Smoking in the Military

The military has a long tradition of mixing warfare and tobacco.  Years ago the army included a pack of smokes in every C-ration distributed to the troops; as a result it was more common for soldiers to take up smoking than to remain abstinent.  The tobacco industry insured itself a whole generation of addicted consumers by volunteering their product to help the war effort.  Years later, of course, we've inherited this tradition in the form of lung cancer, emphysema and heart disease among our veterans.

When I was a young doctor in the air force one of my jobs was to oversee the base's Put Prevention Into Practice Program, an anemic effort to bring down the cost of military medical care tomorrow by implementing preventive health strategies now.  What exactly I was supposed to do never became clear to me, since I had no support staff, operating budget or clear directive.  One thing that did become clear to me, however, was that the USAF was doing itself no favors in the realm of healthy living.

One morning I swung through the Base Commissary (grocery store, for all you civilians) and found an advertising leaflet tossed into my bag in the check-out line.  "The Military Family" was a 6-page brochure with coupons, some recipes, and suggestions for family activities.  What caught my eye was the fact that 3 of the 6 pages were nothing but ads for cigarettes.  This shouldn't have surprised me much, since the Base Exchange and Commissary are tax-free organizations filled with the same types of things you'd find in airport duty-free shops, such as perfumes, fancy alcohols, and cigarettes.

For some reason, though, at that moment I became intensely irked.  Here they stick me in a job for which they provide no more than token guidance and no support—a job where it is my responsibility to convince our people of the merits of healthful living—all the while they run a business dumping cheap tobacco on the military and their families.  Being as naive as I was, I had already wondered why the USAF didn't just mandate a "no smoking" environment—they already ban illicit drug use, why not tobacco?

Well, it just so happened that our base was welcoming a high-level visitor that day.  The head of our command, a four-star general, was flying in to tour our facility and hold a review with the troops in the base auditorium.  I filed into the mandatory meet-and-greet and stood at attention as the dignitary arrived, flanked by a phalanx of colonels and single-starred generals.  At the end of his rousing speech (this was before 9/11, a time when the air force's gravest battle was the pitched war against budget cutbacks and irrelevancy) he invited the audience to pose questions.  "Don't hold back," he intoned, "Don't worry about offending me.  Ask whatever you want."

In retrospect I should have just kept my mouth shut.  But, having joined the active duty corps just months earlier and taking the general at his word, I stood up and posed my question.

"Sir, I'm a doctor tasked with improving the health of our active duty and retired personnel.  If the Air Force is really interested in this goal, why does it continue to promote the use of tobacco?"

"The Air Force has never promoted smoking."

"But sir," I objected, extracting the pamphlet from my BDU pocket, "I was given this advertisement for cigarettes just this morning."

The general looked directly at me, pointedly avoiding even a glance at what I held in my hand.  "The Air Force doesn't promote smoking.  Next question."

I had long been familiar with the chain of command, but as the day went on I became intimately acquainted with the pecking order as one after the next—flight commander, squadron commander, group commander, and finally base commander—filed into my office to dress me down.  Just as I was sure I'd be sent to Leavenworth, in walked the general himself, with enough brass on his shoulders to fill out the French horn section of an orchestra, and stood in front of my desk.

He stood there, sized me up, extended his hand to me and curtly said "No hard feelings.  Keep up the good work."  With a crisp about-face he exited the room.  He must have said something to mollify my chain of command because I never heard a word about it again.  The whole episode made a lot more sense the next day when a colleague of mine reported to me that he'd seen the general lighting up a smoke out on the tarmac just before flying off.

As a new doctor I was young and indignant about smoking.  Readers of my previous rants about the evils of tobacco may think I haven't changed much, but on the issue of cigarette use in the military I have to admit that my opinion has softened.

It's not uncommon to open, say, a Time magazine and see photos of our troops in Afghanistan with cigarettes between their fingers or dangling from their lips.  My first thought is "here we go again; another generation of nicotine-addicted vets."  But, as we all know, one's first impressions are often the result of ingrained biases and don't always remained unaffected by experience.

I was in the military for several years but thankfully never served in combat.  The closest I ever came was the time I spent working in the surgical intensive care unit of Landstuhl Regional Medical Center in Germany.  This facility has become famous as the first large hospital seen by wounded soldiers from Iraq and Afghanistan prior to being shipped back to the U.S.  A soldier who is injured by a roadside bomb will be airlifted to a field hospital for immediate care, but the majority of the larger surgeries are not performed until he reaches Landstuhl.  It was in that ICU where I tended to wounds so horrendous they defy description, so ghastly that it seemed improbable that a human could suffer such utter destruction and continue to survive.  Unfortunately, of course, many didn't.

At Landstuhl I began to appreciate the mental and emotional stress our service personnel are under every day they set out on patrol or climb into a transport vehicle for a trip across the desert where danger lurks literally around every corner.  With so many injuries in our recent wars, nearly all soldiers witness first hand—as I had—the mortal toll that attends the theater of combat.  With that in mind I began to rethink my opinions on the issue: who am I to question what it is that allows these young men and women to make it through the day without descending into nihilism?  Why should a young soldier worry about the health of his lungs 50 years down the road when the rest of his body might not survive the next hour?  Even if a soldier lives through the next roadside attack, isn't the issue of traumatic brain injury and post-traumatic stress a far more pressing problem than his possible need for bypass surgery in the year 2035?

I'm sure I'm not the only one who has put thought to this issue.  I know for a fact that the medical leaders in the military are far more conscious of such health issues now than they were when I was a young captain.  It's highly likely that experts at much higher pay grades are even now struggling with how to handle the future financial toll related to the abundant use of tobacco in our latest armed conflicts.  But if you had to rank this particular problem against all the others that attend to our most recent wars it would undoubtedly fall somewhere in the double digits.  And, looking back, I think even cardiologists would admit that the unhealthy composition of WWII C-rations was a small price to pay to deliver the world from totalitarianism.