Keeping veterans healthy is a priority for the Veterans Health Administration. Smoking is a known risk factor for poor health. In the past, the military had a history and culture supporting smoking. Many veterans began smoking during their service. Although 57% of the U.S. population reports
There were 19.9 million veterans in the United States in 2017 [
A modifiable behavior, such as smoking, is a risk factor for chronic conditions including metabolic disorders, cardiovascular diseases, and
Periodic, regular, and professional dental visits help dentists to prevent, control, delay, or treat dental problems [
Within national data sets, there is a lack of information on U.S. veterans. A U.S. veteran is any person who served on active duty in the U.S. Armed Forces (Army, Navy, Air Force, Marine Corps, and Coast Guard). The researchers of existent studies have consistently identified dental care as a critical need for veterans. For example, researchers in a Massachusetts county identified oral health as the greatest unmet need among veterans [
Dental emergencies have a negative effect on military operations, should someone be recalled to duty [
The Andersen Expanded Behavioral Model is a theoretical model which is used to explain general healthcare utilization and the risk factors that influence healthcare utilization. It was chosen as the theoretical framework for this study on
The analyses included frequency analyses and weighted percentage estimates of the sample. Bivariate analyses (chi-square analyses) were conducted to determine associations between smoking status, sex, race/ethnicity, age, marital status, education, income, insurance, and self-reported health status with dental care utilization. The level of significance selected,
This study received an acknowledgment as nonhuman subject research (protocol 1511920072) from the researchers’ academic institutional review board. A cross-sectional study design was used involving secondary data analyses of previously collected public data from the National Survey of Veterans, 2010 (NSV2010) [
The primary aim of the NSV2010 data source was to survey veterans with the purpose of planning and allocating resources for veterans [
This study included veterans, aged 20 years and above, from the NSV2010 study who had complete data on the dental visit, smoking status, sex, race, age, marital status, income, insurance adequacy, and self-reported health status. The final study sample included the data from 6,308 veterans.
The key variable was dental care utilization within the previous six months (Yes, No). Information for this variable was gathered from the NSV2010 question “In the last six months, have you had any dental care or visited a dentist?” [
The key independent variable was smoking status. Participants were asked in the NSV2010 if they had smoked at least 100 cigarettes in their lifetime. The question had dichotomous response categories of “Yes” (to indicate current or former smokers) or “No” (to indicate never smokers). A follow-up question was posed to respondents who endorsed “Yes” to the previous question. The veteran was asked if he or she smoked cigarettes now with “Yes” being used to identify a current smoker and “No” being used to identify a former smoker. Both questions were used to create the smoking variable (current smoker, past smoker, and nonsmoker) for this current study.
Other variables are known to be associated with access and utilization of dental services and/or be potential explanatory or confounding variables. Of these potential variables, the following were available to be included in the analyses: sex (categorized as male or female); race/ethnicity (categorized as White or Other due to the small number of minorities in the survey); age in years (50 years and above, 35 years to less than 50 years , and 20 years to less than 35 years as the 2010 survey did not have participants who were born before 1991; that is, it did not include participants ages 18 years to less than 20 years); marital status (categorized as married or not married); education (categorized as high school graduate or less, some college, college degree or more); income (categorized as less than $20,000, $20,000 to less than $30,000, or $30,000 and above); insurance (categorized as adequate, or inadequate: based on the question “my family has a health insurance plan that adequately covers me and my family” [
There were 6,308 veterans in this study sample. Most were male (91.6%) and White (86.9%). Almost two-thirds (64.5%) were current or past smokers and 35.4% reported never smoking. There were 55.3% who reported having a dental visit within the previous six months. Details are presented in Table
Sample characteristics of veterans from the National Survey of Veterans, 2010.
All | Total | |
---|---|---|
N = 6,261 | wt.% = 100.0 | |
|
||
Female | 412 | 8.4 |
Male | 5,849 | 91.6 |
|
||
White | 5,719 | 86.9 |
Other race | 542 | 13.1 |
|
||
50 and above | 2,862 | 39.2 |
35 to less than 50 | 2,322 | 33.8 |
20 to less than 35 | 1,077 | 27.0 |
|
||
Married | 4,650 | 71.1 |
No | 1,611 | 28.9 |
|
||
Less than HS/HS degree | 1,938 | 30.9 |
Some college | 1,847 | 30.8 |
College degree/above | 2,476 | 38.2 |
|
||
Less than $20,000 | 769 | 13.8 |
$20,000 to less than $30,000 | 814 | 12.8 |
$30,000 and above | 4,678 | 73.4 |
|
||
Adequate | 4,203 | 66.2 |
Inadequate | 2,058 | 33.8 |
|
||
Excellent/very good/good | 4,499 | 73.0 |
Fair/poor | 1,762 | 27.0 |
|
||
Current smoker | 1,099 | 19.9 |
Past smoker | 3,025 | 44.6 |
Never smoked | 2,137 | 35.5 |
|
||
Excellent/very good/good | 3,675 | 59.1 |
Fair/poor | 2,586 | 40.9 |
|
||
Rural route | 4,737 | 80.1 |
Street address | 671 | 6.5 |
U.S. PO box/other box | 29 | 0.3 |
Missing | 814 | 13.2 |
|
||
Yes | 3,684 | 55.3 |
No | 2,577 | 43.7 |
The Rao-Scott chi-square test results for dental visits within the previous six months and smoking and other variables are presented in Table
Veteran reports of dental care utilization within the previous 6 months by the National Survey of Veterans, 2010.
All | Not reported dental care utilization within 6 months | Reported dental care utilization within 6 months |
| ||
---|---|---|---|---|---|
|
wt.% |
|
wt.% | ||
|
0.8104 | ||||
Male | 2,414 | 43.8 | 3,435 | 56.0 | |
Female | 163 | 43.0 | 249 | 57.0 | |
|
<0.0001 | ||||
White | 2,277 | 41.5 | 3,442 | 58.5 | |
Other | 300 | 58.5 | 242 | 41.5 | |
|
<0.0001 | ||||
50 and above | 1,127 | 40.1 | 1,735 | 59.9 | |
35 to less than 50 | 924 | 41.5 | 1,398 | 58.5 | |
20 to less than 35 | 526 | 51.6 | 551 | 48.4 | |
|
<0.0001 | ||||
Married | 1,715 | 38.7 | 2,935 | 61.3 | |
No | 862 | 56.1 | 749 | 43.9 | |
|
<0.0001 | ||||
Less than HS/HS degree | 1,109 | 59.7 | 829 | 40.3 | |
Some college | 817 | 46.5 | 1,030 | 53.5 | |
College degree/above | 651 | 28.5 | 1,825 | 71.5 | |
|
<0.0001 | ||||
Less than $20,000 | 542 | 73.6 | 227 | 26.4 | |
$20,000 to less than $30,000 | 474 | 59.4 | 340 | 40.6 | |
$30,000 and above | 1,561 | 35.3 | 3,117 | 64.6 | |
|
<0.0001 | ||||
Adequate | 1,447 | 36.6 | 2,756 | 63.4 | |
Inadequate | 1,130 | 57.6 | 928 | 42.4 | |
|
<0.0001 | ||||
Excellent/very good/good | 1,619 | 39.2 | 2,880 | 60.8 | |
Fair/poor | 958 | 55.9 | 804 | 44.1 | |
|
<0.0001 | ||||
Current smoker | 658 | 63.0 | 441 | 37.0 | |
Past smoker | 1,162 | 39.9 | 1,863 | 60.1 | |
Never smoked | 757 | 37.7 | 1,380 | 62.3 | |
|
<0.0001 | ||||
Excellent/very good/good | 1,099 | 33.1 | 2,576 | 66.9 | |
Fair/poor | 1,478 | 59.1 | 1,108 | 40.9 | |
|
0.0002 | ||||
Rural route | 1,906 | 42.7 | 2,841 | 57.3 | |
Street address | 264 | 42.3 | 407 | 57.7 | |
PO box |
|
|
|||
Missing | 399 | 50.7 | 417 | 49.3 |
Logistic regression of smoking on no reports of dental utilization within the previous 6 months (the National Survey of Veterans, 2010).
Unadjusted | Adjusted | |||
---|---|---|---|---|
OR [95% CI] |
|
OR [95% CI] |
| |
|
||||
|
2.81 [2.34, 3.38] | <0.0001 | 1.50 [1.22, 1.84] | <0.0001 |
|
1.09 [0.96, 1.26] | 0.1874 | 0.99 [0.85, 1.15] | 0.8963 |
|
Reference | Reference | ||
|
||||
Male | 1.21 [0.90, 1.62] | 0.2045 | ||
Female | Reference | |||
|
||||
White | Reference | |||
Other | 1.37 [1.08, 1.74] | 0.0105 | ||
|
||||
50 and above | 0.59 [0.48, 0.72] | <0.0001 | ||
35 to less than 50 | 0.60 [0.50, 0.74] | <0.0001 | ||
20 to less than 35 | Reference | |||
|
||||
Married | Reference | |||
No | 1.24 [1.06, 1.47] | 0.0073 | ||
|
||||
Less than HS/HS degree | 2.41 [2.05, 2.83] | <0.0001 | ||
Some college | 1.53 [1.30, 1.81] | <0.0001 | ||
College degree/above | Reference | |||
|
||||
Less than $20,000 | 2.69 [2.14, 3.38] | <0.0001 | ||
$20,000 to less than $30,000 | 1.88 [1.54, 2.29] | <0.0001 | ||
$30,000 and above | Reference | |||
|
||||
Adequate | Reference | |||
Inadequate | 1.19 [1.03, 1.38] | 0.0215 | ||
|
||||
Excellent/very good/good | Reference | |||
Fair/poor | 1.02 [0.87, 1.19] | 0.8104 | ||
|
||||
Excellent/very good/good | Reference | |||
Fair/poor | 2.04 [1.77, 2.36] | <0.0001 |
In a large nationally representative sample of U.S. veterans, we found that veterans who were current smokers were more likely not to have dental care utilization within the previous six months as compared with never smoking veterans [AOR, 1.50; 95% CI: 1.22,1.84]. Only 37.0% of veterans who were current smokers reported having dental care utilization within the previous six months compared with 62.3% of never smoking veterans who reported having a dental care utilization within the previous six months (
While there is a lack of similar studies among veterans, this study’s results corroborate findings from research studies not specific to veterans. For example, researchers of a study of 15,250 U.S. adults, using MEPS 2000 data, reported that current smokers were less likely to have had a dental visit within the previous year than nonsmokers [AOR 0.78; 95% CI: 0.69, 0.88] [
Bloom et al. [
However, some researchers reported results dissimilar to this study. In a Japanese study, current smokers had more dental visits within the previous year as compared with nonsmokers (
More research is needed to understand the smoking-dental care utilization relationship. Statistically significant reasons for low dental care utilization include dental anxiety and financial barriers [
The Office of the Actuary, the Department of Veterans Affairs has projected a steeper growth in the female, minority, and younger age veterans between 2010 and 2040 [
Dentists and dental healthcare professionals are in the position and have the ability to help with tobacco cessation [
This study has several strengths. Researchers used a large, nationally representative sample of U.S. veterans in which weights were applied to maintain population estimates in the data analyses. The survey questions made it possible to determine participants who were current smokers, former smokers, and who never smoked. The authors were able to indicate the independent effect of smoking, while controlling for other potentially confounding variables. The results that veterans who smoke are less likely to have dental care utilization within the previous six months may be helpful to dental care providers and policy makers to create focused interventions. The veteran health is a major concern and access to quality care is challenging. There have been many changes since the NSV2010 was completed. The NSV2010 was the most current of the NSV surveys to use. There is a need for continued surveillance in this important group.
As a cross-sectional study, the results cannot be interpreted as causal. In addition, the data on both key variables, dental care utilization and smoking status, were self-reported. Since smoking is socially unacceptable, participants may have underreported their smoking status. The dental care utilization data included an aggregation of all dental services. Since the researchers could not distinguish among the services, the assessment of the frequency of specific dental visits could not be determined. The dental utilization question also had a 6-month time frame imposed upon it. Health self-perception was used as specific co-morbidities that were not available in the original dataset; however, in sensitivity analysis excluding overall health, the results remained similar to those reported. Additionally, other covariates (metropolitan versus rural status, number of missing teeth) would have strengthened the study but also were not available. However, in the primary dataset, the purpose was not to capture co-morbidities, so questions about hypertension, diabetes, cardiovascular disease, obesity, etc. were not posed to the participants.
Based upon the Andersen Theoretical Model, in this study of 6,308 veterans, those who smoked were more likely to
Previously reported 2010 National Survey of Veterans data were used to support this study and are available at
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript.
The authors have no conflicts of interest to declare.
R. Constance Wiener developed the concept, conducted the data analyses, and wrote the first draft. Ruchi Bhandari, Alcinda Shockey, and Christopher Waters reviewed the data analyses, contributed to the writing and editing of the drafts, and approved the final version of the manuscript.
This work was supported by the National Institute of General Medical Sciences of the National Institutes of Health (grant no. U54GM104942).