UHM 2017, Vol. 44, No.
6 – SMOKING CESSATION PROGRAM IN THE REPUBLIC OF SingAPORE NAVY
Smoking cessation program among naval diver trainees
in the Republic of Singapore Navy
Jake JK Goh
Singapore Armed Forces Medical Corps, Singapore
EMAIL: Jake JK Goh – gohjitkhong@gmail.com
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ABSTRACT
Background: Since 2016, the Naval Diving Unit (NDU) of
the Republic of Singapore Navy (RSN) has instituted a smoking
cessation trial program for their trainees, instituting a blanket
ban on smoking during training hours in order to promote
smoking cessation and create a smoke-free culture among its
servicemen. For the rest of RSN personnel, they would attend a
more costly, established Health Promotion Board (HPB) smoking
cessation program, which employs social support strategies,
while they undergo basic training in the Navy Military Experts
Institute (NMI).
Methodology: We examined the outcomes and direct costs
of the NDU smoking cessation trial program, compared with the
HPB smoking cessation program in NMI. The primary outcome
was self-reported smoking cessation at the end of six months.
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Introduction
Cigarette smoking harms nearly every organ of the
body, causes many diseases, and reduces the health
of smokers in general [1]. In Singapore, a city state in
tropical Southeast Asia, about seven Singaporeans die
prematurely each day from smoking-related diseases.
Smoking-related diseases, including cancer, heart
disease, stroke and chronic obstructive pulmonary dis-
ease (COPD), also known as chronic obstructive lung
disease (COLD), are the nation’s top killers [2-5].
Smoking is bad for diving, not just because of its
association with chronic lung and heart diseases, but
it may also contribute to worsening of decompression
sickness symptoms among divers who smoke compared
to divers who do not smoke. Researchers from Divers
Alert Network (DAN), the diving industry’s largest asso-
ciation dedicated to scuba diving safety, reviewed 4,350
cases of decompression sickness that were reported over
an eight-year period, comparing the severity of symptoms
_____________________________________________________________________________________________________________________________________________________________
KEYWORDS: divers; smoking cessation; Singapore; military; cost
Copyright © 2017 Undersea & Hyperbaric Medical Society, Inc.
Principal findings: The NDU smoking cessation program
led to 50% reduction among smokers with no additional direct
costs. It is comparable to a 59% reduction of smokers among
trainees in the established HPB program, which costs US$1,955
per course in 2017. The results of both programs are not signifi-
cantly different (χ2 = 0.34, P-value = 0.56). Neither program’s
participants raised any nicotine withdrawal issues throughout.
Conclusion: The results of the NDU smoking cessation
program suggests that it is not inferior to the established HPB
smoking cessation program. More studies should be done to
identify factors leading to smoking cessation success among
Naval Diver trainees compared to the established program,
particularly since the NDU program was less costly and had
no engagement with trained counselors.
among non-smokers, light smokers and heavy smokers in
2003 [6]. They found that heavy smokers were more likely
to have severe symptoms compared to non-smokers, and
both heavy and light smokers were more likely to have
severe and moderate symptoms than non-smokers, who
tended to have milder cases of decompression sickness
(DCS).
In Singapore, all able-bodied male Singaporeans are
enlisted for military service for two years after complet-
ing high-school equivalent education, and some will
be deployed to the Republic of Singapore Navy (RSN).
As these young adults (the mean age of Singaporeans
serving their National Service is 21 years old) are more
susceptible than other age groups to start cigarette
smoking [7], several smoking cessation programs have
been implemented within the Singapore military to
help target this age group. This paper studies a smoking
cessation trial program conducted for one batch of
participants in the Combat Diver Course in the Naval
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UHM 2017, Vol. 44, No. 6 – SMOKING CESSATION PROGRAM IN THE REPUBLIC OF SingAPORE NAVY
Diving Unit (NDU) of the RSN. It also compares this
program with an established smoking cessation program
by the Health Promotion Board (HPB) of Singapore,
conducted by trained smoking counselors from 2014 to
2017 for all RSN trainees undergoing basic naval train-
ing in the Navy Military Experts Institute (NMI), RSN.
The purpose of having two different smoking cessa-
tion programs for the NDU and the NMI was to allow
the RSN Healthcare branch to make a comparison be-
tween a more costly but established program employ-
ing social support versus another program employing
a blanket ban without direct costs, and to identify pos-
sible factors leading to the success of either program.
Methods
We examined the outcomes and direct costs of the
NDU smoking cessation trial program, compared with
an established HPB smoking cessation program for
all RSN trainees undergoing basic naval training in
the NMI. Ethical approval was obtained from the
Singapore Armed Forces Joint Medical Command (Re-
search) Committee, which is charged with considering
the appropriate use of potentially identifiable patient
data.
All young and able-bodied Singaporean males are
conscripted into the Singapore Armed Forces, including
different units of the Republic of Singapore Navy, after
completing high-school equivalent education. Except
for a more thorough medical and psychological exami-
nation of the NDU trainees, there are no educational,
ethnicity or socioeconomic restrictions on conscripts
as to whether they are selected into NDU or NMI.
It is assumed that the educational, ethnicity or socio-
economic backgrounds of participants from both
programs are comparable.
Description of the NDU smoking cessation
trial program
The NDU smoking cessation trial program was con-
ceptualized by the NDU Diving School, whereby
instructors would enforce a ban on smoking for NDU
combat diver trainees (n=89) enlisted in 2016. A smok-
ing prevalence survey is conducted on the first day of
the trainees’ enlistment by the NDU Diving School
Sergeant Major and Officer Commanding, as well as
a detailed explanation of the smoking ban for trainees.
This ban was enforced by instructors throughout
the NDU Diving School: No smoking was permitted
602
during training hours (including sleeping hours), but
there was an allowance of up to two cigarette
“smoke-breaks” per week, with only one cigarette
per break permitted for self-identified smokers.
During these breaks smoking was allowed within
a small designated smoking area in the Naval Diving
camp, a restriction enforced by the instructors.
There was no enforcement of this smoking ban for
trainees during non-training hours over the weekends.
The NDU Diving School instructors, who are not
trained smoking cessation counselors, conducted reg-
ular targeted sessions (approximately one per week)
for self-identified smokers during break times. These
couselors advised smokers not to smoke and made
use of free teaching materials provided by the Health
Promotion Board (Singapore) website. Navy Medical
Officers were instructed to attend to any trainee who
reported nicotine withdrawal symptoms by prescribing
bupropion as well as providing health information to
trainees on the harmful effects of cigarette smoking.
At the end of the seven-month combat diver training
course, as well as at the end of their two-year military
service, all 89 trainees were surveyed by their diving
instructors as to whether they were current smokers.
As the NDU Diving School did not employ external
smoking cessation counselors but instead used a ban
enforced by their own diving instructors, no direct
costs were involved.
Description of the HPB smoking cessation program
The Health Promotion Board smoking cessation pro-
gram was customized and implemented for all RSN
service personnel during their trainee phase in the
Naval Military Experts Institute. The program, initiated
in 2014 (n=1,170), aims to reduce smoking preva-
lence among younger RSN personnel (age 18-29) by
providing education through trained smoking cessation
counselors as well as a social support network to help
smokers make the decision to quit smoking, rather
than enforcing a blanket ban on smoking. As in the
NDU program, Navy Medical Officers in the HPB
program were instructed to prescribe bupropion to any
trainee who reported nicotine withdrawal symptoms.
The program was conducted over four sessions per
course, at an hour per session, and with the sessions
spread over three months. The first session provided
general advice on the harmful effects of smoking,
conducted for all trainees (both smokers and non-
Goh JK
UHM 2017, Vol. 44, No. 6 – SMOKING CESSATION PROGRAM IN THE REPUBLIC OF SingAPORE NAVY

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Table 1: Comparison between NDU and NMI

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stopped or reduced smoking no change in smoking habits total
6 months after program 6 months after program
NDU count (expected count) 5 (5.89) [0.14] 5 (4.11) [0.19] 10
and [% within initial smokers]
________________________________________________________________________________________________________________________________
NMI count (expected count) 173 (172.11) [0] 119 (119.89) [0.01] 292
and [% within initial smokers]
________________________________________________________________________________________________________________________________
total 178 124 302
________________________________________________________________________________________________________________________________

smokers), and for active smokers to be identified by
the counselors through the use of smoke analyzers.
The next three sessions were targeted toward active
smokers, personalizing benefits of smoking cessation,
identifying barriers and motivations to quit smoking,
understanding nicotine withdrawal and building a
social support network among the group to encourage
quitting. These trainees were permitted to smoke dur-
ing mealtimes (three times a day). However, each
smoker was limited to one cigarette per meal within
designated smoking areas within the Naval training
base. There was no restriction on smoking during non-
training hours over the weekends.
Upon completion of the fourth session, smokers in-
volved in the program were interviewed by the coun-
selors on their smoking status. Follow-up telephone
calls were conducted by the counselors to these par-
ticipants six months after completion of the program.
Each run of the smoking cessation course costs the
RSN around US $1,955, including the four sessions and
follow-up phone calls six months after the end of
the course.
stopped smoking remained smoke-free, while the five
who did not stop remained active smokers. The 10 self-
declared smokers did not raise any issues related to
nicotine withdrawal symptoms.
HPB smoking cessation program
Six runs of the smoking cessation program have been
completed since 2014 to 2016. A total of 292 smokers
(around 25% of 1170 total trainees) have gone through
the program while training at NMI. The average age
of these trainees was 21 years old; 93% were male.
At the end of the program, 144 trainees declared that
they had managed to reduce the number of cigarettes
smoked daily, while 34 declared they had stopped
smoking completely.
Six months after the end of the course, 29 declared
that they had stopped smoking completely; 144 de-
clared that they are still smoking fewer cigarettes daily
than before the course. This amounts to 59% of the
participants reducing their smoking habits or stopping
completely. No participant raised any issues related to
nicotine withdrawal symptoms with Medical Officers.

Results
NDU smoking cessation trial program
89 NDU trainees were enrolled in the combat diver
course, with an average age of 21 years old. All were
male Singaporean citizens. At the start of the course,
10 trainees (approximately 11.2%) declared to their
instructors that they were active smokers. This is close
to Singapore’s overall prevalence of active smokers
at 13.3% in 2013 [8]. At the end of their seven-month
combat diver training course, five of the 10 self-declared
smokers reported they had stopped smoking com-
pletely, while the remaining five were unable to stop or
reduce their number of cigarettes smoked. At the end
of their two-year military service, the five who
Comparison
The NDU smoking cessation program yielded a 50%
reduction among smokers despite having no additional
direct costs. This is comparable to a 59% reduction
among trainees in the established HPB smoking ces-
sation program, with costs of approximately US $1,955
per course in 2017. Indirect costs were assumed to be
minimal because smoking cessation teaching materials
are readily accessed online, and instructors used their
break times to conduct the training sessions.
A two-tailed chi-square test was performed (Table 1),
with χ2=0.34; P-value=0.56. The difference is not
significant at P < 0.05.

Goh JK 603
UHM 2017, Vol. 44, No. 6 – SMOKING CESSATION PROGRAM IN THE REPUBLIC OF SingAPORE NAVY
Discussion
The results of the NDU smoking cessation program
suggest that it is not inferior to the established HPB
smoking cessation program.
First, abrupt smoking cessation, or “cold-turkey”
treatment, for NDU diver trainees may lead to greater
smoking cessation success. Based on a study by Lind-
son-Hawley, et al, quitting smoking abruptly is more
likely to lead to lasting abstinence than cutting down
first, even for smokers who initially prefer to quit by
gradual reduction [9]. In the Lindson-Hawley study,
at six months 15.5% of the participants in the gradual-
cessation group were abstinent compared with 22.0% in
the abrupt-cessation group (RR=0.71 [CI=0.46-0.91]).
However, study participants in their trial received
regular behavioral support from nurses and used nico-
tine replacement, while the NDU trainee divers had
neither behavioral support from medical professionals
nor nicotine replacement. With more behavioral sup-
port, and possibly the use of nicotine replacement,
more diver trainees may be expected to quit smoking.
Secondly, due to the healthier psychological profile
of NDU diver trainees, they may be more amenable to
smoking cessation than the NMI trainees. This is be-
cause NDU diver trainees undergo extensive medical
and psychological screening prior to joining the physi-
cally and mentally demanding Combat Diver Course.
Only individuals free of physical or mental issues are al-
lowed into the course. As noted from previous studies
{10,11]. having greater mental resilience is associated
with smoking abstinence among non-smokers as well
as successful smoking cessation among smokers.
Also, it is noted that the self-identified NDU cohort’s
average prevalence of active smokers at 11.2% matches
the national average. On the other hand, the HPB ces-
sation program has a smoker prevalence rate of 25%,
but smokers were identified using smoke analyzers. This
higher smoker prevalence rate in the HPB cohort could
be due to increased pickup rate by the smoke analyzer’s
sensitivity compared to self-identification. Therefore, the
HPB program could have been taking in all smok-
ers, including those who are light smokers, while the
NDU program possibly took in only the heavier smok-
ers. Based on the comparable smoking cessation results
of both programs, this may lend further support to the
effectiveness of the “cold-turkey” approach taken by
NDU.
604
Smoking is noted to be not just a health issue, but
an important safety issue for divers because smoking
has led to explosions in oxygen-rich environments like
hyperbaric chambers or oxygen-filled gas cylinders.
In 2014, a patient from China was killed [12] after a
hyperbaric chamber explosion when he lit his cigarette
while undergoing hyperbaric oxygen treatment. The
accident caused severe damage to the hospital as well.
NDU diver trainees are educated to bring no open
flames, including smoking, near their oxygen cylinders
or hyperbaric chambers, because of the increased risk of
explosions in oxygen-rich environments. A smoke-free
diver population will help eliminate the risks of hyper-
baric or oxygen tank explosions due to cigarette
smoking. We can postulate that such safety education
helped reinforce the smoking cessation message to
NDU trainees.
Limitations
However, this study has several weaknesses, particularly
in the small sample size of NDU participants. It in-
volved only one trial program with a small sample
size of divers who smoke; and studies with a smaller
sample size have a higher chance of type II errors.
Extending this study with more participants from
subsequent runs of the NDU diver course would help
reduce the chance of type II errors.
It may be difficult to compare this trial to non-military
settings: The presence of regimentation, military culture
and military working environments may promote or
hinder smoking cessation efforts. A study [13] that
compared U.S. military active-duty personnel with
civilians found that a counseling program in smoking
cessation behavior was significantly more effective at
helping the civilians than the active-duty participants.
This was attributed to poorer class attendance among
the active-duty military personnel, as they were occa-
sionally activated for overseas missions. Although there
may be a lack of generalizability of this trial for non-
military settings, it still has good internal validity within
the RSN, as most smokers among newly enlisted navy
servicemen from 2014 to 2016 have been included
in this study.
For the NDU diver trainees, the identification of
smokers through self-declaration may be difficult, as
smokers have little incentive to volunteer that infor-
mation to their instructors. However, it would also be
Goh JK
UHM 2017, Vol. 44, No. 6 – SMOKING CESSATION PROGRAM IN THE REPUBLIC OF SingAPORE NAVY
difficult for smokers to hide their habit over the long
term in view of the smoking ban. Thus it is likely that
all NDU smokers had been identified through self-
identifications. Unfortunately, NDU instituted the trial
prior to obtaining smoke analyzers. For better compar-
ability, future trials should also use smoke analyzers to
objectively identify active smokers in both NDU and
NMI participants. Unfortunately, neither program re-
corded the number of cigarettes smoked by each partici-
pant before and after their smoking cessation programs.
Comparing an average number of cigarettes smoked by
participants of each program should be done for future
trials.
 
Conclusion
The results of the NDU smoking cessation program
suggest that it is not inferior to the established HPB
smoking cessation program. The NDU smoking ces-
sation program yielded a 50% reduction among its
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smokers despite having no additional direct costs and
engaging no trained counselors. This study would be
useful for other military diving schools to consider for
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their respective settings.
n
Acknowledgments
Ethics approval and consent to participate
Ethical approval was obtained from the Singapore Armed
Forces Joint Medical Command (Research) Committee,
which is charged with considering the appropriate use
of potentially identifiable patient data. Access to data, anal-
yses and release of outputs followed a prespecified protocol,
which prevented the disclosure of any potentially identifi-
able data. The anonymity of patients was ensured
by use of codes for every patient.
The authors declare that no conflicts of interest exist
with this submission.
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