Prevalence of Adverse Behaviors among Young Military Conscripts in Taiwan
Prevalence of Adverse Behaviors among Young Military Conscripts in Taiwan
Guarantor: Nain-Feng Chu 2
Contributors: Nain-Feng Chu 0 2 3
Der-Min Wu 2
Muh-Han Shen 2
Yaoh-Shiang Lin 1 2
0 Department of Community Medicine, Tri-Service General Hospital , National De-
1 Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hosmore than one cigarette per day during the past 30 days and had
2 All participants completed a structured questionnaire that included questions about sociodemographic features, lifestyle, and the adverse behaviors of cigarette smoking, alcohol consumption and betel nut chewing. Sociodemographic characteristics included age , education levels, residential area, and type
3 Department of Public Health, National Defense Medical Center , Taipei , Taiwan
Objectives: To evaluate cigarette smoking prevalence and to examine the clustering of adverse behaviors among young military conscripts in Taiwan. Methods: Cross-sectional screening was conducted among conscripts in southern and eastern sections of Taiwan from August 1 to December 31, 2001. A total of 7,931 conscripts who had 1 month of service were included in this multistage sampling study. Results: Adjusted prevalence rates of cigarette smoking before and during military service were 49.2% and 51.9%, respectively. The prevalence of smoking slightly increased during military service, and this was statistically significant. Adjusted prevalence was highest in the Navy (53.8%) and lowest in the Air Force (48.4%). Less education and longer duration of service were associated with increased prevalence of smoking. Conscripts with high school educations or below and those in service 18 months had higher adjusted prevalence rates (65.6% and 55.2%, respectively). During military service, the adjusted prevalence rates of smoking among conscripts were similar in different geographic areas. There was significant aggregation of adverse behaviors, such as cigarette smoking, alcohol consumption, and betel nut chewing, among these young military conscripts in Taiwan. Conclusions: The prevalence of cigarette smoking was slightly increased during military service. Furthermore, the prevalence of cigarette smoking was still higher among military conscripts, compared with the general population in Taiwan, which suggests that military service is a potential factor associated with cigarette smoking for adolescents and young adults. This finding and the aggregation of adverse behaviors among conscripts indicate that more surveillance and intervention studies are needed to evaluate the best way to control and to stop smoking among military conscripts in Taiwan.
igarette smoking is an important cause of morbidity and
C death in many chronic diseases, such as cardiovascular
disease, cancer, and chronic obstructive pulmonary disease.1–5
Cigarette smoking is the most preventable cause of death in the
could be attributed to cigarette smoking; furthermore, cigarette
smoking caused 21.3% and 2.9% of all cases of cancer among
Taiwanese men and women, respectively.14
Although one study found that smoking prevalence rates
among military conscripts and general populations were
similar,15 several other studies found that cigarette smoking
prevalence was relatively higher among military employees than in
the general population in many countries.16–24 Possible
explanations include greater exposure to tobacco products and
advertising, peer pressure, stress, boredom, inexpensive
cigarettes, and lack of other forms of recreation during military
Not only does assessment of cigarette smoking prevalence
and adverse behavior aggregation depict the total burden of
these conditions, but also these activities are useful in
formulating effective prevention strategies. The purpose of this study
was to evaluate cigarette smoking prevalence and to examine
adverse behavior (such as cigarette smoking, alcohol
consumption, and betel nut chewing) cluster prevalence among
conscripts during their military service in Taiwan.
A cross-sectional screening was conducted among conscripts
in the southern and eastern sections of Taiwan from August 1 to
December 31, 2001. A total of 7,931 conscripts with 1 month
of service were included in this multistage sampling frame.
First, a random sample of roster units in each area was obtained
and then all conscripts, except those on active duty or on
holiday during the time of the survey, were included in the sample.
The prevalence of cigarette smoking, betel nut chewing, alcohol
consumption, and other related risk factors was evaluated. The
ethics committee of the Scientific Institute of the National
Defense Medical Center approved this study, and informed consent
was obtained from the participants.
In Taiwan, the prevalence of cigarette smoking has increased
and become an important public health and medical care
problem.11 Morbidity and mortality rates for lung cancer have
increased since the 1960s, and respiratory malignancies are the
main cause of cancer deaths in Taiwan.12,13 A prospective study
showed that 13.9% of all deaths for men and 3.3% for women
than two drinks per week of liquor (or equal alcohol
concentration) during the previous 30 days (the designation was based on
alcohol concentration classification) or if they still had the habit
of drinking alcohol before or during military service.27 Subjects
were considered current betel nut chewers if they had chewed
more than one betel nut during the past 30 days, had chewed
more than one betel nut per week, and had chewed more than
50 betel nuts in their lifetimes before or during military
Means and SDs were used to describe the distributions of
continuous variables such as age. Frequencies and percentages
were used to describe categorical parameters such as type and
duration of military service, education level, residential area,
cigarette smoking, alcohol consumption, and betel nut chewing
The direct standard method was used to calculate adjusted
cigarette smoking prevalence before and during military
service.28 Total military conscripts in Taiwan served as the
reference population, and results were adjusted for type of military
service, duration of military service, education level, and
residential area, to determine the standardized prevalence of
cigarette smoking among different subgroups. Smoking status
changes were also calculated before and during service, with
respect to those who had never smoked, those who quit
smoking, and those who were current smokers.
McNemar 2 tests compared differences in cigarette smoking
prevalence before or during military service, and 2 tests
compared differences in cigarette smoking prevalence among
different age, education level, residential area, time served in the
military, and lifestyle subgroups. Logistic regression analyses
calculated adverse behavior clustering of cigarette smoking,
alcohol consumption, and betel nut chewing, to evaluate possible
aggregation among these behaviors. A two-tailed p value of
0.05 was considered significant. All statistical analyses were
conducted with the SAS statistical package (SAS Institute, Cary,
General characteristics of study subjects are presented in
Table I. Conscripts were in the Army (65.5%), Air Force (15.1%),
Navy (10.5%), or Marines (8.9%). Approximately 75.7% had an
education level of high school or less, and 24.3% had some
college education or higher. Most resided in southern Taiwan.
Among study subjects, 18.3% had been recruited for 6
months, whereas 27.9% had been in service for 7 to 12 months,
25.8% for 13 to 18 months, and 28.0% for 18 months.
Prevalence rates of betel nut chewing and alcohol consumption were
19.8% and 13.5%, respectively.
Table II shows crude and adjusted prevalence rates of
cigarette smoking before and during military service. Overall,
adjusted prevalence rates of smoking before and during military
service were 49.2% and 51.9%, respectively. The prevalence was
slightly increased after entry into military service, and this
difference was statistically significant. The type and duration of
military service were associated with smoking status. The Navy
had the highest prevalence of current smoking (53.8%) and the
GENERAL CHARACTERISTICS OF STUDY SUBJECTS
Air Force had the lowest (48.4%). With regard to duration of
service, the highest prevalence of current smoking occurred
among subjects who had been in service for 18 months. Before
and during military service, the prevalence of current smoking
was higher among subjects with a high school education or
below, compared with other subgroups. For example, the
prevalence of current smoking was 65.6% for this group, compared
with 26.5% for subjects with some college or higher education,
during military service. No statistically significant differences in
smoking status before recruitment and during service were
found with respect to residential location. Changes in smoking
status before and during military service are presented in Table
III. Approximately 99.0% of subjects who were designated as
current smokers before service continued to smoke during
service, and 93.1% of subjects who had not smoked before service
remained nonsmokers during service. Only 6.9% changed their
behavior from nonsmoking to currently smoking after
recruitment, and only 1.0% quit smoking after entering military
Table IV presents the clustering of adverse behaviors
(cigarette smoking, alcohol consumption, and betel nut chewing)
among conscripts. During service, there were 5,027 conscripts
who did not have the habits of betel nut chewing and alcohol
drinking; among them, 38.9% were defined as current smokers.
More interestingly, for those with two-risk habit conscripts,
96.3% of the conscripts defined as current smokers had the
a Behavior categories: I, one risk habit; II, two risk habits; III, three risk habits.
b , risk habit present; , risk habit absent.
habit of betel nut chewing only, and 68.2% of current smokers
had the habit of alcohol drinking only. Furthermore, of 533
conscripts with the habits of both betel nut chewing and alcohol
drinking, 95.1% engaged in all three adverse behaviors. Among
study conscripts, those with betel nut chewing had the highest
odds ratio for cigarette smoking (odds ratio, 40.8; 95%
confidence interval, 27.8 – 61.5). Subjects with the habits of betel nut
chewing and alcohol drinking also had a relatively higher odds
ratio for cigarette smoking, compared with those without these
adverse behaviors (odds ratio, 30.6; 95% confidence interval,
21.0 – 46.7).
This is the first study in Taiwan to evaluate the prevalence of
cigarette smoking in such a large group of military conscripts. In
this cross-sectional study, the adjusted prevalence of cigarette
smoking was higher among military conscripts than in the
general population and also was higher among Taiwan conscripts
than among conscripts in other countries. Prevalence slightly
increased during service and was still higher than in the general
population. This suggests that military service is a risk factor for
smoking among conscripts. Cigarette smoking prevalence
significantly differed with respect to the branch of military service,
education level, and duration of service. Highest smoking
prevalence rates occurred in the Navy, at a lower education level,
and among those who had served 18 months. Variations in
environmental factors, such as smoking restrictions, working
conditions, and management policies, might account for
differences among service branches. Subjects with less education
might have been exposed to working conditions and
socialization processes more conducive to smoking than were others
with more education.
In this study, adjusted smoking prevalence rates were 49.2%
and 51.9% before and during military service, respectively. This
indicates that smoking is prevalent in military service. Similar
observations were made in the United States (in 1980) and
Norway (in 1986),29,30 but prevalence was higher than among
U.S. military personnel in 1998 (29.9%).24 Reasons for the high
prevalence of cigarette smoking in the military include greater
exposure to tobacco, peer pressure, stress, boredom,
inexpensive cigarettes, and lack of other recreations during military
service.19,25 The prevalence of cigarette smoking was also
relatively higher during military service (51.9%), which suggests
that the higher prevalence persists from behavior established at
an earlier age. These results are similar to our previous study of
young military conscripts in central Taiwan in 1995.31
Furthermore, other studies determined that the prevalence of cigarette
smoking has a range of 22 to 30% among male adolescents and
young adults.32–35 There seemed to be a skewed peak in the plot
of prevalence of cigarette smoking during the military service
age period. However, most of those studies of cigarette smoking
prevalence focused on students or young adults and did not
include those in military service. Therefore, further studies to
evaluate the prevalence of cigarette smoking in Taiwan before
and during service are needed. The aim of such research is to
provide a better understanding of factors that affect decisions
regarding whether or not to smoke and thereby to help
formulate policies successful in reducing and preventing this
With respect to smoking status, of those who were smokers
before military service, 99.0% continued to smoke after
military service. These results are consistent with previous studies
demonstrating that rates of behavior change for smoking
cessation are relatively low among adolescents and young adults.36
Approximately 96.3% and 68.2% of smokers experienced
aggregated adverse behaviors including betel nut chewing and
alcohol consumption, respectively. Moreover, the odds ratios for
cigarette smoking were 40.4 for those who chewed betel nuts
and 3.4 for those who consumed alcohol, compared with
conscripts without these adverse behaviors. Betel nut chewing was
more frequently clustered with smoking than with alcohol
consumption. This finding was consistent with previous studies.
Our results also indicate that adverse behavior clustering exists
before and during military service. It has been recognized that
cigarette smoking is associated with other adverse behaviors
and the effects tend to be additive. Therefore, assessment of
adverse behavior clustering is crucial for identification of
There are limitations in this study. First, most study subjects
were from the southern and eastern parts of Taiwan;
consequently, the northern and western regions are not as well
represented. Second, measurement errors and misclassifications
can occur when a structured questionnaire is used. We think
that such errors and misclassifications would likely be minimal
and random and would only attenuate our results.
In summary, a relatively high prevalence of cigarette smoking
was found among young military conscripts in Taiwan.
Significant clustering of adverse behaviors, especially smoking and
betel nut chewing, existed among conscripts. This study
underscores the need to identify individuals at high risk for cigarette
smoking and to develop population-based, multifactorial
interventions that prevent and reduce smoking and associated
adverse behaviors in the future.
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