Prevalence of Adverse Behaviors among Young Military Conscripts in Taiwan

Military Medicine, Apr 2006

Chu, Nain-Feng, Wu, Der-Min, Shen, Muh-Han, Lin, Yaoh-Shiang

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Prevalence of Adverse Behaviors among Young Military Conscripts in Taiwan

MILITARY MEDICINE 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. Introduction 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 world.6–10 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 service.19,25 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. Methods Study Sample 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 service.27 Statistical Analyses 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 status. 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, North Carolina). Results 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 Military Conscripts (n 7,931) 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 service. 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). Discussion 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 behavior. 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 highrisk populations.37,38 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. 1. Wen CP , Tsai SP , Yen DD : The impact of cigarette smoking in Taiwan . AsianPacific J Public Health 1994 ; 7 : 206 - 13 . 2. Peto R , Lopez AD , Boreham J , Thun M , Health C , Doll R : Mortality from smoking worldwide . Br Med Bull 1996 ; 52 : 12 - 21 . 3. Levesque B , Rochette L , Gingras S : Mortality attributable to tobacco smoking in Quebec . Can J Public Health 1998 ; 89 : 28 - 32 . 4. 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Chu, Nain-Feng, Wu, Der-Min, Shen, Muh-Han, Lin, Yaoh-Shiang. Prevalence of Adverse Behaviors among Young Military Conscripts in Taiwan, Military Medicine, 2006, 301-305, DOI: 10.7205/MILMED.171.4.301