Serving and Smoking

August 25, 2023 | VOLUME 1, ISSUE 2

For a look into the intersectionality of tobacco use and the military, we spoke with Anne Melzer, MD, MS, a pulmonary and critical care physician with the US Department of Veterans Affairs. Dr. Melzer's research is focused primarily on promoting smoking cessation for patients with chronic lung diseases and who are at high risk of lung cancer.

CHEST: It’s great to connect with you, Dr. Melzer. The topic of tobacco in the military is a critical piece of the puzzle of how tobacco use became so prevalent. How did you first get involved in tobacco prevention and cessation?

Dr. Melzer: My interest in tobacco control really grew out of my clinical work. Before medical school, I worked in a quality improvement department, which first got me interested in improving how we deliver care. During residency and fellowship, it was apparent to me that, for the most part, tobacco dependence treatment was quite poorly implemented.

Considering how many of the conditions we treat are due to smoking, we spend little time learning about treatments or addressing it in clinic. It’s a process that belongs to everybody and, therefore, sometimes to nobody.

One of my first research projects showed that most patients even who were hospitalized for COPD exacerbations received little or no tobacco treatments. So my interest really grew from those experiences, wanting to address the root of what is making so many of our patients sick.

CHEST: Tell me about tobacco use among individuals in the military—its history and the current state.

Dr. Melzer: Looking at the literature, tobacco use is still more prevalent among active-duty military than civilian populations, but it seems like the gap is closing. For example, data from the Army from 2020 showed that 27% of soldiers use tobacco products, 9% of which is vaping. That is still higher than the civilian population where about 19% of adults use any tobacco product and about 15% smoke.

The good news is that the use is going down. In 2005, over 30% of military personnel smoked compared to 21% of the general population. Both the military and the US Department of Veterans Affairs (VA) have enacted more tobacco control policies, but—like in the civilian world—there is still a ways to go. Smoking was banned during basic training over 30 years ago, with an indoor military smoking ban in 1994, and all VA campuses went smoke-free 4 years ago.

CHEST: What are some of the unique challenges when it comes to tobacco use and cessation within the veteran population?

Dr. Melzer: In my experience, many of our veterans have barriers to quitting smoking, including mental health diagnoses, [posttraumatic stress disorder], and, oftentimes, social and workplace activities that include tobacco use. Most are also fairly heavily addicted to nicotine and require more intensive treatment with medications and counseling to quit successfully. This can make it harder to engage them in making a supported quit attempt and puts a greater burden on the health system to ensure they have access to really high-quality treatment that is integrated with their mental health care.

CHEST: In your work with military individuals, are there factors other than tobacco use affecting the respiratory system?

Dr. Melzer: Absolutely, and I think the recent passage of the PACT Act really highlights this. I see many older veterans, usually with established tobacco-related lung diseases, and also younger veterans who are concerned about deployment-related exposures such as burn pits, jet fuel, and sandstorms that may have impacted their respiratory health.

The full impact of some of these exposures is unknown, but it’s a very active area of research. It’s important for all pulmonologists to know about the exposures and the legislation so they can steer veterans in the right direction for treatment.

CHEST: In your experience working with the VA, which approaches to tobacco cessation have been more successful and which have been less successful?

Dr. Melzer: The biggest feedback I hear from my patients and the clinicians I’ve spoken to is that patients really need a personalized approach to tobacco dependence treatment. They need options that fit their lives and for clinicians not to lecture them but to really ask them what is stopping them from quitting and what we can do to help.

Any progress is good progress. If someone can’t quit due to stress or mental health concerns, address those first. It’s fine to make cutting down the first goal. Most patients want to quit and have tried to quit before. It’s our job, particularly as pulmonologists, to explore how we can turn “I want to quit someday” into “Let’s work on making changes now.”

Autonomy is very important to my patients. I make sure they know they have a choice. I then directly connect them to the appropriate cessation program and start medications right away if they agree. That direct connection is absolutely key, as is providing help right away. Delays and laying the onus on the patient to call in for help are clearly less effective. I would encourage any clinician to seek training in motivational interviewing if they don’t feel confident in those skills.

I have not had much success with any “low-touch” cessation services, like brief advice, low-dose nicotine replacement, or just handing out information. In my experience, our patients really need more support.

CHEST: What is usually the impetus behind a veteran seeking assistance in tobacco cessation? Is it typically a diagnosis?

Dr. Melzer: Everyone is different. At least in my clinic, it is rarely a diagnosis that prompts people to quit. We know that the motivation to quit changes sometimes day to day. While health is a key motivator, what gives people the final push to try to quit can be as simple as a comment from a family member, a birth, a new living space, symptoms, or just waking up “fed up” with using tobacco. This is one reason why it’s important to keep bringing it up and let patients reflect on their own reasons to quit, not to expect them to always engage on our terms.

CHEST: What are the struggles of the veteran community when it comes to lung cancer screening?

Dr. Melzer: The VA has some particular challenges for implementing lung cancer screening, mainly the very large number of patients who meet the eligibility criteria. But I also think there are some benefits in the VA over the private sector.

I practice in the most rural region of the VA. We work to bring the same high standard of care to a huge geographic area with a large rural population, which is a challenge. Our veterans have high rates of mental health and medical comorbidities as well as financial barriers around transportation that can make it difficult for them to participate. However, as an integrated health care system, I have access to some robust options to track patients, share records, utilize telehealth, and rapidly implement updates as guidelines change. Our site has been able to adopt a more centralized approach that has led to some pretty great outcomes so far.

CHEST: How can your fellow clinicians’ support improve lung cancer screening and smoking cessation?

Dr. Melzer: I think the importance of a champion cannot be overstated. Every successful screening program I’ve spoken to starts with that strong advocacy. A cross-disciplinary approach is also important. We are required to have a multidisciplinary steering committee—we actually just met last week—that represents the key involved disciplines. That has been hugely helpful in navigating any issues that inevitably come up and helping to make our process as standardized and efficient as possible across departments.

CHEST: What resources are available to veterans that they/their doctors may not be aware of?

Dr. Melzer: Locally, we do a lot of tobacco treatment through our pharmacist clinics, and I believe this is an option in many medical centers. They are a truly great resource and utilize some evidence-based treatment strategies that clinicians who don’t treat tobacco use very often might not be aware of, like pre-quit or extended treatment with varenicline. We can also do warm hand-offs to the national VA quitline, which is great for offering counseling to patients who need help off-hours, as they are open later in the evening.

CHEST: Are there any resources you recommend for your fellow clinicians to aid their patients?

Dr. Melzer: There are a lot of really great resources. I like to say that there is something for any patient. Smokefree.gov is a great website that has tools for really everyone, clinicians and patients, including text programs, apps, quitlines, and clinician-facing information. I would encourage every clinician to familiarize themselves with what quit support options are available to them locally and set up streamlined processes, like e-referral, to make them easier to access.

In terms of educational options, there are a number of longer courses available for clinicians who want more in-depth training in tobacco treatment or behavior change. For those who want a bite-sized way to brush up on tobacco treatment, I’m putting in a plug for a series of podcasts called, “Tobacco Unfiltered: Conversations with Clinicians.” It was created by the VA national tobacco office to provide focused topic reviews for frontline clinicians who want to update their skills. It’s available for free online.