Project Sandman: A Quasi-Experimental Evaluation of a Group-Based Brief Sleep Intervention in Air Force Technical Training.

OBJECTIVES: Approximately 70% of the military personnel experience chronic sleep insufficiency, which negatively impacts military readiness and health. Military sleep health does not appear to be improving despite targeted programs to optimize sleep. The present quasi-experimental study aims to evaluate a single-session sleep intervention in United States Air Force (USAF) Technical Training. METHOD: A group-based Brief Sleep Intervention (BSI) was developed for the target population. Participants included 321 technical school students (Mean age = 21; 82% male; 67% White) who were assigned to the BSI (n = 203) or a control group (n = 118). Propensity-score-weighted multivariable logistic regression was employed to compare outcomes. RESULTS: At the 2-week follow-up, students in the BSI were significantly more likely to report sleeping 6 or more hours on weekdays (OR = 1.49, p < .001) and "Good/Very Good" sleep quality (OR = 1.50, p = .032) than those in the control group. In addition, 69.2% of the students in BSI reported having engaged in the self-selected "Action Step" chosen during the intervention. CONCLUSIONS: To our knowledge, this is the first study to test a preventative sleep intervention in USAF Technical Training. Results suggest that a single-session group intervention can promote behavioral changes and improve sleep health.

Use of Tobacco for Weight Control across Products among Young Adults in the U.S. Military.

BACKGROUND: Approximately 17% of young adults currently use tobacco, most commonly cigarettes and/or electronic cigarettes (e-cigarettes), followed by other products (i.e., cigarillos, pipe/hookah, smokeless tobacco). Cigarettes have been historically used to control weight. Little is known about use of non-cigarette products for weight control, particularly among non-college young adults. Tobacco use in the military is higher than civilians, and personnel have increased motivation for weight control due to military fitness standards. This population might be vulnerable to use tobacco for this purpose. Purpose: Exploring prevalence, as well as demographic and behavioral correlates, of using tobacco products for weight control, among a large, diverse sample of military young adults. Methods: U.S. Air Force recruits (N = 24,543) completed a questionnaire about tobacco use. Among users of tobacco products, recruits reported if they had ever used that product to maintain their weight. Results: Smokeless tobacco was most commonly used for weight control (12.2%), followed by cigarettes (7.3%), e-cigarettes (5.5%), cigarillos (3.3%), and hookah/pipe (3.2%). Using tobacco for weight control was associated with fewer harm beliefs and more regular use of that product. Among e-cigarette users, having a higher BMI and a lower educational background was associated with ever using this product for weight control. Conclusions: The belief that a tobacco product helps control one's weight might increase the prevalence, and frequency of use, of that product among military young adults. Tobacco cessation programs should assess for this motivation of use and provide education about tobacco harm and alternative strategies for weight maintenance.

'I Think Smoking's the Same, but the Toys Have Changed.' Understanding Facilitators of E-Cigarette Use among Air Force Personnel.

BACKGROUND: The military has stringent anti-tobacco regulations for new recruits. While most tobacco products have declined in recent years, e-cigarette use has tripled among this population. However, little is known about the factors facilitating this inverse relationship. OBJECTIVES: Examine the facilitators of e-cigarette use during a high risk period following initial enlistment among young adults. METHODS: Focus groups were conducted with Airmen, Military Training Leaders (MTLs) and Technical Training Instructors (TTIs) to qualitatively explore unique characteristics of e-cigarettes leading to use in Technical Training. RESULTS: The most commonly used tobacco product across participants was cigarettes (42.7%), followed by e-cigarettes (28.0%) and smokeless tobacco (22.6%). Almost a third (28.7%) of participants reported using more than one tobacco product. E-cigarette use was much more common among Airmen (76.1%), compared to MTLs (10.9%) and TTIs (13.0%).Four main facilitators around e-cigarette use were identified including: 1) There is no reason not to use e-cigarettes; 2) Using e-cigarettes helps with emotion management; 3) Vaping is a way of fitting in; and 4) Existing tobacco control policies don't work for vaping. E-cigarettes were not perceived as harmful to self and others, which could explain why Airmen were much less likely to adhere to existing tobacco control regulations. Subversion was viewed as the healthy option compared to utilizing designated tobacco use areas due to the potential exposure to traditional tobacco smoke. This coupled with a lack of understanding about e-cigarette regulations and difficulties with enforcement, promoted use among this young adult population. CONCLUSION: Findings suggest that e-cigarettes are used for similar reasons as traditional tobacco products, but their unique ability to be concealed promotes their widespread use and circumvents existing tobacco control policies. In order to see reductions in use, environmental policies may need to be paired with behavioral interventions at the personal and interpersonal level.

Evidence that smokeless tobacco use is a gateway for smoking initiation in young adult males.

BACKGROUND: This study was designed to test the hypothesis that smokeless tobacco (SLT) serves as a gateway drug for smoking among young adult males. Methods. A cohort (n = 7,865) of U.S. Air Force recruits who claimed to have never smoked cigarettes was followed prospectively for 1 year. The participants were male, 32.9% were ethnic minorities, and their average age was 19.84 years (SD = 2.29). Among recruits entering basic military training, 403 (5.1%) reported current SLT use and 198 (2.5%) reported a past history of SLT use. RESULTS: At the 1-year follow-up current SLT users were 233% more likely to have initiated smoking than nonusers (odds ratio = 2.33, 95% CI = 1.84-2.94). Similarly, recruits who reported past SLT use were 227% more likely to begin smoking than participants who had never used SLT (odds ratio = 2.27, 95% CI = 1.64-3.15). SLT use remained a potent predictor of smoking initiation in a multivariate logistic model that included demographic factors and other risk factors for initiation. CONCLUSIONS: SLT use appears to be an important predictor of smoking initiation among young adult males. This study suggests that smoking prevention and cessation programs should also include strategies related to SLT use.

The association of smoking and the cost of military training.

OBJECTIVE: To determine if premature discharge from the US Air Force was associated with the smoking status of recruits. DESIGN AND SETTING: A total of 29 044 US Air Force personnel recruited from August 1995 to August 1996 were administered baseline behavioural risk assessment surveys during basic military training. They were tracked over a 12 month period to determine those who were prematurely discharged. MAIN OUTCOME MEASURES: Excess training costs as a result of premature discharge. RESULTS: In this 12 month period, 14.0% of those entering the US Air Force were discharged at a one year follow up. In both univariate and multivariate models, the best single predictor of early discharge was smoking status. Overall, 11.8% of non-smokers versus 19.4% of smokers were prematurely discharged (relative risk 1.795). CONCLUSIONS: Using US Department of Defense data on the cost of military training, recruits who smoke in the US Air Force are associated with $18 million per year in excess training costs. Applied to all service branches, smoking status, which represents a constellation of underlying behaviours and attitudes that can contribute to early discharge, is associated with over $130 million per year in excess training costs.

Demographic, lifestyle, and psychosocial predictors of frequency of intoxication and other indicators as estimates of alcohol-related problems in Air Force basic military recruits.

This study examined demographic, lifestyle, and psychosocial variables to determine predictors of Air Force recruits who are likely to have alcohol-related problems. Subjects were all Air Force recruits (N = 32,144) entering basic training from August 1995 to September 1996. The dependent measures were self-reported frequency of eight or more drinks per occasion, frequency of fighting while drinking, and typical frequency of alcohol consumption. Demographic analysis revealed that individuals high on any dependent variable were more likely to be male, older, non-Hispanic whites with some college. Lifestyle predictors included positive attitudes toward drug use and smoking status, with risk greater for females than males and for non-whites than non-Hispanic whites at the same smoking level. Psychosocial predictors included positive rebellious attitudes, decreased seatbelt use, and positive risk-taking attitudes, with risk greater for females than males at the same risk attitude level. These findings suggest that problem drinking falls into a broader category of risky problem behaviors.

Ethnic differences in patterns and correlates of age of initiation in a population of Air Force recruits.

Early age of initiation is a significant risk factor for long-term dependent smoking and may also relate to other unhealthy behaviors. The current study assessed age of initiation in relationship to smoking dependence and motivation to quit, physical activity, dietary intake, body mass index (BMI), attitude toward illegal drug use, binge drinking, seat belt use, and smoking status at follow-up. Subjects were 7995 Air Force recruits who reported smoking regularly up to Basic Military Training. Euro-Americans initiated smoking more than a year earlier on average (15.5 years) than did African-Americans (16.8 years), with Hispanic-Americans (16.0 years) between these two groups. No gender differences were found for age of initiation for any ethnic group. Early age of initiation in Euro-Americans was associated with greater dependence on tobacco, reduced motivation to quit, less likelihood of quitting in the next 12 months, and a number of other health risk factors including lower self-reported physical activity, greater intake of high-fat foods, more favorable attitudes toward illegal drugs, increased likelihood of binge drinking, and less reported use of seat belts. Relationships between early age of initiation and other unhealthy behaviors were less consistent for African-Americans and for neither African-Americans nor Hispanics did age of initiation predict smoking status at 1-year follow-up.

Efficacy of forced smoking cessation and an adjunctive behavioral treatment on long-term smoking rates.

This study evaluated the efficacy of a 6-week forced ban on smoking and brief behavioral counseling on long-term smoking rates. Participants were active-duty enrollees in U.S. Air Force basic military training over a 1-year period (N = 25,996). All participants were under a 6-week ban from tobacco products, and 75% were randomized to a brief smoking cessation intervention, with the other 25% randomized to a control condition. At 1-year follow-up, 18% of smokers were abstinent; women, ethnic minorities, and those intending to stay quit at baseline were more likely to be abstinent. Among smokers not planning to remain abstinent at baseline, those receiving the intervention were 1.73 times more likely to be abstinent. Over time, substantial smoking initiation occurred among nonsmokers (8% of never smokers, 26% of experimental smokers, and 43% of ex-smokers). Forced cessation is associated with good levels of long-term cessation, and brief behavioral interventions enhance cessation in certain subgroups.

An examination of cigarette brand switching to reduce health risks.

This study examined cigarette brand switching to reduce health risks in a population of young smokers (N = 7,998) entering United States Air Force Basic Military Training. Because of a comprehensive tobacco ban during training, all smokers were abstinent during the study. Results from this investigation suggested that brand switching to reduce health risks was common among current smokers (31.3% of males; 32.3% of females). Brand switchers smoked fewer cigarettes, were more likely to smoke low-yield brands, had lower scores on a measure of nicotine dependency, and were more confident they could remain abstinent following training. Other discriminators of smokers who had switched brands from other smokers included using smoking to control appetite, greater proclivity to attempt smoking cessation, engaging in fewer safety risks, and healthier dietary composition. Finally, brand switchers quit smoking at a higher rate than other smokers (12.5% versus 11.1%) during the year following basic military training. However, a multivariate logistic regression model that controlled for demographic factors and smoking history suggested that brand switching was not a statistically significant predictor of smoking cessation during the follow-up period.

A population comparison of participants and nonparticipants in a health survey.

OBJECTIVES: This study examined the characteristics of Air Force recruits willing to take part in a health survey vs those unwilling to participate. METHODS: US Air Force recruits undergoing basic military training (n = 32,144) were surveyed regarding demographic and health variables. RESULTS: Respondents indicating an unwillingness to participate in a health survey reported less healthy lifestyles than those willing to participate. Prediction equations modeling the characteristics of those engaging in 4 risky behaviors were nearly identical regardless of whether those refusing to participate were included. CONCLUSIONS: Results suggest that, despite some low estimates of health behaviors due to response bias, relationships between most risk factors are generally unaffected by those not responding to health surveys.

Smokeless tobacco use in a population of young adults.

The current study examined characteristics of smokeless tobacco users in a large population of Air Force recruits. In addition, smokeless tobacco users were compared to non-tobacco users, to cigarette smokers, and to users of both smokeless tobacco and cigarettes. Participants were 32,144 individuals who entered Basic Military Training from August 1995 to August 1996. A 53-item questionnaire assessed demographics, tobacco use history, risk taking, and other health-risk factors. Those who both chewed and smoked scored considerably higher on a number of risk factors than did those who limited their tobacco consumption to either cigarettes or chew. Cigarette smokers in turn tended to score consistently higher on self-reported risk factors than did nontobacco users.

Predictors of milk consumption in a population of 17- to 35-year-old military personnel.

OBJECTIVE: The purpose of this investigation was to survey an entire population of Air Force recruits (N = 32,144) regarding milk consumption and demographic and health-related factors that may predict milk consumption. DESIGN: All subjects were required to fill out a 53-item health survey at the start of basic military training. SUBJECTS/SETTING: All recruits who entered the US Air Force from August 1995 to August 1996 participated in this study (N = 32,144). STATISTICAL ANALYSES PERFORMED: Potential correlates of milk intake were analyzed using Spearman rank order correlations and multiple linear regression. Variables were removed if they did not make a meaningful contribution to variance in milk intake. Because of skewed distributions, several variables were dichotomized (e.g., age: 17 to 24 vs 25 to 35 years). RESULTS: In terms of milk consumption, 51.7% of the respondents reported intake of fewer than 1 serving per day; only 17.9% reported intake of 3 servings or more per day. Milk intake was positively associated with body weight and fruit/vegetable intake and negatively associated with age, education level, reported milk-related gastric distress, physical activity level, dieting frequency, and concern about weight. Gender (women reported lower intake) and ethnicity (minorities reported lower intake) were independently related to milk consumption. Of all respondents, 16.1% reported themselves to have milk-related gastric distress, but rates varied depending on age, gender, and ethnicity (ranging from 10.2% for younger non-Hispanic white men to 60.4% for older Asian men). APPLICATIONS/CONCLUSIONS: Despite the efforts of large, costly campaigns designed to increase milk consumption, self-reported milk consumption in young adults is extremely low. Given the importance of dairy products as a major source of calcium in the American diet, dietetics practitioners should assess milk consumption among young adults to ensure sufficient calcium intake to maximize peak bone mass in this group.

Prevalence and predictors of discharge in United States Air Force Basic Military Training.

The purpose of the current investigation was to determine the prospective predictors of discharge in a population of individuals entering U.S. Air Force Basic Military Training (BMT). Subjects were 32,144 consecutive individuals entering Air Force BMT. In the first week, subjects filled out a comprehensive lifestyle and behavioral assessment. Over time, a total of 1,999 subjects (6.2%) dropped out of BMT for a variety of reasons, the most common being medical (33.6%), psychiatric (21.3%), legal (20%), and poor performance (13.1%). Overall, discharges by gender were equal, but the reasons for discharge varied by gender. Ethnicity predicted for medical, psychiatric, and legal discharge. Results suggest that women and ethnic minorities are not biased in favor of discharge and that both lifestyle and psychosocial variables are consistent predictors of discharge. Future research could potentially yield other significant predictors of success versus discharge in the U.S. military.

An examination of body weight standards and the association between weight and health behaviors in the United States Air Force.

This study examined the weight standards used by the U.S. Air Force and tested whether Air Force personnel who exceed the maximum allowable weight standard are more likely to engage in health risk behaviors compared with individuals who do not exceed current Air Force weight standards. Participants were 32,144 individuals who completed basic military training from August 1995 to August 1996. Compared with body mass levels known to predict increased health risks, the Air Force maximum allowable weight standards were found to be more stringent for women than for men. Furthermore, exceeding the maximum allowable weight standard of the weight management programs did not consistently indicate that an individual engaged in a less healthy lifestyle than other airmen. Perhaps other risk factors, such as cigarette smoking, may be more closely linked to negative health consequences than body weight.

A study of the psychometric and predictive properties of the Fagerström Test for Nicotine Dependence in a population of young smokers.

This study examined the psychometric properties of the Fagerström Test for Nicotine Dependence (FTND) in a population (N = 7998) of young smokers entering US Air Force Basic Military Training (BMT). An exploratory factor analysis suggested that the FTND is comprised of two factors. The first factor, labeled Smoking Pattern, included items assessing the number of cigarettes smoked per day, time to first cigarette, difficulty refraining from smoking, and smoking when ill. The second factor, labeled Morning Smoking, consisted of two items measuring whether one smokes more in the morning and whether one would rather give up the first cigarette of the day or all others. The Smoking Pattern factor proved to have adequate internal consistency, impressive criterion-related validity, and was strongly related to smoking cessation 1 year following BMT. In contrast, the Morning Smoking factor demonstrated questionable psychometric properties and was not supported by a confirmatory factor analysis.

Smoking prevalence and risk factors for smoking in a population of United States Air Force basic trainees.

OBJECTIVE: To provide a comprehensive assessment of smoking prevalence and risks for smoking in an entire population of United States Air Force (USAF) military basic trainees (n = 32,144). DESIGN: Population-based survey with every individual entering the USAF enlisted force from August 1995 to August 1996. SETTING: USAF Basic Military Training (BMT) facility at Lackland Air Force Base, Texas. All trainees were assessed during the first week of BMT. MAIN OUTCOME MEASURES: A 53-item questionnaire was developed to assess four domains: demographics, smoking history, risk factors for smoking, and other health behaviours. RESULTS: Approximately 32% of the trainees smoked regularly before basic training and a small percentage of the trainees (7.6%) described themselves as ex-smokers. Men, Euro-Americans, and those from lower educational backgrounds were more likely to smoke than other trainees. On average, smokers had smoked for approximately four years and had low nicotine dependence scores. Individuals who had smoked before BMT were more likely to use other drugs (such as alcohol, binge drinking, smokeless tobacco), and were less physically active than never-smokers. These findings were particularly strong for those who smoked up to basic training but were also evident for ex-smokers. CONCLUSIONS: Smoking is a prevalent risk factor among individuals entering the USAF. Furthermore, smoking was related to other risk factors believed to lower military readiness, including alcohol use and decreased physical activity. Comprehensive tobacco control policies aimed at reducing smoking among military trainees are needed.

The relationship between smoking and body weight in a population of young military personnel.

Evidence indicates that middle-aged smokers weigh less than nonsmokers and that smoking cessation reliably produces weight gain, but recent studies have questioned the weight control "benefits" of smoking in younger populations (the time that people typically initiate smoking). The relationship between smoking and body weight was evaluated in all U.S. Air Force Basic Military Training recruits during a 1-year period (n = 32,144). Those who smoked prior to Basic Military Training (n = 10,440) were compared to never smokers or experimental smokers. Results indicated that regular-current smoking had no relationship to body weight in women (p > .05) and a very small effect in men (p < .05). Ethnicity, education, income, and duration and intensity of smoking did not affect the relationship between smoking and body weight. It was concluded that smoking has no effects on the body weights of young women and minimal effects in young men.

Co-occurrent use of cigarettes, alcohol, and caffeine in a retired military population.

Previous studies have linked the use of caffeine, nicotine, and alcohol to health complications and have also found that the use of these substances significantly covary. Given the prevalence of health problems of older adults, it is surprising that no studies to date have examined the co-occurrent use of alcohol, caffeine, and nicotine in a senior population. This investigation evaluated the co-occurrent use of cigarettes, caffeine, and alcohol in a community sample of older Americans. Respondents (1,095 women and 1,371 men) completed a questionnaire examining their use of caffeine, nicotine, and alcohol. This study replicated earlier findings that tobacco, caffeine, and alcohol use co-occur and that there are consistent use patterns for these substances. The results suggest that health organizations could better target services by prescreening for smoking, alcohol, and caffeine use and possibly targeting smokers and ex-smokers for potentially problematic use patterns of caffeine and alcohol.

Home-based behavioral treatments for chronic benign headache: a meta-analysis of controlled trials.

Controlled clinical trials have consistently demonstrated that behavioral treatments for chronic benign headache produce clinically beneficial outcomes both post-treatment and at follow-up. Given these results there is interest in cost-reduction and redesign of these treatments to improve their accessibility. One promising approach in this regard is home-based headache treatment. These treatments seek to provide the same amount of treatment as clinic-based treatments; however, some of the material typically presented to the patient by a clinician is presented through home-study materials (e.g., manuals, audiotapes). To date, the published literature contains 20 controlled clinical trials which have examined the outcomes produced by home-based treatments. This article presents the first comprehensive meta-analysis of these clinical outcome studies. Results of the quantitative analyses suggest that home-based treatments produce comparable, or with certain outcome measures, superior results to clinic-based treatments. Moreover, costeffectiveness scores of home-based treatments were found to be more than five times larger than those of clinic-based therapies. Methodological analyses are also presented along with suggestions for future research.

Bulimic weight-loss behaviors in military versus civilian weight-management programs.

This descriptive study evaluated the presence of bulimic weight-loss behaviors in individuals enrolled in: (1) a military weight-management program (N = 51); (2) a civilian weight-management program (N = 53); and (3) a comparison (military normal-weight) group (N = 51). A modified version of the Stanford Eating Disorders Questionnaire was administered to all subjects. The results indicated that the military weight-management program group reported that they engaged in bulimic weight-loss behaviors two to five times more often than the comparison group, and that they engaged in vomiting, strenuous exercise, or use of sauna/steam room four times as often as the civilian weight-management program group. The results suggest that bulimic weight-loss behaviors may develop in individuals who feel extreme pressure to lose weight.