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The International Journal of the Addictions, 26(6), 685-696, 1991
A Comprehensive Worksite Smoking Control, Discouragement, and Cessation Program Harold H. Dawley Jr.,* PhD VeteransAdministration Medical Center New Orleans, Louisiana Tulane University Schools of Medicine and Public Health Louisiana State University Medical Center New Orleans, Louisiana
Linda T. Dawley, PhD Wellness Institute, Inc. Gretna, Louisiana
Pelayo Correa, MD Louisiana State University New Orleans, Louisiana
Barbara Fleischer, PhD Loyola University New Orleans, Louisiana
*To whom reprint requests should be directed at Smoking Control Officer, Veterans Administration Medical Center, 1601 Perdido Street, New Orleans, Louisiana 70146. 685
Copyright 0 1991 by Marcel Dekker, Inc.
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Abstract The effectiveness of a comprehensive program of worksite smoking control, discouragement, and cessation was compared with a program of smoking cessation alone. Two comparable oil refineries served as the research sites. Outcome variables consisted of employee seIf-reported smoking rate assessed by the use of a smoking questionnaire and unobtrusive observations of smoking behavior before and after the intervention. One company was randomly assigned to the comprehensive program of smoking control, discouragement, and cessation while the other company only received smoking cessation. Humorous antismoking posters emphasizing the benefits of quitting smokmg were distributed throughout the first worksite and changed every 2 weeks. Large banners stating "Go SmokeFree" were also placed at all locations to this plant and left up for the duration of the study. Three weeks after the initiation of the smoking discouragement program at one refinery, a group smoking cessation program was begun at both plants. At a 5-month follow-up, participants in the smoking cessation treatment at the plant receiving the comprehensive program achieved a 5-month abstinence rate of 43 % in comparison with a rate of 2 1% at the refinery receiving only smoking cessation.
INTRODUCTION The importance of addressing the problem of smoking at the worksite as a way to promote health among employees and save money for employees can hardly be overstated. The only problem with most smoking cessation efforts is their limited effectiveness (Bernstein, 1969; Danaher, 1980; Bemstein and Glasgow, 1977; Schwartz, 1978; U.S. Department of Wealth, Education, and Welfare, 1979). The failure of many of these treatments does not lie in their inability to change behavior, but rather in the lack of this change to generalize beyond treatment. In searching for an explanation of why so many people return to smoking following treatment, it is clear that environmental factors play a major role in smoking behavior (Insel and Chadwick, 1975; West et al., 1977; Marlatt and Gordon, 1980; Evans and Lane, 1981). The worksite environment appears to be one setting that can be modified to control and discourage smoking. As such, it represents a unique opportunity for effectively addressing the addictive behavior of tobacco smoking. This conclusion is especially significant in view of the high rate of smoking among blue-collar workers ( U S Department of Health and Human Services, 1985). The worksite is not only a setting where an individual spends one-third of his/her average day, it is also a setting in which administrative structure and policy can be arranged to discourage and control smoking. A Gallup Poll (Gallop Opinion Index,
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1974) reported that worksite smoking cessation programs have the potential to reach 25% of the American blue-collar workforce who smoke. This group not only has one of the highest smoking rates, but is one that underutilizes available smoking cessation programs (Danaher, 1980). The incentive for business to support efforts to reduce smoking at the worksite is the staggering increase in health care costs. According to the U.S. Chamber of Commerce (198 l), American businesses now pay at least half of the national health bill. The economic impact of smoking on business and industry is reflected in the 1980 National Interagency Council on Health’s (1980) estimate that the average employee who smokes costs his or her employer up to $600 a year in otherwise avoidable expenses. Smokers utilize health care services up to 50% more than nonsmokers (Fielding, 1986). A more detailed estimate of the economic impact of tobacco smoking has been presented by Kristein showing smokers of one pack a day having a 50% greater rate of hospitalization and absenteeism with employees who smoke two packs a day having twice the absence rate of nonsmokers (Kristein, 1977). Because of the magnitude of the health effects of smoking and the benefits of stopping smoking, smoking cessation programs can be expected to yield a higher return on investment than worksite programs addressing other lifestyle changes such as obesity and lack of exercise (Fielding, 1986). In addition to concern over health and productivity, increasingly vocal efforts by nonsmoking employees for an environment free of secondhand smoke have also made companies concerned about their vulnerability to lawsuits and claims from the effects of environmental tobacco smoke (E.T.S.). Surveys reported by the Washington Business Group on Health (1978) have shown 15 to 19% of American businesses reported employee filed claims of illness related to exposure to E.T.S. The decision of the New Jersey Superior Court in favor of an employee allergic to tobacco smoke to an environment free of the smoke of other employees (Shrimp et al., 1976) stands as a landmark case in this area. As new research demonstrates additional adverse effects on nonsmokers from E.T.S., the efforts of nonsmoking employees to protect themselves will increase. For both humanitarian and economic reasons, business and industry are showing a strong and rapidly increasing interest in addressing the problem of tobacco smoking at the worksite. In discussing tobacco smoking, it is important to recognize several distinctly different approaches to the solution of this problem. Some approaches directly help people stop smoking by providing treatment to achieve this goal. Other approaches do not focus on cessation but on the control and/or discouragement of smoking. Much of the literature, however, uses the terms smoking control, discouragement, and cessation interchangeably. As a case in point, the report on smoking and cardiovascular disease of the Surgeon General (U.S. Department of Health and Human Services, 1982), in reviewing the literature on smoking cessation, first of all identifies it as “smoking cessation evaluation research” and five paragraphs later as “smoking control studies” (pp. 244-245). In an attempt to
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establish consistent terminology, Dawley (1987)has proposed the differentiation of smoking control to refer to efforts to control where smoking may and may not occur, stnuking discuurageinent as educational efforts designed to reduce smoking rate by encouraging nonsmoking behavior, and smoking cessation to identify formal treatments designed to help people stop smoking. Unfortunately, the vast majority of smoking programs have focused exclusively on direct cessation efforts to the exclusion of smoking control and discouragement. While there is a large amount of research on worksite smoking cessation, little attention has been directed toward worksite smoking control and discouragement. There appears to be little awareness of the value of smoking control as a way of helping employees stop smoking. One of the major reasons given by companies for not controlling smoking is fear of employee unrest and difficulties with enforcement (U.S. Department of Health and Human Services, 1985). Research suggests that excellent compliance can be achieved to smoking control when coupled with enforcement in the form of verbal prompts (Dawley and Burton, 1985). Additional research has also shown that no smoking signs alone without enforcement tcnd to be ignored over time (Dawley et ah, 1980), that positively worded signs (Thank you for not smoking) appear to be slightly more effective than negatively worded signs (No smoking-violators subject to fine) (Dawley et al., 1981b), and that when someone smokes in a no smoking area, the effects of modeling tend to influence others to smoke (Dawley et al., 1981b). The lack of information on how to implement a smoking control program is an additional reason given by companies for not doing more in this area (U.S. Department of Health and Human Services, 1985). It is estimated that 35 to 40% of private companies have established worksite smoking control policies and that the trend of these policies is becoming increasingly more restrictive in terms of where employees may smoke (Rigotti, 1986). While numerous educational efforts to discourage smoking have been reported, Orleans and Shipley (1982)state that workplace health education programs have not been systematically evaluated. They go on to state that comprehensive measures of effectiveness could help business management provide more useful educational campaigns. A promising smoking discouragement strategy is the use of humorous antismoking posters to discourage smoking (Dawley et al., 198%). While there is an obvious need for additional research evaluating worksite education efforts, it is clear such efforts do hold the promise of helping to change the worksite to an environment capable of discouraging smoking. Previous research has shown that a smoking discouragement program of humorous antismoking posters placed throughout a hospital setting resulted in a significant reduction in unobtrusively observed smoking at various locations, an increase in the awareness of health risks associated with smoking, and a decrease in the percentage of tobacco products sold in the hospital canteen (Dawley et al., 1985b).
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It is in the area of smoking cessation where the widest variety of worksite smoking cessation programs have been tried (Danaher, 1980; Klesges and Glasgow, 1985; Schwartz, 1987). A review by Danaher (1980) cites research showing a success rate at 6 months for 29 programs that were studied. No literature is available, however, on the effectiveness of multifaceted commercial smoking cessation programs that include smoking control and discouragement, components that may enhance participation rate and overall effectiveness of cessation by making the worksite environment more conducive to not smoking. In addition to focusing on quit rate as an indication of success of a smoking intervention, an often neglected variable is the acceptance of health risks associated with smoking. Fishbein’s (1977) research has shown that approximately 25 % of the total population and almost 50% of all smokers have not fully accepted the general proposition that “smoking cigarettes is dangerous to health with even less general acceptance of the proposition linking cigarettes to specific health consequences such as heart disease, emphysema, chronic bronchitis, and lowered birth weights. With Fishbein’s conceptual framework in mind, it seems reasonable to assess acceptance of health risks associated with smoking in evaluating the effectiveness of smoking interventions. Previous research in this area has shown an inverse relationship to the acceptance of health risks associated with smoking and smoking rate (Dawley et a]., 1985a). In addition, increase in acceptance of health risks associated with reduced smoking was demonstrated in this research evaluating the effectiveness of a smoking discouragement program using humorous antismoking posters emphasizing the advantages of quitting. In reviewing the cost of smoking from both a health and economic standpoint, there are clear humanitarian, economic, and legal incentives for business and industry to actively control and discourage smoking at the worksite and to provide smoking cessation assistance to those who want help in stopping smoking. The use of worksite smoking cessation programs is increasing among American businesses (Glasgow, 1987). It has been reported that 15%of a sample of United States corporations currently offer smoking cessation programs and that another 33% want to expand in this area (U.S. Chamber of Commerce, 1981; National Interagency Council on Health, 1980). One of the difficulties facing business and industry is the limited amount of research on the relative effectiveness of worksite smoking control, discouragement, and cessation programs. The recent Surgeon General’s report on smoking at the worksite (U.S. Department of Health and Human Services, 1985)cited the contention of Dawley and his associates (Dawley et al., 1985a) that worksite smoking cessation programs work best when coupled with smoking control and discouragement effort and pointed out the lack of research on this topic. This study was done to compare the effectiveness of a comprehensive program of smoking control, discouragement, and cessation with those achieved by smoking cessation alone.
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METHOD
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Subjects
Workers at two petroleum refineries in Southern Louisiana served as subjects for this study. Workers who agreed to participate completed a questionnaire designed to assess their smoking behavior. Thirty-five percent of the employees completed the smoking questionnaire at one plant while 28% completed it at the other plant. The workforces at both companies were comparable, primarily blue-collar in nature with the average age of 39 and a median education of high school graduation. Eighty percent of the respondents were White. Both sites were unionized and had a similar management style.
Procedure Outcoine Variables All workers were asked to voluntarily complete the Worksite Smoking Questionnaire to assess their smoking status and interest in participating in the smoking cessation treatment. Unobtrusive observations of smoking behavior at five different locations at each refinery were taken in five 10-minute time samples for a 5-day period. One refinery was then randomly assigned to receive the comprehensive program of smoking control, discouragement, and cessation (comprehensive) while the other received cessation alone (cessation). Smoking Control and Discouragement Approximately 2 weeks after the completion of the preintervention assessment described above, the SmokeFree smoking control and discouragement program was started at the refinery selected to receive the comprehensive program. Smoking was already controlled at both sites, with a strong smoking policy in effect restricting smoking to only designated locations. Smoking discouragement consisted of placing large banners (2’ by lo’) stating “Go SmokeFree” at all entrances to the refinery. Humorous antismoking posters were also placed throughout this worksite. Multiple copies of these posters were around the worksite and left up for a 2-week period of time. The original posters were then replaced with multiple copies of a different poster which in turn was left up for a 2-week period before being replaced. This procedure was followed until all 12 posters were placed throughout the worksite. These posters were quite visible and were placed at locations where the majority of the workforce would see them.
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Smoking Cessation Smoking cessation was offered to all employees. At both sites, announcements describing this program were distributed to the workforce. Three weeks after the smoking discouragement program was initiated, employees who indicated an interest in participating in the group smoking cessation program were informed of the time, date, and location of the group smoking cessation program. Sixteen employees participated at the refinery receiving the comprehensive program while only 14 employees participated at the refinery receiving cessation alone. The smoking behavior and demographics of these subjects are listed in Table 1. The SmokeFree smoking cessation program was then applied at both refineries by the senior and second author. A morning group was held at the refinery receiving cessation alone while an afternoon group was held at the refinery receiving the comprehensive program. All other aspects of the program were the same. The smoking cessation program consisted of six I-hour group sessions. All participants received the self-help book SmokeFree-How to Stop Smoking in Nine Easy Steps and the audio tape HypnoQuit-Stopping Smoking through Self-Hypnosis (Dawley, 1987) designed to help them stop smoking along with a pack of cigarette substitutes called Quit Stiks. Quit Stiks are natural cinnamon sticks shaped like a cigarette and packaged in a cigarette-like box. Highlights of the program include setting the fourth session as the quit date. At that point subjects were asked to discard all of their smoking paraphernalia at the same time they read aloud their “SmokeFree declaration” stating that they were stopping smoking and giving their reasons for doing so. Their pictures were taken with an instant camera as they read their declaration and discarded their smoking paraphernalia. This picture was then given to each subject who in turn taped it to his/her “SmokeFree declaration.” Subjects were then instructed to post their declaration in some prominent location where it would be visible to them and the other people in their life. Attention was
Tahle 1 Demographic Characteristics of Participants in Smoking Cessation Site 1: Smoking cessation alone ( N = 14)
Site 2: Control, discouragement, and cessation (N = 16)
~~~
Average age
39
42
Sex
75% male
78% male
Education (years)
13.5
12.5
Number of cigarettes per day
20
23
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also directed to identifying reasons for smoking and wanting to stop smoking. Cop-
ing strategies were also taught along with suggestions o n how to handle lapses and relapses.
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Results At the end of the group smoking cessation treatment, 13 participants (81%) had quit at the company receiving the comprehensive program while 10 participants (71%) had quit at the refinery receiving smoking cessation alone. At a 5-month follow-up seven participants (43%)were abstinent at the refinery receiving the comprehensive program while three participants (21 %) were abstinent at the other refinery. Urinary cotinine, obtained from all participants who reported that they were abstinent, was found to be negative. Although no formal measurements were taken in regard to the use of the selfhelp kit, 90% of participants did report on a follow-up questionnaire that the SmokeFree self-help book and Quit Stiks did help them. Numerous requests were received for additional packs of Quit Stiks, which were provided.
DISCUSSION The basic hypothesis that smoking cessation efforts are enhanced when coupled with smoking discouragement appears to be supported by the results of this study. Although smoking was already controlled at both refineries and the contribution of smoking control could not be assessed in this study, smoking discouragement clearly contributed to greater effectiveness a s attested to by the significantly greater 5-month abstinence rate at the refinery receiving this program. The placement of the humorous antismoking posters throughout the worksite had the apparent effect of changing the environment to one that supported cessation of smoking. Several authors have indicated the value of efforts to create an environment more supportive of stopping smoking (Fielding, 1986; Schwartz and Rider, 1978). It is clear that the worksite offers the opportunity to reach more than half of the adult population as well as the majority of smokers (Hallett, 1986). Furthermore, the rate of smoking in blue-collar worksites, the setting in which the present study was applied, can reach segments of the population which have a smoking rate as high as 47%,well above the national male rate of 32%.In addition, even though the overall rate of smoking in America has declined significantly in the last two decades, those who remain smoking tend to be heavy smokers (U.S. Department of Health and Human Services, 1985). It is these individuals who tend to be bluecollar in nature, where the effects of a comprehensive program of smoking control, discouragement, and cessation offers the greatest potential. Kristiansen (1985), after discovering that heavy smokers were less aware of and concerned with health aspects of smoking, stated that these smokers could benefit from health educational
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efforts and that “. .. a value confrontation program increasing the value of health might result in changes in smoking behavior” (p. 43). It has also been pointed out that a strong health educational program could not only facilitate smoking control policies but may well contribute to an increased number of employees quitting smoking (Klesges and Glasgow, 1985), a view supported by the present research. The results of this study suggest that a multifaceted program of smoking control, discouragement, and cessation offers greater potential for addressing the problem of smoking in a worksite setting than single faceted programs. The cost of such a program is minimal. The approximate cost per participant in the group smoking cessation program is $29.00, and the approximate costs for the smoking discouragement program using posters and banners for an average sized worksite of 1000 employees is $1,000. Worksites typically spend this amount on safety education programs. The addition of worksite smoking control, discouragement, and cessation programs is clearly a cost-effective approach for improved employee health and productivity.
ACKNOWLEDGMENT This research was funded by a grant from the Louisiana Lung and Cancer Trust Fund.
REFERENCES BERNSTEIN, D. A. (1969). Modification of smoking behavior: An evaluative review. Psychol. Bull. 71: 418-440. BERNSTEIN, D. A,, and GLASGOW, R. E. (1979). In 0. F. Pomerleau and I. P. Brady (eds.),Behavioral Medicine. Baltimore: Williams & Wilkens. DANAHER, B. C. (1977). Research on rapid smoking: Interim summary and recommendations, Addict. Behav. 2: 151-166. DANAHER, B. (1980). Smoking cessation programs in occupational settings. Health promotion at the worksite. Public Health Rep. 95(2): 149-157. DAWLEY, H. H. (1987). StnokeFree:A Comprehensive Worhite Stnoking Control, Discouragement, and Cessation Program New Orleans: Wellness Institute. DAWLEY, H. H., and BURTON, M. (1985). Smoking control in a hospital setting. Addict. Behav. lO(4): 351-355. DAWLEY, H. H., CARROL, S.,and MORRISON, I. (1981a). The discouragement of smoking behavior in a hospital setting: The importance of modeled behavior. Int. J. Addict. 16(5): 905-910. DAWLEY, H. H., FLEISCHER, B., and DAWLEY, L. T. (1985a). Attitudes toward smoking and smoking rate: Implications for smoking discouragement Inr. J. Addicr. 20: 483-487. DAWLEY, H. H., FLEISCHER, B., and DAWLEY, L. T. (1985b). Smoking discouragement in a hospital setting: An example of worksite smoking cessation. Int. J. Addict. 20: 783-793. DAWLEY, H. H., MORRISON, I., and CARROL, S. (1980). Compliance behavior in a hospital setting: Patient and employee reaction lo no smoking signs. Addict. Behav. 5: 239-331. DAWLEY, H. H., MORRISON, J., and CARROL, S. (1981b). The effect of differently worded no smoking signs on smoking behavior. Itif. J. Addict. 16(8): 1467- 147 1.
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EVANS, D., and LANE, D. S. (1981). Smoking cessation follow-up: A look at post-workshop behavior. Addict. Behuv. 6: 325-329. FIELDING, J. E. (1986). Baiuung worksite smoking. Am. 1 Public Health 76(8): 957-959. FISHBEIN, M. (1977). Consumer bcliefs and behavior with respect to cigarette smoking: A critical analysis of the public literature. In Federal Trade Cornmission Report to Congress Pursuant to the Federal Health Cigarette Smoking Act for Year 1976. GALLUP OPINION INDEX (1974). Report No. 108, June. GLASGOW, R. E. (1987). Worksite smoking cessation: Current progress and future directions. Can. J. Public Healfh 78(6): S21-S27. HALLE’IT, R. (1986). Smoking intervention in the workplace: Rcview and rccormnendalion Prev. Med. 15(3): 213-231. INSEL, P., and CHADWICK, J. (1975). Smoking cessation in the industrial setting. In J. Steinfield, W. Friffitks, K. Ball, and R. M. Taylor (eds.), Health Consequences, Education Cessation Activities, and Governaient Action. Vol. II. Proceedings uf Third World Conference on Smoking. KLESGES, R. C., and GLASGOW, R. E. (1985). Smoking inudification 3t the worksite. In M. F. Cataldo and R. J. Coates (eds.), Health Pronrotion in Industry-A Behavioral Medicine Perspective. New York: Wiley. KRISTEIN, M. M. (1977). Economic issues in prevention. Prev. Med. 6: 252-264. KRISTIANSEN, C. M. (1985). Smoking, health behavior, and value priorities. Addicf. Behav. 10: 41-44. MARLATT, G. A,, and GORDON, J. R. (1980). Determinants of relapse: Implications for the maintenance of bchavior change. In P. 0. Davidson and S. M. Davidson (cds.), Behuvioral Medicine: Changing Heulth Lifestyles. Ncw York: Brunner/Mazel. NATIONAL INTERAGENCY COUNCIL ON HEALTH (NICSH) (1980). Snioking and the Workplace. Ncw York: NICSH Business Survcy, 921 Broadway, Suite 1005, 10007. ORLEANS, C. S., and SHlPLEY, R. H. (1982). Worksite smoking cessation initiatives: Review and reeommendalions. Addict. Beluiv. 7: 1 - 16. RIGOITI, N. A. (1986). Policieb restricting snioking in puhlic places and the workplacc. In Surgeon General’s Report, The Health Consequences of Involuntary Smoking (DHHS 87-8398). Washington, D.C.: U S . Govcrnrnent Printing Oflice, pp. 261-334. SCHWARTZ, J . L. (1987). Review and Evaluation of Stnoking Cessation Method: The United States and Canada, 1978-2985, National Canccr Institute, Division of Cancer Prevention and Control, U.S. Dcpanincnt of Health and Human Services, NIH Publication. SCHWARTZ, J. L., and RIDER, G. (1978). Review and Evaluafion of Sirrokirig Control Methods: The US & Canada, 1969-1977. DHEW Publication No. (CDC) 78-83696. SHRIMP, D. M., BLUMROSEN, A. W., and FINFTER, S. B. (1976). How to Protect Your Health ctt Work. A Cornplere Guide for Making the Workplace Safe. Salem, New Jersey: Environmental Improveinenls Associate. U.S. CHAMBER OF COMMERCE (1981). Report on Sirtoking. US. DEPARTMENT OF HEALTH AND HUMAN SERVICES (1982). The Health Cornequences of’ Smoking: Cardiovmculur Disease, Public Health Service, Office of Smoking and Health, DHHS Pub. No. (PHS) 2-50179. U S . DEPARTMENT OF HEALTH AND HUMAN SERVICES (1985). The Health Consequences of Smoking-CaticerandChrorlic Lung Diseuse it1 the Workplace.Public Health Service, Office of Smoking and Health. DHHS (PHS) R5-50207. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE (1979). Smoking arid Health: A Report ofthe Surgeon Cenerul. DHEW Publication No. (PHS) 79-50066. WASHINGTON BUSINESS GROUP ON HEALTH (1978). A Survey of Industry Sponsored Health Proinofion, Prrvention, and Educution frogranis. Washington, D.C.: 922 Pennsylvania Ave., S.E., 20003.
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WEST, D. W., GRAHAM, S., SWANSON, M., and WILKINSON, C.(1977). Five year follow-up of a smoking withdrawal clinic population. Am. J. Public Health 67: 536-544.
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THE AUTHORS Harold H. Dawley, Jr., PhD, is the Smoking Control Officer at the New Orleans Department of Veterans Affairs Medical Center. He is also on the clinical faculty of the Tulane and Louisiana State University schools of medicine and the Tulane University School of Public Health. His research area of interest is in the use of cost effective multifaceted approaches to worksite smoking cessation.
Linda T. Dawley, PhD, is President of the Wellness Institute, Inc., a firm specializing in the development and implementation of worksite health promotion programs. She has also received a grant from the National Institute of Drug addiction for the investigation of the SmokeFree Smoking Control, Discouragement, and Cessation at blue-collar worksites.
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Pelayo Correa, MD, is a Professor of Pathology at the Louisiana State University Medical Center in New Orleans. As the recipient of several major research grants, he is involved in ongoing research investigating cancer in bluecollar worksites.
Barbara Fleischer, PhD, is an organizational psychologist on the faculty of Loyola University, New Orleans. She is also on the staff of the Wellness Institute, Inc., where she is involved with the organizational aspects of worksite smoking control, discouragement, and cessation programs.
The International Journal of the Addictions, 26(6), 685-696, 1991
A Comprehensive Worksite Smoking Control, Discouragement, and Cessation Program Harold H. Dawley Jr.,* PhD VeteransAdministration Medical Center New Orleans, Louisiana Tulane University Schools of Medicine and Public Health Louisiana State University Medical Center New Orleans, Louisiana
Linda T. Dawley, PhD Wellness Institute, Inc. Gretna, Louisiana
Pelayo Correa, MD Louisiana State University New Orleans, Louisiana
Barbara Fleischer, PhD Loyola University New Orleans, Louisiana
*To whom reprint requests should be directed at Smoking Control Officer, Veterans Administration Medical Center, 1601 Perdido Street, New Orleans, Louisiana 70146. 685
Copyright 0 1991 by Marcel Dekker, Inc.
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Abstract The effectiveness of a comprehensive program of worksite smoking control, discouragement, and cessation was compared with a program of smoking cessation alone. Two comparable oil refineries served as the research sites. Outcome variables consisted of employee seIf-reported smoking rate assessed by the use of a smoking questionnaire and unobtrusive observations of smoking behavior before and after the intervention. One company was randomly assigned to the comprehensive program of smoking control, discouragement, and cessation while the other company only received smoking cessation. Humorous antismoking posters emphasizing the benefits of quitting smokmg were distributed throughout the first worksite and changed every 2 weeks. Large banners stating "Go SmokeFree" were also placed at all locations to this plant and left up for the duration of the study. Three weeks after the initiation of the smoking discouragement program at one refinery, a group smoking cessation program was begun at both plants. At a 5-month follow-up, participants in the smoking cessation treatment at the plant receiving the comprehensive program achieved a 5-month abstinence rate of 43 % in comparison with a rate of 2 1% at the refinery receiving only smoking cessation.
INTRODUCTION The importance of addressing the problem of smoking at the worksite as a way to promote health among employees and save money for employees can hardly be overstated. The only problem with most smoking cessation efforts is their limited effectiveness (Bernstein, 1969; Danaher, 1980; Bemstein and Glasgow, 1977; Schwartz, 1978; U.S. Department of Wealth, Education, and Welfare, 1979). The failure of many of these treatments does not lie in their inability to change behavior, but rather in the lack of this change to generalize beyond treatment. In searching for an explanation of why so many people return to smoking following treatment, it is clear that environmental factors play a major role in smoking behavior (Insel and Chadwick, 1975; West et al., 1977; Marlatt and Gordon, 1980; Evans and Lane, 1981). The worksite environment appears to be one setting that can be modified to control and discourage smoking. As such, it represents a unique opportunity for effectively addressing the addictive behavior of tobacco smoking. This conclusion is especially significant in view of the high rate of smoking among blue-collar workers ( U S Department of Health and Human Services, 1985). The worksite is not only a setting where an individual spends one-third of his/her average day, it is also a setting in which administrative structure and policy can be arranged to discourage and control smoking. A Gallup Poll (Gallop Opinion Index,
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1974) reported that worksite smoking cessation programs have the potential to reach 25% of the American blue-collar workforce who smoke. This group not only has one of the highest smoking rates, but is one that underutilizes available smoking cessation programs (Danaher, 1980). The incentive for business to support efforts to reduce smoking at the worksite is the staggering increase in health care costs. According to the U.S. Chamber of Commerce (198 l), American businesses now pay at least half of the national health bill. The economic impact of smoking on business and industry is reflected in the 1980 National Interagency Council on Health’s (1980) estimate that the average employee who smokes costs his or her employer up to $600 a year in otherwise avoidable expenses. Smokers utilize health care services up to 50% more than nonsmokers (Fielding, 1986). A more detailed estimate of the economic impact of tobacco smoking has been presented by Kristein showing smokers of one pack a day having a 50% greater rate of hospitalization and absenteeism with employees who smoke two packs a day having twice the absence rate of nonsmokers (Kristein, 1977). Because of the magnitude of the health effects of smoking and the benefits of stopping smoking, smoking cessation programs can be expected to yield a higher return on investment than worksite programs addressing other lifestyle changes such as obesity and lack of exercise (Fielding, 1986). In addition to concern over health and productivity, increasingly vocal efforts by nonsmoking employees for an environment free of secondhand smoke have also made companies concerned about their vulnerability to lawsuits and claims from the effects of environmental tobacco smoke (E.T.S.). Surveys reported by the Washington Business Group on Health (1978) have shown 15 to 19% of American businesses reported employee filed claims of illness related to exposure to E.T.S. The decision of the New Jersey Superior Court in favor of an employee allergic to tobacco smoke to an environment free of the smoke of other employees (Shrimp et al., 1976) stands as a landmark case in this area. As new research demonstrates additional adverse effects on nonsmokers from E.T.S., the efforts of nonsmoking employees to protect themselves will increase. For both humanitarian and economic reasons, business and industry are showing a strong and rapidly increasing interest in addressing the problem of tobacco smoking at the worksite. In discussing tobacco smoking, it is important to recognize several distinctly different approaches to the solution of this problem. Some approaches directly help people stop smoking by providing treatment to achieve this goal. Other approaches do not focus on cessation but on the control and/or discouragement of smoking. Much of the literature, however, uses the terms smoking control, discouragement, and cessation interchangeably. As a case in point, the report on smoking and cardiovascular disease of the Surgeon General (U.S. Department of Health and Human Services, 1982), in reviewing the literature on smoking cessation, first of all identifies it as “smoking cessation evaluation research” and five paragraphs later as “smoking control studies” (pp. 244-245). In an attempt to
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establish consistent terminology, Dawley (1987)has proposed the differentiation of smoking control to refer to efforts to control where smoking may and may not occur, stnuking discuurageinent as educational efforts designed to reduce smoking rate by encouraging nonsmoking behavior, and smoking cessation to identify formal treatments designed to help people stop smoking. Unfortunately, the vast majority of smoking programs have focused exclusively on direct cessation efforts to the exclusion of smoking control and discouragement. While there is a large amount of research on worksite smoking cessation, little attention has been directed toward worksite smoking control and discouragement. There appears to be little awareness of the value of smoking control as a way of helping employees stop smoking. One of the major reasons given by companies for not controlling smoking is fear of employee unrest and difficulties with enforcement (U.S. Department of Health and Human Services, 1985). Research suggests that excellent compliance can be achieved to smoking control when coupled with enforcement in the form of verbal prompts (Dawley and Burton, 1985). Additional research has also shown that no smoking signs alone without enforcement tcnd to be ignored over time (Dawley et ah, 1980), that positively worded signs (Thank you for not smoking) appear to be slightly more effective than negatively worded signs (No smoking-violators subject to fine) (Dawley et al., 1981b), and that when someone smokes in a no smoking area, the effects of modeling tend to influence others to smoke (Dawley et al., 1981b). The lack of information on how to implement a smoking control program is an additional reason given by companies for not doing more in this area (U.S. Department of Health and Human Services, 1985). It is estimated that 35 to 40% of private companies have established worksite smoking control policies and that the trend of these policies is becoming increasingly more restrictive in terms of where employees may smoke (Rigotti, 1986). While numerous educational efforts to discourage smoking have been reported, Orleans and Shipley (1982)state that workplace health education programs have not been systematically evaluated. They go on to state that comprehensive measures of effectiveness could help business management provide more useful educational campaigns. A promising smoking discouragement strategy is the use of humorous antismoking posters to discourage smoking (Dawley et al., 198%). While there is an obvious need for additional research evaluating worksite education efforts, it is clear such efforts do hold the promise of helping to change the worksite to an environment capable of discouraging smoking. Previous research has shown that a smoking discouragement program of humorous antismoking posters placed throughout a hospital setting resulted in a significant reduction in unobtrusively observed smoking at various locations, an increase in the awareness of health risks associated with smoking, and a decrease in the percentage of tobacco products sold in the hospital canteen (Dawley et al., 1985b).
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It is in the area of smoking cessation where the widest variety of worksite smoking cessation programs have been tried (Danaher, 1980; Klesges and Glasgow, 1985; Schwartz, 1987). A review by Danaher (1980) cites research showing a success rate at 6 months for 29 programs that were studied. No literature is available, however, on the effectiveness of multifaceted commercial smoking cessation programs that include smoking control and discouragement, components that may enhance participation rate and overall effectiveness of cessation by making the worksite environment more conducive to not smoking. In addition to focusing on quit rate as an indication of success of a smoking intervention, an often neglected variable is the acceptance of health risks associated with smoking. Fishbein’s (1977) research has shown that approximately 25 % of the total population and almost 50% of all smokers have not fully accepted the general proposition that “smoking cigarettes is dangerous to health with even less general acceptance of the proposition linking cigarettes to specific health consequences such as heart disease, emphysema, chronic bronchitis, and lowered birth weights. With Fishbein’s conceptual framework in mind, it seems reasonable to assess acceptance of health risks associated with smoking in evaluating the effectiveness of smoking interventions. Previous research in this area has shown an inverse relationship to the acceptance of health risks associated with smoking and smoking rate (Dawley et a]., 1985a). In addition, increase in acceptance of health risks associated with reduced smoking was demonstrated in this research evaluating the effectiveness of a smoking discouragement program using humorous antismoking posters emphasizing the advantages of quitting. In reviewing the cost of smoking from both a health and economic standpoint, there are clear humanitarian, economic, and legal incentives for business and industry to actively control and discourage smoking at the worksite and to provide smoking cessation assistance to those who want help in stopping smoking. The use of worksite smoking cessation programs is increasing among American businesses (Glasgow, 1987). It has been reported that 15%of a sample of United States corporations currently offer smoking cessation programs and that another 33% want to expand in this area (U.S. Chamber of Commerce, 1981; National Interagency Council on Health, 1980). One of the difficulties facing business and industry is the limited amount of research on the relative effectiveness of worksite smoking control, discouragement, and cessation programs. The recent Surgeon General’s report on smoking at the worksite (U.S. Department of Health and Human Services, 1985)cited the contention of Dawley and his associates (Dawley et al., 1985a) that worksite smoking cessation programs work best when coupled with smoking control and discouragement effort and pointed out the lack of research on this topic. This study was done to compare the effectiveness of a comprehensive program of smoking control, discouragement, and cessation with those achieved by smoking cessation alone.
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METHOD
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Subjects
Workers at two petroleum refineries in Southern Louisiana served as subjects for this study. Workers who agreed to participate completed a questionnaire designed to assess their smoking behavior. Thirty-five percent of the employees completed the smoking questionnaire at one plant while 28% completed it at the other plant. The workforces at both companies were comparable, primarily blue-collar in nature with the average age of 39 and a median education of high school graduation. Eighty percent of the respondents were White. Both sites were unionized and had a similar management style.
Procedure Outcoine Variables All workers were asked to voluntarily complete the Worksite Smoking Questionnaire to assess their smoking status and interest in participating in the smoking cessation treatment. Unobtrusive observations of smoking behavior at five different locations at each refinery were taken in five 10-minute time samples for a 5-day period. One refinery was then randomly assigned to receive the comprehensive program of smoking control, discouragement, and cessation (comprehensive) while the other received cessation alone (cessation). Smoking Control and Discouragement Approximately 2 weeks after the completion of the preintervention assessment described above, the SmokeFree smoking control and discouragement program was started at the refinery selected to receive the comprehensive program. Smoking was already controlled at both sites, with a strong smoking policy in effect restricting smoking to only designated locations. Smoking discouragement consisted of placing large banners (2’ by lo’) stating “Go SmokeFree” at all entrances to the refinery. Humorous antismoking posters were also placed throughout this worksite. Multiple copies of these posters were around the worksite and left up for a 2-week period of time. The original posters were then replaced with multiple copies of a different poster which in turn was left up for a 2-week period before being replaced. This procedure was followed until all 12 posters were placed throughout the worksite. These posters were quite visible and were placed at locations where the majority of the workforce would see them.
69 1
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Smoking Cessation Smoking cessation was offered to all employees. At both sites, announcements describing this program were distributed to the workforce. Three weeks after the smoking discouragement program was initiated, employees who indicated an interest in participating in the group smoking cessation program were informed of the time, date, and location of the group smoking cessation program. Sixteen employees participated at the refinery receiving the comprehensive program while only 14 employees participated at the refinery receiving cessation alone. The smoking behavior and demographics of these subjects are listed in Table 1. The SmokeFree smoking cessation program was then applied at both refineries by the senior and second author. A morning group was held at the refinery receiving cessation alone while an afternoon group was held at the refinery receiving the comprehensive program. All other aspects of the program were the same. The smoking cessation program consisted of six I-hour group sessions. All participants received the self-help book SmokeFree-How to Stop Smoking in Nine Easy Steps and the audio tape HypnoQuit-Stopping Smoking through Self-Hypnosis (Dawley, 1987) designed to help them stop smoking along with a pack of cigarette substitutes called Quit Stiks. Quit Stiks are natural cinnamon sticks shaped like a cigarette and packaged in a cigarette-like box. Highlights of the program include setting the fourth session as the quit date. At that point subjects were asked to discard all of their smoking paraphernalia at the same time they read aloud their “SmokeFree declaration” stating that they were stopping smoking and giving their reasons for doing so. Their pictures were taken with an instant camera as they read their declaration and discarded their smoking paraphernalia. This picture was then given to each subject who in turn taped it to his/her “SmokeFree declaration.” Subjects were then instructed to post their declaration in some prominent location where it would be visible to them and the other people in their life. Attention was
Tahle 1 Demographic Characteristics of Participants in Smoking Cessation Site 1: Smoking cessation alone ( N = 14)
Site 2: Control, discouragement, and cessation (N = 16)
~~~
Average age
39
42
Sex
75% male
78% male
Education (years)
13.5
12.5
Number of cigarettes per day
20
23
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also directed to identifying reasons for smoking and wanting to stop smoking. Cop-
ing strategies were also taught along with suggestions o n how to handle lapses and relapses.
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Results At the end of the group smoking cessation treatment, 13 participants (81%) had quit at the company receiving the comprehensive program while 10 participants (71%) had quit at the refinery receiving smoking cessation alone. At a 5-month follow-up seven participants (43%)were abstinent at the refinery receiving the comprehensive program while three participants (21 %) were abstinent at the other refinery. Urinary cotinine, obtained from all participants who reported that they were abstinent, was found to be negative. Although no formal measurements were taken in regard to the use of the selfhelp kit, 90% of participants did report on a follow-up questionnaire that the SmokeFree self-help book and Quit Stiks did help them. Numerous requests were received for additional packs of Quit Stiks, which were provided.
DISCUSSION The basic hypothesis that smoking cessation efforts are enhanced when coupled with smoking discouragement appears to be supported by the results of this study. Although smoking was already controlled at both refineries and the contribution of smoking control could not be assessed in this study, smoking discouragement clearly contributed to greater effectiveness a s attested to by the significantly greater 5-month abstinence rate at the refinery receiving this program. The placement of the humorous antismoking posters throughout the worksite had the apparent effect of changing the environment to one that supported cessation of smoking. Several authors have indicated the value of efforts to create an environment more supportive of stopping smoking (Fielding, 1986; Schwartz and Rider, 1978). It is clear that the worksite offers the opportunity to reach more than half of the adult population as well as the majority of smokers (Hallett, 1986). Furthermore, the rate of smoking in blue-collar worksites, the setting in which the present study was applied, can reach segments of the population which have a smoking rate as high as 47%,well above the national male rate of 32%.In addition, even though the overall rate of smoking in America has declined significantly in the last two decades, those who remain smoking tend to be heavy smokers (U.S. Department of Health and Human Services, 1985). It is these individuals who tend to be bluecollar in nature, where the effects of a comprehensive program of smoking control, discouragement, and cessation offers the greatest potential. Kristiansen (1985), after discovering that heavy smokers were less aware of and concerned with health aspects of smoking, stated that these smokers could benefit from health educational
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efforts and that “. .. a value confrontation program increasing the value of health might result in changes in smoking behavior” (p. 43). It has also been pointed out that a strong health educational program could not only facilitate smoking control policies but may well contribute to an increased number of employees quitting smoking (Klesges and Glasgow, 1985), a view supported by the present research. The results of this study suggest that a multifaceted program of smoking control, discouragement, and cessation offers greater potential for addressing the problem of smoking in a worksite setting than single faceted programs. The cost of such a program is minimal. The approximate cost per participant in the group smoking cessation program is $29.00, and the approximate costs for the smoking discouragement program using posters and banners for an average sized worksite of 1000 employees is $1,000. Worksites typically spend this amount on safety education programs. The addition of worksite smoking control, discouragement, and cessation programs is clearly a cost-effective approach for improved employee health and productivity.
ACKNOWLEDGMENT This research was funded by a grant from the Louisiana Lung and Cancer Trust Fund.
REFERENCES BERNSTEIN, D. A. (1969). Modification of smoking behavior: An evaluative review. Psychol. Bull. 71: 418-440. BERNSTEIN, D. A,, and GLASGOW, R. E. (1979). In 0. F. Pomerleau and I. P. Brady (eds.),Behavioral Medicine. Baltimore: Williams & Wilkens. DANAHER, B. C. (1977). Research on rapid smoking: Interim summary and recommendations, Addict. Behav. 2: 151-166. DANAHER, B. (1980). Smoking cessation programs in occupational settings. Health promotion at the worksite. Public Health Rep. 95(2): 149-157. DAWLEY, H. H. (1987). StnokeFree:A Comprehensive Worhite Stnoking Control, Discouragement, and Cessation Program New Orleans: Wellness Institute. DAWLEY, H. H., and BURTON, M. (1985). Smoking control in a hospital setting. Addict. Behav. lO(4): 351-355. DAWLEY, H. H., CARROL, S.,and MORRISON, I. (1981a). The discouragement of smoking behavior in a hospital setting: The importance of modeled behavior. Int. J. Addict. 16(5): 905-910. DAWLEY, H. H., FLEISCHER, B., and DAWLEY, L. T. (1985a). Attitudes toward smoking and smoking rate: Implications for smoking discouragement Inr. J. Addicr. 20: 483-487. DAWLEY, H. H., FLEISCHER, B., and DAWLEY, L. T. (1985b). Smoking discouragement in a hospital setting: An example of worksite smoking cessation. Int. J. Addict. 20: 783-793. DAWLEY, H. H., MORRISON, I., and CARROL, S. (1980). Compliance behavior in a hospital setting: Patient and employee reaction lo no smoking signs. Addict. Behav. 5: 239-331. DAWLEY, H. H., MORRISON, J., and CARROL, S. (1981b). The effect of differently worded no smoking signs on smoking behavior. Itif. J. Addict. 16(8): 1467- 147 1.
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EVANS, D., and LANE, D. S. (1981). Smoking cessation follow-up: A look at post-workshop behavior. Addict. Behuv. 6: 325-329. FIELDING, J. E. (1986). Baiuung worksite smoking. Am. 1 Public Health 76(8): 957-959. FISHBEIN, M. (1977). Consumer bcliefs and behavior with respect to cigarette smoking: A critical analysis of the public literature. In Federal Trade Cornmission Report to Congress Pursuant to the Federal Health Cigarette Smoking Act for Year 1976. GALLUP OPINION INDEX (1974). Report No. 108, June. GLASGOW, R. E. (1987). Worksite smoking cessation: Current progress and future directions. Can. J. Public Healfh 78(6): S21-S27. HALLE’IT, R. (1986). Smoking intervention in the workplace: Rcview and rccormnendalion Prev. Med. 15(3): 213-231. INSEL, P., and CHADWICK, J. (1975). Smoking cessation in the industrial setting. In J. Steinfield, W. Friffitks, K. Ball, and R. M. Taylor (eds.), Health Consequences, Education Cessation Activities, and Governaient Action. Vol. II. Proceedings uf Third World Conference on Smoking. KLESGES, R. C., and GLASGOW, R. E. (1985). Smoking inudification 3t the worksite. In M. F. Cataldo and R. J. Coates (eds.), Health Pronrotion in Industry-A Behavioral Medicine Perspective. New York: Wiley. KRISTEIN, M. M. (1977). Economic issues in prevention. Prev. Med. 6: 252-264. KRISTIANSEN, C. M. (1985). Smoking, health behavior, and value priorities. Addicf. Behav. 10: 41-44. MARLATT, G. A,, and GORDON, J. R. (1980). Determinants of relapse: Implications for the maintenance of bchavior change. In P. 0. Davidson and S. M. Davidson (cds.), Behuvioral Medicine: Changing Heulth Lifestyles. Ncw York: Brunner/Mazel. NATIONAL INTERAGENCY COUNCIL ON HEALTH (NICSH) (1980). Snioking and the Workplace. Ncw York: NICSH Business Survcy, 921 Broadway, Suite 1005, 10007. ORLEANS, C. S., and SHlPLEY, R. H. (1982). Worksite smoking cessation initiatives: Review and reeommendalions. Addict. Beluiv. 7: 1 - 16. RIGOITI, N. A. (1986). Policieb restricting snioking in puhlic places and the workplacc. In Surgeon General’s Report, The Health Consequences of Involuntary Smoking (DHHS 87-8398). Washington, D.C.: U S . Govcrnrnent Printing Oflice, pp. 261-334. SCHWARTZ, J . L. (1987). Review and Evaluation of Stnoking Cessation Method: The United States and Canada, 1978-2985, National Canccr Institute, Division of Cancer Prevention and Control, U.S. Dcpanincnt of Health and Human Services, NIH Publication. SCHWARTZ, J. L., and RIDER, G. (1978). Review and Evaluafion of Sirrokirig Control Methods: The US & Canada, 1969-1977. DHEW Publication No. (CDC) 78-83696. SHRIMP, D. M., BLUMROSEN, A. W., and FINFTER, S. B. (1976). How to Protect Your Health ctt Work. A Cornplere Guide for Making the Workplace Safe. Salem, New Jersey: Environmental Improveinenls Associate. U.S. CHAMBER OF COMMERCE (1981). Report on Sirtoking. US. DEPARTMENT OF HEALTH AND HUMAN SERVICES (1982). The Health Cornequences of’ Smoking: Cardiovmculur Disease, Public Health Service, Office of Smoking and Health, DHHS Pub. No. (PHS) 2-50179. U S . DEPARTMENT OF HEALTH AND HUMAN SERVICES (1985). The Health Consequences of Smoking-CaticerandChrorlic Lung Diseuse it1 the Workplace.Public Health Service, Office of Smoking and Health. DHHS (PHS) R5-50207. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE (1979). Smoking arid Health: A Report ofthe Surgeon Cenerul. DHEW Publication No. (PHS) 79-50066. WASHINGTON BUSINESS GROUP ON HEALTH (1978). A Survey of Industry Sponsored Health Proinofion, Prrvention, and Educution frogranis. Washington, D.C.: 922 Pennsylvania Ave., S.E., 20003.
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WEST, D. W., GRAHAM, S., SWANSON, M., and WILKINSON, C.(1977). Five year follow-up of a smoking withdrawal clinic population. Am. J. Public Health 67: 536-544.
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THE AUTHORS Harold H. Dawley, Jr., PhD, is the Smoking Control Officer at the New Orleans Department of Veterans Affairs Medical Center. He is also on the clinical faculty of the Tulane and Louisiana State University schools of medicine and the Tulane University School of Public Health. His research area of interest is in the use of cost effective multifaceted approaches to worksite smoking cessation.
Linda T. Dawley, PhD, is President of the Wellness Institute, Inc., a firm specializing in the development and implementation of worksite health promotion programs. She has also received a grant from the National Institute of Drug addiction for the investigation of the SmokeFree Smoking Control, Discouragement, and Cessation at blue-collar worksites.
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Pelayo Correa, MD, is a Professor of Pathology at the Louisiana State University Medical Center in New Orleans. As the recipient of several major research grants, he is involved in ongoing research investigating cancer in bluecollar worksites.
Barbara Fleischer, PhD, is an organizational psychologist on the faculty of Loyola University, New Orleans. She is also on the staff of the Wellness Institute, Inc., where she is involved with the organizational aspects of worksite smoking control, discouragement, and cessation programs.
