Preventing Deaths in the
Canadian Military
Homer C.N. Tien, MD, MSc, FRCSC, FACS, Sanjay Acharya, MD, FRCPC,
Donald A. Redelmeier, MD, MS, FRCPC
Background: Combat fatalities are reported by the media as a frequent cause of military deaths, yet
they may not reflect the most common and preventable ways that soldiers die.
Purpose: The purpose of this study was to quantify the leading causes of death in the military and to
identify modifıable behaviors that potentially contributed to death.
Methods: This was a retrospective chart review of all Canadian Forces members who died during
the past quarter century (January 1, 1983, to December 31, 2007) and included autopsy reports, death
certifıcates, coroner reports, hospital records, military reports, and other miscellaneous sources.
Underlying cause of death and modifıable behaviors potentially contributing to death were
determined.
Results: A total of 1889 individuals died during the study period, and a cause of death was identifıed
for 1710 cases (91%). Traumatic injuries caused 57% of deaths, and medical disease was responsible
for 43%. The four leading specifıc causes of death were motor-vehicle crashes (384 deaths, 22%);
neoplasms (374 deaths, 22%); suicide (289 deaths, 17%); and cardiovascular disease (285 deaths,
17%). Combat deaths accounted for less than 5% of all deaths (70 deaths). Approximately 35% of all
deaths were attributable to potentially modifıable behaviors, which included suicide (219 non–
alcohol-related deaths, 13%); smoking (159 deaths, 9%); and alcohol use (186 deaths, 11%).
Conclusions: Public attention focuses on combat fatalities, yet most military members die from
other causes. Avoiding future deaths requires targeting suicide, smoking, and alcohol consumption,
in addition to trauma care for combat injuries.
(Am J Prev Med 2010;38(3):331–339) © 2010 American Journal of Preventive Medicine
Introduction
T
he profession of arms is dangerous. Ongoing media coverage1–3 of the conflicts in Iraq and Afghanistan documents the mortal threats that military members face during war. What may be overlooked,
however, is that inadvertent injuries, natural diseases,
and suicides may cause more deaths than does combat.4 –7 If so, disease prevention and lifestyle modifıcation
programs might help to substantially reduce all-cause
mortality.5
Developing prevention programs requires an understanding of the mortality burden attributable to external,
From the Department of Surgery (Tien) and the Department of Medicine
(Redelmeier), Sunnybrook Health Sciences Centre, University of Toronto;
and Canadian Field Hospital (Tien, Acharya), Canadian Forces Health
Services, Department of National Defence, Ottawa, Ontario, Canada
Address correspondence and reprint requests to: Lt. Col. Homer C.N.
Tien, MD, MSc, FRCSC, FACS, Tory Regional Trauma Center, Sunnybrook Health Sciences Centre, H-Wing, Room 186, 2075 Bayview Avenue,
Toronto, Ontario, Canada M4N 3M5. E-mail: [email protected].
0749-3797/00/$17.00
doi: 10.1016/j.amepre.2009.12.012
© 2010 American Journal of Preventive Medicine. All rights reserved.
modifıable factors (actual causes of death).8 In 2004, it
was reported9 that tobacco, poor diet, inadequate physical activity, excessive alcohol consumption, and motorvehicle crashes were the leading actual causes of death in
the U.S. No such analysis has been performed for the
military.
The purpose of this study was to determine causes of
death in an entire military force—the Canadian Forces.
Primary attention was focused on distinguishing between
medical and traumatic causes of death and on determining behaviors contributing to death. The goal was to help
reduce future deaths in military members serving their
country.
Methods
The Canadian Forces consists of 62,000 regular force members and 25,000 reservists.10 Health records of all active-duty
members who died between January 1, 1983, and December
31, 2007, were retrospectively reviewed. Active-duty members were identifıed as those receiving a salary from the DepartAm J Prev Med 2010;38(3)331–339 331
332
Tien et al / Am J Prev Med 2010;38(3):331–339
Table 1. Baseline characteristics, n (%) unless otherwise indicated
ment of National Defense
at the time of their death
Cause of death known Cause of death unknown
(Table 1).
Characteristics
(total nⴝ1710)
(total nⴝ179)a
p-value
The Directorate of CaAge (years; M [95% CI])
34.9 (34.4, 35.5)
31.4 (29.5, 33.4)
⬍0.001
sualty Support and Administration for the CanaGender
dian Forces identifıed all
Maleb
1627 (95)
160 (90)
0.05
relevant cases. These cases
b
Rank
were deterministically linked
via a unique social insurSenior officer
116 (7)
6 (3)
0.1
ance number or military
Junior officer
237 (14)
25 (14)
0.8
service number to a miliSenior NCM
483 (28)
28 (16)
⬍0.001
tary human resource database for demographic
Junior NCM
868 (50)
105 (59)
0.02
information (Human
Unknown
6 (1)
15 (8)
0.8
Resources Management
Element
System, PeopleSoft Inc.).
This database was also
Army
685 (40)
76 (42)
0.5
used to obtain the total
Navy
239 (14)
31 (17)
0.15
population size of the CaAir Force
532 (31)
44 (25)
0.2
nadian Forces for each
study year. This study
Unknown
254 (15)
28 (16)
0.8
was approved by the Sura
Cause of death was unknown because the cause was indeterminate or because the chart was not found
geon General of the Cab
Senior officer: Major, Lieutenant-Colonel, Colonel, and all General officers; Junior officer: 1st, 2nd
nadian Forces Health
Lieutenant, Captain; Senior NCM: Sergeant, WO, Master WO, Chief WO; Junior NCM: Private, Corporal,
Services and the instituMaster Corporal
tional ethics board at
NCM, noncommissioned member; WO, warrant officer
Sunnybrook Health Sciences Centre.
made by the author. Full details of the methodology are
The health records of all study patients were retrieved
described elsewhere.12 The anticipated sample size of
from the National Archives of Canada. These records
1500 was designed to provide suffıcient statistical power
included autopsy and coroner reports, death certifıcates,
to identify point estimates with a standard deviation of
hospital records, and military reports investigating the
less than 1.25%.
death. Also included were the periodic health examinaData on demographic factors, cause of death, circumtions and diagnostic testing obtained for each patient
stances surrounding death, as well as clinical details from the
during their military career. Upon enlisting, all military
most recent periodic health examination preceding death
members undergo a screening health examination with a
were collected. Double data entry was performed on 5% of
full history and physical exam, baseline BMI measurethe primary data and yielded a kappa statistic of 0.75. In
ments, laboratory testing, and chest radiography. These
response, 100% of all entries were double-checked with abscreening procedures are then repeated every 5 years until
straction sheets to minimize data-entry errors. Five percent
age 40 years, when the frequency increases to every 2
of records were also checked for reliability for cause of death
years.
by an independent physician assessor, yielding a kappa staData were abstracted using a standardized data sheet
tistic for this reliability check of 0.95.
with the underlying cause of death categorized using one
Individual behaviors contributing to death9 were anaof 17 ICD-9-CM diagnostic categories.11 The primary
lyzed. These included smoking, alcohol use, physical inacanalysis compared the proportion of deaths from trauma
tivity and poor diet, certain sexual behavior, suicide, illicit
relative to medical causes. Medical deaths corresponded
drug use, not using a life-jacket in water-transport deaths,
to codes 001–799. Traumatic deaths corresponded to one
and seat-belt usage in motor vehicle–related deaths. In some
of the external codes (E800 –999). The exceptions were
cases, a death was deemed completely attributable to a modheat-induced illness (E900) and exertion-related illness
ifıable behavior.13,14 For most medical diseases, however,
(E927), which were classifıed as medical deaths. Combat
only a fraction of deaths can be attributed to behaviors.
deaths (E979, E990 –E999) were also identifıed, which
Details of the methods used to calculate the fraction of
were any fatal injury caused intentionally by foreign
deaths that can be attributed to each behavior are described
(nonallied) paramilitary or military forces. The fınal dein Appendix A, available online at www.ajpm-online.net
termination of each cause of death for this study was
and elsewhere.15,16
www.ajpm-online.net
Tien et al / Am J Prev Med 2010;38(3):331–339
333
Smoking-Attributable Deaths
Other Behavior-Attributable Deaths
In this study, the number of ischemic heart disease and
respiratory cancer deaths attributable to smoking was directly calculated using study data, annual smoking prevalence data in the Canadian Forces Health and Lifestyle Information Surveys,17–19 and estimates of the total Canadian
Forces population for each year (Appendix A, available online at www.ajpm-online.net). Former smokers were considered to have no lingering health risks associated with
smoking, and those with unknown smoking status were
considered nonsmokers. Smoking-related fıre deaths
were classifıed as 100% smoking-attributable.14 For all
other smoking-attributable diseases, published populationattributable fractions were used to calculate smoking-attributable
mortality.20
Physical inactivity and poor diet are behaviors associated
with obesity.9 Obesity is defıned as a BMI of ⱖ30.23 Although obesity increases the risk of developing many
chronic diseases,24,25 the population-attributable fractions
of deaths from obesity are small when taking into account
other confounding risk factors such as diabetes and smoking.24 Therefore, in this study, the number of obesity-attributable
deaths for each chronic disease was not calculated. Instead,
the total number of obesity-attributable deaths was calculated using published population-attributable fractions.24
There is also considerable controversy regarding the relationship between being overweight (BMI of 25–29.9) and
the risk of premature mortality.26,27 Because of these uncertainties, deaths associated with being overweight were not
analyzed.
An earlier study9 attributed all HIV deaths to sexual behavior. The same methodology was used in this study. However, “sexual behavior—HIV” was distinguished from “sexual behavior— other.” A death was classifıed as being from
suicide behavior only if it was not already ascribed to alcohol
use. A death was classifıed as being from illicit drug use only
if the death was deemed to be inadvertent and was not
already ascribed to alcohol use. A death was classifıed as
being from seat-belt usage in motor-vehicle crashes only if it
was not already ascribed to alcohol use and only if the
coroner or autopsy report specifıcally recorded that the military member was not using seat belts at the time of the crash.
A death was classifıed as being from life-jacket usage in
water-transport deaths only if it was not already ascribed to
alcohol use and only if the coroner or autopsy report specifically recorded that the member drowned and was not wearing a life jacket. Data were analyzed using SAS, version 8.2.
Alcohol-Attributable Deaths
Alcohol-attributable deaths were identifıed and calculated
for acute and chronic conditions. As with smoking, the number
of alcohol-attributable deaths was directly calculated using
study data related to ischemic heart disease deaths.21 The prevalence of high-risk drinking was considered constant throughout the study period.19 To avoid overestimation, former drinkers, occasional drinkers, and those with unknown alcohol
consumption were presumed to have no lingering detrimental
health effects. Alcohol-induced cirrhosis was considered to be
100% attributable to alcohol.13 For all other chronic conditions, published population-attributable fractions were
used to calculate the number of alcohol-attributable
deaths.22 For all acute injuries, a death was identifıed as
alcohol-attributable if the blood alcohol level exceeded
10 g/dL at time of death.13
Figure 1. Causes of death
March 2010
Tien et al / Am J Prev Med 2010;38(3):331–339
334
Results
(n⫽384), of which about one in seven (n⫽57) occurred
on duty. Neoplasms caused 22% of deaths overall (n⫽
374); suicide caused 17% (n⫽289); and cardiovascular
diseases caused 17% (n⫽285). Combat caused 4% of total
deaths (n⫽70; Figure 1). About 84% of combat deaths
(n⫽59) occurred during the last 2 years of the study,
during which time members of the Canadian Forces were
deployed to southern Afghanistan.
A total of 1889 deaths were identifıed, of which 1738
charts (92%) were available, located, and reviewed. Cause
of death was not determinable in 28 cases, leaving 1710
cases (91%) on which further analyses were conducted for
cause of death. A periodic health examination was located
for 1436 cases (84%) and was used for determining smoking, alcohol, and BMI status. Details of death were determined from autopsy reports in 26% of cases (n⫽447);
coroner reports in 3% (n⫽50); hospital records in 37%
(n⫽627); death certifıcates in 9% (n⫽162); and military
investigations in 10% of cases (n⫽178). Other additional
documentation was used for 15% (n⫽246).
Most deaths occurred outside of normal working
hours (n⫽1369), and only a few occurred on duty while
on overseas missions (n⫽118). Major trauma caused 57%
of total deaths (n⫽968), and medical diseases caused 43%
(n⫽742). Motor vehicle–related deaths caused 22% of
deaths and were the leading single cause of death
Firearms and Blast
Firearms and blast were the underlying mechanism causing death in about one in 12 deaths (n⫽147); however,
about 50% of these were due to inadvertent training incidents or suicide rather than actual combat. Of the 289
military suicides, 21% (n⫽60) involved fırearm use. Of
ten murders, three involved fırearm use. There was one
death from a fırearm from an inadvertent incident during
a hunting trip, and six inadvertent deaths from fırearms
that were related to military training. Of 70 combat
Table 2. Smoking-attributable deaths
Cause of death
Number
Smoker
Former
smoker
Nonsmoker
Unknown
status
Smoking-attributable
death
Malignant neoplasm
Lip/oral cavity/pharynx/larynx
7
4
0
3
0
5
Esophagus
5
3
0
0
0
4
Stomach
7
4
0
0
1
2
7
3
0
1
1
1
49
39
0
8
2
38
Cervix uteria
4
2
0
1
0
0
Kidney, other urinary
8
3
0
4
0
3
Bladder
4
3
0
0
1
2
14
5
0
6
3
3
191
120
2
28
29
89
Other heart disease
27
8
1
11
5
Cerebrovascular disease
14
6
0
5
3
2
Aortic aneurysm
6
3
0
1
1
4
Other arterial disease
1
1
0
0
0
0
Pneumonia/influenza
3
1
0
1
1
0
Bronchitis/emphysema/COPD
5
4
0
1
0
4
2
2
354
211
Pancreas
Trachea/lung/bronchus
a
Acute myeloid leukemia
Cardiovascular diseases
Ischemic heart diseasea
Respiratory diseases
Burn deaths (smoking-related)
Totals
2
3
70
47
159
a
Direct calculation
COPD, chronic obstructive pulmonary disease
www.ajpm-online.net
Tien et al / Am J Prev Med 2010;38(3):331–339
335
deaths, six were from fırearms. Therefore, a total of 76
deaths were attributable to fırearm use.
A total of 71 military members died as a consequence
of blast injuries, of which 63 were from combat action.
The blast mechanisms included land mines, improvised
explosive devices, and air-dropped munitions. Seven military members died from blast-related injuries sustained
during training exercises: three associated with handgrenade mishaps and four from a single catastrophic munitions explosion. One military member committed suicide using a hand grenade.
ing water-transport activities and in which alcohol consumption was not a contributing factor. In four cases, life
jackets were not used. In the remainder, no mention was
made of life-jacket use at all. The three cases of sexualbehavior deaths unrelated to HIV infection were deaths
caused from auto-erotic asphyxiation. There were four
deaths from illicit drug overdose; however, these cases
were also associated with alcohol use and were therefore
classifıed as alcohol-attributable deaths.
Behaviors Contributing to Death
Military members are almost equally at risk of dying from
medical diseases as from traumatic injuries. Although
traumatic deaths are common, the majority reflect inadvertent roadway crashes or suicide. Indeed, most deaths
occurred during off-duty hours away from military bases.
Combat deaths were rare, and caused less than 5% of
overall deaths. As a result, only limited opportunities are
available to substantially reduce future premature military deaths by improving the quality of acute care provided by the military healthcare system. Greater opportunities remain for primary prevention and medical risk
factor management.
Almost one quarter of all military deaths can be attributed to individual behaviors, the three major ones being
suicide, alcohol consumption, and tobacco use. These
results differ from the general population because of the
reduced risks attributable to physical inactivity and poor
Of the 1710 deaths, approximately 35% (n⫽600) were
attributable to individual behaviors. Tables 2– 4 list the
chronic and acute conditions used to calculate the number of deaths that can be attributed to smoking and alcohol consumption. Suicide behavior (where alcohol was
not involved) caused 13% (n⫽219) of all reviewed deaths.
Alcohol potentially caused 11% (n⫽186) and smoking
potentially caused 9% (n⫽159). Unlike in the general
Western population,9 physical inactivity and poor diet
(obesity) contributed to few military deaths (Table 5).
There were 309 motor vehicle–related deaths in which
alcohol use was not a factor. Of these, the autopsy reports
in six cases specifıcally state that seat belts were not used.
However, there was no specifıc mention of seat-belt usage
in the majority of the other cases. Likewise, there were 21
cases in which Canadian Forces members drowned dur-
Discussion
Table 3. Alcohol-attributable deaths from chronic conditions
Cause of death: chronic
conditions
Number
Unknowna
No
alcohola
Occasionala
drinking
(<2 drinks/day)
Excessivea
drinking
(>2 drinks/day)
Alcohol-attributable
death
Breast cancer
5
1
1
3
0
0
Liver cirrhosis, unspecified
3
0
1
0
2
2
Alcoholic liver disease
4
N/A
N/A
N/A
N/A
4
Esophageal cancer
5
3
0
2
0
1
191
44
18
87
19
3
Laryngeal cancer
3
1
0
2
0
1
Liver cancer
2
0
0
2
0
1
Oropharyngeal cancer
3
1
0
2
0
1
Prostate cancer
1
0
0
1
0
0
13
3
1
6
3
3
1
0
0
1
0
0
Ischemic heart diseaseb
Stroke, hemorrhagic
Stroke, ischemic
Totals
a
Refers to alcohol consumption pattern documented in the last periodic health examination.
Directly calculated
N/A, not applicable
b
March 2010
16
Tien et al / Am J Prev Med 2010;38(3):331–339
336
Table 4. Alcohol-attributable deaths from acute
conditions
Cause of death: acute
conditionsa
Air–space transport
Alcohol-attributable
death
Number
92
0
Alcohol poisoning
3
3
Aspiration
1
1
Drowning
31
10
Fall injuries
18
7
Fire injuries
3
2
Firearm injuries
(inadvertent)
6
0
10
2
1
0
Motor-vehicle (traffic)
384
75
Suicide
289
70
Homicide
Hypothermia
Totals
170
a
For acute conditions, death is alcohol-attributable if blood alcohol
concentration was ⬎10 mmol/L at time of death.
diet in young, healthy military members, for whom
trauma remains the leading cause of death.28 Incidents
involving fırearms and munitions caused 147 deaths (9%
of deaths overall), yet many of these were related to training or suicide.
These results argue for more disease prevention, mental health care, and safety programs to complement the
traditional military focus on trauma. During times of war,
trauma care is critical and saves lives.29 However, future
gains in survival are likely to be small.30 Prevention measures will likely have a greater impact than improved
trauma care on reducing future combat deaths, as the
majority of deaths on the modern battlefıeld are nonsurvivable.31 However, efforts to improve body armor or
develop blast countermeasures rely on organizational
commitment rather than individual behavior.
Focusing solely on combat deaths may result in missed
opportunities to save lives. Combat soldiers are more
likely to start smoking to cope with the stress of deployment32 and more likely to abuse alcohol after returning
from deployment.33 Combat veterans are also more likely
to suffer from mental health problems.34 Further, combat
veterans are more likely to die from inadvertent injury
after deployments.35,36 Therefore, even in times of war,
prevention strategies targeting seat-belt usage, tobacco
use, excessive alcohol consumption, and mental health
may have the greatest impact on reducing future military
deaths.
The Canadian military already offers comprehensive
health promotion programs, and future prevention efforts should build on this tradition. For example, the Canadian Task Force on Preventive Health Care (CTFPHC)37
reports good evidence to support smoking-cessation
counseling and using nicotine-replacement therapy as
an adjunct, and fair evidence to support referrals to
smoking-cessation programs. Consequently, the Canadian
Forces already offers a smoking-cessation program called
Butt Out38 that has met with substantial success. The
number of smokers within the Canadian military has
decreased more rapidly than in the general population.19
One area for improvement, however, is smoking initiation, as many recruits in various military organizations
start smoking during or after basic training.19,39 Military
organizations should target future smoking-prevention
efforts at new recruits during induction.
The Canadian Forces now also routinely screens military members for alcohol problems during their periodic
health examination and offers an alcohol rehabilitation
program to those with identifıed alcohol dependence.38
Unfortunately, very few interventions have been shown
to reliably treat alcohol dependence. Further, alcohol use
and alcohol abuse remain an important part of off-duty
military culture. It is hoped that ongoing efforts to limit
the availability of alcohol in the military and to encourage
responsible alcohol consumption will reduce future alcoholrelated deaths.
Table 5. Obesity-attributable deaths
Cause of death
Numbera
Underweight
20<
BMI<25
Ischemic heart disease (n⫽226)
162
3
44
86
29
Breast cancer (n⫽5)
4
0
1
2
1
Colon cancer (n⫽36)
31
4
11
14
2
1
0
0
0
1
187
7
66
102
33
Diabetes (n⫽1)
Totals
Overweight
Obese
Obesity-attributable
deaths
8
a
Number of deaths where weight and height are recorded on last periodic health examination.
www.ajpm-online.net
Tien et al / Am J Prev Med 2010;38(3):331–339
Motor vehicle–related fatalities can be prevented by
increasing seat-belt usage.40 The CTFPHC41 reports
good evidence to support the use of legislation to increase
seat-belt usage, and fair evidence to support the role of
individual counseling. Both U.S. and Canadian military
regulations require seat-belt usage by on-duty personnel.
As a substantial number of fatal motor-vehicle crashes
occur during on-duty times, military commanders are
uniquely positioned to further reduce crash fatalities.
Commanders can dispel misperceptions and actively
support and enforce these regulations.42 In addition, future prevention efforts could focus on individual counseling at the time of periodic health examinations to
reinforce the need for seat-belt usage.
With regard to the mental health of military members,
the popular press has reported43,44 increased numbers of
suicides in young combat veterans. Unfortunately, few
interventions have been reliably shown to prevent suicide. The CTFPHC45 reports fair evidence for the positive
impact of only physician education programs on suicide
prevention. Despite the lack of evidence to support the
use of suicide prevention interventions, the Canadian
Forces has proactively established a comprehensive program to attempt to reduce suicides in its returning combat veterans. Physicians are deployed to prepare soldiers
for reintegration, and the Canadian Forces has established operational stress centers to help returning soldiers
reintegrate and to reduce the risk of suicide.38 However,
further research is required in this area.
This study also found that the proportion of Canadian
soldiers using fırearms to commit suicide (21%) was substantially lower than that in the U.S. military. It was
found46 that approximately 60% of U.S. military members use a fırearm to commit suicide. This difference is
likely accounted for by more stringent Canadian guncontrol laws. However, it is not clear whether this difference caused a reduced rate of suicide or merely affected
the proportion of suicides that were fırearm related.
Limitations
Cause-of-death studies are subject to many biases; in
particular, suicides tend to be under-reported and cardiovascular causes over-reported.47– 49 In this study, these
biases were minimized by using and reviewing multiple
sources of data, including autopsy reports. However, approximately 8% of charts were not located, and these
tended to be for younger men who were probably less
likely to have died from medical causes. Hence, this study
may have underestimated the frequency of trauma deaths
relative to natural deaths.
Another limitation is the confounding of factors that
can occur when attributable fractions are calculated. For
March 2010
337
example, other cardiac risk factors such as diabetes and
hypertension were not controlled for when calculating
the fraction of deaths from ischemic heart disease that
can be attributed to smoking. Even so, such confounders
likely had a minimal impact on the study results, as they
are uncommon in otherwise healthy soldiers. In addition,
population-attributable fractions were used to calculate
mortality attributable to less commonly observed medical diseases in the military, which raises many methodologic diffıculties.16,50,51 Overall, behavior-attributable
mortality was likely underestimated because it was assumed that the behavior was absent if its actual status was
unknown.
Based on this study, the authors advocate for prevention strategies to reduce future military deaths. However,
the limitation of such an approach is acknowledged, especially with regard to changing behavior. Many of these
behaviors leading to death may be perpetuated by organizational issues or culture. For example, although smoking and alcohol consumption remain individual behaviors, the military milieu may predispose its members to
misuse because of the reduced costs and availability of
cigarettes and alcohol.
Finally, the results of this study can be extrapolated to
other settings only with caution. During the study period,
the Canadian Forces was involved primarily in peacekeeping missions. Eighty-four percent of all combat
deaths occurred during the last 2 years of the study (2006
and 2007) when Canadian soldiers were deployed to Kandahar, Afghanistan.52 Excluding these last 2 years, combat deaths would have been 1% of deaths.
The results of this study are similar to reports on U.S.
and British military deaths during periods of relative
peace. Specifıcally, from 1980 to 1993, it was reported5
that inadvertent injuries were the leading cause of U.S.
military death, followed by natural causes and suicide.
Combat caused only 2% of deaths. Inadvertent injury and
diseases were also leading causes of death in British Military Forces from 1980 to 1984, despite the Falkland Islands War.53 Since 2003, however, U.S. and British military members have been actively engaged in combat in
Iraq and so have sustained more combat deaths.1– 4 Although Canadian Forces have not been deployed to Iraq,
the fatality rate for the Canadian military in Afghanistan
is almost four times higher than the fatality rate of the
U.S. military in Iraq.54 Therefore, the conclusions from
this study are likely to be valid for U.S. and British military forces as well as for the Canadian Forces.
Conclusion
Canadian military members were almost as likely to die
from medical diseases as from traumatic causes. About
338
Tien et al / Am J Prev Med 2010;38(3):331–339
35% of all deaths were attributable to potentially modifıable behaviors. In addition, combat missions end, whereas
soldiers continue to drive, smoke, and drink, making recommendations about improving preventive strategies likely
to remain important.
We acknowledge the support of the Clinical Epidemiology Program of the Department of Health Policy, Management, and Evaluation at the University of Toronto.
We also thank Peter Chu, Alex Kiss, Jolie Ringash, Barry
McLellan, Damon Scales, Gordon Rubenfeld, and Robert
Fowler for their advice. We are also thankful for the
support and funding from the Canadian Forces Health
Services and the Canada Research Chair in Medical Decision Sciences.
No fınancial disclosures were reported by the authors
of this paper.
References
1. Hendawi H. U.S. military deaths in Iraq campaign pass 1,000.
www.commondreams.org/headlines04/0907-11.htm.
2. Dao J. 2,000 Dead: As Iraq tours stretch on, a grim mark. www.
nytimes.com/2005/10/26/international/middleeast/26deaths.html.
3. Alvarez L, Lehren A. 3,000 dead in Iraq, countless tears at
home. www.nytimes.com/2007/01/01/us/01deaths.html.
4. Beary JF, Walter LJ, Johns JH. Leading causes of death for
active duty military personnel. Mil Med 1984;149:316 –7.
5. Helmkamp JC. Cause of death among U.S. military personnel:
a 14-year summary, 1980 –1993. Mil Med 1996;161:311–7.
6. Helmkamp JC. A descriptive summary of active-duty deaths in
the U.S. Navy in 1986. Mil Med 1988;153:621–5.
7. Almond MD, Carlton J, Bohnker BK. Navy and Marine Corps
active duty mortality patterns for 1995 to 1999. Mil Med
2003;168:32–9.
8. McGinnis JM, Foege WH. Actual causes of death in the U.S.
JAMA 1993;270:2207–12.
9. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual
causes of death in the U.S. JAMA 2004;291:1238 –98.
10. National Defence and the Canadian Forces. http://www.
forces.ca/flash.aspx?gclid⫽COrc7aa4p4CFQ4NDQod0ml29w#/
flash/en/1-52-222-37/who-we-are/our-people/our-people-ourstrength/introduction.
11. WHO. International classifıcation of diseases: manual of the
international statistical classifıcation of diseases, injuries and
causes of death [based on the recommendations of the Ninth
Revision Conference, 1975]. Geneva, WHO, 1977.
12. Tien HC. Causes of death of active duty personnel in the
Canadian forces. Koln, Germany: Lambert Academic Publishing, 2009.
13. CDC. Alcohol-attributable deaths and years of potential life
lost—U.S., 2001. MMWR Morb Mortal Wkly Rep 2004;
53(37):866 –70.
14. CDC. Annual smoking-attributable mortality, year of potential life lost, and productivity losses—U.S., 1997–2001.
MMWR Morb Mortal Wkly Rep 2005;54:625– 8.
15. Levine B. What does the population attributable fraction
mean? Prev Chronic Dis 2007;4(1):A14. www.cdc.gov/PCD/
issues/2007/jan/06_0091.htm.
16. Rockhill B, Newman B, Weinberg C. Use and misuse of population attributable fractions. Am J Public Health 1998;88:15–9.
17. Directorate of Force Health Protection. Canadian Forces
Health and Lifestyle Information Survey 1996 Regular Force
Report. Ottawa, Canada, 1997.
18. Directorate of Force Health Protection. Canadian Forces
Health and Lifestyle Information Survey 2000 Regular Force
Report. Canadian Forces Health Services website. Available at:
http://www.forces.gc.ca/health-sante/pub/hlis-sssv/pdf/HLISSSSV-2000-Reg-eng.pdf.
19. Directorate of Force Health Protection. Canadian Forces Health
and Lifestyle Information Survey 2004 Regular Force Report.
Document A-MD-015-FHP-AF-001. Canadian Forces Health
Services website. Available at: http://www.forces.gc.ca/healthsante/pub/hlis-ssv/pdf/AMD015FHPAF001-20050901-eng.pdf.
20. Baliumas D, Patra J, Rehm J, Popova S, Kaiserman M, Taylor B.
Smoking-attributable mortality and expected years of life lost in
Canada 2002: conclusions for prevention and policy. Chronic
Diseases in Canada [serial online] 2007;27(4):154 – 62.
www.phac-aspc.gc.ca/publicat/cdic-mcc/27-4/pdf/cdic2743_e.pdf.
21. Corrao G, Bagnardi V, Zambon A, Arico A. Exploring the
dose–response relationship between alcohol consumption and
the risk of several alcohol-related conditions: a meta-analysis.
Addiction 1999;94(10):1551–73.
22. WHO. Global Status Report on Alcohol 2004. whqlibdoc.
who.int/publications/2004/9241562722_(425KB).pdf.
23. Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity
and mortality in a large prospective cohort of persons 50 –71
years old. N Eng J Med 355:763–78.
24. Luo W, Morrison H, de Groh M, et al. The burden of adult
obesity in Canada. Chronic Dis Can [serial online] 2007;27(4):
135– 44. www.phac-aspc.gc.ca/publicat/cdic-mcc/27-4/index.
html.
25. Tjepkema M. Measured obesity. Adult obesity in Canada:
measured height and weight. Statistics Canada Cat. No. 82620-MWE2005001, 2005.
26. Katzmarzyk PT, Craig CL, Bouchard C. Underweight, overweight and obesity: relationships with mortality in the 13-year
follow-up of the Canada Fitness Survey. J Clin Epidemiol
2001;54:916 –20.
27. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess
deaths associated with underweight, overweight and obesity.
JAMA 2005;293(5):1861–7.
28. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma
deaths: a reassessment. J Trauma 1995;38(2):185–93.
29. Gawande A. Casualties of war—military care for the wounded
from Iraq and Afghanistan. N Engl J Med 2004;351(24):2471–5.
30. Stewart RM, Myers JG, Dent DL, et al. Seven hundred fıftythree consecutive deaths in a level I trauma center: the argument for injury prevention. J Trauma 2003;54(1):66 –71.
31. Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in
U.S. Special Operations Forces in the global war on terrorism:
2001–2004. Ann Surg 2007;245(6):986 –91.
32. Smith B, Ryan MA, Wingard DL, Patterson TL, Slymen DJ,
Macera CA; Millennium Cohort Study Team. Cigarette smoking and military deployment: a prospective evaluation. Am J
Prev Med 2008;35(6):539 – 46.
www.ajpm-online.net
Tien et al / Am J Prev Med 2010;38(3):331–339
33. Hooper R, Rona RJ, Jones M, Fear NT, Hull L, Wessely S.
Cigarette and alcohol use in the UK Armed Forces, and their
association with combat exposures: a prospective study. Addict Behav 2008;33(8):1067–71.
34. Sareen J, Belik SL, Afıfı TO, Asmundson GJ, Cox BJ, Stein MB.
Canadian military personnel’s population attributable fractions of mental disorders and mental health service use associated with combat and peacekeeping operations. Am J Public
Health 2008;98(12):2191– 8.
35. Sareen J, Cox BJ, Afıfı TO, et al. Combat and peacekeeping
operations in relation to prevalence of mental disorders and
perceived need for mental health care: fındings from a large
representative sample of military personnel. Arch Gen Psychiatry 2007;64(7):843–52.
36. Kang HK, Bullman TA. Mortality among U.S. veterans of
the Persian Gulf War: 7-year follow-up. JAMA 2001;
154(5):399 – 405.
37. Taylor MC, Dingle JL. Prevention of tobacco-caused disease.
In: Canadian Task Force on the Periodic Health Examination.
Canadian Guide to Clinical Preventive Health Care. Ottawa:
Health Canada, 1994;500-11.
38. Department of National Defence. Health Promotion ProgramCore Programs. Canadian Forces Health Services website. Available at: http://www.forces.gc.ca/health-sante/ps/hpp-pps/aapsdp/bo-el-eng.asp.
39. Haddock CK, Pyle SA, DeBon M, et al. Cigarette use among
two cohorts of U.S. Air Force recruits, compared with secular
trends. Mil Med 2007;172(3):288 –94.
40. CDC. Prevention of motor vehicle–related injuries: a compendium of articles from the Morbidity and Mortality Weekly
Report 1985–1996. Atlanta GA: USDHHS, CDC, 1997.
41. Elford RW. Prevention of motor vehicle accident injuries. In:
Canadian Task Force on the Periodic Health Examination.
Canadian Guide to Clinical Preventive Health Care. Ottawa:
Health Canada, 1994;514 –24.
42. Okpala NC, Ward NJ, Bhullar A. Seatbelt use among military
personnel during operational deployment. Mil Med 2007;
172(12):1231–3.
43. Spooner MH. Suicide claiming more British Falkland veterans
than fıghting did. Can Med Assoc J 2002;166(11):1453.
March 2010
339
44. Morris N, Sengupta K. Shocking suicide toll on combat veterans. www.independent.co.uk/news/uk/home-news/shockingsuicide-toll-on-combat-veterans-1746475.html.
45. McNamee JE, Offord DR. Prevention of suicide. In: Canadian
Task Force on the Periodic Health Examination. Canadian
Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994;456 – 67.
46. Helmkamp JC. Occupation and suicide among males in the
U.S. Armed Forces. Ann Epidemiol 1996;6(1):83– 8.
47. Sainsbury P. Validity and reliability of trends in suicide statistics. World Health Stat Q 1983;36:339 – 48.
48. Litman RE, Curphey T, Scneidman ES, Farberow NL, Tabachnick
N. Investigations of equivocal suicides. JAMA 1963;184:
924 –9.
49. Engel LW, Strauchen JA, Chiazze L, Heid M. Accuracy of death
certifıcation in an autopsied population with specifıc attention
to malignant neoplasms and vascular disease. Am J Epidemiol
1980;111(1):99 –112.
50. Malarcher AM, Schulman J, Epstein LA, et al. Methodologic
issues in estimating smoking-attributable mortality in the U.S.
Am J Epidemiol 2000;152:573– 84.
51. Flegal KM, Williamson DF, Pamuk ER, Rosenberg HM. Estimating deaths attributable to obesity in the U.S. Am J Public
Health 2004;94(9):1486 –9.
52. Department of National Defence. Fallen Canadians. www.
forces.gc.ca/site/focus/fallen/index_e.asp.
53. Finnegan TP, Lewis DT. The major causes of death in the army
and comparisons with the civilian population. J R Army Med
Corps 1988;134(1):22– 6.
54. Bird SM, Fairweather CB. Military fatality rates (by cause) in
Afghanistan and Iraq: a measure of hostilities. Int J Epidemiol
2007;36(4):841– 6.
Appendix
Supplementary data
Supplementary data associated with this article can be
found, in the online version, at doi:10.1016/j.amepre.
2009.12.012.