LP762-L2 WEEK 7

© 2020 American Journal of Preventive Medicine. Publis reserved.

RESEARCH ARTICLE

From the 1Depar School of Dental University of Cre Addison, Texas

Address corre ment of Oral He Medicine, 188 Lo [email protected]

0749-3797/$3 https://doi.org

hed by Elsevier Inc. All rights

U.S. Military Veteran Versus Nonveteran Use of Licit

and Illicit Substances

Israel Agaku, DMD, MPH, PhD,1 Satomi Odani, MPH,2 Jantel R. Nelson, PsyD3

Introduction: To provide up-to-date substance use surveillance data among U.S. military veterans versus nonveterans, this study assesses current use of tobacco products, alcohol, marijuana, pre- scription pain relievers, tranquilizers, sedatives, stimulants, cocaine, heroin, methamphetamines, inhalants, and hallucinogens.

Methods: Pooled data were from the 2015−2017 National Survey on Drug Use and Health, a nationally representative, self-reported survey of the U.S. adult non-institutionalized population. Military veterans were those who had “ever been in the United States Armed Forces” and were “now separated/retired from reserves/active duty” (n=7,301). Nonveterans were those who had never been in the U.S. Armed forces (n=121,366). Age- and gender-stratified weighted prevalence estimates were calculated and compared with chi-square tests. All analyses were conducted in 2019.

Results: Illicit substance use, including marijuana and cocaine, was generally lower among veter- ans than nonveterans, whereas use of licit substances such as tobacco and alcohol was higher among veterans than nonveterans. The most commonly used substances among veterans were tobacco and alcohol. Among male participants aged 18−25 years, 59.8% of veterans reported past-12-month cig- arette/cigar smoking (vs 46.6% of nonveterans), whereas 17.6% reported heavy drinking (vs 12.2% of nonveterans). For both cigarette/cigar smoking and binge drinking, there was a marked narrow- ing of the male−female gap in prevalence with increasing age among veterans. Female veterans aged 18−25 years reported significantly higher opioid use than their nonveteran counterparts (54.7% vs 35.0%); they also had the highest prevalence of opioid misuse (15.3%) than any other group.

Conclusions: Intensified efforts are needed to reduce substance use among veterans and provide cessation and mental health services. Am J Prev Med 2020;59(5):733−741. © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

INTRODUCTION

tment of Oral Health Policy and Epidemiology, Harvard Medicine, Boston, Massachusetts; 2School of Medicine, te, Heraklion, Greece; and 3Great Life Counseling Center,

spondence to: Israel Agaku, DMD, MPH, PhD, Depart- alth Policy and Epidemiology, Harvard School of Dental ngwood Avenue, Boston MA 02125. E-mail: ard.edu. 6.00 /10.1016/j.amepre.2020.04.027

S ince the release of the first Surgeon General’s Report more than 50 years ago, major strides have been made in reducing the smoking rate in

the U.S.; yet, progress has been uneven and some groups, including veterans, bear a disproportionate burden of tobacco use.1,2 Not only do more veterans smoke ciga- rettes than nonveterans, they also engage in higher rates of polysubstance use, which can increase the likelihood of a lifetime of addiction and of initiating new substance use behaviors (gateway effects).1,2 Studies show high prevalence of heavy drinking among veterans, and most veterans who drink alcohol at heavy levels do not engage in specialty substance use services.3−9

To capture the full scope of substance use behaviors among veterans, it is paramount to surveil the spectrum of abuse substances—licit and illicit. A better under- standing of differences in substance use behaviors between and within veteran statuses can help inform the

Am J Prev Med 2020;59(5):733−741 733

734 Agaku et al / Am J Prev Med 2020;59(5):733−741

development of targeted interventions aimed at health promotion. One such campaign is the Centers for Dis- ease Control and Prevention’s Tips from Former Smok- ers campaign,10 which features hard-hitting, mass media messages regarding the harmful consequences of smok- ing. Although the general target audience for the cam- paign is adults aged 18−54 years, some messages are tailored specifically for veterans. To optimize the effec- tiveness of such population-level interventions among veterans, however, audience segmentation is critical as the 18.2 million11 military veterans in the U.S. are not a homogeneous group. Veterans and nonveterans may have different beliefs and behaviors related to the use of certain substances and may respond differently to certain types of messages. But even among veterans, background demo- graphics such as gender or age can impact individuals’ perception of smoking and the credibility of a specific message. Female veterans tend to be younger, have a higher education level, and include a greater percentage of minorities.12 Similarly, veterans who participated in the major wars of the last century may also have unique behavioral characteristics and beliefs than younger veter- ans; age differences are therefore important to consider when tailoring messages to the veteran population. With projected changes in the veteran population by

age and gender,11 and with the evolving landscape com- posed of conventional and emerging substances of abuse, up-to-date information on various substances among vet- erans by age and gender is timely, especially relative to the general population. To provide the most up-to-date sur- veillance data of substance use behaviors among U.S. mili- tary veterans, this study assessed prevalence of 12 types of substances using the 2015−2017 National Survey on Drug Use and Health (NSDUH). The assessed substances were tobacco products, alcohol, marijuana, prescription pain relievers, tranquilizers, sedatives, stimulants, cocaine, heroin, methamphetamines, inhalants, and hallucinogens. Because of small sample sizes, some substances were ana- lyzed together as a class, rather than individually. Corre- sponding prevalence estimates were also computed among nonveterans as a comparative group.

METHODS

Study Sample An IRB review was not required for this study as it was a second- ary data analysis. NSDUH is a nationally representative survey of the U.S. population aged ≥12 years. The target population includes residents of households and non-institutional group quarters (e.g., college dormitories) and civilians living on military bases. NSDUH’s sampling frame does not include military per- sonnel on active duty. Analyses were conducted on individuals aged ≥18 years. To ensure precise estimates, the authors pooled 2015, 2016, and 2017 data (pooled n=128,720 for people aged ≥18

years). Previous waves could not be used because of changes in NSDUH methodology for certain substances. NSDUH collected detailed information on recency of use, classified as either past- 30-day or past-12-month usage, all operationalized as dichoto- mous indicators of use/no use in this study. Both time windows were utilized in this study to assess the impact of occasional use on prevalence estimates. This is important because for individuals who are social users, a measure of past-30-day use may not cap- ture their relatively infrequent usage. Besides being methodologi- cally more sensitive than a past-30-day measure, the information gleaned from a past-12-month measure of use also has implica- tions for public health practice, programs, and policies. For exam- ple, those who use abuse substances only occasionally may be systematically different from those using it daily in terms of their underlying risks and risk perceptions. The types of interventions they may benefit from may also be different, including behavioral and pharmacologic interventions.

Measures Military veteran status was self-reported. Individuals who had “ever been in the United States Armed Forces” and were “now separated/retired from reserves/active duty” were classified as vet- erans (pooled n=7,301). Individuals who had never been in the U. S. Armed Forces were classified as nonveterans (pooled n=121,366). Individuals who were currently in a reserve compo- nent or did not provide an answer were classified as missing.

Five specific tobacco product types were assessed: regular ciga- rettes, roll-your-own/hand-rolled cigarettes, cigars, pipes, and smokeless tobacco. Any past-30-day tobacco product use was defined as using at least 1 of these 5 products in the past 30 days. Any past-12-month tobacco smoking was defined as use of ciga- rettes or cigars; past-12-month use was not assessed in NSDUH for pipes, smokeless tobacco, and roll-your-own cigarettes.

This study analyzed both recency (past 30 days and past 12 months) and intensity of drinking (binge and heavy drinking). Binge drinking was defined as having 5 or more drinks for male participants, or 4 or more drinks for female participants, on the same occasion for ≥1 day in the past month. Heavy drinking was defined as binge drinking on ≥5 days within the past month.

Recreational marijuana use was assessed, regardless of the form in which it was consumed. Both past-30-day and past-12-month usage indicators were assessed.

Any use or misuse within the past 12 months of psychothera- peutics (prescription pain relievers, tranquilizers, sedatives, and stimulants) were assessed. Any use was nonspecific and included either medical or nonmedical use. Misuse was usage in any way not directed or prescribed, including use without a prescription of the individual’s own or taking the medication in greater doses, fre- quency, or duration than prescribed. Use of prescription pain relievers were assessed for any use and misuse. Aggregate meas- ures of any use and misuse of any psychotherapeutics (i.e., any one of prescription pain relievers, tranquilizers, stimulants, and sedatives) were also created.

Use of illicit drugs was assessed regardless of the route it was administered (i.e., injected, snorted, smoked, or used in any other way). Aggregate measures of past-30-day and past-12-month use of any illicit drug other than marijuana (i.e., any one of cocaine, heroin, methamphetamine, inhalants, and hallucinogens) were created.

www.ajpmonline.org

Agaku et al / Am J Prev Med 2020;59(5):733−741 735

Statistical Analysis Veterans in this study differed markedly from nonveterans by having a higher distribution of individuals who were male (92.3% vs 44.0%) and aged ≥50 years (76.2% vs 42.2%). Direct veteran −nonveteran comparisons may therefore yield attenuated preva- lence differences because substance use behaviors are markedly lower among older adults.2 To account for the confounding effects of age and gender within the analyses, the authors stratified within the levels of age and gender. Eight unique substrata were created: males aged 18−25 years, females aged 18−25 years, males aged 26 −34 years, females aged 26−34 years, males aged 35−49 years, females aged 35−49 years, males aged ≥50 years, and females aged ≥50 years. Chi-square tests were used for within- and between-group comparisons. Statistical comparisons were made between and within veteran status by age and gender; post hoc (pairwise) comparisons were not performed, and only global dif- ferences were evaluated to minimize the likelihood of type I statis- tical error. Data were weighted to account for the complex survey design of NSDUH. Estimates with relative SEs ≥40% were sup- pressed. All CIs were conservatively calculated at the 99% level. Analyses were conducted in 2019 using R, version 3.5.3.

RESULTS

Veteran−nonveteran differences in age and gender were statistically significant in bivariate analyses (all p<0.05). Furthermore, more veterans than nonveterans had some college or higher education (66.8% vs 61.4% respec- tively), were living at 2 times the federal poverty level (75.4% vs 64.5%), or were married (66.2% vs 50.7%) (Appendix Table 1, available online). Veterans had a significantly higher prevalence of past-

30-day any tobacco use than nonveterans in all age strata except those aged ≥50 years (Table 1). Among female participants, veterans had a higher prevalence of past- 30-day any tobacco use than nonveterans among those aged 26−34 years (42.1% vs 29.0%, respectively) and ≥50 years (23.3% vs 16.7%). Among male participants, veterans had a higher prevalence of past-30-day any tobacco use than nonveterans in all age strata, except those aged ≥50 years, where prevalence was lower among veterans than nonveterans (22.5% vs 27.6% respectively). Smokeless tobacco use was significantly higher among

male veterans than their nonveteran counterparts for both past-30-day and past-12-month use in all strata of age, except those aged ≥50 years, where a reversal was seen for past-30-day and past-12-month use. Male veter- ans aged 18−25 years had the highest prevalence of smokeless tobacco use among all veterans (past 30 days, 19.9%; past 12 months, 27.0%). Among female partici- pants, the only stratum for which reliable estimates existed (age 26−34 years) found a higher prevalence of past-12-month smokeless tobacco use among veterans than nonveterans (3.7% vs 1.2%).

November 2020

Cigarette/cigar smoking patterns were similar to those of any tobacco use. Prevalence was higher among veter- ans than nonveterans in most age/gender substrata for both past-30-day and past-12-month smoking. Among male veterans, those aged 26−34 years had the highest prevalence of cigar/cigarette smoking for past-30-day use (46.2%), and those aged 18−24 years had the highest prevalence for past-12-month use (59.8%). Among female veterans, those aged 26−34 years had the highest smoking prevalence than any other age group (past 30 days, 36.6%; past 12 months, 43.9%). Gender differ- ences in cigarette/cigar smoking were much higher among younger veterans than nonveterans of the same age group but became attenuated within the older cohort. For example, prevalence of past-30-day ciga- rette/cigar smoking was 14.8 percentage points higher among male veterans than female veterans among those aged 18−25 years but reversed to �1.9 percentage points among veterans aged ≥50 years; among nonveterans, a less dramatic decline was seen. Alcohol drinking in the past 30 days and past 12

months was higher among veterans than nonveterans in all assessed age and gender strata, except female adults aged 18−25 years for both past-30-day and past-12- month drinking and female adults aged ≥50 years for past-30-day drinking where no significant difference was observed, and male participants aged ≥50 years where veterans had lower prevalence of drinking than nonve- terans (past 30 days, 53.9% vs 56.3%; past 12 months, 63.9% vs 67.9%) (Table 2). In all age strata except people aged ≥50 years, veterans

overall had higher prevalence of binge drinking than non- veterans as follows: age 18−25 years (44.3% vs 38.0%), age 26−34 years (45.7% vs 37.2%), age 35−49 years (33.5% vs 29.2%). Exceptionally, among male participants aged ≥50 years, veterans had a lower prevalence of binge drinking than nonveterans (17.1% vs 24.8%). For heavy drinking, veterans overall had a higher

prevalence than nonveterans in all assessed age strata. Male veterans reported a higher prevalence of heavy drinking than their nonveteran counterparts among those aged 18−25 years (17.5% vs 12.2%) and 36 −49 years (12.4% vs 9.8%). Lower marijuana use was reported within the follow-

ing subgroups among male veterans aged 18−25 years (past 30 days, 17.7% vs 24.1%; past 12 months, 29.9% vs 36.7%) and ≥50 years (past 30 days, 4.6% vs 6.3%; past 12 months, 6.4% vs 9.6%). By contrast, female veterans reported a higher prevalence of marijuana use among those aged ≥50 years (past 30 days, 5.7% vs 2.9%; past 12 months, 9.9% vs 4.9%). Use of any psychotherapeutics was higher among vet-

erans and nonveterans within most assessed age and

Table 1. Age- and Gender-Stratified Prevalence of Tobacco Product Use Among U.S. Military Veterans and Nonveteran Aged ≥18 Years, National Survey on Drug Use and Health, 2015‒2017

Any tobaccoa Smokeless tobacco Cigarettes/cigars

Past-30-day Past-30-day Past-12-month Pa t-30-day Past-12-month

Age/gender Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran

18‒25 years

Female 32.9 (17.1, 48.7)

27.9 (26.7, 29.1)

— 0.8 (0.5, 1.1)

— 2.0 (1.7, 2.3)

31.4 (16.1, 46.7

22.6 (21.7, 23.5)

40.5 (24.0, 57.0)

32.0 (30.9, 33.1)

Male 57.0 (48.0, 66.0)

43.0 (41.7, 44.3)

19.9 (13.2, 26.6)

9.3 (8.6, 10.0)

27.0 (19.6, 34.4)

14.4 (13.6, 15.2)

46.2 (37.5, 54.9

33.6 (32.5, 34.7)

59.8 (51.2, 68.4)

46.6 (45.4, 47.8)

26‒34 years

Female 42.1 (30.6, 53.6)

29.0 (27.7, 30.3)

— 0.6 (0.3, 0.9)

3.7 (0.1, 7.3)

1.2 (0.9, 1.5)

36.6 (26.2, 47.0

24.8 (23.6, 26.0)

43.9 (33.1, 54.7)

30.5 (29.3, 31.7)

Male 58.6 (52.4, 64.8)

45.2 (43.6, 46.8)

16.7 (12.1, 21.3)

8.2 (7.4, 9.0)

23.3 (18.0, 28.6)

11.5 (10.6, 12.4)

46.5 (40.2, 52.8

37.3 (35.7, 38.9)

58.1 (52.0, 64.2)

47.9 (46.3, 49.5)

35‒49 years

Female 26.0 (18.0, 34.0)

24.5 (23.4, 25.6)

— 0.6 (0.3, 0.9)

— 0.9 (0.6, 1.2)

23.9 (16.4, 31.4

21.1 (20.2, 22.0)

29.4 (21.4, 37.4)

24.3 (23.2, 25.4)

Male 44.3 (40.1, 48.5)

36.8 (35.4, 38.2)

13.2 (10.6, 15.8)

8.2 (7.4, 9.0)

15.5 (12.7, 18.3)

9.3 (8.5, 10.1)

33.0 (29.1, 36.9

28.5 (27.2, 29.8)

39.4 (35.3, 43.5)

35.3 (34.0, 36.6)

≥50 years

Female 23.3 (13.8, 32.8)

16.7 (15.6, 17.8)

— 0.4 (0.3, 0.5)

— 0.6 (0.3, 0.9)

20.2 (11.8, 28.6

14.1 (13.3, 14.9)

21.4 (12.7, 30.1)

15.7 (14.6, 16.8)

Male 22.5 (20.3, 24.7)

27.6 (26.0, 29.2)

3.3 (2.5, 4.1)

4.4 (3.7, 5.1)

3.8 (2.9, 4.7)

4.9 (4.2, 5.6)

18.1 (16.1, 20.1

21.5 (20.1, 22.9)

21.6 (19.5, 23.7)

25.6 (24.2, 27.0)

Note: Veterans were individuals who had “ever been in the United States Armed Forces” and were “now separated/retired from reserves/activ duty” at the time of survey. Estimates with ≥40% relative SEs were suppressed (‒). CIs were generated at the 99% level. aAny tobacco product use was defined as using at least 1 of the 5 tobacco products assessed (regular cigarettes, roll-your-own/hand-rolled cig ettes, cigars, pipes, and smokeless tobacco).

736 A gaku

etal/A m

JPrev M ed

2020;59(5):733− 741

w w w .ajpm

online.org

s

s

)

)

)

)

)

)

)

)

e

ar

Table 2. Age- and Gender-Stratified Prevalence of Alcohol Consumption and Recreational Marijuana Use Among U.S. Military Veterans and Nonveterans Aged ≥18 Years, National Survey on Drug Use and Health, 2015‒2017

Alcohol Marijuana

Past-30-day Past-12-month Binge drinkinga Heavy drinkingb Past-30-day Past-12-month

Age/gender Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran

18‒25 years

Female 62.0 (46.2, 77.8)

56.5 (55.3, 57.7)

84.6 (73.3, 95.9)

75.1 (74.0, 76.2)

35.9 (20.0, 51.8)

36.4 (35.3, 37.5)

15.3 (1.6, 29.0)

8.2 (7.7, 8.7)

22.0 (7.0, 37.0)

17.6 (16.7, 18.5)

33.6 (21.3, 45.9)

30.2 (29.1, 31.3)

Male 68.7 (60.7, 76.7)

57.8 (56.6, 59.0)

88.6 (83.1, 94.1)

74.1 (73.0, 75.2)

46.1 (37.5, 54.7)

39.7 (38.5, 40.9)

17.5 (10.9, 24.1)

12.2 (11.4, 13.0)

17.7 (11.8, 23.6)

24.1 (23.0, 25.2)

29.9 (24.2, 35.6)

36.7 (35.6, 37.8)

26‒34 years

Female 73.1 (63.9, 82.3)

58.7 (57.3, 60.1)

91.0 (85.6, 96.4)

76.5 (75.3, 77.7)

37.7 (27.0, 48.4)

30.9 (29.6, 32.2)

8.0 (1.7, 14.3)

6.1 (5.4, 6.8)

11.7 (4.6, 18.8)

10.4 (9.6, 11.2)

18.5 (12.3, 24.8)

17.7 (16.6, 18.8)

Male 77.3 (72.2, 82.4)

69.6 (68.2, 71.0)

89.0 (85.2, 92.8)

82.2 (81.0, 83.4)

47.6 (41.4, 53.8)

44.0 (42.4, 45.6)

13.4 (9.2, 17.6)

12.7 (11.6, 13.8)

16.0 (11.7, 20.3)

18.1 (16.8, 19.4)

25.9 (21.9, 30)

26.9 (25.6, 28.2)

35‒49 years

Female 66.5 (58.3, 74.7)

54.3 (53.1, 55.5)

86.1 (80.7, 91.5)

71.0 (69.9, 72.1)

26.3 (18.8, 33.8)

24.0 (22.9, 25.1)

7.4 (2.8, 12.0)

4.5 (4.0, 5.0)

4.3 (1.1, 7.5)

5.7 (5.2, 6.2)

8.3 (4.8, 11.7)

9.8 (9.1, 10.5)

Male 70.7 (66.9, 74.5)

64.3 (63.0, 65.6)

82.4 (79.4, 85.4)

76.8 (75.7, 77.9)

34.9 (31.0, 38.8)

35.2 (33.9, 36.5)

12.4 (9.6, 15.2)

9.8 (8.9, 10.7)

10.7 (8.1, 13.3)

10.4 (9.5, 11.3)

15.5 (13.2, 17.9)

15.1 (14.2, 16.0)

≥50 years

Female 48.9 (37.8, 60.0)

44.7 (43.4, 46.0)

69.1 (59.1, 79.1)

58.4 (57.1, 59.7)

18.1 (9.5, 26.7)

13.3 (12.4, 14.2)

— 2.7 (2.3, 3.1)

5.7 (1.0, 10.4)

2.9 (2.4, 3.4)

9.9 (5, 14.8)

4.9 (4.2, 5.6)

Male 53.9 (51.4, 56.4)

56.3 (54.5, 58.1)

63.9 (61.5, 66.3)

67.9 (66.3, 69.5)

17.1 (15.1, 19.1)

24.8 (23.2, 26.4)

5.9 (4.7, 7.1)

7.0 (6.1, 7.9)

4.6 (3.4, 5.8)

6.3 (5.5, 7.1)

6.4 (5.5, 7.4)

9.6 (8.5, 10.7)

Note: Veterans were individuals who had “ever been in the United States Armed Forces” and were “now separated/retired from reserves/active duty” at the time of survey. Estimates with ≥40% relative SEs were suppressed (‒). CIs were generated at the 99% level. aBinge drinking was defined as having 5 or more drinks for males, or 4 or more drinks for females, on the same occasion for at least 1 day in the past month. bHeavy drinking was defined as binge drinking on 5 or more days within the past month.

A gaku

etal/A m

JPrev M ed

2020;59(5):733− 741

737

N ovem

ber 2020

Table 3. Age- and Gender-Stratified Prevalence of Use and Misuse of Psychotherapeutics Among U.S. Military Veterans and Nonveterans Aged ≥18 Years, National Survey on Drug Use and Health, 2015‒2017

Any psychotherapeuticsa Prescription pain relievers

Any use (past-12-month)b Misuseb Any use (past-12-month)b Misuseb

Age/gender Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran

18‒25 years

Female 62.3 (46.9, 77.7)

45.2 (44.1, 46.3)

16.0 (2.3, 29.7)

13.9 (13.1, 14.7)

54.7 (0.0, 70.9)

35.0 (33.9, 36.1)

15.3 (1.6, 29.0)

6.9 (6.2, 7.6)

Male 40.3 (31.9−48.7)

38.6 (37.4, 39.8)

12.2 (7.1, 17.3)

15.8 (14.9, 16.7)

32 (0.0, 40.2)

27.7 (26.6, 28.8)

6.8 (2.9, 10.7)

8.2 (7.5, 8.9)

26‒34 years

Female 61.0 (50.3, 71.7)

47.6 (46.3, 48.9)

13.3 (5.7, 20.9)

9.5 (8.7, 10.3)

45 (0.0, 55.8)

38.9 (37.5, 40.3)

8.1 (1.5, 14.7)

5.7 (5.0, 6.4)

Male 42.8 (36.6, 49.0)

39.9 (38.5, 41.3)

10.3 (6.6, 14.0)

12.5 (11.4, 13.6)

36.6 (0.0, 42.5)

31.3 (29.9, 32.7)

7.0 (4.0, 10.0)

8.2 (7.3, 9.1)

35‒49 years

Female 61.1 (52.5, 69.7)

48.4 (47.2, 49.6)

6.1 (2.4, 9.8)

6.1 (5.4, 6.8)

49.8 (0.0, 58.6)

39.3 (38.1, 40.5)

5.3 (1.9, 8.7)

4.2 (3.7, 4.7)

Male 49.5 (45.4, 53.6)

38.7 (37.4, 40.0)

7.6 (5.4, 9.8)

6.8 (6.1, 7.5)

41.9 (0.0, 46.0)

32.0 (30.8, 33.2)

5.0 (3.3, 6.7)

5.0 (4.3, 5.7)

≥50 years

Female 62.8 (52.3, 73.3)

49.4 (48.1, 50.7)

4.5 (0.4, 8.6)

3.4 (2.9, 3.9)

49.1 (0.0, 60.2)

38.7 (37.4, 40.0)

— 2.1 (1.7, 2.5)

Male 47.5 (44.9, 50.1)

41.8 (40.1, 43.5)

3.0 (2.1, 3.9)

4.2 (3.5, 4.9)

40.6 (0.0, 43.1)

35.1 (33.5, 36.7)

2.0 (1.3, 2.7)

3.1 (2.6, 3.6)

Note: Veterans were individuals who had “ever been in the United States Armed Forces” and were “now separated/retired from reserves/active duty” at the time of survey. Estimates with ≥40% relative SEs were suppressed (‒). CIs were generated at the 99% level. aAny psychotherapeutic use was defined as using at least one of the psychotherapeutics assessed (prescription pain relievers, tranquilizers, stimu- lants, and sedatives). bAny use in the past 12 months was defined regardless of the appropriateness for which it occurred (i.e., regardless of clinical indication, prescription availability or fidelity, or usage patterns). Misuse was defined as usage in any way not directed or prescribed, including use without a prescription of the individual’s own, or taking the medication in greater doses, frequency, or duration than prescribed.

738 Agaku et al / Am J Prev Med 2020;59(5):733−741

gender strata (Table 3). Among female participants, most veterans reported past-12-month use of any psy- chotherapeutics, whereas <50% of nonveterans reported past-12-month use within all age groups: 18−25 years (62.3% vs 45.2%), 26−34 years (61.0% vs 47.6%), 35 −49 years (61.1% vs 48.4%), and ≥50 years (62.8% vs 49.4%). Among male participants, veterans reported a higher prevalence of past-12-month use of any psycho- therapeutics among those aged 35−49 years (49.5% vs 38.7%) and ≥50 years (47.5% vs 41.8%). Misuse of any psychotherapeutics did not differ significantly between veterans and nonveterans, except among male veterans aged ≥50 years, who reported a lower prevalence of mis- use than nonveterans (3.0% vs 4.2%). Similar patterns were seen for any use of prescription

pain killers as indicated by a generally higher prevalence among veterans than nonveterans. For misuse of prescrip- tion pain killers, the largest difference was seen among female veterans aged 18−25 years, who reported higher misuse prevalence than nonveterans (15.3% vs 6.9%). With few exceptions, there were no significant differ-

ences in any illicit drug (other than marijuana) use

between veterans and nonveterans across age and gender strata (Table 4). The few significant differences that existed were among male participants and consistently showed lower prevalence of any illicit drug other than marijuana among veterans than nonveterans, including among those aged 18−25 years (past 12 months, 8.4% vs 13.2%) and those aged ≥50 years (past 12 months, 0.8% vs 2.1%).

DISCUSSION

This study utilized cross-sectional data from NSDUH to examine age- and gender-stratified prevalence estimates of substance use among U.S. veterans and nonveterans. With few exceptions, illicit substance use, including marijuana and cocaine, was lower among veterans than nonveterans, whereas use of licit substances such as tobacco, alcohol, or prescription opioids was higher among veterans than nonveterans. The widespread prev- alence of use in both veteran and nonveteran popula- tions for prescription psychotropic medications, tobacco consumption, or binge drinking is striking and of great

www.ajpmonline.org

Table 4. Age- and Gender-Stratified Prevalence of Use of Illicit Drugs Other Than Marijuana Among U.S. Military Veterans and Nonveterans Aged ≥18 Years, National Survey on Drug Use and Health, 2015‒2017

Any illicit drugs other than marijuanaa Cocaine

Past 30-day Past 12-month Past 30-day Past 12-month

Age/gender Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran Veteran Nonveteran

18‒25 years

Female — 2.7 (2.4, 3.0) — 8.7 (8.0, 9.4) — 1.2 (0.9, 1.5) — 4.6 (4.1, 5.1)

Male 3.7 (0.1, 7.3) 4.7 (4.2, 5.2) 8.4 (3.7, 13.1) 13.2 (12.4, 14.0) — 2.2 (1.8, 2.6) 5.3 (1.9, 8.7) 6.7 (6.0, 7.4)

26‒34 years — Female — 1.7 (1.3, 2.1) — 4.6 (3.9, 5.3) — 0.8 (0.5, 1.1) — 2.5 (2.1, 2.9)

Male 2.2 (0.4, 4.0) 4.0 (3.3, 4.7) 7.3 (4.3, 10.3) 9.6 (8.7, 10.5) — 2.1 (1.7, 2.5) 3.5 (1.3, 5.7) 5.4 (4.7, 6.1)

35‒49 years — Female — 0.8 (0.7, 0.9) — 1.7 (1.4, 2.0) — 0.4 (0.1, 0.7) — 0.8 (0.7, 0.9)

Male 1.8 (0.5, 3.1) 2.0 (1.6, 2.4) 3.7 (2.0, 5.4) 4.0 (3.5, 4.5) — 1.0 (0.7, 1.3) 2.0 (0.7, 3.3) 2.2 (1.8, 2.6)

≥50 years — Female — 0.3 (0.2, 0.4) — 0.7 (0.6, 0.8) — 0.4 (0.1, 0.7) — 0.4 (0.3, 0.5)

Male 0.4 (0.0, 0.9) 1.1 (0.7, 1.5) 0.8 (0.4, 1.2) 2.1 (1.6, 2.6) — 1.0 (0.7, 1.3) 0.3 (0.0, 0.6) 1.3 (0.9, 1.7)

Note: Veterans were individuals who had “ever been in the United States Armed Forces” and were “now separated/retired from reserves/active duty” at the time of survey. Estimates with ≥40% relative SEs were suppressed (‒). CIs were generated at the 99% level. aAny illicit drug (other than marijuana) use was defined as using at least 1 of the 5 illicit drugs assessed (cocaine, heroin, methamphetamine, inha- lants, and hallucinogens).

Agaku et al / Am J Prev Med 2020;59(5):733−741 739

clinical and public health concern.13−18 The authors also observed that the magnitude of occasional or nondaily use, using the difference in past-12-month versus past- 30-day use as a proxy, was similar between veterans and nonveterans for cigarette smoking; for smokeless tobacco, however, veterans reported much higher occa- sional use. For example, among male participants aged 26−34 years, this marker for occasional use was twofold higher among veterans than nonveterans. Although some smokers may use smokeless tobacco to help with quitting, there is no conclusive evidence of its effective- ness as a smoking-cessation aid19; dual users may be exposing themselves to more nicotine and carcinogens in smokeless tobacco.20

Although female veterans reported a lower prevalence of substance abuse than male veterans in general, these estimates were higher than those observed among female nonveterans. For example, past-12-month cigarette/cigar smoking among female veterans aged 18−25 years (40.5%) was 8.5 percentage points higher than the corre- sponding prevalence among female nonveterans in the same age group (32.0%). Similarly, smokeless tobacco use among female veterans aged 26−34 years was 3 times higher than their nonveteran counterparts (3.7% vs 1.2%). For both cigarette/cigar smoking and binge drink- ing, the authors observed a narrowing of the male −female gap in prevalence with increasing age among veterans. Various explanations may account for these observations, including the possibility of higher mortal- ity among the heavier smoking and drinking male veter- ans than female veterans and nonveterans. It is also

November 2020

possible that older male veterans may have higher rates of successfully quitting substance use behaviors than their female veteran counterparts. Misuse of prescription pain relievers was highest

among female veterans aged 18−25 years. The differen- tial use and misuse of pain relievers between the genders may be attributable to differential patterns of musculo- skeletal injuries, which are more common among women military members than men. Bedno and col- leagues21 described 50% greater injury prevalence among women military members in a 3-year cohort study with injuries occurring at a mean of 3 months of service ver- sus 5 months for men. Notably, the 50% greater preva- lence of self-reported use of prescription pain relievers in the female group aged 18−25 years parallels the increased injury rate in the study by Bedno et al.21 The Centers for Disease Control and Prevention’s opioid guidelines note that musculoskeletal injuries and their overtreatment with pain relievers are major causes of overuse, as well as dental prescription.22 A higher pro- portion of younger patients have also been shown to receive opioid prescriptions following dental visits,23−25

and the trend shows an increase in the quantity of pain relievers prescribed over time,25,26 which is a source of concern given the risk of developing drug dependence in otherwise opioid-naive patients27 and the incidence of drug diversion among this population subgroup.28

The health consequences of substance use among vet- erans extend beyond just the individual user and include the risk of exposing other members of the household to secondhand smoke. Further potential consequences for

740 Agaku et al / Am J Prev Med 2020;59(5):733−741

families and societies, particularly with substance use behavior that is heavy or illegal, are increased risk of vio- lence, drunk driving, and lost wages. Furthermore, given that 83% of new recruits into the U.S. military come from a family with a veteran,29 there is also the danger of perpetuating a culture of substance use and abuse within the military and among veterans. Substance use behaviors among active duty military and veterans are tightly intertwined, especially as veterans continue to have access to military installations after retirement. Sev- eral advances have been made in recent years to decrease tobacco sales and utilization on military facilities, includ- ing eliminating the tax-free status of tobacco products in commissaries and on-base establishments, leading to a 25%−35% price increase in 2016.30 Recalibration of social norms among active duty military and veterans, coupled with barrier-free clinical cessation and mental health services, can help these individuals quit substance addiction.

Limitations This study has some limitations. First, the definition of veterans may not necessarily be identical with the statu- tory definition of veterans; for example, it may include individuals who served in the U.S. Armed Forces but were dishonorably discharged. Second, data are cross- sectional and rely on self-report. Additionally, the selec- tion of variables is limited by those included in the NSDUH data set, which was not specifically designed to examine important military-related factors that might influence substance use such as branch or length of ser- vice, reason for military separation, combat experience, or other military trauma. Finally, despite pooled data, sample sizes were small for certain substances and popu- lation subgroups (e.g., female veterans).

CONCLUSIONS

With few exceptions, illicit substance use, including marijuana and cocaine, was lower among veterans than nonveterans, whereas use of licit substances including tobacco, alcohol, and prescription pain relievers was higher among veterans than nonveterans. The most used substances among veterans were tobacco and alco- hol, especially among male veterans aged 18−25 years. Intensified efforts are needed to reduce substance use among veterans, as well as provide cessation and mental health services.

ACKNOWLEDGMENTS No copyrighted materials, surveys, instruments, or tools were used in this study. Data analyses and medical writing services were supported by Zatum LLC, www.zatumcorp.com.

IA conceptualized and designed the study and drafted the initial manuscript. SO and JN helped conceptualize the study, assisted in the statistical analyses, and critically reviewed and revised the manuscript. All authors approve the final manu- script as submitted and agree to be accountable for all aspects of the work.

No financial disclosures were reported by the authors of this paper.

SUPPLEMENTAL MATERIAL Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j. amepre.2020.04.027.

REFERENCES 1. Odani S, Agaku IT, Graffunder CM, Tynan MA, Armour BS. Tobacco

product use among military veterans—United States, 2010−2015. MMWR Morb Mortal Wkly Rep. 2018;67(1):7–12. https://doi.org/ 10.15585/mmwr.mm6701a2.

2. National Center for Chronic Disease Prevention and Health Promo- tion. Office on Smoking and Health. The health consequences of smok- ing—50 years of progress: a report of the Surgeon General . Atlanta, GA: Centers for Disease Control and Prevention, 2014.

3. O’Brien CP, Oster M, Morden E, eds. Substance use disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press, 2013.

4. Vest BM, Heavey SC, Homish DL, Homish GG. Alcohol misuse in reserve soldiers and their partners: cross-spouse effects of deployment and combat exposure. Subst Use Misuse. 2018;53(5):800–807. https:// doi.org/10.1080/10826084.2017.1385632.

5. Bray RM, Pemberton MR, Lane ME, Hourani LL, Mattiko MJ, Babeu LA. Substance use and mental health trends among U.S. military active duty personnel: key findings from the 2008 DoD Health Behav- ior Survey. Mil Med. 2010;175(6):390–399. https://doi.org/10.7205/ milmed-d-09-00132.

6. Pedersen ER, Marshall GN, Kurz J. Behavioral health treatment receipt among a community sample of young adult veterans. J Behav Health Serv Res. 2017;44(4):536–550. https://doi.org/10.1007/s11414- 016-9534-7.

7. Glass JE, Perron BE, Ilgen MA, Chermack ST, Ratliff S, Zivin K. Prev- alence and correlates of specialty substance use disorder treatment for Department of Veterans Affairs Healthcare System patients with high alcohol consumption. Drug Alcohol Depend. 2010;112(1−2):150–155. https://doi.org/10.1016/j.drugalcdep.2010.06.003.

8. Bray RM, Pemberton MR, Hourani LL, et al. Department of Defense survey of health related behaviors among active duty military person- nel. Research Triangle Park, NC: Research Triangle Inst (RTI), 2009.

9. Walton TO, Walker DD, Kaysen DL, Roffman RA, Mbilinyi L, Neigh- bors C. Reaching soldiers with untreated substance use disorder: les- sons learned in the development of a marketing campaign for the Warrior Check-Up study. Subst Use Misuse. 2013;48(10):908–921. https://doi.org/10.3109/10826084.2013.797996.

10. Tips from former smokers: about the campaign. Centers for Disease Control and Prevention. www.cdc.gov/tobacco/campaign/tips/about/ index.html?s_cid=OSH_tips_D9393. Published 2016. Accessed November 4, 2016.

11. National Center for Veterans Analysis and Statistics. Veteran population. www.va.gov/vetdata/docs/Demographics/VetPop_Infographic_2019.pdfTa gg ed En d. Published 2019. Accessed April 27, 2020.

12. Department of Veterans Affairs, National Center for Veteran Analysis and Statistics. The veteran population. www.va.gov/VETDATA/docs/ SurveysAndStudies/VETPOP.pdf. Published April 1995. Accessed April 27, 2020.

www.ajpmonline.org

Agaku et al / Am J Prev Med 2020;59(5):733−741 741

13. Bray RM, Brown JM, Williams J. Trends in binge and heavy drinking, alcohol-related problems, and combat exposure in the U.S. military. Subst Use Misuse. 2013;48(10):799–810. https://doi.org/10.3109/ 10826084.2013.796990.

14. Green KT, Beckham JC, Youssef N, Elbogen EB. Alcohol misuse and psychological resilience among U.S. Iraq and Afghanistan era veter- ans. Addict Behav. 2014;39(2):406–413. https://doi.org/10.1016/j. addbeh.2013.08.024.

15. Jacobson IG, Ryan MA, Hooper TI, et al. Alcohol use and alcohol- related problems before and after military combat deployment. JAMA. 2008;300(6):663–675. https://doi.org/10.1001/jama.300.6. 663.

16. Grodensky CA, Golin CE, Ochtera RD, Turner BJ. Systematic review: effect of alcohol intake on adherence to outpatient medication regi- mens for chronic diseases. J Stud Alcohol Drugs. 2012;73(6):899–910. https://doi.org/10.15288/jsad.2012.73.899.

17. Margolese HC, Malchy L, Negrete JC, Tempier R, Gill K. Drug and alcohol use among patients with schizophrenia and related psychoses: levels and consequences. Schizophr Res. 2004;67(2−3):157–166. https://doi.org/10.1016/S0920-9964(02)00523-6.

18. Zeber JE, Miller AL, Copeland LA, et al. Medication adherence, eth- nicity, and the influence of multiple psychosocial and financial bar- riers. Admin Policy Ment Health. 2011;38(2):86–95. https://doi.org/ 10.1007/s10488-010-0304-1.

19. Bergman HE, Hunt YM, Augustson E. Smokeless tobacco use in the United States military: a systematic review. Nicotine Tob Res. 2012;14 (5):507–515. https://doi.org/10.1093/ntr/ntr216.

20. Cheng YC, Reyes-Guzman CM, Christensen CH, et al. Biomarkers of exposure among adult smokeless tobacco users in the Population Assessment of Tobacco and Health Study (Wave 1, 2013‒2014). Can- cer Epidemiol Biomarkers Prev. 2020;29(3):659–667. https://doi.org/ 10.1158/1055-9965.EPI-19-0766.

21. Bedno SA, Nelson DA, Kurina LM, Choi YS. Gender differences in the associations of body mass index, physical fitness and tobacco use with lower extremity musculoskeletal injuries among new U.S. Army sol- diers. Inj Prev. 2019;25(4):295–300. https://doi.org/10.1136/injury- prev-2017-042669.

November 2020

22. CDC guideline for prescribing opioids for chronic pain. Centers for Disease Control and Prevention. www.cdc.gov/drugoverdose/prescrib- ing/guideline.html. Updated August 28, 2019. Accessed March 27, 2020.

23. McCauley JL, Hyer JM, Ramakrishnan VR, et al. Dental opioid pre- scribing and multiple opioid prescriptions among dental patients: administrative data from the South Carolina prescription drug moni- toring program. J Am Dent Assoc. 2016;147(7):537–544. https://doi. org/10.1016/j.adaj.2016.02.017.

24. Gupta N, Vujicic M, Blatz A. Multiple opioid prescriptions among pri- vately insured dental patients in the United States: evidence from claims data. J Am Dent Assoc. 2018;149(7):619–627.e1. https://doi.org/ 10.1016/j.adaj.2018.02.025.

25. Gupta N, Vujicic M, Blatz A. Opioid prescribing practices from 2010 through 2015 among dentists in the United States: what do claims data tell us? J Am Dent Assoc. 2018;149(4):237–245.e6. https://doi.org/ 10.1016/j.adaj.2018.01.005.

26. Steinmetz CN, Zheng C, Okunseri E, Szabo A, Okunseri C. Opioid analgesic prescribing practices of dental professionals in the United States. JDR Clin Trans Res. 2017;2(3):241–248. https://doi.org/ 10.1177/2380084417693826.

27. Larach DB, Waljee JF, Hu HM, et al. Patterns of initial opioid pre- scribing to opioid-naive patients. Ann Surg. 2020;271(2):290–295. https://doi.org/10.1097/SLA.0000000000002969.

28. McCabe SE, West BT, Boyd CJ. Leftover prescription opioids and nonmedical use among high school seniors: a multi-cohort national study. J Adolesc Health. 2013;52(4):480–485. https://doi.org/10.1016/j. jadohealth.2012.08.007.

29. Rostker BD, Klerman JA, Zander-Cotugno M. Recruiting older youths: insights from a new survey of Army recruits. Washington, DC: RAND Corporation. www.rand.org/content/dam/rand/pubs/research_re- ports/RR200/RR247/RAND_RR247.pdf T a g g e d E n d. Published 2012. Accessed September 3, 2019.

30. Department of Defense. Policy Memorandum 16-001, Department of Defense tobacco policy. www.med.navy.mil/sites/nmcphc/Docu- ments/health-promotion-wellness/tobacco-free-living/INCOMING- CARTER-Tobacco-Policy-Memo.pdf. Accessed January 24, 2020.