Smoking and drinking behaviors of military spouses: Findings from the Millennium Cohort Family Study

Addictive Behaviors 77 (2018) 121–130

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Smoking and drinking behaviors of military spouses: Findings from the Millennium Cohort Family Study

MARK

Daniel W. Tronea,⁎, Teresa M. Powella, Lauren M. Bauera, Amber D. Seeligd, Arthur V. Petersonb,c, Alyson J. Littmand,e,f, Emily C. Williamsf,g, Charles C. Maynardd,f,g, Jonathan B. Brickerb,h, Edward J. Boykod,e,i a

Deployment Health Research Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521, USA Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, Seattle, WA 98109, USA c Department of Biostatistics, University of Washington, UW Tower, 15T-420, 4333 Brooklyn Avenue NE, Campus Box 359461, Seattle, WA 98105, USA d Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, 1660 South Columbian Way MS152E, Seattle, WA 98108, USA e Department of Epidemiology, University of Washington School of Public Health, 1959 NE Pacific Street, Health Sciences Building F-250, Box 357236, Seattle, WA 98195-7236, USA f Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research Development, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA g Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific Street, Magnuson Health Sciences Center, Room H-664, Box 357660, Seattle, WA 98195-7660, USA h Department of Psychology, University of Washington, 119A Guthrie Hall, UW Box 351525, Seattle, WA 98195-1525, USA i Department of Medicine, University of Washington, RR-512, Health Sciences Building, Box 356420, 1959 NE Pacific Street, Seattle, WA 98195-6420, USA b

H I G H L I G H T S paper examines risk factors for current smoking, risky drinking, and problem drinking among spouses of U.S. Service members, while accounting for spouse • This demographics, family size and socio-economic status, as well as military information regarding the Service member of spouses reported current cigarette smoking, 36.3% reported risky drinking, and 7.3% reported problem drinking • 17.2% deployment of the Service member was not associated with a higher odds of smoking or drinking among spouses • Current of Service members who communicated about their deployment experiences were half as likely to smoke than spouses who did not communicate • Spouses bothered by hearing about deployment experiences, and spouses reporting feeling very stressed by a combat-related deployment or duty assignment had • Spouses consistently higher odds of both risky and problem

A R T I C L E I N F O

A B S T R A C T

Keywords: Military family Smoking Risky drinking Problem drinking Mental health

Introduction: The associations between stressful military experiences and tobacco use and alcohol misuse among Service members are well documented. However, little is known about whether stressful military experiences are associated with tobacco use and alcohol misuse among military spouses. Methods: Using 9872 Service member–spouse dyads enrolled in the Millennium Cohort Family Study, we employed logistic regression to estimate the odds of self-reported cigarette smoking, risky drinking, and problem drinking among spouses by Service member deployment status, communication regarding deployment, and stress associated with military-related experiences, while adjusting for demographic, mental health, military experiences, and Service member military characteristics. Results: Current cigarette smoking, risky drinking, and problem drinking were reported by 17.2%, 36.3%, and 7.3% of military spouses, respectively. Current deployment was not found to be associated with spousal smoking or drinking behaviors. Communication about deployment experiences with spouses was associated with lower odds of smoking, but not with risky or problem drinking. Spouses bothered by communicated deployment experiences and those who reported feeling very stressed by a combat-related deployment or duty assignment had consistently higher odds of both risky and problem drinking. Conclusions: Our findings suggest that contextual characteristics about the deployment experience, as well as the perceived stress of those experiences, may be more impactful than the simple fact of Service member deployment itself. These results

⁎

Corresponding author at: Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA. E-mail address: [email protected] (D.W. Trone).

http://dx.doi.org/10.1016/j.addbeh.2017.09.015 Received 24 February 2017; Received in revised form 12 September 2017; Accepted 25 September 2017 Available online 28 September 2017 0306-4603/ © 2017 Published by Elsevier Ltd.

Addictive Behaviors 77 (2018) 121–130

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suggest that considering the impact of deployment experiences on military spouses reveals important dimensions of military community adaptation and risk.

1. Introduction

compared with nonsmokers who included never and former smokers. Alcohol misuse was examined through two outcomes: risky drinking and problem drinking. Risky drinking was defined according to national recommendations as ≥5 drinks per day on at least one occasion in the past year or ≥14 drinks in a typical week for men, and drinking ≥4 drinks per day on at least one occasion in the past year or ≥ 7 drinks in a typical week for women (Dawson, Grant, & Li, 2005; Smith, Schmidt, Allensworth-Davies, & Saitz, 2009; U.S. Department of Health & Human Services, 2003, 2005). Using the Patient Health Questionnaire (PHQ) alcohol screening tool, problem drinking was defined as a positive endorsement of any alcohol-related problem happening on more than one occasion over the past 12 months (Kroenke, Spitzer, & Williams, 2001; Spitzer, Kroenke, & Williams, 1999; Williams et al., 2015). The PHQ included the following items: (1) drank alcohol even though a doctor suggested stopping because of a problem with your health; (2) drank alcohol, were high from alcohol, or hung over while working, going to school, or taking care of children or other responsibilities; (3) missed or were late for work, school, or other activities because of drinking or being hung over; (4) had a problem getting along with people while drinking; or (5) drove a car after having several drinks or after drinking too much.

The associations between deployment and tobacco use and alcohol misuse among Service members are well documented (Brady & Sonne, 1999; Hoge et al., 2004; McFarlane, 1998; Shipherd, Stafford, & Tanner, 2005; Sillaber & Henniger, 2004; Smith et al., 2008; Wells et al., 2010), however, little is known about whether Service member deployment is associated with tobacco use and alcohol misuse among military spouses. U.S. military service and deployments commonly result in separation from family, irregular working hours, strenuous training, potential exposure to chemical or biological agents, and extreme violence and death. All of these experiences may contribute to increased symptom reporting or psychological distress of Service members during and after deployment (Ryan et al., 2007). Military spouses may experience higher levels of stress compared with their civilian counterparts due to the many stressors that can vary greatly through the different phases of deployment: predeployment preparation, separation during deployment, and reintegration of the Service member upon their return home (de Burgh, White, Fear, & Iversen, 2011; Dimiceli, Steinhardt, & Smith, 2010; Marnocha, 2012). Furthermore, tobacco use and alcohol misuse of spouses may also influence Service members' long-term military performance and readiness (Homish & Leonard, 2005; Robbins et al., 2000). The Millennium Cohort Family Study was designed to assess the impact of military life on the health and wellbeing of the entire military family, including the Service member, spouse, and children (Crum-Cianflone, Fairbank, Marmar, & Schlenger, 2014). Moreover, the Family Study includes U.S. military opposite-sex married couples, and it is the only ongoing Department of Defense (DoD)-wide longitudinal study of the well-being of military families, as well as the largest and most comprehensive study of military families to date. Using data from Service member–spouse dyads enrolled in the Millennium Cohort Family Study, we examined whether deployment–elated stressors and experiences were associated with smoking and alcohol misuse among military spouses.

2.3. Primary exposures We investigated three main characteristics of the deployment experience that could be associated with increased spousal stress and subsequent tobacco use and alcohol misuse: (1) Service member deployment history; (2) couple communication about deployment experiences; and (3) stress related to past-year combat deployments and Service member injuries. Objective data regarding Service member deployment history were obtained from the Defense Manpower Data Center (DMDC) Contingency Tracking System (CTS) electronic personnel files. Using the CTS data, we identified all Service members deployed at the time their spouse completed the Family Study survey. We further categorized those Service members with any prior deployments and computed the time since most recent deployment as the difference between the spouse's survey completion date and the Service member's most recent deployment date. Couple communication about the Service member's most recent deployment was assessed among spouses whose Service member ever deployed. Specifically, this exposure was evaluated by the Family Study survey question, “How much has your spouse shared his/her deployment experiences with you?” Response options included “none,” “a little,” “somewhat,” or “a lot.” Among participants who indicated at least some level of communication, associated spousal stress was assessed by the question, “To what degree were/are you bothered by the deployment experiences your spouse shared with you?” Response options included “not at all,” “a little bit,” “moderately,” “quite a bit,” or “extremely.” Additionally, spouses were asked to report if they had experienced the following events during the past year: (1) Service member combatrelated deployment or duty assignment, (2) Service member combatrelated injury, and (3) providing care for an ill, injured, or disabled Service member. We first dichotomously assessed each experience. Then among participants who responded affirmatively to the experience, we assessed the perceived stress of each experience on a 4-level scale ranging from “not at all stressful” to “very stressful.”

2. Methods 2.1. Study population The study population was drawn from the 9872 Millennium Cohort Family Study spouses married to Millennium Cohort Study Service members enrolled between 2011 and 2013. Invited Millennium Cohort Study Service members had 2–5 years of military service and were from all branches and components of the military as of October 2010. The cohort was oversampled for married and female Service members to ensure adequate power in these subgroups. After married Service members completed their Millennium Cohort questionnaire, their spouses were invited to participate in the Family Cohort Study. Participants enrolled in the Family Study completed a comprehensive questionnaire detailing health, lifestyle, and behavioral information as well as questions regarding military life. A more detailed description of this study's methodology can be found elsewhere (Crum-Cianflone et al., 2014). 2.2. Outcomes Current smoking was defined as having reported smoking at least 100 cigarettes in one's lifetime and smoking cigarettes in the past year. A dichotomous smoking status was created where current smokers were

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Table 1 Characteristics of military spouses and Service members.

Variable Demographic (military spouse) Age (years; mean [SD])† Sex Femalem Male Race/ethnicity Non-Hispanic Whitem Non-Hispanic Black Hispanic Other BMI (kg/m2) < 18.5 18.5–24.9m 25.0–29.9 ≥ 30.0 Educational level High school diploma or lessm Some college or associate degree Bachelor's degree Master's or higher degree Household income ($1000/year) < 25m 25–49 50–74 75–99 ≥ 100 Personal (military spouse) Employment status Full-timem Part-time Homemaker Unemployed Other Military service (of spouse) No, never servedm Currently serving Former Service member Number of children from current or prior relationship 0m 1–2 >2 Years married < 2m 2–5 6–10 11–15 > 15 Mental health and stress (military spouse) Major depressiona Nom Yes PTSDb Nom Yes Panic/other anxietyc Nom Yes Current use of medication for anxiety/depression/stress Nom Yes Life stressorsd Lowm Moderate

123

Current smoking

Risky drinking

Problem drinking

Total N (% current smoking)

Total N (% risky drinking)

Total N (% problem drinking)

9282 (17.2)

9242 (36.3)

9182 (7.3) ⁎

28.5 (5.7); 28.4 (5.8)

28.5 (5.8); 27.8 (5.2)

8092 (16.0) 1190 (25.8)⁎

8050 (34.3) 1192 (50.2)⁎

8006 (6.9) 1176 (10.4)⁎

7317 (18.0) 376 (14.4) 835 (12.8)⁎ 754 (15.9)

7298 (37.6) 373 (24.9)⁎ 827 (35.2) 744 (31.3)⁎

7234 (7.5) 370 (5.1) 828 (7.2) 750 (6.5)

252 (19.4)⁎ 4479 (14.1) 2610 (19.2)⁎ 1941 (21.6)⁎

252 (31.3) 4457 (34.9) 2596 (39.8) 1937 (35.6)

252 (11.5) 4423 (6.9) 2588 (7.9) 1919 (6.9)

1164 4309 2703 1106

1162 4280 2695 1105

1155 4271 2670 1086

(31.4) (22.2)⁎ (8.0)⁎ (5.4)⁎

(37.5) (37.2) (34.4) (36.3)

28.5 (5.7); 28.0 (5.1)

(7.1) (7.8) (6.7) (7.0)

1063 (21.7) 3988 (22.0) 2238 (14.3)⁎ 1129 (10.5)⁎ 864 (6.1)⁎

1054 (33.2) 3974 (35.8) 2228 (34.6) 1122 (39.2)⁎ 864 (43.4)⁎

1056 (6.3) 3952 (7.4) 2212 (7.7) 1114 (7.4) 848 (7.2)

3183 (15.6) 1083 (14.1) 3075 (17.5) 1247 (22.5)⁎ 694 (18.9)⁎

3177 (44.6) 1073 (38.6)⁎ 3056 (24.4)⁎ 1242 (41.9) 694 (37.6)⁎

3148 (9.3) 1064 (7.9) 3044 (4.7)⁎ 1238 (8.2) 688 (7.4)

7641 (16.4) 864 (18.6) 777 (24.2)⁎

7599 (35.0) 865 (45.4)⁎ 778 (39.1)

7556 (6.9) 856 (9.0) 770 (9.4)

3432 (14.8) 4717 (17.9)⁎ 1133 (22.1)⁎

3416 (46.7) 4697 (31.2)⁎ 1129 (26.5)⁎

3390 (10.0) 4673 (6.0)⁎ 1119 (4.8)⁎

1259 (19.3) 5362 (17.2) 2070 (17.1) 354 (12.4) 237 (14.8)

1254 (46.6) 5341 (38.3)⁎ 2062 (29.4)⁎ 350 (18.9)⁎ 235 (24.7)⁎

1246 (10.8) 5311 (7.4)⁎ 2047 (5.7)⁎ 349 (4.6)⁎ 229 (4.8)⁎

8827 (16.4) 455 (33.4)⁎

8791 (35.8) 451 (46.6)⁎

8732 (6.8) 450 (16.9)⁎

8591 (15.7) 691 (36.8)⁎

8554 (35.4) 688 (47.4)⁎

8498 (6.4) 684 (19.3)⁎

8384 (15.6) 898 (32.5)⁎

8346 (35.5) 896 (43.6)⁎

8297 (6.4) 885 (16.0)⁎

8160 (15.6) 1122 (29.5)⁎

8130 (35.5) 1112 (42.4)⁎

8081 (6.5) 1101 (13.6)⁎

8027 (15.2) 1001 (27.1)⁎

7989 (35.5) 1001 (43.3)⁎

7937 (6.6) 990 (12.5)⁎ (continued on next page)

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Table 1 (continued)

Major Lived with problem drinker or alcoholic before age of 17 years Nom Yes Service member characteristics Military pay grade Junior enlisted (E1–E4)m Senior enlisted (E5–E7)h Officer/warrant officer Service component Active dutym Reserve/National Guard Service branch Armym Navy/Coast Guard Air Force Marine Corps Exposures of interestl Currently deployedi Nom Yes Ever deployedj Nom Yes Most recent deployment (months ago)k Currently deployed ≤6 > 6–12 > 12–24 > 24m Service member communicated about deployment experiences with spousee Nom Yes Extent deployment experiences were communicatede None A littlem Somewhat A lot Bothered by communicated deployment experiencesf Not at allm A little bit Moderately Quite a bit Extremely A combat-related deployment or duty assignment for a Service memberg Nom Yes Perceived level of stress in a spouse associated with a combat- related deployment or duty assignment of a Service member Not at all stressfulm Slightly stressful Moderately stressful Very stressful A combat-related injury to a Service member Nom Yes Perceived level of stress in a spouse associated with a combat- related injury to a Service member Not at all stressfulm Slightly stressful Moderately stressful Very stressful Providing care for an ill, injured, or disabled Service member Nom Yes

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Current smoking

Risky drinking

Problem drinking

Total N (% current smoking)

Total N (% risky drinking)

Total N (% problem drinking)

254 (41.7)⁎

252 (35.7)

255 (9.0)

7071 (14.5) 2211 (25.9)⁎

7035 (34.2) 2207 (43.1)⁎

6991 (6.3) 2191 (10.7)⁎

4835 (22.8) 2142 (18.0)⁎ 2305 (4.8)⁎

4809 (37.2) 2135 (36.8) 2298 (34.0)⁎

4794 (7.6) 2119 (8.4) 2269 (5.8)⁎

7228 (17.0) 2054 (18.1)

7196 (36.5) 2046 (35.6)

7150 (7.2) 2032 (7.8)

4272 (21.3) 1575 (15.0)⁎ 2550 (12.6)⁎ 885 (15.1)⁎

4249 (36.5) 1567 (38.8) 2544 (32.0)⁎ 882 (43.9)⁎

4236 (8.2) 1561 (7.8) 2505 (4.9)⁎ 880 (9.3)

8713 (17.2) 569 (17.9)

8674 (36.3) 568 (37.3)

8621 (7.2) 561 (8.6)

2909 (16.5) 6373 (17.6)

2902 (34.5) 6340 (37.2)⁎

2870 (6.6) 6312 (7.7)

569 (17.9) 714 (17.4) 838 (18.0) 1798 (17.7) 2454 (17.3)

568 (37.3) 712 (37.9) 837 (39.1) 1782 (37.8) 2441 (35.8)

561 (8.6) 709 (8.7) 830 (7.5) 1777 (7.5) 2435 (7.3)

36 (33.3) 5994 (17.5)⁎

36 (50.0) 5966 (37.1)

36 (11.1) 5938 (7.7)

36 (33.3)⁎ 2045 (18.6) 1993 (15.7)⁎ 1956 (18.4)

36 (50.0) 2037 (36.1) 1976 (37.0) 1953 (38.3)

36 (11.1) 2027 (8.1) 1971 (7.4) 1940 (7.7)

2352 (16.2)⁎⁎ 2013 (16.0) 1005 (18.8) 449 (24.7)⁎ 175 (26.9)⁎

2342 (34.0)⁎⁎ 2006 (36.7) 998 (42.7)⁎ 445 (40.9)⁎ 175 (42.3)⁎

2334 (5.9)⁎⁎ 1994 (8.0)⁎ 993 (8.3)⁎ 441 (11.6)⁎ 176 (16.5)⁎

5587 (16.4) 3583 (18.4)⁎

5566 (35.7) 3565 (37.6)

5525 (7.0) 3547 (7.8)

371 (22.4) 772 (18.4) 1099 (16.2)⁎ 1341 (19.2)

367 (30.5)⁎⁎ 765 (33.6) 1094 (40.2)⁎ 1339 (39.7)⁎

368 (4.9)⁎⁎ 765 (4.8) 1086 (7.8) 1328 (10.4)⁎

7657 (16.5) 1505 (21.3)⁎

7628 (36.3) 1495 (37.5)

7569 (7.0) 1496 (9.3)⁎

358 357 293 497

355 354 292 494

356 354 293 493

(20.7) (21.8) (20.8) (21.5)

7035 (16.1) 2121 (21.1)⁎

(34.4) (37.0) (42.1) (37.2)

7009 (35.8) 2108 (38.7)⁎

(8.1)⁎⁎ (5.9) (11.6) (11.2)

6956 (6.9) 2103 (8.8)⁎ (continued on next page)

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Table 1 (continued)

Perceived level of stress in a spouse associated with providing care for an ill, injured, or disabled Service member Not at all stressfulm Slightly stressful Moderately stressful Very stressful

Current smoking

Risky drinking

Problem drinking

Total N (% current smoking)

Total N (% risky drinking)

Total N (% problem drinking)

687 617 412 405

685 609 407 407

686 608 405 404

(20.5) (20.6) (21.8) (22.0)

(39.1) (38.3) (42.3) (35.1)

(6.7)⁎⁎ (8.6) (11.1)⁎ (10.6)⁎

Note. % is row percentage. BMI = body mass index; CTS = Contingency Tracking System; DMDC = Defense Manpower Data Center; PCL-C = PTSD Checklist–Civilian Version; PHQ9 = Patient Health Questionnaire; PTSD = posttraumatic stress disorder; SD = standard deviation. a Depression was assessed using the nine depression items of the PHQ-9. b PTSD was assessed using the PCL-C. c Fifteen panic items and six generalized anxiety items from the comprehensive PHQ were used to assess presence of panic or other anxiety syndromes. d History of life stress was determined using a shortened version of the Holmes and Rahe Social Readjustment Rating Scale, focusing on experiences such as divorce, financial problems, sexual or violent assaults, or death of a family member. e The survey asked “How much has your (Service member) spouse shared his/her deployment experiences with you?” f The survey asked “To what extent were/are you bothered by the deployment experiences your (Service member) spouse shared with you?” g The survey asked “For each of the following stressful (military) situations you and your family personally experienced in the past 12 months, please indicate how stressful you felt it was for you and your family.” h The highest senior enlisted (E8–E9) were not included in this study population. i Currently deployed at the time of survey completion. Deployment data were from the DMDC CTS database. j Ever deployed prior to the survey completion date. Deployment data were from the DMDC CTS database. k The time since the most recent deployment was calculated by the difference between the military spouse's survey completion date and the Service member's most recent deployment, determined by the CTS database. l Sample sizes for each variable will differ due to variations in sample size within each hypothesis and missing data. m Reference category. ⁎ p < 0.05 for all deployment-related exposures. ⁎⁎ Two-sided Cochrane-Armitage trend test, univariable p < 0.05. † Means and SDs of the sample population and outcome subpopulations are included.

mental health, and Service member military characteristics by current cigarette smoking, risky drinking, and problem drinking behaviors among military spouses. Multivariable logistic regression models were fit for each of the three outcomes of interest in relation to the main exposures of Service member deployment history and other potentially stressful deployment-related experiences, while adjusting for all covariates described above. We computed odds ratios (ORs) and 95% confidence intervals (CIs). Multicollinearity was assessed using the variance inflation factor, with a value of > 4 suggesting presence of this condition (Harrell, Lee, & Mark, 1996). Data management and statistical analyses were conducted using SAS software (version 9.3, SAS Institute, Inc., Cary, NC). The analyses for this study were planned and executed prior to the availability of Family Study survey weights, which were developed based on nonresponse propensity modeling (Rosenbaum & Rubin, 1984). Therefore, the primary analyses for the present study were conducted without weights. However, we repeated our analyses using the weights once they became available.

2.4. Covariates To evaluate mental health issues that could potentially be associated with tobacco and alcohol use as maladaptive coping mechanisms, we assessed spousal symptoms of depression, panic, and anxiety as determined by the PHQ, as well as posttraumatic stress disorder (PTSD) using the PTSD Checklist–Civilian Version (American Psychiatric Association, 1994; Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Kroenke et al., 2001; Spitzer, Williams, Kroenke, Hornyak, & McMurray, 2000; Spitzer et al., 1994; Weathers, Litz, Herman, Huska, & Keane, 1993, October). Use of any medications for anxiety, depression, or stress was assessed by one item on the PHQ. Stressful life events and family history of alcohol misuse were selected a priori as covariates based on previous literature (Dimiceli et al., 2010; Lester et al., 2010). A history of life stressors was measured using a shortened version of the Holmes and Rahe Social Readjustment Rating Scale (Holmes & Rahe, 1967), focusing on lifetime experiences such as divorce, financial problems, sexual or violent assaults, or death of a family member. Additionally, spouses were asked if they lived with a problem drinker or alcoholic before the age of 17 years. Spouses' self-reported demographic characteristics, body mass index, educational level, annual household income, employment status, number of children from current or prior relationships, years married, and current or prior military service were also included in analyses. Service member military-specific variables obtained from DMDC records included pay grade, service component, deployment history, and service branch.

3. Results Table 1 presents the population characteristics of military spouses and Service members, as well as the prevalence of current smoking, risky drinking, and problem drinking by characteristic subgroup. In order to model each of the three spousal behaviors, three subpopulations were determined for these analyses: cigarette smoking, risky drinking, and problem drinking. After ensuring participants were still married at the time the survey was completed and accounting for missing data for focal health behaviors and covariates, the number of spouses eligible for analyses was reduced to 9382 for cigarette smoking, 9242 for risky drinking, and 9182 for problem drinking. Across the three subpopulations, participants were mostly female (87%), with an average age of 28.5 years, of non-Hispanic White ethnicity (79%), and

2.5. Statistical analyses Unadjusted descriptive statistics including chi-squared (χ2) and Cochran-Armitage tests for trends were performed to compare the exposures of interest, demographic characteristics, behavioral health, 125

126

No Yes Not at all stressful Slightly stressful Moderately stressful Very stressful No Yes Not at all stressful Slightly stressful Moderately stressful Very stressful No Yes Not at all stressful Slightly stressful Moderately stressful Very stressful

No Yes None A little Somewhat A lot Not at all A little bit Moderately Quite a bit Extremely

No Yes

Category

1.00 1.05 1.00 0.85 0.76 0.79 1.00 0.99 1.00 1.15 1.04 0.93 1.00 0.94 1.00 1.04 1.03 0.90

1.00 0.45 2.19 1.00 0.89 1.08 1.00 0.98 1.04 1.34 1.14

(0.78–1.40) (0.74–1.43) (0.64–1.26)

(0.82–1.08)

(0.77–1.70) (0.68–1.59) (0.63–1.36)

(0.85–1.15)

(0.61–1.18) (0.55–1.04) (0.58–1.08)

(0.93–1.20)

(0.83–1.17) (0.84–1.28) (1.03–1.75) (0.77–1.69)

(0.74–1.06) (0.90–1.29)

(0.21–0.96) (1.02–4.69)

1.00 1.15 (0.90–1.46)

AOR (95% CI)a

0.85

0.37

0.74

0.88

0.35

0.42

0.23

0.03

0.04

0.26

p⁎

Current cigarette smoking

2121

9156

1505

9162

3583

9170

5994

6030

6030

9282

n

1.00 1.05 1.00 1.13 1.51 1.35 1.00 0.99 1.00 1.13 1.23 1.06 1.00 1.05 1.00 0.96 1.07 0.80

1.00 0.59 1.74 1.00 1.05 1.05 1.00 1.15 1.40 1.26 1.11

(0.76–1.21) (0.82–1.40) (0.60–1.05)

(0.94–1.17)

(0.81–1.57) (0.87–1.74) (0.77–1.45)

(0.87–1.12)

(0.85–1.50) (1.15–1.98) (1.03–1.76)

(0.95–1.16)

(1.01–1.32) (1.18–1.64) (1.01–1.58) (0.79–1.56)

(0.91–1.20) (0.92–1.21)

(0.29–1.19) (0.86–3.53)

1.00 1.11 (0.92–1.34)

AOR (95% CI)a

Risky drinking

0.25

0.42

0.67

0.87

< 0.01

0.34

< 0.01

0.43

0.14

0.26

p⁎

2108

9117

1495

9123

3565

9131

5966

6002

6002

9242

n

1.00 1.02 1.00 0.93 1.58 1.83 1.00 1.19 1.00 0.63 1.23 1.07 1.00 1.07 1.00 1.30 1.43 1.22

1.00 0.82 1.15 1.00 0.92 0.91 1.00 1.36 1.17 1.62 1.93

(0.84–2.02) (0.90–2.26) (0.76–1.96)

(0.89–1.30)

(0.34–1.16) (0.70–2.17) (0.63–1.82)

(0.96–1.47)

(0.51–1.68) (0.92–2.73) (1.08–3.12)

(0.85–1.22)

(1.07–1.75) (0.87–1.58) (1.13–2.33) (1.20–3.10)

(0.73–1.18) (0.71–1.16)

(0.27–2.48) (0.38–3.47)

1.00 1.25 (0.91–1.72)

AOR (95% CI)a

Problem drinking

0.47

0.47

0.15

0.12

< 0.01

0.87

< 0.01

0.85

0.73

0.17

p⁎

2103

9059

1496

9065

3547

9072

5938

5974

5974

9182

n

Note. AOR = adjusted odds ratio; CI = confidence interval. a Odds ratios were adjusted for the following variables: age; sex; race/ethnicity; body mass index; education; income; employment; spouse military service; number of children; years married; depression; posttraumatic stress disorder; panic/ anxiety; medication use for stress, depression, or anxiety; life stressors; living with an alcoholic before the age of 17 years; Service member's service branch; pay grade; and service component. b Service member currently deployed at the time the survey was completed by spouse. Deployment data were from the Defense Manpower Data Center Contingency Tracking System database. c The survey asked “How much has your (Service member) spouse shared his/her deployment experiences with you?” d The survey asked “To what extent were/are you bothered by the deployment experiences your (Service member) spouse shared with you?” e The survey asked “For each of the following stressful situations you and your family personally experienced in the past 12 months, please indicate how stressful you felt it was for you and your family.” ⁎ Overall p value.

Perceived level of stress in spouse associated with providing care for an ill, injured, or disabled Service membere

Providing care for an ill, injured, or disabled Service member

Perceived level of stress in spouse associated with a combat-related injury to a Service member

A combat-related injury to a Service member

Perceived level of stress in spouse associated with a combat-related deployment or duty assignment of a Service member

Stressful military life experiences (as reported by military spouse)d A combat-related deployment or duty assignment for a Service member

Bothered by communicated deployment experiences

d

Extent deployment experiences were communicatedc

Communication about deployments (as reported by military spouse) Service member communicated about deployment experiences with spousec

Service member Currently deployedb

Characteristic

Table 2 Multivariable adjusted odds ratios of current cigarette smoking, risky drinking, and problem drinking in relation to deployment, communication about deployments, and stressful military life experiences, among military spouses.

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exploring additive effects of cigarette smoking and alcohol misuse (data not shown). Results of secondary analyses, in which data were weighted to address nonresponse, were largely similar (Supplementary Table 1). However, the overall prevalence rates for our three substance use outcomes were slightly higher by 1–3%. There were four small additional significance effects in our multivariable models. Spouses providing care for an ill, injured, or disabled Service member (unweighted p = 0.42; weighted p = 0.03) and those reporting at least moderate stress related to caregiving (unweighted p = 0.25; weighted p = 0.03) had somewhat higher odds of risky drinking; spouses who reported at least a slight level of stress associated with a partner's combat-related injury had higher odds of problem drinking (unweighted p = 0.15; weighted p = 0.02); and spouses whose Service members communicated about deployment did not have a statistically significant lower odds of smoking (unweighted p = 0.04; weighted p = 0.08).

had an associate degree or less education (59%). The Service members of the enrolled Family Cohort participants were primarily Army (46%), of enlisted rank (75%), active duty (78%), and deployed at least once in support of the recent operations in Iraq and Afghanistan (69%). Overall, current smoking was reported by 17.2% of spouses, risky drinking by 36.3%, and problem drinking by 7.3%. The prevalence rates for all outcomes were significantly higher among male spouses; those who screened positive for major depression, PTSD, or panic/other anxiety disorder; those taking medication for anxiety, depression, or stress; those who reported moderate life stressors; and those who lived with a problem drinker or alcoholic before the age of 17 years. The rates of current smoking, risky drinking, and problem drinking were lower among spouses of officers/warrant officers and those married to Service members in the Air Force. Current deployment of a Service member did not impact the prevalence of smoking or alcohol misuse among spouses, although a higher prevalence of risky drinking was observed among spouses of Service members who had a previous deployment. Couple communication during deployment resulted in a lower prevalence of smoking among spouses; however, spouses who were more than moderately bothered by these communications reported higher rates of smoking. Higher prevalence of smoking was observed among spouses who experienced any of the three deployment-related events examined. Spouses of Service members who experienced a combat injury also had increased rates of problem drinking, and caring for an ill, injured, or disabled spouse resulted in increased rates of all three behaviors of interest. A statistically significant positive trend was seen with the degree to which the spouse was bothered by the communicated deployment experiences and the prevalence of all three outcomes. A positive trend was also seen with the spouse's perceived level of stress associated with a combat-related deployment or duty assignment and the prevalence of risky and problem drinking. Likewise, a statistically significant positive trend was observed for the following factors: spouse's perceived level of stress related to a combat-related injury; the perceived level of stress associated with providing care for an ill, injured, or disabled Service member; and the prevalence of problem drinking. The independent associations between the current deployment of a Service member, Service member–spouse deployment communication, and three stressful deployment-related experiences are shown in Table 2. We did not find a significant association between current cigarette smoking, risky drinking, or problem drinking and Service member being currently deployed after adjusting for all covariates. Spouses of Service members who communicated about their deployment experiences had significantly lower odds of being a current smoker compared with those whose Service members did not communicate about deployment experiences (OR = 0.45, 95% CI: 0.21–0.96) after adjusting for all covariates. We did not find a significant association between current smoking and any of the other exposures of interest (Table 2). Among spouses whose Service member communicated about their deployment experiences, those who were bothered at least “a little bit” had higher odds of being a risky or problem drinker. Among spouses whose Service member had any combat-related deployment or duty assignment in the past year, those who reported at least a moderate level of associated stress had higher odds of being risky drinkers, while those who reported being very stressed had higher odds of being problem drinkers. No other exposures of interest were independently associated with either alcohol misuse outcome (Table 2). Additional analyses on the clustering of cigarette smoking, risky drinking or problem drinking compared different clustering levels with the objective to explore the difference between groups in deployment status and stressful military life experiences. The reference group was no cigarette smoking and no alcohol misuse, with the other categories being only cigarette smoking, only alcohol misuse, and the more extreme behaviour being both cigarette smoking and alcohol misuse. There were no additional significant effects in the multivariable models

4. Discussion To our knowledge, this study is the first to examine risk factors for current cigarette smoking, risky drinking, and problem drinking among spouses of U.S. Service members. We found that current Service member deployment was not associated with spousal smoking or drinking behaviors; however, communication about deployment experiences was associated with lower odds of smoking (55% lower odds) but not risky or problem drinking. Spouses bothered by communicated deployment experiences and those who reported feeling very stressed by a recent combat-related deployment or duty assignment for their Service member had consistently higher odds of both risky (15–40% higher odds) and problem drinking (36–93% higher odds). While deployment has been reported to be stressful for military spouses and detrimental to marriages, our findings suggest that contextual characteristics about the deployment experience, as well as the perceived stress of those experiences, may be more impactful than the simple fact of deployment itself (de Burgh et al., 2011; Dimiceli et al., 2010; Padden, Connors, & Agazio, 2011). Communication between spouses about deployment experiences was associated with current smoking in this population, with a 2-fold reduction in smoking risk found between couples who communicated versus those who did not. Research suggests that communication between spouses during deployment is beneficial to both partners and can result in lower temper, better coping, and less stressful reactions (Houston, Pfefferbaum, Sherman, Melson, & Brand, 2013; Merolla, 2010). Given the well-known association between stress and smoking (Boyko et al., 2015; Choi, Ota, & Watanuki, 2015), it is understandable that increased communication may reduce the risk of stress-induced smoking. Like smoking, drinking may be used as a maladaptive coping mechanism to deal with stress (Sacco, Bucholz, & Harrington, 2014). Spouses who perceived their Service member's combat-related deployment or duty assignment as at least moderately stressful were more likely to misuse alcohol. Our observation of higher odds of both risky and problem drinking in spouses in relation to greater deployment-related stress is consistent with the theory that these behaviors may be serving as maladaptive coping mechanisms. Smoking prevalence in our study population was slightly lower than the U.S. national smoking prevalence in 2010 (17.2% vs. 19.3%) (Centers for Disease Control and Prevention, 2011). Since women have a lower prevalence of smoking than men, this lower overall prevalence may be due to a larger proportion of women in our sample than the U.S. population (87.2% vs. 50.8%) (Howden, Meyer, & Census Bureau, 2011). Consistent with other studies (Barbeau, Krieger, & Soobader, 2004; Power et al., 2005), we found participants with a lower educational level and household income had a higher prevalence of smoking compared with those who had attained a higher educational degree or reported a higher household income. To reduce smoking prevalence in 127

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between deployment and military-related experiences and the wellbeing of military families, and the resulting impact on force readiness, is critically important to the DoD, Department of Veterans Affairs, and society in general (Sheppard, Malatras, & Israel, 2010). These results suggest that considering the impact of deployment experiences on military spouses reveals important dimensions of military community adaptation and risk. Supplementary data to this article can be found online at https:// doi.org/10.1016/j.addbeh.2017.09.015.

military spouses, tailoring cessation and prevention efforts to these specific populations may be warranted. However, we did not find that higher educational achievement was linked with lower prevalence rates for either risky or problem drinking. In fact, participants in the two highest household income brackets were more likely to be risky drinkers than participants with low household income. This finding is consistent with previous research (Humensky, 2010) that found young adults with high socioeconomic status were more likely to engage in alcohol and illicit drug use. Policymakers should consider targeting those with higher household incomes for risky drinking reduction campaigns. In addition, various deployment-related stressors may play a role in tobacco use and alcohol misuse of military spouses and potentially affect the children of military couples (Lester et al., 2010), perpetuating a transgenerational cycle of substance dependence and misuse. Findings indicate parental combat deployment has a cumulative effect on children which remains even after the deployed parent returns home, and is predicted by psychological distress of both the active duty and at-home civilian parent (Lester et al., 2010). Further research is needed to assess the long-term trends and risk factors for risky drinking in this population. Several limitations and strengths should be noted. The study population consisted of a sample of responders married to opposite sexed Service members enrolled in the Millennium Cohort Study and may not be representative of all military spouses. However, the Millennium Cohort Study was oversampled for married and female Service members to enroll a powered sample of 10,000 in the Family Study; 9872 were enrolled. In addition, the study has broad representation of the U.S. military by virtue of including Service members from all military branches as well as reservists and National Guard members. Nonresponse in the Family Study may have limited generalizability of the findings, and our primary analyses did not account for response bias. However, results of our secondary analyses, in which weights were applied to address non-response (Supplementary Table 1), suggest the primary findings were likely conservative estimates that somewhat underestimate the extent of substance use in this cohort of military spouses of young Service members. The number of spouses who reported no communication with Service members about deployment experiences was small, but sufficient to detect a statistically significant association with current smoking. Much of the data were derived from self-report and may be subject to recall bias. Also, the measure used to assess tobacco use was during the past year and may not represent current smoking behaviors. Due to the cross-sectional study design, temporal relationships could not be determined. Specifically, the study design does not permit us to determine whether Service member deployment preceded the spouse's behaviors of interest. Finally, since we had a priori hypotheses we planned to test, the multiple comparisons conducted in this study were not accounted for by adjusting the alpha level for rejection of the null hypothesis. In conclusion, we found that current deployment was not associated with smoking or drinking behaviors among military spouses, but quantity of communication regarding deployment experiences and the spouses' reaction to these communications were associated with higher odds of these outcomes. To better assess these associations, longitudinal research using follow-up data from the Millennium Cohort Family Study is needed to determine if deployment, intra-spouse communication, and spousal reaction to communicated experiences precedes a change in drinking and smoking habits among military spouses. Additionally, future examinations of how concordance and discordance in smoking and drinking behaviors of military couples may moderate these associations are warranted. As the Millennium Cohort Family Study follow-up data for this longitudinal effort become available, it will be possible to further investigate some of these prospective dyadic associations. These longitudinal efforts, in conjunction with the present findings, may guide the implementation of targeted interventions that facilitate improvement in couples' communications about deployment, as well as reductions in spouse's stress. Understanding the associations

Role of funding sponsors This work was supported by the U.S. Navy agreement NMR4070–13, under the Naval Health Research Center work unit no. 60002, and by the U.S. Department of Veterans Affairs Clinical Science Research and Development Merit Award (ZDA1–04-W10). Dr. Littman was supported by a Rehabilitation Research and Development Career Development Award (CDA 6892). Dr. Williams is supported by a Career Development Award from VA Health Services Research and Development (CDA 12–276). The first author is an employee of the U.S. Government. This work was prepared as part of his official duties. Title 17 U.S.C. § 105 provides the “Copyright protection under this title is not available for any work of the United States Government.” Title 17U.S.C. § 101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person's official duties. The views expressed in this research are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of the Air Force, Department of Veterans Affairs, Department of Defense, or the U.S. Government. Approved for public release; distribution unlimited. Human subjects participated in this study after giving their free and informed consent. This research has been conducted in compliance with all applicable federal regulations governing the protection of human subjects in research (Protocol NHRC.2015.0019). Contributors E. J. Boyko led all aspects of this project, from conceptualization to science approval of the final manuscript. D. W. Trone aided in the conceptualization, design, took the lead in the progress of the project, and wrote the final manuscript. T. M. Powell contributed to all aspects of this project, including conceptualization and design, ran all analyses, assisted in interpretation of results, and was responsible for the statistical analyses section. L. M. Bauer contributed to conceptualization and design, data collection, and assisted T. M. Powell with analyses. A. D. Seelig contributed to conceptualization and design, interpretation of results, and drafting and revision of the manuscript. A. V. Peterson took the lead in the design of statistical methods for this manuscript and aided in the overall conceptualization and design of the project and interpretation of results. A. J. Littman, E. C. Williams, C. Maynard, and J. B. Bricker contributed to the conceptualization and design of the analyses and the interpretation of results. All authors were personally and actively involved in substantive work leading to this manuscript; read and reviewed the final version of the manuscript and approved it for publication; acknowledge they exercised due care in ensuring the integrity and validity of the work; and hold themselves jointly and individually responsible for its content. Conflict of interest All authors declare that they have no conflicts of interest. Disclaimer I am a military service member (or employee of the U.S. 128

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Government). This work was prepared as part of my official duties. Title 17 U.S.C. § 105 provides the “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. § 101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person's official duties. Report No. 17-25 was supported by NMR4070-13, under work unit no. 60002, and by the U.S. Department of Veterans Affairs Clinical Science Research and Development Merit Award (ZDA1-04-W10). Dr. Littman was supported by a Rehabilitation Research and Development Career Development Award (CDA 6892). Dr. Williams is supported by a Career Development Award from VA Health Services Research and Development (CDA 12-276). The views expressed in this research are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of the Air Force, Department of Veterans Affairs, Department of Defense, or the U.S. Government. Approved for public release; distribution unlimited. Human subjects participated in this study after giving their free and informed consent. This research has been conducted in compliance with all applicable federal regulations governing the protection of human subjects in research (Protocol NHRC.2015.0019). Acknowledgments The Family Study Team includes Carlos Carballo, CPT Carrie Donoho, CDR Dennis Faix, Cynthia LeardMann, William Lee, Gordon Lynch, Hope McMaster, Christopher O'Malley, Serguey Parkhomovsky, Steven Speigle, Valerie Stander, and Evelyn Sun. Family Study Co-Investigators are William Schlenger, Nida Corry (Abt Associates), Charles Marmar and Maria Steenkamp (New York University), and John Fairbank and Ellen Gerrity (Duke University). The Millennium Cohort Study Team includes Richard Armenta, Deborah Bookwalter, CPT Adam Cooper, James Davies, CPT Carrie Donoho, CDR Dennis Faix, Lt Col Susan Farrish, Kathleen Gunn, Isabel Jacobson, Claire Kolaja, So Yeon Kong, Cynthia LeardMann, William Lee, Denise Lovec-Jenkins, Kyna Long, Gordon Lynch, Rayna Matsuno, Danielle Mitchell, Chiping Nieh, Anna Rivera, Chris O'Malley, Anet Petrosyan, Christopher Phillips, Ben Porter, Rudy Rull, Kari Sausedo, Beverly Sheppard, Steven Speigle, Laura Tobin, and Jennifer Walstrom. Project collaborator: Kara Bensely, Department of Health Services, University of Washington School of Public Health. References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Barbeau, E. M., Krieger, N., & Soobader, M. J. (2004). Working class matters: Socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. American Journal of Public Health, 94(2), 269–278. Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD checklist (PCL). Behaviour Research and Therapy, 34(8), 669–673. Boyko, E. J., Trone, D. W., Peterson, A. V., Jacobson, I. G., Littman, A. J., Maynard, C., et al. (2015). Longitudinal investigation of smoking initiation and relapse among younger and older US military personnel. American Journal of Public Health, 105(6), 1220–1229. http://dx.doi.org/10.2105/AJPH.2014.302538. Brady, K. T., & Sonne, S. C. (1999). The role of stress in alcohol use, alcoholism treatment, and relapse. Alcohol Research & Health, 23(4), 263–271. Centers for Disease Control and Prevention (2011). Vital signs: Current cigarette smoking among adults aged ≥ 18 years – United States, 2005–2010. MMWR. Morbidity and Mortality Weekly Report, 60(35), 1207–1212. Choi, D., Ota, S., & Watanuki, S. (2015). Does cigarette smoking relieve stress? Evidence from the event-related potential (ERP). International Journal of Psychophysiology, 98(3 Pt 1), 470–476. http://dx.doi.org/10.1016/j.ijpsycho.2015.1010.1005. Crum-Cianflone, N. F., Fairbank, J. A., Marmar, C. R., & Schlenger, W. (2014). The Millennium Cohort Family Study: A prospective evaluation of the health and wellbeing of military service members and their families. International Journal of Methods in Psychiatric Research, 23(3), 320–330. http://dx.doi.org/10.1002/mpr.1446. Dawson, D. A., Grant, B. F., & Li, T. K. (2005). Quantifying the risks associated with exceeding recommended drinking limits. Alcoholism, Clinical and Experimental Research, 29(5), 902–908.

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