacco Use Status Participant smoking status was classified based on responses to questions about smoking history over the past 30 days and lifetime consumption of cigarettes. Those who had not smoked 100 or more cigarettes in their lifetime were classified as never smokers. Individuals who had not smoked in the past 30 days, but had smoked 100 cigarettes in their lifetime were classified as former smokers. Those who had smoked in the past 30 days and had smoked 100 cigarettes in their lifetime were considered current smokers. Participants who reported both currently smoking and using SLT 20 times in their lives were classified as poly users. Stress Questions A series of questions regarding various sources of stress were used to assess stress experienced by the participants. Questions targeted the domains of work,, and military stress experienced during the past 12 months and were selected based on areas of concern for military health policy personnel. For instance, the question was posed: In the past 12 months, how much stress have you experienced from coworker relationships (Table I presents a comprehensive list of the questions assessed). To facilitate analyses and interpretation of results, response options were dichotomized to be either a lot of stress versus the other possible responses (i.e., none, a little, or some ). Survey items also assessed the extent to which various forms of stress interfered with the individual s life. In particular, questions asked how much stress at work and in life interfered with the ability to perform their military job. Response options were dichotomized to be either a lot of stress versus the other possible responses (i.e., none, a little, or some ). All stress questions can be viewed in the DoD Survey of Health-Related Behaviors among Military Personnel. 1 Coping Techniques Participants were asked to identify reasons why they initiated smoking. Among the list was to help relieve stress. Smokers were categorized into those who smoked specifically to relieve stress and those who did not report smoking due to stress. Another survey item asked, When you feel pressured, stressed, depressed, or anxious, how often do you engage in each of the following activities? The list that followed included a variety of positive techniques (e.g., talking to a friend or member, praying, exercising or playing sports, thinking of a plan to solve the problem) and negative techniques (e.g., drinking, eating, smoking marijuana or other illegal drugs) for handling stress. For analysis, responses to these items were categorized as the participant frequently used this coping strategy versus sometimes, rarely, or never. This dichotomization allowed the examination of the relationship between tobacco use status and coping mechanisms the participants commonly use. Approach to Statistical Analysis Logistic models were used to examine the relationship between tobacco use status and items assessing perceived stress from sources of stress in military life. Never smokers were used as the 272

3 TABLE I. Tobacco Use Status and Perceived Stress TABLE I. Being deployed at sea or in the field Former smokers Current smokers Poly users Having a permanent station change Former smokers Current smokers Poly users relationships with the people you work with Former smokers Current smokers Poly users relationship with your immediate supervisor(s) Former smokers Current smokers Poly users Concern about performance rating Former smokers Current smokers Poly users Increases in your workload Former smokers Current smokers Poly users Decreases in your workload Former smokers Current smokers Poly users Being away from your Former smokers Current smokers Poly users Changes in your such as the birth of a baby, divorce, or a death in the Former smokers Current smokers Poly users Conflicts between your military and responsibilities Former smokers Current smokers Poly users Problems with money Former smokers Current smokers Poly users Problems with housing Former smokers Current smokers Poly users Health problems that you had Former smokers Current smokers Poly users Health problems in your Former smokers Current smokers Poly users Behavior problems in some of your children Former smokers Current smokers Poly users referent category in each of the logistic models. Logistic models were also developed to examine the relationship between different levels of tobacco use and perceived stress. Next, those who reported being current smokers were stratified based on their level of tobacco use, and the relationship between level of tobacco use and perceived stress was explored. Finally, current tobacco users (i.e., current smokers or poly users) were categorized based on whether or not they reported using smoking to alleviate stress. 2 tests were performed to determine whether a relationship exists between using tobacco specifically to reduce stress and experiencing significant work-, -, or militaryrelated stress. Finally, to determine whether use of other potential stress-coping methods differed by smoking status, logistic regression models were constructed with smoking status serving as the predictor variable and use of the coping strategy as the criterion variable. RESULTS Table I presents logistic regression models for the stress items. Overall, current smokers and poly users were more 273

4 likely to report significant stress from the work,, and military life items than former or never smokers. Poly users tended to report experiencing stress at an even higher rate than those who only reported using cigarettes. In general, former smokers did not differ significantly from never smokers in their reported experiences of stress. In relation to work relationships, poly users were 90% (odds ratio (OR) 1.90, 95% confidence interval (CI) ) more likely than never smokers to report stressful coworker relationships while current smokers were 55% (OR 1.55; 95% CI ) more likely. Poly users (OR 2.25, 95% CI ) and current smokers (OR 1.38, 95% CI ) were also more likely to report stress from their supervisory relationship than their nonsmoking peers. Both groups were significantly more likely to report experiencing stress about their performance ratings (poly users OR 1.62, 95% CI ; current smokers OR 1.45, 95% CI ). Similar to work relationships, poly users and current smokers were consistently more likely to experience stress in their personal lives. Poly users (OR 1.73, 95% CI ) and current smokers (OR 1.79, 95% CI ) were more likely to report stress from changes in their personal life. They also were more likely to report stress from /military conflicts (poly users OR 1.84, 95% CI ; current smokers OR 1.44, 95% CI ). Only current smokers differed significantly from never smokers in terms of stress from health problems (OR 1.33, 95% CI ). Smoking status was unrelated to stress experienced from problems with children. Table II presents contrasts between those who reported using smoking specifically to reduce stress and those who did not on their evaluation of specific stressors. Consistently, those who reported using smoking to alleviate stress reported experiencing stress at a significantly higher rate than those who reported they did not use tobacco to cope with stress. For instance, of those who reported using smoking to alleviate stress, 18.39% reported experiencing stress from being deployed compared to 11.73% who reported not using smoking as a coping mechanism ( , p 0.001). Similarly, those who use smoking to relieve stress reported more stress with coworker (15.52%) and supervisor (15.42%) relationships than those who did not (7.82% and 7.93%, respectively; , p 0.001, , p 0.001). Those who used smoking to relieve stress also were more likely to report stress from health problems (6.24%) than those who did not (2.91%; , p 0.001). Based on the findings that smoking status was consistently related to perceived stress, it was determined that looking at the relationship between different levels of tobacco use and perceived stress also would be useful. In general, heavy smoking (1.5 packs per day or more) was most consistently related to increased odds of reporting stress. In some instances, moderate smokers (people who reported smoking pack per day) also reported more stress than their TABLE II. In the Past 12 Months, How Much Stress Did You Experience from Each of the Following? Being deployed at sea or in the field Having a permanent change of station (PCS) Problems in my relationships with the people I work with Problems in my relationship with my immediate supervisor(s) Concern about my performance rating Increases in my workload Decreases in my workload Being away from my Changes in my personal life (birth of baby, divorce, break-up, death in the ) Conflicts between my military and responsibilities Stress Level Stratified by Instrumental Smoking to Reduce Stress % Reporting A Lot of Stress, (SE) Do Not Use Smoking to Alleviate Stress Use Smoking to Alleviate Stress 2 (p) (2.12) (1.88) (0.001) (0.44) (0.63) (0.021) (0.83) (1.08) ( 0.001) (0.84) (0.99) ( 0.001) (0.87) (0.66) (0.003) (1.00) (1.47) ( 0.001) (0.64) (0.36) (0.274) (2.00) (1.23) ( 0.001) (1.36) (0.88) ( 0.001) (0.73) (0.93) ( 0.001) Problems with money (1.26) (1.38) ( 0.001) Problems with housing (0.68) (0.65) (0.013) Health problems that I had (0.43) (0.49) ( 0.001) Health problems that my had (0.48) (0.66) ( 0.001) Behavior problems in some of my children (0.51) (0.54) (0.012) lighter smoking ( 0.5 pack per day) peers (Table III). For instance, those who were heavy smokers were 48% more likely (OR 1.48, 95% CI ) to report problems with coworkers. Heavy smokers were 73% more likely (OR 1.73, 95% CI ) and moderate smokers were 47% more likely (OR 1.47, 95% CI ) to report perceived stress from money problems. Heavy and moderate smokers also were more likely to report stress from health problems with heavy smokers being more than twice (OR 2.27, 95% CI ) as likely and moderate smokers 70% more likely (OR 1.70, 95% CI ) to report health-related stress. 274

5 TABLE III. Tobacco Use Levels and Perceived Stress TABLE III. Being deployed at sea or in the field pack/day packs/day Having a permanent station change pack/day packs/day relationships with the people you work with pack/day packs/day relationship with your immediate supervisor(s) pack/day packs/day Concern about performance rating pack/day packs/day Increases in your workload pack/day packs/day Decreases in your workload pack/day packs/day Being away from your pack/day packs/day Changes in your such as the birth of a baby, divorce, or a death in the pack/day packs/day Conflicts between your military and responsibilities pack/day packs/day Problems with money pack/day packs/day Problems with housing pack/day packs/day Health problems that you had pack/day packs/day s Health problems in your pack/day packs/day Behavior problems in some of your children pack/day packs/day To determine whether former smokers, current smokers, and poly users implement other coping techniques at a rate different from never smokers, logistic regressions were performed with never smokers as the referent group. Table IV presents the resulting logistic models. Poly users were nearly 12 times (OR 12.01, 95% CI ) more, and current smokers 5 times (OR 5.63, 95% CI ) more, likely than never smokers to drink alcohol during times of distress. Likewise, poly users were 13 times (OR 13.35, 95% CI ) and current smokers were 6 times (OR 6.08, 95% CI ) more likely to report using marijuana or other illicit drugs to handle distress than never smokers. Poly users, current smokers, and former smokers were substantially less likely than never smokers to employ positive coping strategies. For instance, poly users were 2.50 times (OR 0.42, 95% CI ), current smokers were 1.82 times (OR 0.55, 95% CI ), and former smokers were 1.23 times (OR 0.81, 95% CI ) less likely to report using exercise or sports as a means of dealing with distress. Both poly users and current smokers were less likely then never smokers to report that they think of a plan to solve their problems in times of distress (poly users OR 0.73, 95% CI ; current users OR 0.85, 95% CI ). Former smokers were more likely than their never-smoking peers to employ problem-solving techniques (OR 1.22, 95% CI ). DISCUSSION This study examined the relationship between tobacco use status and stress in a large survey of U.S. military personnel from the four armed services. The associations between to- 275

6 TABLE IV. Reported Use of Coping Mechanism by Smoking Status OR 95% CI Model p Have a drink Former smokers Current smokers Poly users Smoke marijuana or use other illegal drugs Former smokers Current smokers Poly users Think about hurting myself or killing myself Former smokers Current smokers Poly users Talk to a friend or member Former smokers Current smokers Poly users Get something to eat Former smokers Current smokers Poly users Say a prayer Former smokers Current smokers Poly users Exercise or play sports Former smokers Current smokers Poly users Engage in a hobby Former smokers Current smokers Poly users Think of a plan to solve the problem Former smokers Current smokers Poly users bacco use and the potential stressors in military life were consistent and often large in magnitude. Tobacco users (both current smokers and poly users, those who both smoke and use SLT) were consistently more likely to report experiencing a lot of stress from a variety of stressors including work and personal relationships and military life. Paradoxically, those who reported using tobacco specifically to reduce stress were more likely to report significant stress than those who did not use tobacco to reduce stress. Finally, tobacco users were more likely to use other negative coping behaviors (e.g., alcohol) and less likely to use positive coping strategies (e.g., problem solving) than those who did not use tobacco. Thus, this study provides evidence that tobacco use is not an effective method for coping with the stresses of military life and may, in fact, make it less likely an individual will use positive coping strategies. The results of this study are consistent with a large literature on the general population of smokers which suggests that tobacco use is not only an ineffective stress-coping strategy, but also is likely related to the stress experienced by smokers. 4,6 8,20 Several researchers have noted that smoking and the experience of stress can be explained by a Deprivation Reversal Model, where the apparent benefits of smoking simply represent the alleviation of the unpleasant effects of nicotine withdrawal. 21 The Deprivation Reversal Model also predicts that smokers who quit will experience reduced levels of daily stress. 22 Consistent with this model, military personnel in this study who had quit smoking demonstrated significantly lower levels of stress than those reported by current tobacco users and their stress levels were not significantly different from never smokers. Furthermore, those who ostensibly received the highest daily dose of nicotine (poly users) were most likely to report high levels of stress. This suggests that the high levels of stress experienced by tobacco users may be related to tobacco use itself and may not necessarily be due to genetic or personality factors. Although many smokers and some commanders in the military believe that tobacco use is an effective method of coping with the stresses of military life, the opposite appears to be true. Tobacco users in the military experience the most daily stress and are least likely to use coping methods which will help them to effectively manage stress. Given the current high operations tempo for the military and the importance of successful stress coping during combat, it is critical that the military combat the negative impact of tobacco use on the readiness of its troops. Given that smokers report more stress than other participants and because smokers mistakenly believe that tobacco reduces stress, military health education campaigns should include information about the relationship between smoking and stress. In addition, the military should inform commanders about the potential negative role tobacco use plays in managing the stress of military life, including deployment. Limitations to the current analyses exist. For instance, the response rate, while not inconsistent with similar large-scale surveys, may mean that the findings are not representative of the proposed study population. Although we assume that weighting the participants responses to be representative of the entire military helps to decrease this bias, there remains the chance that those who responded are fundamentally different from those who chose to not participate. In addition, the results were a secondary analysis of a previously existing database rather than an original data collection. The benefit of using existing data in this case was the large sample size available for analyses and the well-standardized methods of 276

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