Operation Stay Quit: Evaluation of Two Smoking Relapse Prevention Strategies for Women after Involuntary Cessation during U.S. Navy Recruit Training

Transcription

1 MILITARY MEDICINE, 169, 3:236, 2004 Operation Stay Quit: Evaluation of Two Smoking Relapse Prevention Strategies for Women after Involuntary Cessation during U.S. Navy Recruit Training Guarantor: Terry L. Conway, PhD Contributors: Terry L. Conway, PhD*; Susan I. Woodruff, PhD*; Christine C. Edwards, MPH*; John P. Elder, PhD MPH*; Suzanne L. Hurtado, MPH ; Linda K. Hervig, MS The present study evaluated two relapse-prevention interventions intended to help women smokers maintain the quit status mandated during Navy basic training. Women with any smoking experience before entering the Navy (N 2,781) were assigned to either a control group or to one of two intervention groups (access to a telephone help line or receive a series of monthly mailings) after graduating from basic training. Smoking/quit rates at 3, 6, and 12 months after graduation were assessed with mailed surveys. Response rates to the surveys ranged from 39% to 52%. There were no phone or mail intervention effects: cessation rates for the three conditions at the 12-month follow-up were 43% for control, 45% for the mail intervention, and 41% for the phone intervention. Results suggest the need for more aggressive relapse-prevention efforts, although quit rates were higher than expected spontaneous quit rates, indicating an impact of the totally smoke-free recruit training environment. *Graduate School of Public Health, San Diego State University, 9245 Sky Park Court, Suite 120, San Diego, CA Department of Family and Preventive Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA Naval Health Research Center, P.O. Box 85122, San Diego, CA This manuscript was received for review in July The revised manuscript was accepted for publication in May Reprint & Copyright by Association of Military Surgeons of U.S., Introduction obacco use is of particular concern to the U.S. Department T of Defense (DoD) because the military has historically had higher and heavier rates of tobacco use than civilians 1 and because of the adverse effects of cigarette smoking on personnel health, performance, and excess costs. 2 4 Although smoking in the military has decreased dramatically since 1980, 5 the prevalence continues to be well above the Healthy People 2000 goal of 20% for the military 6 as well as above civilian rates. In addition, studies show high rates of smoking persist even after discharge from military service. 7,8 Of particular concern to the U.S. DoD, a study comparing substance use in standardized samples of civilians and military personnel concluded that military women are more likely to smoke and to smoke more heavily than their civilian counterparts. 1,9,10 As the numbers and roles of women in the military expand, it is of critical importance to reduce their smoking prevalence and the smoking-related adverse effects on readiness, personal health, medical care costs, and the health of their children. U.S. military smoking rates have declined in recent years due at least in part to military health promotion efforts, yet increased support for cessation is needed to further reduce smoking rates. 11 Cessation is a complex behavioral challenge for smokers, most of whom experience substantial difficulty quitting. 12 In general, smokers prefer to quit without intensive intervention, and convenient information and support in the form of telephone hotlines and mailed self-help materials have been shown to be effective. 13,14 The issue of cessation is complicated, however, by the fact that women and men may have different cessation experiences, suggesting that smoking cessation interventions should be gender specific Comprehensive DoD and service-specific policies have been implemented to address prevention and smoking reduction by mandating smoke-free workplaces and cessation support for military personnel. 22,23 The U.S. Navy, for example, prohibits tobacco use during recruit training for the entire 8-week duration of basic training. A study by Hurtado and Conway 24 found a meaningful impact of the Navy s no-smoking policy on the smoking behavior of male recruits at graduation from basic training (40% self-reported quit rate); however, the 1-year quit rate indicated substantial relapse. An unpublished study by the same investigators of male and female enlisted recruits found that the short-term positive effects of the smoking ban during basic training were more dramatic for women smokers than for men (i.e., a 43% reduction in smoking prevalence for women vs. 15% reduction for men). However, women also showed greater relapse at the 1-year follow-up (67% increase in smoking for women vs. 38% increase for men). A recent study of Navy women smokers reported that the ban significantly changed perceptions of being a smoker at graduation from recruit training, although relapse at a short-term postgraduation follow-up was substantial. 25 Several authors have recommended cessation education and skills training to help new Navy personnel maintain the quit status achieved during recruit training. 11,24,25 The primary purpose of this study was to test convenient approaches aimed at reducing tobacco use among Navy women. The study, called Operation Stay Quit, was designed to implement and evaluate two relatively nonobtrusive (i.e., telephone help line and mail) relapse-prevention strategies supporting maintenance of the organizationally enforced quit status achieved by all recruits during their basic training. In addition to a standard treatment control group, one intervention group was encouraged to access a toll-free telephone help line for support and counseling to remain a nonsmoker or to quit again if they had relapsed into smoking; the other intervention group received a series of monthly mailings to support and encourage nonsmoking during their first year of naval service. A second purpose was to examine sociodemographic and smoking-related correlates of relapse 12 months after graduating from recruit training. 236

2 Smoking Relapse Prevention for Navy Women Methods Recruit Setting All Navy recruits (women and men) receive their basic training at the Recruit Training Command (RTC), Great Lakes, Illinois. The RTC was the setting for recruitment into the study as well as baseline and graduation assessments of smoking. All recruits go through an 8-week basic training program as their introduction to the Navy. A 24-hour-per-day ban on smoking is in place for the entire 8 weeks of training. Over the course of 1 year, 5,503 women provided voluntary consent to participate in this study and completed entry (i.e., baseline) smoking surveys. This represented a participation rate of 93% of those eligible based on counts of women recruits provided by RTC rosters. Refusals to provide consent and complete the entry survey were virtually nonexistent; the 7% of women not completing entry surveys was primarily due to scheduling conflicts when small numbers of recruits were completing tasks away from their primary group. Initial participants consisted of almost all of the female recruits entering the Navy between March 1996 and March A 1-year recruitment period was chosen due to the seasonal variation in the characteristics of recruits. In general, women recruits were young with a mean age of years, and over 90% were less than 24 years of age. The majority (85%) had a high school education with approximately 6% not completing high school and the remaining having some education beyond high school. Recruits were ethnically diverse with 42% belonging to ethnic groups other than Caucasian, non-hispanic. Study Design: Follow-Up of Smokers Baseline surveys were completed by all incoming Navy women recruits that volunteered for participation in this study. However, only those that reported some smoking experience before entering the Navy (see below) participated in the longitudinal intervention study after graduating from recruit training. The study s three experimental conditions were: (a) control group, which was the standard treatment (i.e., the recruit training smoking ban and a very small amount of health education as part of the standard training curriculum); (b) serial mailings group, which was the standard treatment plus a series of post-rtc regular mailings with incentive items to support relapse prevention and encourage quit attempts; and (c) telephone help line group, which was the standard treatment plus access after RTC to a toll-free telephone help line to support relapse prevention or provide support for quitting again. Because all recruit training activities were conducted in divisions of approximately 80 women, random assignment to condition was made at the division level rather than the individual level. Divisions were formed in basically a random fashion, typically in the order in which recruits arrive at RTC. All women recruits were approached during processing week (the first week of basic training) regarding participation in the study. After being given a description of the study, they were asked to give voluntary consent to participate and complete a baseline survey. Just before graduation, these recruits were asked to complete a graduation survey to measure several variables related to perceptions of smoking at the end of the mandatory abstinence period. All female recruits who reported on the entry survey that they had any experience with smoking 237 (referred to in the present study as smokers ) comprised the post-rtc follow-up study group, which was assessed three additional times: 3, 6, and 12 months after RTC training. At entry into the Navy, there were 3,036 women smokers (i.e., identified themselves as either daily smokers, occasional smokers, experimenters, or former smokers before entering the Navy). The rationale for the inclusive, liberal definition of smokers was based on previous studies of Navy personnel suggesting that some new service members take up the habit once joining the Navy or relapse if they were former smokers. 1,26 It was speculated that former smokers and those who had experimented with smoking might be at risk for becoming regular smokers after joining the Navy. Thus, daily smokers, those that occasionally smoked or experimented with smoking, and former smokers were targeted for post-rtc intervention and follow-up. Of the 3,036 smokers, 255 left the Navy and did not graduate from recruit training, leaving a sample of 2,781 smokers that were targeted for follow-up after graduation from recruit training. Of these, 922 smokers were assigned to the control group, 938 were in the mail intervention group, and 921 were in the telephone-counseling group. Description of Relapse-Prevention Interventions Two intervention strategies were used in this study. One intervention group was encouraged to call a toll-free telephone help line for support and counseling on how to remain a nonsmoker or how to quit again if relapse had occurred after leaving the RTC. The second intervention group received a series of regular motivational mailings to support and encourage nonsmoking during the first year of naval service. Both relapseprevention interventions used a cognitive-behavioral approach that assumes behavioral changes such as quitting smoking are primarily attributable to self-regulation and motivation. 27,28 These interventions addressed issues specific to women and cessation and were based on empirical findings on gender differences in smoking cessation. 29 Finally, both interventions were designed to address issues relevant to Navy life and use strategies for quitting and remaining smoke free that were Navy specific. Mail Intervention Materials Development and Procedures Subjects assigned to the mail intervention condition received a series of six mailings beginning 1 month after graduation and continuing for a period of 10 months. The mailings consisted of colorful, one-page motivational flyers accompanied by small behavioral cue items. The intervention modules were mailed out once per month for the first 4 months after RTC, then every 3 months for the remainder of the 10-month period. The study used several Navy data sources to locate and track study participants after graduation from RTC for mailing intervention materials. No fewer than two attempts were made to deliver mailed intervention materials. Telephone Counseling Intervention and Procedures The telephone help line represented an innovative approach to smoking relapse prevention. Women assigned to this condition received information regarding the help line services the week before leaving recruit training and were encouraged to call the number upon leaving recruit training. Incentives, such

3 238 Smoking Relapse Prevention for Navy Women as a prepaid long distance phone card, were offered to encourage phone calls. Once the participant made the initial call, the help line counselor scheduled a series of follow-up phone calls, thus creating a proactive counseling procedure. This procedure yielded a certain level of participant accountability, as well as counselor-provided social support. The subsequent sessions were scheduled in relation to the participant s probability of relapse, thereby providing assistance when needed most. 30 The counseling protocol was adapted to reflect the relapse issues most relevant to Navy women as discussed above. In particular, the phone counselor would help the caller identify situations in which she felt most likely to relapse and then would work with her to identify responses/alternative actions to take to reduce the likelihood of relapse. In subsequent phone calls, the counselor would discuss any relapse episodes and would work with the caller to identify better ways to respond in situations that prompt smoking. Alternatively, if the caller had remained quit, subsequent phone calls were used to reinforce the success and identify long-term strategies for remaining quit. Data Collection at RTC and after RTC On the fourth day of training, all female recruits went through a wellness clinic. Before being given any health information, the Operation Stay Quit study was introduced, and informed consent procedures were uniformly conducted using a 10- minute videotaped presentation. Recruits who volunteered to participate in the study were asked to complete a brief one-page entry survey assessing their tobacco use just before entering the Navy. During the final week of recruit training, recruits attended recruit critique sessions where they provided anonymous feedback by questionnaire about their training. At this time, they completed a graduation survey that asked several questions about smoking and perceptions of being a smoker after having experienced 8 weeks of enforced abstinence from smoking. The study used several Navy data sources to locate and track study participants after graduation from RTC for mailing follow-up surveys to their current duty stations throughout the world. A number of strategies were used to maximize the response rates to the follow-up surveys, particularly the 12-month survey. These strategies, described elsewhere, included monetary incentives, repeated mailings, prepaid phone card incentives, reminder postcards, and alternative survey administration options. 31,32 Survey Measures Self-report smoking measures were based upon those used by other researchers investigating smoking and cessation among Navy and civilian personnel. 1,24,33 35 The primary measure for evaluating intervention effects was a dichotomous variable (yes vs. no) measured at the 3-, 6-, and 12-month follow-up that assessed any cigarette smoking during the past 30 days. Items on the follow-up surveys that assessed smoking included the phrase since graduating from recruit training to provide a temporal reference point. Several sociodemographic and baseline smoking variables were examined as correlates of relapse at the 12-month assessment, including age category (17 18, 19 23, and years); race/ethnic group (Caucasian, non-hispanic, African American, Hispanic, Asian/Pacific Islander, and Native American); education category (less than high school, high school, and more than high school); type of smoker at entry into the Navy (experimenter, occasional, daily, or former); number of cigarettes typically smoked measured on a scale ranging from 0 (0 cigarettes per day in the 30 days before RTC) to 10 (typically more than 40 cigarettes per day in the 30 days before RTC); minutes after waking one typically smoked her first cigarette measured on a scale ranging from 1 (immediately after waking) to 6 (more than 2 hours after waking); intentions to smoke after leaving RTC measured on a scale ranging from 1 (definitely no) to 4 (definitely yes); perceptions of being a smoker at graduation (smoker vs. non/former smoker); and intentions to smoke in the future measured at graduation using a scale ranging from 1 (definitely no) to 4 (definitely yes). Analyses Assessments of intervention effects at the 3-, 6-, and 12- month follow-ups were conducted with multivariate analysis using a generalized estimating equations approach for repeated measures. 36 Although the unit of randomization to condition was division, the unit for this analysis was the individual. This was appropriate because individuals were essentially randomly assigned to divisions (i.e., in the order they arrived at recruit training) and because initial analyses determined that any dependency in the data due to division clustering was negligible. A major advantage of generalized estimating equations is that it uses all available data across time periods rather than including only those cases with complete data, thereby reducing potential biases in assessing intervention effectiveness. Forward stepwise logistic regression was used to determine significant predictors of smoking relapse at the 12-month follow-up. Results Smoking and Cessation Experiences at Entry to Recruit Training Information from baseline surveys suggested that young women had unusually high smoking rates at entry into the Navy and were heavy smokers, considering their typical age. When asked to describe themselves before recruit training according to five smoking categories, 45% reported never having smoked, 29% reported daily smoking, 12% reported occasional smoking, 11% reported experimenting, and 3% categorized themselves as former smokers. Thus, 55% were considered to be smokers who had current or previous experience with smoking before entering RTC. Slightly more than one-fourth of all recruits (48% of smokers) reported smoking as recently as the day they arrived at recruit training. Women smokers had an average of 6 to 10 cigarettes (median category) on typical days that they smoked. Exactly 42.5% of all recruits (N 2,337) reported any smoking in the past 30 days at entry. Despite their considerable experience with smoking, recruits were not lacking in interest or attempts at cessation before entering RTC. Approximately 65% of those who had smoked reported ever having tried to quit and more than one-half of these had tried within the 3 months before entering recruit training.

4 Smoking Relapse Prevention for Navy Women Extent of Intervention Delivery after Recruit Training Two attempts were made to successfully deliver all intervention mailings and the outcome of attempts was recorded (i.e., delivered at first attempt, delivered at second attempt, not delivered). The rate of undeliverable mail was low, approximately 3%. With regard to the telephone help line, at the end of the intervention, only 29 participants had contacted the telephone help line. Of these, only five completed the full counseling protocol. Follow-Up Response Rates The response rate to the 3-month follow-up survey was 39.2% or 1,077 respondents of 2,748 thought to be eligible (i.e., still in the Navy). The response rate to the 6-month survey was 41.4% (988 respondents from 2,386 eligible). The response rate to the 12-month survey was 52% (1,177 respondents from 2,263 eligible). Response rates at all follow-ups were higher than those typically achieved in other surveys of Navy enlisted personnel. 37,38 Analysis showed few differences between respondents and nonrespondents on sociodemographic characteristics and entry smoking-related variables, 31,32 indicating minimal response bias. Intervention Effects and Smoking Relapse up to 12 Months after RTC Overall, the two interventions tested in this study yielded smoking prevalence rates that did not differ from those of the control group (Table I). Using the standard definition of being a current smoker (i.e., smoked during the past 30 days), approximately 77% of incoming women recruits with any smoking experience were current smokers before entering the Navy, and 57% were current smokers after being in the Navy for approximately 1 year. This decline of 20 percentage points represented a highly statistically significant (p 0.001) change across the four repeated assessments (Table II). There were no significant differences among groups in terms of change over time, although there was a very weak trend for an interaction between the phone group and time (p 0.152). Figure 1 provides a pictorial view of the results for smoking TABLE I PAST 30-DAY SMOKING PREVALENCE: FOLLOW-UP TRENDS AMONG SMOKERS WITH ANY SMOKING EXPERIENCE AT ENTRY TO RTC % Smoking in Past 30 Days Baseline a Follow-up Assessment Condition (follow-up n) Entry 3 Month 6 Month 12 Month Control (n 922) Mail (n 938) Phone (n 921) All groups (n 2,781) a At entry into the Navy, women who identified themselves as either daily smokers, occasional smokers, experimenters, or former smokers were subsequently categorized as smokers (i.e., had some previous experience with smoking that might predispose them to smoking after leaving the 8-week ban imposed during recruit training). Percentages of these smokers at entry that also reported smoking during the previous 30 days was less than 100%, primarily because former smokers and many experimenters had not recently smoked. prevalence among groups and over time as indicated by the results in Tables I and II. There is a clear decline in smoking prevalence for all three groups over time. Also, the smoking prevalence for each of the groups cluster consistently at the assessment points with the exception of the phone group at the 3-month follow-up. The phone group s smoking prevalence is slightly lower than expected 3 months after graduation from RTC, which produces the trend for an interaction by time. Correlates of Smoking Relapse at the 12-Month Follow-Up The following variables were considered as potential correlates of relapse at the final 12-month follow-up: (a) sociodemographic characteristics including age, race/ethnicity, and education; (b) baseline smoking variables measured at entry into the Navy including type of smoker (i.e., experimenter, occasional, daily, or former), number of cigarettes typically smoked per day in the past 30 days, minutes until first cigarette of the day, and intentions to smoke after leaving RTC; and (c) smoking variables measured at graduation from RTC, including perceptions of still being a smoker, and intentions to smoke after leaving RTC. Two variables entered the stepwise logistic regression model: type of smoker just before entry and number of cigarettes typically smoked per day in the 30 days before entry, both of which can be considered measures of a smoker s level of addiction at baseline. Relapse rates were highest for baseline daily smokers (77%) and lowest for baseline experimenters (24%). Occasional and daily smokers were both approximately four times more likely to have relapsed by the 12-month follow-up than experimenters. Surprisingly, former smokers were almost 6.5 times more likely to have relapsed than experimenters. However, the few number of former smokers in this analysis (n 20) suggests that this finding should be interpreted with caution. The number of cigarettes typically smoked per day at entry was associated with relapse at the 12-month follow-up, such that the greater the amount smoked at baseline, the more likely one was to have relapsed. Discussion 239 Several interesting findings were found in this study regarding the smoking behavior of women entering the U.S. Navy and how smokers behavior changed over their first year in the Navy. However, evaluation of the relapse-prevention intervention effects proved disappointing. Except for a weak trend for smokers in the phone counseling condition to have a slightly lower relapse rate during the first 3 months after graduating from RTC, no significant effects related to the interventions were found. The mail intervention was a nonintrusive health education intervention that was originally hypothesized to have a weaker effect than the more phone intervention. However, we had expected the mail intervention to have some effect considering that it followed immediately after an 8-week period of exposure to a total smoking ban. We had anticipated that recruits already in a nonsmoking mode would be further affected by supportive reminders and encouraging messages received in the mail. This did not appear to happen. The lack of an effect for the phone-counseling intervention was an even more disappointing finding. Similar telephone

5 240 Smoking Relapse Prevention for Navy Women TABLE II ANALYSIS OF INTERVENTION EFFECTS AND CHANGES OVER TIME USING GENERALIZED ESTIMATING EQUATIONS (GEE) METHODS TO DETERMINE INDEPENDENT EFFECTS AMONG THOSE WITH ANY SMOKING EXPERIENCE AT ENTRY TO RTC Parameter Generalized Estimating Equations Estimate counseling available to California smokers who call to get help quitting smoking has been successful. 39 However, it must be noted that evaluations of the California telephone help line are based on quitting successes among thousands of smokers who have voluntarily called for help on their own. Unfortunately, among our phone-counseling group of over 900 smokers (including experimenters, light smokers, and former smokers), only a very small number of women ever called the help line. Although incentives (e.g., a free phone calling card) and several mailed reminders about the availability of the help line were provided to the women in the phone intervention group, clearly these did not motivate or reduce barriers for many smokers to make use of the help line. Among all women recruits with any smoking experience before entering the Navy, the relapse smoking rates (i.e., percent that smoked in the past 30 days) were 68%, 62%, and 57% at the 3-, 6-, and 12-month follow-ups after RTC. However, relapse varied considerably by the type of smoker one was at entry to 95% Confidence Interval Z p Experimental condition Phone group Mail group Control group Changes over time Time Interactions Phone time Mail time Control time Intercept recruit training. For example, at the 12-month follow-up, the relapse rates ranged from approximately 24% smoking among those who entered the Navy as experimenters (i.e., 76% maintained cessation) to approximately 76% smoking among those who entered as daily smokers (i.e., 24% maintained cessation). Thus, the most conservative estimate of the minimum smoking cessation rate after 1 year in the Navy is approximately 24% for Navy women. Identifying an appropriate group to help interpret this cessation/relapse rate is difficult for several important reasons. Studies differ in their definitions of smoking and cessation, their data collection time frames, and most importantly, their target study group. The present study focused on women experiencing protracted involuntary 24-hour-a-day abstinence from smoking over an 8-week period. Ideal comparison data to assess the effects of the 8-week ban on subsequent smoking rates would be those from a longitudinal study of a representative sample of military women not exposed to the 8-week smoking ban during Fig. 1. Past 30-day smoking prevalence: follow-up trends among those with any smoking experience at entry to RTC.

6 Smoking Relapse Prevention for Navy Women recruit training. Such an investigation has not been conducted, although studies conducted with male recruits 24,26 suggest that the quit rate among those exposed to the smoking ban was sizably higher than a spontaneous quit rate and comparable with 1-year quit estimates reported across a variety of more costly cessation interventions. Taken as a whole, comparisons with population studies, intervention studies, and workplaces with smoking restrictions suggest that the RTC smoking ban was moderately effective in helping smokers quit smoking and stay quit long term. The 24% follow-up cessation rate among baseline daily smokers is higher than expected had no ban been in place. Thus, restrictions on smoking during recruit training may provide smokers who desire to quit, but have been unable to, with an external impetus and support to quit. The recruit training smoking ban may have been most effective for casual smokers (i.e., experimenters), although appropriate comparison data are not available for these types of smokers. At least one study indicated that smoke-free workplaces are more likely to positively affect light and infrequent smokers than heavier smokers. 58 Although it is encouraging that at least some recruits did not return to smoking after recruit training, most did relapse. Recruit training may be a type of imposed of external motivator that does not require attitude change or the use of cognitive and behavioral coping strategies that typically help people in their cessation efforts. 59 Another reason for the high rate of return to smoking may be related to recruits feelings of deprivation and loss of personal freedom during recruit training. Anecdotal reports from female Navy service members recently graduated from recruit training confirm that many recruits look forward to partying once they leave recruit training and plan to indulge in behaviors prohibited during that time, although many expect to quit smoking later. Implementing even brief behavioral or motivational strategies during recruit training could help encourage some smokers to remain smoke-free once leaving recruit training, as suggested by a recent study by Klesges et al. 60 with Air Force recruits. Enforcement of the no-smoking policy within the context of the benefits to individual health and fitness vs. restriction of freedom may encourage smokers to make positive changes in perceived smoking status. Furthermore, an emphasis on the incompatibility of smoking and physical fitness could be useful, as suggested in a recent study of Air Force recruits. 61 In summary, these results indicate that mailed materials and the availability of telephone help line support were not effective in helping female smokers maintain the quit status achieved at U.S. Navy recruit training. More expansive strategies may be needed. In general, the impact of the 8-week involuntary ban on smoking appeared useful in providing some smokers an external impetus to quit. However, high relapse rates, particularly among heavier smokers, clearly show that most young female smokers entering the Navy need more than an organizationally mandated smoking ban during recruit training to achieve longterm abstinence from smoking. Like most complex health behaviors, smoking cessation is probably more likely to succeed if diverse strategies that encompass both individual level (e.g., attitude change) and social/environmental strategies are used. Acknowledgments This research was supported by the DoD Defense Women s Health Research Program Grant DAMD References Bray RM, Marsden ME, Peterson MR: Standardized comparisons of the use of alcohol, drugs, and cigarettes among military personnel and civilians. Am J Public Health 1991; 81: Conway TL, Cronan TA: Smoking, exercise, and physical fitness. Prev Med 1992; 21: Conway TL, Cronan TA: Smoking and physical fitness among Navy shipboard personnel. Milit Med 1988; 153: Klesges RC, Haddock K, Chang CF, Talcott GW, Lando HA: The association of smoking and the cost of military training. Tob Control 2001; 10: Kroutil LA, Bray RM, Marsden ME: Cigarette smoking in the U. S. military: findings from the 1992 Worldwide Survey. Prev Med 1994; 23: Public Health Service: Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS publication no Washington, DC, U.S. Department of Health and Human Services, Feigelman W: Cigarette smoking among former military service personnel: a neglected social issue. Prev Med 1994; 23: Klevens RM, Giovino GA, Peddicord JP, Nelson DE, Mowery P, Grummer-Strawn L: The association between veteran status and cigarette-smoking behaviors. Am J Prev Med 1995; 11: Weaver KB, Woodruff S, Conway TL, Edwards CC, Zhu, S-H, Elder JP: Does the U.S. Navy attract young women who smoke? Occup Environ Med 1998; 55: Woodruff SI, Conway TL, Edwards CC, Elder JP: The U.S. Navy attracts young women who smoke. Tob Control 1999; 8: Pokorski TL, Chen W, Pigg RM, Dorman SM: Effect of educational intervention on smoking prevalence of U.S. Navy recruits. Health Values 1995; 19: Fiore MC, Novotny TE, Pierce JP, Hatziandreu EJ, Patel KM, Davis RM: Trends in cigarette smoking in the United States: the changing influences of gender and race. JAMA 1989; 261: Gruder CL, Mermelstein RJ, Kirkendol S, et al: Effects of social support and relapse prevention training as adjuncts to a televised smoking-cessation intervention. J Consult Clin Psychol 1993; 61: Ossip-Klein DJ, Giovino GA, Megahed N, et al: Effects of a smokers hotline: results of a 10-county self-help trial. J Consult Clin Psychol 1991; 59: Kabat GC, Wynder EL: Determinants of quitting smoking. Am J Public Health 1987; 77: U.S. Department of Health and Human Services: The Health Consequences of Smoking for Women: A Report of the Surgeon General. Rockville, MD, Public Health Service, Gritz ER, Jarvik ME: Handbook of Psychopharmacology. New York, NY, Iverson, Iverson and Snyder, Geronimus AR, Neider LJ, Bound J: Age patterns of smoking in U.S. black and white women of childbearing age. Am J Public Health 1993; 83: Blake SM, Klepp KI, Pechacek TF, et al: Differences in smoking cessation strategies between men and women. Addict Behav 1989; 14: Marcus BH, Albrecht AE, Niaura RS, Abrams DB, Thompson PD: Usefulness of physical exercise for maintaining smoking cessation in women. Am J Cardiol 1991; 68: Martinelli AM: A theoretical model for study of active and passive smoking in military women: an at-risk population. Milit Med 1999; 64: Department of Defense: DoDINST , Smoke-Free Workplace, March 7, Secretary of the Navy: SECNAVINST A, Tobacco Prevention Program in the Navy and Marine Corps, July 17, Hurtado SL, Conway TL: Changes in smoking prevalence following a strict nosmoking policy in U.S. Navy recruit training. Milit Med 1996; 61: Woodruff SI, Conway TL, Edwards CC: Effect of an 8-week smoking ban on women at U.S. Navy recruit training command. Tob Control 2000; 9: Cronan TA, Conway TL, Kaszas SL: Starting to smoke in the Navy: when, where and why. Soc Sci Med 1991; 33: Marlatt GA, Gordon JR: Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behavior. New York, NY, Guilford Press, Baumeister RF, Heatherton TF, Tice DM: Losing Control: How and Why People Fail at Self-Regulation. San Diego, CA, Academic Press, Gritz ER, Brooks L, Nielson I: Tobacco and Health. New York, NY, K. Slama, 1995.

7 242 Smoking Relapse Prevention for Navy Women 30. Zhu S-H, Pierce JP: A new scheduling method for time-limited counseling. Prof Psychol Res Pr 1995; 6: Woodruff SI, Conway TL, Edwards CC: Increasing response rates to a smoking survey for U.S. Navy enlisted women. Eval Health Prof 2000; 23: Woodruff SI, Edwards CC, Conway TL: Enhancing response rates to a smoking survey for enlisted U.S. Navy women. Eval Rev 1998; 22: Bray RM, Kroutil LA, Wheeless SC, Marsden ME, Bailey SL, et al: 1995 Department of Defense Survey Among Military Personnel. Research Triangle Park, NC, Research Triangle Institute, Conway TL, Trent L, Conway SW: Physical Readiness and Lifestyle Habits among U.S. Navy Personnel during 1986, 1987, and San Diego, CA, Naval Health Research Center, Farkas AJ, Pierce JP, Zhu S-H, et al: Addiction versus stages of change models in predicting successful smoking cessation in California. Addiction 1996; 91: Liang K-Y, Zeger SL: Longitudinal data analysis using generalized linear models. Biometrika 1986; 73: Kantor J, Ford M, Heron JE: Navy-Wide Personnel Survey (NPS) 1995: Statistical Tables for Enlisted Personnel. San Diego, CA, Navy Personnel Research and Development Center, Kantor J, Ford M, Olmstead M: Navy-Wide Personnel Survey (NPS) 1996: Statistical Tables for Officers and Enlisted Personnel. San Diego, CA, Navy Personnel Research and Development Center, Zhu S-H, Stretch V, Balabanis M, Rosbrook B, Sadler G, Pierce JP: Telephone counseling for smoking cessation: effects of single-session and multiple session interventions. J Consult Clin Psychol 1996; 64: Burns D, Pierce J: Tobacco Use in California Sacramento, CA, California Department of Health Services, Zhu S-H, Sun J, Billings S, Choi WS: Predictors of smoking cessation in U.S. adolescents. Am J Prev Med 1999; 16: Moss AJ, Allen KF, Giovino GA, Mills SL: Recent trends in adolescent smoking, smoking-uptake correlates, and expectations about the future. In Advance Data. Hyattsville, MD, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics, Hansen WB, Collins LM, Johnson CA, Graham JW: Self-initiated smoking cessation among high school students. Addict Behav 1985; 10: Ershler J, Levanthal H, Fleming R, Glynn K: The quitting experience for smokers in sixth through twelfth grade. Addict Behav 1989; 14: Stanton WR, McClelland M, Elwood C, Ferry D, Silva PA: Prevalence, reliability and bias of adolescents reporting of smoking and quitting. Addiction 1996; 91: Sussman S, Lichtman K, Ritt A, Pallonen U: Effects of 34 adolescent tobacco use cessation and prevention trails on regular users of tobacco products. Subst Use Misuse 1999; 34: Perry CL, Killen J, Telch M, Slinkard LA, Danaher BG: Modifying smoking behavior of teenagers: a school-based intervention. Am J Public Health 1980; 70: Perry CL, Telch MJ, Killen J, Burke A, Maccoby N: High school smoking prevention: the relative efficacy of varied treatment and instructors. Adolescence 1983; 18: U.S. Department of Health and Human Services: Preventing Tobacco Use among Young People: A Report of the Surgeon General. Atlanta, GA, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Becker DM, Conner HF, Waranch HR, et al: The impact of a total ban on smoking in the Johns Hopkins Children s Center. JAMA 1989; 262: Biener L, Abrams DB, Follick MJ, Dean L: A comparative evaluation of a restrictive smoking policy in a general hospital. Am J Public Health 1989; 79: Borland R, Chapman S, Owen N, Hill D: Effects of workplace smoking bans on cigarette consumption. Am J Public Health 1990; 80: Borland R, Owen N, Hocking B: Changes in smoking behavior after a total workplace smoking ban. Aust J Public Health 1991; 15: Gottlieb NH, Eriksen MP, Lovato CY, Weinstein RP, Green LW: Impact of a restrictive work site smoking policy on smoking behavior, attitudes, and norms. J Occup Med 1990; 32: Millar WJ: Evaluation of the impact of smoking restrictions in a government work setting. Can J Public Health 1988; 79: Petersen LR, Helgerson SD, Gibbons CM, Calhoun CR, Ciacco KH, Pitchford KC: Employee smoking behavior changes and attitudes following a restrictive policy on worksite smoking in a large company. Public Health Rep 1988; 103: Rosenstock IM, Stergachis A, Heaney C: Evaluation of smoking prohibition policy in a health maintenance organization. Am J Public Health 1986; 76: Pierce JP, Evans N, Farkas AJ, et al: Tobacco Use in California: An Evaluation of the Tobacco Control Program, San Diego, CA, University of California, San Diego, Stotts AL, DiClemente CC, Carbonari JP, Mullen PD: Pregnancy smoking cessation: a case of mistaken identity. Addict Behav 1996; 21: Klesges RC, Haddock CK, Lando H, Talcott GW: Efficacy of forced smoking cessation and an adjunctive behavioral treatment on long-term smoking rates. J Consult Clin Psychol 1999; 67: Haddock CK, O Byrne KK, Klesges RC, Talcott CW, Lando H, Peterson AL: Relapse to smoking after basic military training in the U.S. Air Force. Milit Med 2000; 11: