, 2009). The observed imbalance of ST use studies among the service branches may be attributable, at least in part, to varying institutional review board (IRB) requirements across Ganetespib OSA the service branches. Because each branch has its own set of procedures in place for obtaining IRB and other military approvals, the obstacles to engaging in data collection across the service branches can be formidable. A standardized or centralized IRB approval process would help to reduce this limiting factor. Clinical Implications The results of this literature review have a number of important clinical implications. Broadly, the findings indicate that ST use represents an important target for intervention in the U.S. military population because it impairs ��military readiness�� and hurts the health of the military.

Prevalence estimates of ST use across all studies were high, even when compared with demographically similar nonmilitary populations, suggesting that military personnel carry a disproportionate burden of ST use and its associated risks. Targeted interventions are needed to reduce ST use in this population. In addition to a high overall prevalence of ST use, the review found that many military personnel use both cigarettes and ST concurrently. Concurrent use was reported in nearly half of the studies (n = 19). From an intervention perspective, concurrent use presents a unique challenge for intervening with ST use in population. Dual users are exposed to higher levels of nicotine (Wetter et al., 2002), may be less likely to make a quit attempt (Hatsukami & Severson, 1999; Tomar, Alpert, & Connolly, 2010; Walsh et al.

, 2010), and more likely to relapse (Wetter et al., 2002). The extent to which existing cessation approaches are effective in addressing concurrent use patterns of tobacco use is largely unknown. New strategies may be needed to effectively address the problem of concurrent use in this population. It is noteworthy that the current review identified only a handful of ST intervention studies involving military personnel (n = 5). Three of these studies were conducted in the Air Force, one in the Army, and one with participants from multiple branches. Only one intervention study had both a behavioral and a pharmacological component (Shipley et al., 2002). The results of these studies suggest that it is possible to effectively intervene with ST use in this population.

However, more intervention studies are clearly needed. Future Directions To address significant gaps in research on ST use in the military, we offer the following recommendations. First, more longitudinal and cohort studies of ST use are needed in this population. Such studies would provide a better understanding GSK-3 of important critical periods for intervening with ST use. In particular, more research is needed that examines the developmental trajectories of tobacco use among military personnel.