Letters to the Editor

Military Medicine, Feb 2007 by Brown, David W

To the Editor

I read with interest, the detailed article by Major Richard Malish [Milit Med 2006, 171 (3): 224227] describing his experiences of medical care with the 250th Forward Surgical Team (Airborne) during a military operation into Northern Iraq in 2003. We have used his informative article as a valuable planning tool for our own current operations in Southern Afghanistan.

As senior surgeon in the FST of 23 Air Assault Squadron (the successor to 23 Parachute Field Ambulance), I must take exception however at the following lines in the article: "The jump was historic because of the inclusion of the FST. The FST became the first such team to perform a combat jump since World War II." This is incorrect!

On 5 November 1956, an FST from 23 Parachute Field Ambulance jumped with the Third Battalion, The Parachute Regiment into El Gamil Airfield in Egypt as part of Operation Musketeer - The occupation of the Suez Canal Zone. Major (later Major-General) Norman Kirby was the senior surgeon. This event is vividly described in 'Airborne to Suez' by Sandy Cavanagh who as a lieutenant was the Regimental Medical Officer to 3 Para. He was himself wounded in the eye by shrapnel during the drop. The operation itself was a military success with all intended objectives being achieved. International political pressure later led to the force being withdrawn. Overall, 660 men took part in the drop.

Lt Col Paul J. Parker FIMC FRCSEd RAMC

To the Editor

I read with interest the data in Letters to the Editor, [Milit Med 2006, Vol 171 (6):v-vi] presented by DiNicola and colleagues regarding smoking behavior among enlisted military personnel during deployment and their call for opportunities to participate in effective smoking cessation programs. I would like to further this message by focusing on another important group, namely US veterans with coronary heart disease (CHD).

Quitting smoking is essential for patients with CHD. Current guidelines recommend that clinicians ask about tobacco use and provide counseling about quitting within the context of a comprehensive plan for secondary prevention. Nevertheless, smoking remains widespread among persons with CHD.

Using data from the 2005 Behavioral Risk Factor Surveillance System, a state-based surveillance system that collects data on U.S. adults (age ≥18 years), the prevalence of smoking was estimated for adult veterans with CHD. A description of the design and sampling procedures is available at www.cdc.gov/brfss. Veterans were identified by an affirmative response to the question, "Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?" Surveyed adults were asked, "Has a doctor, nurse, or other health professional ever told you that you had a heart attack, also called a myocardial infarction?" Those who responded affirmatively were considered to have CHD. Respondents who smoked 100 cigarettes in their lives and currently smoked were considered current smokers. Data were weighted to produce national estimates, and Stata (College Station, TX) was used to account for the complex sampling.

Approximately 13% of respondents were veterans (2000 Census estimate, 12.7% of civilians, age ≥18 years). After adjustment for age, an estimated 5% of veterans had CHD. The age-standardized prevalence of smoking among veterans with CHD was 51% (95% confidence interval [CI], 41%-61%) (20% is the figure for American adults generally). The prevalence of smoking was greater for men (55%; 95% CI, 45%-64%) than women (29%; 95% CI, 18C%) although there were few female veterans as evidenced by the wide confidence interval. The prevalence differed somewhat by race/ethnicity (white, non-Hispanic: 58%; 95% CI, 51%-65%; black, non-Hispanic: 36%; 95% CI, 25%-49%; other, non-Hispanic: 43%; 95% CI, 34%-52%; Hispanic: 36%; 95% CI, 25%-48%) or education (less than high school: 46%; 95% CI, 38%-54%; high school: 58%; 95% CI, 52%-63%; some college: 46%; 95% CI, 35%-57%; college graduate: 39%; 95% CI: 29%-50%). Of the 25% (95% CI, 23%-27%) of smokers with CHD who made a visit in 2005 to a health professional, 74% (95%, 70%-77%) were advised to quit smoking or had discussions about medications for quitting.

The well-known adverse effects of smoking and the documented benefits of quitting; notwithstanding, the prevalence of smoking among US veterans with CHD remains high. Available strategies include identifying and documenting smoking status in all patients, referral for consultation and counseling, prescription of appropriate drugs in accordance with clinical guidelines, and the provision of quit lines and community support services. In addition, increases in health plan coverage for smoking cessation and initiatives to promote cessation at the work site are needed, as is enforcement of smoke-free legislation in public places.

Ultimately, smokers must decide themselves that they need to quit smoking. Clinicians have a responsibility here to assist patients, and health plans need to cover treatment. Opportunities remain to develop more effective programs. I hope these findings and those of others will stimulate further efforts to design and implement cost-effective programs for cessation that reach all patients, including those with CHD.