Attitudes to smoking on submarines: Results of a questionnaire study

Norris, William D

An anonymous survey to assess the attitudes to smoking of men serving on two Trident Nuclear submarines was conducted by questionnaire. A total of 244 questionnaires were completed, representing 87% of the two crews. Thirty-two percent of respondents declared themselves to be smokers, 69% were nonsmokers, and of these, 31% were ex-smokers. Attitudes of all respondents to an enforced ban of smoking on submarines indicated that 55% felt that it would be justifiable, 46% felt that it would be unfair, 42% felt that it was uncalled for, 46% thought that it would be illegal, and 47% thought that a ban was about time. The separate opinions of smokers and nonsmokers were polarized, whereas the overall results indicate indifferent attitudes of crew members. Further research into the atmospheric effects of environmental tobacco smoke on a submarine is required.

Introduction

Smoking in the work place has been the focus of much medical and legal discussion during the past 20 years. Changes in attitudes to smoking and a greater awareness of the health risks associated with environmental tobacco smoke (ETS) have caused many authorities and employers to ban smoking from the work place.1 Recent legislation has placed the onus on the employer to provide a smoke-free environment for employees; in fact, employers may be subject to prosecution if they do not do so.2 In the past, smoking in the United Kingdom's armed forces may have been facilitated to a certain degree by the availability of duty-free cigarettes and tobacco. The practice of providing duty-free cigarettes and tobacco continues on Her Majesty's ships and submarines today.

Nuclear submarines, like any other submarine that remains submerged for long periods of time, constitute a completely isolated atmosphere when at sea on patrol. Therefore, the ventilation and air purification systems must be capable of producing oxygen, removing carbon dioxide and other gaseous contaminants such as hydrogen and carbon monoxide, and removing odors and particulate contaminants.

Given that a submarine may be required to remain submerged for up to 12 weeks with no access to the atmosphere, stringent restrictions are applied to substances that can be used on board. This is to prevent contamination of the submarine's atmosphere beyond predetermined limits, which would pose a health threat to personnel on board. Therefore, any material on board with toxicological or odorous characteristics has been assigned a maximum permissible concentration that must not be exceeded during a patrol.3 Should this concentration be exceeded, the submarine is required to ventilate to the atmosphere. If this occurred during a patrol, the submarine's requirement to remain undetected, and consequently the patrol aim, may be compromised.

Tobacco smoke has long been regarded as an acceptable contaminant on submerged submarines. The authors, as medical officers on submarines, became aware of increasing concern from crew members regarding the potential health effects to nonsmoking submariners. Nevertheless, there is currently no published evidence on the level of ETS contamination of the submarine atmosphere and whether this poses a threat to the health of nonsmoking submariners on board.

Smoking is restricted to certain areas on submarines at the commanding officer's discretion. This is an attempt to minimize the direct exposure of nonsmokers to ETS. These areas usually consist of one compartment forward and one aft of the reactor compartment. Smoking is not allowed in any accommodation or communal areas. However, because of the constricted space, it is not possible to provide a dedicated smoking area; therefore, all compartments in which smoking is permitted will be manned for varying amounts of time during the day by smokers and nonsmokers.

Cigarette smoke is a source of thousands of contaminants; some studies estimate the number to be up to 100,000, and currently, 3,000 to 4,000 have been identified.4 Carbon monoxide, particulates (such as tar, polyaromatic hydrocarbons, and nicotine), and volatile organic compounds (such as benzene, toluene, and formaldehyde) are considered to be the most important contaminants with respect to health as a result of their known carcinogenic properties. In addition their presence may increase the requirement to purify the submarine atmosphere.5

Although the risks of smoking to health are well documented, the evidence for health risks as a result of ETS exposure, although growing, has not been fully evaluated. Wahlgren et al. cite involuntary smoking as the third leading cause of death in the general populations and Dockery and Trichopoulos identify tobacco smoke as an environmental carcinogen.7 Recent studies have documented an increased risk of developing lung cancer as a result of ETS exposure,8,9 and one study puts the risk at as much as a 25% increase over that of matched controls after exposure to ETS at work.

There are additional reports of increased incidence of ischemic heart disease and stroke in association with ETS exposure, 11,12 and a recent study suggested a link with neoplastic and chronic nonneoplastic nasal and sinus diseases." There is also strong evidence of a correlation with sudden infant death syndrome, with one study finding that having a mother who smoked doubled the risk of sudden infant death. 14 Other studies have found that with increased exposure to passive smoking at work, there are increased absences from the work place, doctor consultations, and use of certain medications.15 More comprehensive studies are required to fully elucidate the effect of passive smoking on health.

This study was designed to elucidate the attitude of submariners to current smoking practices while submerged at sea.

Methods

Members of two Trident Nuclear Vanguard-class submarine crews (approximately 140 men each) were asked to complete an anonymous questionnaire regarding their attitudes to smoking on board.

The questionnaire sought to determine the age, length of service in the Royal Navy and in the submarine service, whether the respondent was a current or ex-smoker, how long they had smoked, and whether their partner smoked.

Respondents were asked whether they thought that submarines should be nonsmoking, whether they were concerned about passive smoking on board, whether having restricted areas for smoking was unfair to smokers, and whether having smoking restricted to specific areas protected the interests of nonsmokers.

They were further asked to state whether they felt that a ban on smoking would be justifiable, unfair, uncalled for, illegal, or about time. Opportunity was provided for them to make further comments of their own. There was no introductory preface to the questionnaire with regard to current submarine smoking policy or the known health effects of smoking. After the initial demographic inquiries, respondents were invited to circle "yes" or .no" after the stem questions, as indicated in Table 111. A copy of this questionnaire is available on request.

Demographic data are displayed as years with SD values in parentheses. Percentages shown are on known responses only (missing values were excluded); the actual number of responders is given in parentheses after the percentage.

Results

A total of 244 questionnaires were analyzed; this represents 87% of the two crews combined. The average age, length of service in the Royal Navy, and length of service in submarines were 31 (7) years, 13 (7) years, and 10 (7) years, respectively (Table 1). Thirty-eight percent of crew members had never smoked, 31% were current smokers, and 31% declared themselves ex-smokers. With regard to smokers, the average length of time of smoking was 13 (6) years. Of those who had given up smoking, the average length of time since giving up smoking was 6 (6) years.

A total of 94% of the smokers bought duty-free tobacco on board. Fourteen percent of nonsmokers had partners who smoked, and 48% of smokers had partners who smoked. To analyze the responses to questions regarding smoking on board and a proposal to ban smoking on board, respondents were divided into smokers and nonsmokers.

Smokers

Six percent (5) thought that submarines should be nonsmoking, 19% (15) thought that allowing smoking in restricted areas only was unfair, and 79% (61) thought that allowing smoking in restricted areas protected the interests of nonsmokers.

In response to whether they objected to other people smoking in their company, 84% (62) answered no, 16% (11) answered sometimes, 0% (0) answered most of the time, and 0% (0) answered all of the time.

In response to whether they were concerned about passive smoking on board, 70% (54) answered not at all, 21% (16) answered a little, 6% (5) answered quite a bit, and 1% (1) answered a lot.

A total of 74% (57) thought that a ban on smoking in submarines would be unfair, 12% (9) thought that a ban would be justifiable, 78% (60) thought that a ban would be uncalled for, 77% (59) thought that a ban would be illegal, and 6% (5) thought that a ban would be about time (Table II).

Nonsmokers

Seventy-three percent (118) thought that submarines should be nonsmoking, 3% (5) thought that allowing smoking in restricted areas only was unfair, and 51% (83) thought that allowing smoking in restricted areas protected the interests of nonsmokers.

In response to whether they objected to other people smoking in their company, 12% (20) answered no, 49% (79) answered sometimes, 20% (33) answered most of the time, and 20% (33) answered all of the time.

In response to whether they were concerned about passive smoking on board, 7% (11) answered not at all, 41% (66) answered a little, 24% (39) answered quite a bit, and 28% (45) answered a lot.

A total of 32% (61) thought that a ban on smoking in submarines would be unfair, 75% (122) thought that a ban would be justifiable, 25% (41) thought that a ban would be uncalled for, 31% (51) thought that a ban would be illegal, and 66% (107) thought that a ban would be about time (Table III).

Discussion

This study assessed the views of a unique population: male, between 18 and 45 years old, and meeting the stringent medical criteria for service aboard submarines. Inevitably, this makes comparison with other published data difficult. Nevertheless, the rate of smoking in this population of submariners is similar to that of the British population (31% vs. 29%).16

The views of smokers and nonsmokers as expressed on this questionnaire are diametrically opposed, and it is not surprising that smokers have a far lower concern for passive smoking or being in the company of other smokers. This is in contrast to the nonsmokers, who have a greater range of views in their concern over passive smoking and people smoking in their company. This may be indicative of submariners' tolerance of other crew members' personal preferences in this uniquely challenging environment. The nonsmoking group also included ex-smokers, who may be expected to have less strong views and concerns regarding passive smoking.

Although 79% of smokers stated that they felt smoking in restricted areas protected the interests of nonsmokers, this question may have been open to interpretation by nonsmokers. Individuals may feel that smoking in a separate area does protect their interests; however, others may feel that because the atmosphere is enclosed, any smoking is a threat to their health.

The overwhelming benefits of a cessation in smoking are widely accepted and acknowledged. 17 It is notable that only 741/16 of smokers felt that a ban on smoking would be unfair; this may indicate a recognition among smokers that passive smoking is deleterious to health, reflecting recent national health warning messages and counseling from medical officers during routine medical examinations.

Recent research has suggested that an advantage is conferred to smokers attempting to give up when counseling, follow-up, and nicotine replacement therapy, among other support, are offered in primary care.18.19 The use of a nicotine inhaler has been shown to enhance sustained long-term reduction in smoking, with 6.5% more of a treated group still not smoking at 2 years over matched controls.21 Counseling and encouragement to give up smoking form part of the consultation agenda when service members have routine medical examinations, and this is endorsed in the joint services publication dealing with these issues.21 The rate of quitting smoking in the general population of men aged 35 to 54 years has doubled in the last 50 years.17 Yet, although both authors of this report actively counsel smokers to quit, the success of this in the submarine environment has yet to be determined.

The provision of duty-free tobacco is inconsistent with promoting a nonsmoking policy among service personnel, with 94% of smokers indicating that they take advantage of the duty-free facility. Arguably, this does little to discourage smokers; furthermore, this is now particularly incongruous because increasing the cost of cigarettes has been shown to increase the number of smokers who quit.22 Recently, nicotine replacement products, which are the most effective treatment available to help smokers quit, have been made available through service channels by prescription. Bupropion (an atypical antidepressant that shows promise in helping smokers to quit23) has also been made available by prescription to service personnel.

Despite the apparent risks of ETS exposure, it could be argued that if the atmosphere purification equipment removes some of the contaminants of smoking, the risks to a ship's company may reduced. However, there is no evidence to support this. Even if the efficiency of ETS reduction were established, it would be ethically extremely difficult to establish a maximum permissible concentration of any known carcinogen contained in ETS. In any case, it is inevitable that some personnel will be directly exposed to ETS in performing their duties in compartments in which smoking is permitted.

Despite the United Kingdom law protecting the rights of nonsmokers, the current policy of smoking only in restricted areas appears to be well tolerated on board, with low percentages of smokers and nonsmokers stating that they felt it unfair to smokers. By law, however, an employer has the responsibility to protect all employees with or without their agreement, and employees have a duty to cooperate with the introduction of new health and safety regulations.2 So far, this has not been enforced in the submarine fleet by imposing a ban on smoking.

The subject of banning smoking in submarines has proved controversial with submariners, and this article is the first to report the attitudes of an entire unit-based work force within the armed services. The decision in the year 2000 not to enforce a previously proposed Royal Navy submarine fleet-wide ban of smoking on board may reflect consideration of this controversy.

A common theme in the "further comments" section of the questionnaire was the issue of the rights of individuals. It is possible that because only 31% of nonsmokers felt a ban on smoking would be unfair and illegal, the nonsmoking group is respecting the preferences of smokers. This may also reflect the views of primarily the ex-smokers (31% of the group), who may be more understanding of the position of smokers.

Passive smoking on board a submarine is a potentially avoidable health risk. Arguably, the rights of nonsmokers should take precedence over those of smokers, because although a health risk exists from passive smoking, there is no recognized risk from not smoking. This assumes greater significance for those submariners who did not volunteer for service on submarines.

Our study has highlighted the current attitudes of Royal Navy submariners with regard to smoking while submerged at sea. It has shown that although there is a strong depth of feeling among smokers and nonsmokers on this matter, the overall results are polarized, with no one overwhelming opinion predominating. Consideration of the relative strengths of feeling should be taken into account, in addition to any legal issues and environmental evidence, in the establishment of a smoking policy on board, and this study is the first to provide such information.

Acknowledgments

The authors are grateful to the commanding officers of the submarines for allowing the survey to be carried out.

References

1. Doll 1- Uncovering the effects of smoking: historical perspective. Stat Methods 1998; 7: 87-117.

2. Kloss DM: Occupational Health Law, Ed 3, pp 216-7. Oxford, U.K., Blackwell Scientic, 1998.

3. Royal Navy Book of Reference 1326A. London, Ministry of Defence.

4. Guerin MR. Jenkins RA, Tomkins BA: The Chemistry of Environmental Tobacco Smoke: Composition and Measurement. Florida, Lewis Publishers, 1992.

5. Earwicker S, Downing C: Implications of a smoking ban for submarine air purification requirements. Gosport, Hants, U.K., Defence Evaluation Research Agency, Haslar, May 1998.

6. Wahlgren DR. Hovell MF, Meltzer EO, et al: Involuntary smoking and asthma. Curr Opin Pulm Med 2000; 6: 31-6.

7. Dockery DW, Trichopoulos D: Risk of lung cancer from environmental exposures to tobacco smoke. Cancer Causes Control 1997; 8: 333-45.

8. Zhong L, Goldberg MS, Parent ME, et al: Exposure to environmental tobacco smoke and the risk of lung cancer: a meta-analysis. Lung Cancer 2000; 27: 3-18. 9. Kreuzer M, Krauss M, Kreinbrock L, et al: Environmental tobacco smoke and lung

cancer: a case control study in Germany. Am J Epidemiol 2000: 151: 241-50. 10. Brown KG: Lung cancer and environmental tobacco smoke: occupational risk to nonsmokers. Environ Health Perspect 1999; 107: 885-90.

11. Smith CJ, Fischer TH, Sears SB: Environmental tobacco smoke, cardiovascular disease, and the nonlinear dose-response hypothesis. Toxicol Sci 2000; 54: 46272.

12. Bonita R, Duncan J, Truelsen T, et al: Passive smoking as well as active smoking increases the risk of acute stroke. Tob Control 1999; 8: 156-60.

13. Benninger MS: The impact of cigarette smoking and environmental tobacco smoke on nasal and sinus disease: a review of the literature. Am J Rhino] 1999; 13: 435-8.

14. Anderson HR, Cook DG: Passive smoking and sudden infant death syndrome: a review of the epidemiological evidence. Thorax 1997; 52: 1003-9.

15. McGhee SM, Adab P, Hedley Ad, et al: Passive smoking at work: the short term cost. J Epidemiol Community Health 2000; 54: 673-6.

16. Office for National Statistics, Social Survey Division: Living in Britain. Results from the 1996 General Household Survey. London, Her Majesties Stationary Office, 1998.

17. Peto R, et al: Smoking, smoking cessation and lung cancer in the UK since 1950: a combination of national statistics with two case control studies. Br Med J 2000; 321: 323-9.

18. Grandes G, Cortada JM, Arrazola A: An evidence-based programme for smoking cessation: effectiveness in routine general practice. Br J Gen Pract 2000; 50: 803-7.

19. Lang T, Nicaud V, Slama K, et al; Smoking cessation at the workplace: results of a randomized controlled intervention study. J Epidemiol Community Health 2000;54:349-54.

20. Bollinger CT, et al: Smoking reduction with oral nicotine inhalers: double blind randomized clinical trial of efficacy and safety. Br Med J 2000; 321: 329-33.

21. Joint Services Publication 375, Vol 3, Chapter 19. London, Ministry of Defence. 22. Cox HS, Williams JW de Courten MP, et al: Decreasing prevalence of cigarette smoking in the middle income country of Mauritius: questionnaire survey. Br Med J 2000: 321: 345-9.

23. Britton J, Jarvis MJ: Bupropion: a new treatment for smokers. Br Med J 2000; 321: 65-6.

Guarantor: Surgeon Lieutenant William D. Norris, Royal Navy

Contributors: Surgeon Lieutenant William D. Norris, Royal Navy; Surgeon Lieutenant Fraser J.H. Brims, Royal Navy

Royal Hospital Haslar, Gosport, Hampshire, P012 2AA United Kingdom.

The views expressed here are those of the authors and do not necessarily represent those of Her Majesty's Government.

This manuscript was received for review in July 2001. The revised manuscript was accepted for publication in January 2002.

Reprint & Copyright by Association of Military Surgeons of U.S., 2002.

Copyright Association of Military Surgeons of the United States Jul 2002
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