Substance Use Disorders in the Veteran Population

Approximately 11 percent of veterans presenting for first-time care at U.S. Department of Veterans Affairs (VA) facilities meet criteria for a substance use disorder (SUD), compared to 8.6 percent of the general population. This difference is more pronounced in specific subgroups, such as veterans with combat exposure or co-occurring mental health disorders. For example, 20 percent of veterans with post-traumatic stress disorder (PTSD) also have an SUD, and 63 percent of recent Afghanistan/Iraq veterans with SUDs meet PTSD criteria. The lifetime prevalence of SUDs among veterans is estimated at 53 percent—significantly higher than the general population rate of approximately 17 percent. The VA offers a robust suite of SUD services including screening, outpatient and inpatient treatment, harm reduction, and specialized programs for veterans of Middle East conflicts, women veterans, and veterans from rural areas. These programs help reduce mortality, improve SUD and mental health symptoms, and address social needs like homelessness.

Tobacco use among U.S. veterans also remains a significant health concern. Data from the 2010-2015 National Survey on Drug Use and Health shows that 29.2 percent of veterans reported using tobacco, with cigarettes (21.6 percent) being the most common, followed by cigars (6.2 percent) and smokeless tobacco (5.2 percent). Younger veterans (18-25 years old) showed the highest rates at 56.8 percent, influenced by factors like low income, lack of insurance, and psychological distress. Tobacco use in the Military Health System (MHS) declined from 2016 to 2022 but saw a slight uptick in the last two years. Military culture, deployment stress, and targeted tobacco industry marketing contribute to these elevated rates. Studies like the National Health and Resilience in Veterans Study highlight that veterans, especially younger ones, use both cigarettes and non-cigarette products like e-cigarettes at higher rates than non-veterans. Smokeless tobacco use is also prevalent, with 9 percent of veteran and current service member students at postsecondary institutions reporting smokeless tobacco use in 2018. Cessation efforts face challenges, with counseling rates declining in the MHS.

The VA primarily focuses on traditional tobacco cessation approaches, emphasizing complete abstinence through counseling, pharmacotherapy (e.g., nicotine replacement therapy [NRT], varenicline, bupropion), and digital tools like SmokefreeVET and Quit VET. While these approaches achieve some success, combat exposure and PTSD increase relapse risks. Tobacco harm reduction (THR) approaches, which involve substituting cigarettes with lower-risk nicotine products like smokeless tobacco or electronic nicotine delivery systems (ENDS), are less emphasized within VA programs.

Research suggests a multipronged approach—including harm reduction strategies—for veterans with schizophrenia that employs atypical antipsychotics, NRT, and bupropion to reduce cigarette consumption progressively; however, its effectiveness has not been fully evaluated. A 2010 study of Air Force personnel, including some transitioning to veteran status, found that 87 percent of smokers who initiated smokeless tobacco use post-training escalated harm (e.g., dual use of cigarettes and smokeless tobacco) rather than reducing it, with only 16 percent achieving the full benefits of tobacco harm reduction by switching entirely to smokeless tobacco. While this suggests THR’s potential, it also highlights the risks of dual use, which could undermine health benefits compared to VA’s abstinence-focused programs.

VA policies promote NRT and counseling without mentioning THR alternatives like ENDS.  The barriers to THR adoption are significant, including concerns about the long-term safety of smokeless tobacco and regulatory restrictions on ENDS, which remain unaddressed in current VA guidelines. While THR research shows potential for those resistant to quitting, VA programs and policies heavily favor traditional approaches. The VA should continue to support trials comparing THR to existing methods and expand harm reduction approaches for veterans who smoke. Modernizing the VA’s tobacco cessation policies in a similar manner to how the agency has embraced harm reduction approaches in treating other SUDs would provide veterans with a larger toolkit to improve their personal health.