A Tobacco-Free Medical Campus Policy is Associated With Decreased Secondhand Smoke Exposure and Increased Satisfaction Among Military Medical Employees: Results of a Mixed-Methods Evaluation.

INTRODUCTION: Tobacco control is an ongoing concern for the U.S. Army. Although tobacco use is currently prohibited within all military hospitals and clinics, known as military treatment facilities (MTFs), no such facility had implemented a tobacco-free medical campus (TFMC) policy before 2012. This evaluation examined the effects of one Army installation's TFMC policy implementation at its medical facilities. MATERIALS AND METHODS: Online questionnaires were distributed to medical campus employees, including Active Duty Soldiers, civilians, and contractors, before policy implementation (N = 1,210) and 12 months following policy implementation (N = 1,147). Chi-square analyses, independent t tests, and logistic regression models were utilized to examine pretest/post-test changes in employees' secondhand smoke (SHS) exposure; tobacco use, motivation to quit, and cessation; and health outcomes. Twenty-three focus groups, interviews, and informal discussions with 65 employees and patients were conducted 13 months after initial policy implementation to capture both the intended and unintended policy effects. RESULTS: After controlling for demographic characteristics, the study found that employees had more than twice the odds of exposure to SHS in the workplace at baseline than at 12-month follow-up (odds ratio: 2.06, 95% confidence interval: 1.73-2.46, p < 0.001). Employees also reported a lower prevalence of diagnosis with chronic bronchitis (p < 0.05) at follow up compared to baseline. Although the mean number of sick days taken for respiratory illness decreased over time, results were not significant after controlling for demographic factors. No significant differences existed in tobacco-use prevalence or quit rates among tobacco users over time. Employees reported significantly higher levels of satisfaction with a TFMC policy than the original policy (p < 0.001) though this finding was moderated by smoker status such that smokers reported lower levels of satisfaction with the policy over time. Qualitative findings revealed that the most common policy effect was that the policy caused smokers to change the location of where they used tobacco to off campus. Findings further revealed several unintended policy effects, including safety concerns and greater visibility of smokers in front of the MTF. CONCLUSION: The first Army MTF TFMC policy was associated with reported reductions in SHS exposure and improvements in some short-term health outcomes. The policy had no observed association with tobacco-use prevalence, motivation to quit, or cessation at 12-month follow-up. Focus group participants discussed several positive and negative policy effects. These policies should be expanded and studied in more depth across military installations, and policy makers should plan mitigation strategies to reduce unintended effects. This is an important step in military tobacco control, but additional efforts will be necessary to curb tobacco use within this population.

The importance of leadership in Soldiers' nutritional behaviors: results from the Soldier Fueling Initiative program evaluation.

INTRODUCTION: Improving Soldiers' nutritional habits continues to be a concern of the US Army, especially amidst increasing obesity and high injury rates. This study examines leadership influence on nutritional behaviors within the context of the Soldier Fueling Initiative, a program providing nutrition education and improved dining facility menus to Soldiers in Basic Combat Training (BCT) and Advanced Individual Training (AIT). METHODS: A mixed methods design using surveys (N=486) and focus groups (N=112) was used to collect data at Fort Jackson, SC, and Fort Eustis, VA, in 2011. RESULTS: Survey results showed 75% of Soldiers in BCT believed their drill sergeant was helpful in making performance-enhancing food choices, and 86% agreed their drill sergeant believed it is important to eat for performance. Soldiers in AIT perceived their cadre as less helpful than their BCT drill sergeants and agreed less frequently that the AIT cadre believed it was important to eat for performance (P<.05). These measures of leader influence were significantly associated with nutritional attitudes and behaviors in both BCT and AIT. Focus groups revealed 5 key themes related to cadre influence and nutrition behavior (listed in order of most to least frequent): (1) cadre influence food choices through consequences related to selection, (2) cadre teach Soldiers how to eat, (3) cadre rush Soldiers to eat quickly to return to training, (4) cadre influence choice through example but often do not make healthy choices, and (5) cadre have no influence on food choices. COMMENT: Leaders influence most Soldiers' nutrition practices within the training environment, particularly within BCT. Given that leader influence can impact Soldiers' attitudes and behaviors, it is critical that military leaders become knowledgeable about optimal nutrition practices to disseminate appropriate information to their Soldiers, avoid reprimand associated with trainees' food choices, reinforce key messages associated with nutrition programming, and lead by example in their own food choices.