Developing evidence-based clinical guidelines for military use: case study of smoking cessation guidelines.

OBJECTIVE: To develop evidence-based clinical guidelines on smoking cessation, for use throughout the British military. METHOD: A ten-member, multiprofessional smoking cessation working group met five times between October 2000 and July 2001 to develop targeted smoking cessation guidelines for use by military health professionals in the clinical setting. The guidelines were based on the best available scientific evidence at that time, mainly systematic review of controlled trials, and individual randomised trials. RESULTS: The agreed military guidelines on smoking cessation were promulgated in July 2001. Three tiers of support were defined. Military health professionals have a key role as nonsmoking models and advocates, and should be trained to use 'brief intervention' at every clinical encounter with a military smoker. 'Intermediate support' (defined as a specialist service delivered by military health professionals who have undergone specific training and continuation training) is to be available at local level. The most heavily addicted military smokers will require referral to civilian smoking cessation clinics. Effective technologies for use at any one of the three levels of care are: nicotine skin patches, nicotine gum, nicotine lozenges and bupropion. CONCLUSIONS: These are the first ever clinical guidelines for military use which meet accepted modern quality criteria. Informal monitoring of the uptake of these guidelines between July 2001 to December 2001 suggests that they have been well received by military health professionals. An audit of their impact on smoking patterns within the UK Armed Forces will commence in 2002. The guidelines will be updated 5-yearly, or sooner.

Does military service damage females? An analysis of medical discharge data in the British armed forces.

There is anecdotal and some scientific evidence that females in military service experience an excess of work-related injuries, compared with males. To investigate this more fully, we analysed data collected routinely by the Defence Analytical Services Agency on medical discharges in male and female personnel in the British armed forces. We found that for all disease and injury categories of medical discharge there is a statistically significant excess in females; this disparity is particularly marked for discharges on account of injury [relative risk (RR) = 1.65, 95% confidence interval (95% CI) = 1.30-2.10] and musculoskeletal disease (RR = 3.34, 95% CI = 2.75-4.06). Royal Navy females are eight times more likely (RR = 7.92, 95% CI = 3.03-20.66) and Army females seven times more likely (RR = 6.53, 95% CI = 2.60-16.42) than Royal Air Force females to be medically discharged on account of injury. Over the period 1993-1996, there was a statistically significant increase in the rate of medical discharge for both musculoskeletal disease and injury in female personnel in the British armed forces. During the period 1996-2000, a marked gender differential was maintained, but the rate of increase in females reached a plateau. We concur with previous investigators that mixed-sex training imposes particular ergonomic stresses on females and that it is a major risk factor for overuse injury. We discuss other possible explanations for the marked gender differential in medical discharge rates in the military. Some changes to training programmes are now being introduced to correct this health inequality, but further interventions are needed. Modifications to training programmes must be audited systematically and candidate interventions tested through randomized controlled trials.

The malaria threat.

The British experience of the past two decades indicates that fixed-schedule chemoprophylaxis is difficult because of the variety of epidemiological situations and increasing incidence of drug resistance. Of the 110 cases of malaria contracted in Kenya between 1982 and 1996, 74% were due to Plasmodium falciparum. Of the 45 malaria infections contracted in Belize, 84% were due to Plasmodium vivax. In 1985 the fixed drug combination of chloroquine base 300 mg weekly plus proguanil 200 mg daily was adopted as standard chemoprophylaxis for use in all parts of the world where chemoresistant Plasmodium falciparum had been observed. Mefloquine was recommended as first-line prophylaxis in Papua New Guinea in 1986 and in East Africa in 1993. Doxycycline hyclate was prescribed in September 1999 when a Gurkha company was deployed on peacekeeping duties to East Timor, but its effectiveness has not yet been evaluated. Chemoprophylaxis must be combined with non-drug antimalaria technologies, especially insecticide-treated bed nets.