Smoking Behavior Change During Compulsory Military Service in Israel, 1987-2011

Introduction: Smoking in military settings is of major concern. We aimed to assess the association between personal, family, and military factors and smoking behavior change during compulsory military service in Israel. Methods: Participants were soldiers recruited between 1987 and 2008 who were interviewed at recruitment and reinterviewed at discharge (1987-2011) (total: 29 189; males: 15 136; females: 14 053). The primary outcome variables were smoking initiation during service among nonsmokers at recruitment, and cessation during service among smokers at recruitment. We examined potential predictors of change, and trends by calendar year. Results: Smoking prevalence increased by 39.4% during military service (recruitment: 26.2%, discharge: 36.5%). 18.4% of nonsmoking recruits initiated smoking, and 12.4% of smoking recruits quit smoking between recruitment and discharge. There was no observed trend in initiation between 1987 and 2011. The strongest predictor of smoking initiation among nonsmokers at recruitment was smoking history (former vs. never-smoker, odds ratio (OR) [95% confidence interval [CI]]: males: 5.63 [4.63,6.85], females: 6.76 [5.27, 8.68]. Other variables had smaller effects on initiation. Females were less likely to initiate smoking than males (OR [CI]): 0.75 [0.69,0.81]. Both males and females with high military fitness levels were more likely to initiate smoking. Among women, those with lower education, with fathers with lower education, of lower socioeconomic status, and ever-users of contraceptives were more likely to initiate smoking. Cessation among males modestly increased over the years (OR [CI]): 1.03 [1.01,1.05]. Conclusions: Smoking increased substantially during mandatory military service in Israel. Former smokers were at greatly increased risk of initiation and should be targeted for relapse prevention. Military service represents a golden opportunity for tobacco control. Implications: Military tobacco control policy is an important contributor to longevity among service personnel, and population-wide mortality in countries with compulsory service. The increased smoking prevalence among military personnel, and increases in smoking during military service should act as a wake-up call to governments and health systems in countries lacking strong military tobacco control policies. The substantial progress in military tobacco control in the United States, which includes strong antitobacco policies for prevention of smoking initiation, aid to smokers to quit smoking, and protection of nonsmokers from tobacco smoke, should be emulated by others. Former smokers and others at high risk should be targeted for relapse prevention. The closed environment of military service provides a golden opportunity for tobacco control.