The Journal of Primary Prevention, Vol. 14, No. I 1993
Organizational Factors Affecting Smoking at Work: Results from Focus Group Interviews with Smokers and Ex-smokers Linda Gearhart Pucci 1,2-~ and Bo J. A. Haglund 2
A theoretical model addressing worksite factors affecting health behaviors was applied to data from focus group interviews. Organizational factors that might have influenced implementation of restrictive smoking policies at two social welfare districts were identified. There was greater policy awareness at the district where active dissemination of information took place. However, greater policy awareness was not associated with patterns of on-the-job smoking or support for~barriers to quitting. Instead specific patterns associated with general organizational characteristics, job characteristics and work role stress emerged. Findings suggest that changes in policy f o r m u l a t i o n and application which take into account work itself and not only the worker are warranted. KEY-WORDS: Smoking control policy; organizational constraints; focus group.
INTRODUCTION Worksites have long been the focus of efforts to restrict smoking. While the relationship among occupational hazard, smoking and disease is long established (Covey, 1981; Pearle, 1982; Cotton D. J., et al., 1983), occupational differences, as reflected in smoking prevalence rates, are in part indicative of different norms affecting behavior in social groups (Nellis, IDana-Farber Cancer Institute, Boston, MA. 2Karolinska Institute, Department of Social Medicine, Kronan Health Center, S-172 83 Sundbyberg, Sweden. 3Address correspondence to Linda Gearhart Pucci, M.P.H., Dana-Farber Cancer Institute, Dept. of Epidemiology and Cancer Control, 44 Binney Street, Boston, MA 02115. 115 © 1993Human SciencesPress, inc.
116
Pucci and Haglund
1982; Rosen, 1987). The importance of the work setting both as a factor in determining smoking habits and as a potential aid in fostering smoking cessation has begun to be recognized (Orleans, 1982; Glasgow, 1984; Sorensen et al., 1989; Waldon & Ley, 1989). Studies have shown that worksite smoking control has a greater impact on smoking reduction than on cessation (Rosenstock, 1986; Beiner et al., 1989). Emont and Cummings (1990), in their investigations of worksite organizational factors influence on employee participation in worksite smoking cessation programs, concluded that future interventions should concentrate on specific employee, manager and worksite characteristics that facilitate group level participation in cessation rates. One model (Gupta and Jenkins 1984) addresses organizational antecedents of substance use. It identifies conditions that either stimulate or inhibit it. (Figure 1). The authors limit their attention to precursors at work, by explaining "the etiology of substance use is still unclear and that in-depth examination of one set of antecedents is preferable to a superficial study of all possible antecedents." In their model, substance is conceptualized as the employee's response to aversive organizational conditions and is restricted to its onset or aggravation as a response to the work environment. Substance use is then hypothesized as resulting from a complex interplay among mree forces, namely distanc~rJg forces, attractions and constraints. Distancing forces, which push the individual away from the organization, arise from perceived aversive organizational conditions, for example: work role stress, occupational obsolescence, supervisors, work group characteristics and/or organizational characteristics. Attractions pull and constraints push the individual toward the organization. Attractions are valued by employees and include both intrinsic rewards such as pay and/or a challenging job and extrinsic rewards for example fringe benefits, job security and social support. They represent the energy that keeps workers at work, both physically and psychologically. In this model, constraints are specific to substance use and function as mediators in preventing individuals from acting in ways contrary to existing organizational norms. They are divided into three categories; individual, organizational and environmental. Individual constraints include healthy personality structures and/or demographic variables such as morals or religious beliefs which intervene. Organizational constraints include characteristics of the organization itself, supervision, work-group and the task at hand. Environmental constraints lie outside the organization and characterize the larger socio-cultural setting in which the employee functions. They include legal, cultural and economic constraints. Our discussion in this study is limited to organizational constraints.
Organizational Factors Affecting Smoking at Work
DISTANCING FORCES Supervisory characteristics Work group characteristics Job characteristics Organizational characteristics Work role stress Occupational obsolecence
• . CONSTRAINTS
Individual contjaints Personality characteristics Background characteristics Oramnizational constraints Organizational characteristics Supervisory characteristics Work group characteristics Job characteristics Environmental constraints Cultural constraints Legal constraints Economic constraints
MINUS
117
Z ATTRACTIONS Organizational rewards
(e.g., salary, •nge benefits security, intrinsic rewards) Job satisfaction
LEVELOF DISTANCING NECESSARY
v
SUBSTANCE USE
Fig. 1. Conceptual framework for examination of smoking as a response to the work environment, Adapted from Gupta, N. and Jenkins, G. D. (1984).
When the total distancing force outweighs total attractions, the expected consequence is that employees will distance themselves either physically or psychologically from work. T h e individual, being thrown off balance, attempts to regain it by adapting her/his behavior. Adaptive behaviors can be directed outward. They can be positive, i.e. discussing the problem or learning new skills, or negative i.e. complaining and accusing others or calling in sick. The intensity of the adaptive behavior depends on the level of distancing necessary. Substance use which is one of many behaviors, emerges to the degree that institutionalized constraints allow. The aim of this study was to identify organizational factors that might have influenced implementation of restrictive smoking policies at two social welfare districts utilizing the Gupta-Jenkins model as a framework.
118
Pucci and Haglund
BACKGROUND
In 1988 the Personal Policy Board of the city of Stockholm approved new guidelines for smoking control at municipal work sites and assigned its administrative agency the task of facilitating policy implementation in the city's agencies and organizations (R6kfritt ar naturligt, 1988). Briefly, the policy recommended prohibiting smoking in all municipal places of employment. In situations where ordinary ventilation did not protect employees from exposure to environmental tobacco smoke (ETS), either ventilated smoking lounges with direct external exhaust or total ban on smoking was recommended. Whenever smoking restrictions were introduced, smoking cessation programs were to be offered employees during working hours. The Personnel Policy Board's two-year intervention, N A T U R A L L Y SMOKE-FREE, targeted all local governmental agencies and municipal organizations in the city of Stockholm. It was conducted between May 1988 and November 1990. The intervention included community organizational components intended to help identify common problems or goals, mobilize resources and in other ways develop and implement strategies for attaining the specified goals (Minkler, 1990). These included conferences, seminars and workshops. Health education materials and analytical tools were also developed and training programs for smoking cessation group leaders were conducted (Pucci and Haglund, 1992a). All agencies and organizations in the municipality including the city's 18 social welfare districts, were tracked from November 1986 to November 1990.
MATERIAL AND METHOD Settings and Subjects The subjects for our focus group interviews were recruited by district wellness coordinators and by the moderator. Only smokers and former smokers were invited to participate in the interviews. All participants were women employed either as home helpers or as child care workers. The cooperating sights were the two social welfare districts that had been surveyed earlier (Pucci and Haglund, 1992b). They will be referred to as District A and District B in the rest of this paper. Seven focus groups varying in size from two to six members were conducted.
Organizational Factors Affecting Smoking at Work
119
The Focus Group Discussion A series of focus group interviews examining 1) smokers' and exsmokers' perception and understanding of the new regulations, 2) their own smoking behavior, and 3) organizational factors impacting on policy implemention was conducted. The interviews provided access to a narrower sample than in the survey and at the same time allowed us to address the issues in more depth. The m e t h o d o l o g y incorporated s t a n d a r d focus group f o r m a t (Kruegar, 1989; Morgan 1988;) around a set of questions aimed at eliciting reactions to the policy itself as well as providing information about smoking behavior at work and smoking as it related to professional role. A discussion guide was developed in which questions were presented in a logical order. The groups were moderated by the first author (LGP) between April and June 1991. Focus groups were conducted in the respective facilities of the host organizations. The moderator explained that the purpose of the group interview was to obtain smokers' and former smokers' views and ideas about the new smoking regulations. An assistant took notes during the interviews. Consent was obtained from participants to tape-record the sessions. Discussion topics began with the policy itself and proceeded to smoking behavior as it related to work and professional roles. The interview procedure included asking the group a general question, obtaining several responses, then probing further with more specific questions until all relevant views had been expressed. Each session lasted approximately one and one-half hours. After the discussion, the moderator listened to the recorded tapes, made additional notes and made comparisons with the assistant's notes. Transcripts of the tapes were used together with the notes in order to complete the moderator's impression and to facilitate analysis. The responses were categorized, specific information was extracted, compiled and summarized.
RESULTS Procedures suggested by Morgan (1988) and Kruegar (1989) were adapted in examining the responses. The process consisted of generating categories of concerns from key words, phrases and verbatim quotes. Each category was examined for subtopics. The most useful quotes and illustrations were then selected for the various categories.
120
Pucci and Haglund
The focus groups provided valuable information about policy awareness, adherence, changes in smoking status, smoking in the work setting and disruptions in work as a result of the newly implemented policy. Policy Awareness Discussions about policy content and implementation provided two distinctly different patterns at the two districts. Participants at District A knew the exact date when the smoking control policy went into effect. They also knew locations of designated smoking areas. H o m e helpers identified designated smoking areas in centers for the elderly. F u r t h e r m o r e participants reported how the "smoking control policy" had gone into effect and were able to describe steps taken by the district for preparing employees for the policy change. One participant provided the following account: "..a program was endorsed in the fall of '90. We inspected the various worksites and made suggestions for where designated smoking areas should be located" In contrast, participants from District B had only a vague recollection of the "ban on smoking" as they called it, and were unable to give details about its content or implementation. "There never were any rules about smoking, there aren't any now." "I think we're supposed to keep the doors closed when we smoke."
Adherence Discussions about adherence to new smoking regulations also revealed differences between the two districts. W h e n relating what had happened during policy implementation, participants at Districts A discussed specific changes in the physical environment often citing designated smoking areas. In contrast, participants from District B discussed how supervisor's smoking behavior might affect "eventual" policy implementation. "'As long as.......(supervisor) smokes, it's alright to smoke at work "'
Changes in Smoking Status One section of the focus group interview brought out factors affecting smoking behavior. Since participants were smokers and ex-smokers, we were interested in eliciting factors in the work setting that facilitated or
Organizational Factors Affecting Smoking at Work
121
impeded their quitting smoking. Participants at both districts reported the positive effects of co-worker/client support and how they were encouraged to quit smoking. Several remarked that quitting smoking was "contagious", i.e. when one person quit, others followed suit. "I decided, I wasn't going to quit (smoking), but when everyone else was doing it, I t h o u g h t 'why not!'."
The temptation to start smoking after having quit, was also discussed at length. Again, responses from the two districts were similar. The smell of cigarette smoke and co-workers who smoked had negative effects on those who had quit or were trying to. Several participants mentioned that their relationship to cigarettes was similar to alcoholics relationship to alcohol. "Once an alcoholic, always an alcoholic." Participants revealed that they often took up smoking as a response to job pressures. They also associated smoking with comradery, which made it easy to start smoking after they had quit. "Sometimes its just to have fun. Your buddies say, c'mon, let's take a break. It's fun ...the whole gang jokes and smokes."
Smoking and Work This section of the focus group interviews brought out how smoking behavior was impacted by the work setting. The discussion turned to the topic of taking cigarette breaks. Home helpers adapted their smoking breaks to the task at hand, while child care workers integrated smoking into their work day. Home helpers revealed that they smoked mostly when they went to shop for their clients. They considered it natural to take the opportunity to smoke when they were outdoors, they also reported that they smoked during lunch and coffee breaks. There were other times when they really wanted to smoke, for example: when they had a problem, to quiet their nerves, or when the pressure was on. Participants revealed that for them, smoking was a way of coping with work pressures. "I meet people e v e ~ day, new people in new situations. I have to pace myself, get to know people and their homes. It's the clients who count. I'm not important. So l have to shift gears (take a smoke) three or four times a day."
The home helpers also described smoking as an integral part of their duties. In cases where clients smoked, it was natural for them to sit and talk over a cup of coffee and a cigarette. In this sense smoking fulfilled their professional responsibilities of providing company for their clients.
122
Pucci and Haglund "It's like when they offer you coffee and a roll and you say, no thanks, I'm trying to lose weight. They always say, take just one, you won't get fat.' And, you do it because you want to keep them company. The same goes for smoking."
Child care w o r k e r ' s smoking b e h a v i o r in relationship to the w o r k situation, differed s o m e w h a t from t h a t o f the h o m e helpers. T h e child care w o r k e r s described smoking as an integral part o f the w o r k day. T h e y b e g a n and e n d e d their day with a cigarette. S m o k i n g was a "given" during lunch and regular breaks. O n e participant gave the following account: "At morning coffee I go with the other smokers to the smoking lounge. I don't smoke anymore before lunch. Now, if things are pretty quiet, I mean not total chaos, I might have a cigg before lunch...or if I've got to discuss something with someone. I might say, can we discuss it while we take a smoke? Then I smoke after lunch and at afternoon coffee break. Maybe there's even time for one between. And, then right before I go home. I guess about 20 in all." Child care workers also indicated that s m o k i n g was a way o f coping with w o r k stress. T h e y s m o k e d m o r e w h e n they were tired, when they were u n d e r pressure, w h e n the kids w e r e rowdy and the p a r e n t s complained. "Sometimes when I feel I just can't satisfy everyone....parents have unreasonable expectations...that's when I start smoking. It's hard working with people." F o r child care workers, discussions during focus interviews emphasized conflict between their smoking and their professional behavior. T h e y didn't want the children to know they s m o k e d o r to see t h e m with a cigarette. Disruption of Work It was primarily in child care settings that the restrictive smoking policy disrupted work. Child care w o r k e r s w h o s m o k e d , left the premises between existing breaktimes. Participants readily a d m i t t e d that five-minute breaks were often drawn out and that w h e n several s m o k e r s took breaks together, their non-smoking colleagues were left to carry on alone. Participants were in a g r e e m e n t that n o n - s m o k e r s got fewer breaks. O n e p e r s o n r e p o r t e d that "extra" breaktime was often the topic of discussion during focus groups. O n e ex-smoker expressed her dismay: " S m o k e r s get m o r e breaks. If non smokers sit down to read the paper, it's not the same thing, The)' think we're shirking our d u ~ . "
DISCUSSION W e f o u n d g r e a t e r policy awareness at District A than at District B, which is consistent with earlier results f r o m p r o g r a m evaluation of the two
Organizational Factors Affecting Smoking at Work
123
districts. Pucci and Haglund (1992b) attributed this difference to District A's active dissemination of information and the fact that District A had followed the prescribed model and in the recommended time framework (Pucci, 1991). In contrast, District B had compromised the time table by trying to do everything at one point in time. In addition implementation (information) had stagnated on the administrative level at District B. However, differences in policy awareness at the two districts did not seem to be associated with patterns of smoking behavior at work, or support for/barriers to quitting smoking. Instead, specific patterns associating work stress and work norms with smoking at work emerged for home helpers and childcare workers. Investigations of smoking policy implementation at places of employment have concentrated on smoker's behavior and measured success/failure of the implementation in terms of changing that behavior (Pucci 1991). Earlier investigations have, however identified a need for addressing work environmental factors that affect employee health behavior. LaRocco, House and French, (1980) pointed out that occupational task structure and environment may play a central role in determining which sources of support are most salient for altering health behaviors. Emont and Cummings (1990) assessed the effects of worksite-level factors on clinic participation and smoking cessation at multiple work settings and concluded that, in addition to intervention efforts focused on employee behavior, manager and worksite characteristics should also be addressed. Gupta and Jenkins' model (1984), although developed as a tool for discussing substance use at work, is also appropriate to our discussion of smoking policy/behavior, since nicotine is a drug with immediate psychoneurological and physiological effects (Golding et al. 1982; Taveira Da Silva et al., 1982). Furthermore it has been suggested that on-the-job smoking is one way of coping with or adapting to work induced stress (Conway et al., 1981; Hatch, 1983; Crutchfietd, 1984). Applying the Gupta-Jenkins model (Figure 1) to our interview results allows us to systematically examine organizational characteristics as they relate to smoking behavior at work. Distancing Forces Distancing forces that were identified by participants included job characteristics and work role stress. As one child-care worker put it, "Sometimes when I feel I just can't satisfy everyone, parents have unreasonable expectations, that's when I start smoking. Its hard working with people". Home helpers found that smoking helped them disengage from one client
124
Pucci and Haglund
and prepare to meet the next. These findings are consistent with earlier investigations (Conway, 1981; Crutchfield et al., 1984). Attractions
Attractions, which are both intrinsic and intrinsic rewards, were also mentioned by participants. Child-care workers both smokers and ex-smokers clearly saw smoking as a reward for smokers since it allowed them to leave the worksite at will. In addition the comradery that smokers experienced at morning report, during breaktimes and at the end of the day had intrinsic social value for them. Participants described how smoking behavior was inadvertently encouraged. Cigarette breaks were viewed by smokers as an entitlement, by non-smokers as a fringe benefit. Home helpers saw smoking as an expected part of their job and indirectly the source of job satisfaction. ("You keep them company"). Smoking behavior was, in Gupta & Jenkins' words, "an attraction which pulled employees toward the organization". Organizational Constraints
Of the three categories of constraints that would have otherwise mediated on-the-job smoking, individual constraints and environmental constraints lie beyond the realm of this discussion. For our purposes we will restrict our comments to the various organizational constraints.
General organizational characteristics, i.e. formal policies and procedures: At the two social welfare districts, formal worksite smoking control policies had been endorsed by management and labor. Opportunity for employees to attend smoking cessation groups during working hours was an integrated component in the policy. However, the policy lacked guidelines for enforcement. This together with the fact that employees interpreted the policy as "only recommendations" seemed to engender confusion and served to weaken it as a potential organizational constraint. Supervisor characteristics: According to Gupta and Jenkins, supervisors' characteristics affect the extent to which substance use is a viable option on the premises since supervisors vau in their tolerance of substance use by subordinates. This is also the case for cigarette smoking, since as one participant pointed out, "If the boss smokes, it's okay to smoke wherever...if the supervisors smoke it's even okay to take a cigarette break on the worksite". Emont and Cummings (1990) reported participation rates were slightly higher for worksites at which the manager was willing to restrict smoking or promote a smoking cessation clinic. Gottleib et al (1992)
Organizational Factors Affecting Smoking at Work
125
emphasize that the role of middle management supervisors in policy implementation was a critical factor in implementation success. These earlier findings lend credence to ours. Work group characteristics: Participants provided a picture of childcare workers who found time to enjoy the company of their co-workers, to plan their work and to review the day over a cigarette and coffee, which is also consistent with earlier findings (Emurian et al., 1982; Schilling, 1985, Gottleib et al., 1992). Home helpers considered smoking with clients as • legitimate and an integral part of their professional role. Job characteristics: Earlier studies have reported smoking control policy implementation in medical settings (Rigotti, 1986; Biener, 1989; Hurt, 1989). It is only logical that the health education message in these interventions included an appeal to professional pride. From our findings, we sense an opening with regard to child-care workers who express guilt about their smoking. Their professional role which includes being a role model for health behavior, could be a potential organizational constraint against on-the-job smoking.
CONCLUSIONS Findings in this study represent the two districts in question and cannot be applied generally. Nevertheless they draw our attention to important areas for future research. Occupational groups represented here fit what Schiller (1985) calls stress-associated model (quantitative overload, qualitative underload, lack of control and lack of social support). A great deal of attention has been devoted to work role stress (Levi, Frankenhauser & Gardell, 1980, Theorell, 1990). There is reason for stress and substance use to be positively related. By definition, stress is aversive. People generally avoid aversive situations. The presence of stressful (hence aversive) work environment is likely to motivate employees to avoid the environment physically or psychologically hence distancing forces. (Gupta & Jenkins, 1984). At the same time, existing attractions encourage on-the-job smoking at the two districts and organizational constraints against smoking at work as well as adherence to restrictive smoking policies are weak. In order to implement smoking control policies in work settings, there should be a clear formulation of what the policy is intended to accomplish such as protecting nonsmokers, helping smokers quit (Gottlib et al., 1992). Furthermore, there should be a shift from recommendations to regulations in which breaktimes are clearly defined. (Fielding, 1991, Gottleib et al., 1992). Health education initiatives that emphasize on-the-job smoking as
126
Pucci and Haglund
a work environment issue rather than an individual right and that target middle managers and supervisors are also indicated (Emont 8,: Cummings, 1990, Gottleib 1992). And finally, Weinstein (1989) reminds us that to be successful, worksite health promotion strategies (vis it vis smoking control policies) must focus attention upon the work itself, not only on the worker. Creating a work environment that enhances healthy behavior requires an understanding of management practices, job characteristics, as well as how professional and/or occupational roles relate to smoking.
REFERENCES Beiner, L. Abrams, D. B., Follick, M. J., Dean, L. (1989). A comparative evaluation of restrictive smoking policy in a general hospital. Am J Public Health 79:192-195. Conway, T. L., Vickers, R. R., Ward, H. W., Rahe, R. H. (1981). Occupational stress and variation in cigarette, coffee and alcohol consumption. Journal of Health and Social Behavior 22 (6): 155-165. Cotton, T. J. et al. (19~z3). Effects of grain dust exposure and smoking on symptoms and lung function. J. Oeeup. Med. 25: 131-141. Covey, L. S. & Wynder, E. L. (1981). Smoking habits and occupational status. J. Occup. Med. 23:531-542. Crutchfield, R. D. & Gove, W. R. (1984). Determinants of drug use a test of the coping hypothesis. Soc. Sci. Med. 18:503-509. Emont, S. L., Cummings, K. M. (1990). Organizational factors affecting participation in a smoking cessation program and abstinence among 68 auto dealers. Am. J. Health Promot. 5(2):107-114. Emurian, H. H., Nelis, M. J. Brady, J. V. and Ray, R. L. (1982). Event time-series relationship between cigarette smoking and coffee drinking. Addict Behav. 7: 441-444. Fielding; J. E. (1991). Smoking control at the workplace. Annual Review of Public Health 12:209-234. Glasgow, R. E. (1989). Assessment of smoking behavior in relation to worksite smoking policies. NY State J. Med. 89(1):31-34. Golding, J. F. & Mangan, G. L. (1982). Effects of cigarette smoking on measures of arousal response suppression and excitation/inhibition balance. Int. J. Addict. 17: 793-804. Gottlieb, N. H., Lovato, C. Y., Weinstein, R., Green, L. W., Eriksen, M. P. (1992). The implementation of a restrictive worksite smoking policy in a large decentralized organization. Health Education Quarterly 19(1): 77-100. Gupta, N. & Jenkins, G. D. (~984). Substance use as an employee response to the work environment. Journal of "v~cational Behavior 24:$4-93. Hatch, J P.. Biener, S. M. and Fischer, J. G. (1983). The effects of smoking ,rod cigarette nicotine content on smokcrs' preparation and pcrlormancc of psychosociall_,, stressful tasks. J. Behav. Med. 6: 207-216. Hurt, R. D., Bergc, K. G., Oflord, K P. et al. (t989) The making of a smoking-free medical center. JAMA 261(1):95-97. Kruegar, R. A. (1989). Focus groups - a practical guide for applied research, Sage Publications, London. LaRocco, J. M., House, J. S. French, J. R. P jr. (1980). Social support, occupational stress, and health. Journal of Health and Social Behavior 21:202-218.
Organizational Factors Affecting Smoking at Work
127
Levi, L., Frankenhaeuser, M., Gardell, B. (1981). Report on work stress related to social structures and processes. In: Elliot, G. R. & Eisendorf, C (eds) Research on Stress and Human Health. Springer Publishers. New York. Minkler, M. (1990). Improving health through community organization In: Glanz, K., Lewis E. M., Rimer, B. K. (eds) Health behavior and health education. Jossey-Bass Publishers, San Francisco. Morgan, D. L. (1988). Focus groups as qualitative research, Qualitative Research Methods Series 16. A Sage Publication, London. Nellis, M. J., Emurian, H. H., Brady, J. V. and Ray, R. L. (1982). Behavior and analysis of cigarette smoking. Pavlovian J. Biol. Sci. 17:140-149. Orleans, C. S. and Shipley, R. H. (1982). Worksite smoking cessation initiatives: review and recommendations. Addict Behav. 7:1-16. Pearle, J. L. (1982). Smoking and duration of asbestos exposure in the production of functional and roentgenographic abnormalities in shipyard workers. J. Occup. Med. 24:37-40. Pucci, L. G. (I991). Implementing restrictive smoking policies and smoking behavior at places of employment - commentary on current evidence. European Journal of Public Health 1:105-109. Pucci, L. G., Haglund, B. J. A. (1992a). Focus groups: a tool for developing better health education materials and approaches for smoking intervention. Health Promotion International 7(1): 11-15. Pucci, L. G. Haglund, B. J. A. (1992b). Restricting smoking at places of employment - program evaluation at two social welfare districts. (Submitted for publication). Rigotti, N. A., Hill Pilk, B., Cleary, P., Singer D. T., Mulley, A. G. (1986). The impact of banning smoking on a hospital ward. Clinical Research 34(2):833A. Rosen, M., Wall, S., Hanning, M., Lindberg, G., Nystr6m, L. (1987). Smoking habits and their confounding effects among occupational groups in Sweden. Scand J. Soc. Med. 15:233-240. Rosenstock, I. M., Stergachis, A., Heany, C. (1986). Evaluation of smoking prohibition policy in a health maintenance organization. Am. J. Pub. Health (Public Health Briefs) 76 1014-1015. R6kfritt ar naturligt Naturally smoke free (author's translation) - en information fr~n Dilsooch milj6politiska enheten -Personal och organisations F6rvaltning, (1988). Stockholm (in Swedish). Schiling, R. F. III, Gilchrist, L. D., Schinke, S. P. (1985). Smoking in the workplace - review of critical issues. Public Health Rep 100:473-477. Sorensen, G., Pachacek, T. and Pallonen, M. (1986). Occupational and worksite norms and attitudes about smoking cessation. AJPH 76(5): 544-549. Theorell, T. (1989). Personal control at work and health: a review of epidemiological studies .in Sweden. In: Steptoe, A & Appels, A. (eds) Stress, Personal Control and Health. Wiley. Taveira Da Silva, A. M. & Hamosh, P. (1982). Effect of smoking a cigarette on the density dependence of maximal expiratory flow. Respiration 43: 258-263. Waldron, I. and Lye D. (1989). Employment, unemployment, occupation and smoking. Am. J. Prey. Med. 5(3): 142-149, Weinstein, M. S. (1989). Lifestyle, stress and work: strategies lor hcalth promotion. In: Federal Centrc for Health Education (ed). Hcalth Promolion in the Working World. Springer-Verlag, Berlin.
Organizational Factors Affecting Smoking at Work: Results from Focus Group Interviews with Smokers and Ex-smokers Linda Gearhart Pucci 1,2-~ and Bo J. A. Haglund 2
A theoretical model addressing worksite factors affecting health behaviors was applied to data from focus group interviews. Organizational factors that might have influenced implementation of restrictive smoking policies at two social welfare districts were identified. There was greater policy awareness at the district where active dissemination of information took place. However, greater policy awareness was not associated with patterns of on-the-job smoking or support for~barriers to quitting. Instead specific patterns associated with general organizational characteristics, job characteristics and work role stress emerged. Findings suggest that changes in policy f o r m u l a t i o n and application which take into account work itself and not only the worker are warranted. KEY-WORDS: Smoking control policy; organizational constraints; focus group.
INTRODUCTION Worksites have long been the focus of efforts to restrict smoking. While the relationship among occupational hazard, smoking and disease is long established (Covey, 1981; Pearle, 1982; Cotton D. J., et al., 1983), occupational differences, as reflected in smoking prevalence rates, are in part indicative of different norms affecting behavior in social groups (Nellis, IDana-Farber Cancer Institute, Boston, MA. 2Karolinska Institute, Department of Social Medicine, Kronan Health Center, S-172 83 Sundbyberg, Sweden. 3Address correspondence to Linda Gearhart Pucci, M.P.H., Dana-Farber Cancer Institute, Dept. of Epidemiology and Cancer Control, 44 Binney Street, Boston, MA 02115. 115 © 1993Human SciencesPress, inc.
116
Pucci and Haglund
1982; Rosen, 1987). The importance of the work setting both as a factor in determining smoking habits and as a potential aid in fostering smoking cessation has begun to be recognized (Orleans, 1982; Glasgow, 1984; Sorensen et al., 1989; Waldon & Ley, 1989). Studies have shown that worksite smoking control has a greater impact on smoking reduction than on cessation (Rosenstock, 1986; Beiner et al., 1989). Emont and Cummings (1990), in their investigations of worksite organizational factors influence on employee participation in worksite smoking cessation programs, concluded that future interventions should concentrate on specific employee, manager and worksite characteristics that facilitate group level participation in cessation rates. One model (Gupta and Jenkins 1984) addresses organizational antecedents of substance use. It identifies conditions that either stimulate or inhibit it. (Figure 1). The authors limit their attention to precursors at work, by explaining "the etiology of substance use is still unclear and that in-depth examination of one set of antecedents is preferable to a superficial study of all possible antecedents." In their model, substance is conceptualized as the employee's response to aversive organizational conditions and is restricted to its onset or aggravation as a response to the work environment. Substance use is then hypothesized as resulting from a complex interplay among mree forces, namely distanc~rJg forces, attractions and constraints. Distancing forces, which push the individual away from the organization, arise from perceived aversive organizational conditions, for example: work role stress, occupational obsolescence, supervisors, work group characteristics and/or organizational characteristics. Attractions pull and constraints push the individual toward the organization. Attractions are valued by employees and include both intrinsic rewards such as pay and/or a challenging job and extrinsic rewards for example fringe benefits, job security and social support. They represent the energy that keeps workers at work, both physically and psychologically. In this model, constraints are specific to substance use and function as mediators in preventing individuals from acting in ways contrary to existing organizational norms. They are divided into three categories; individual, organizational and environmental. Individual constraints include healthy personality structures and/or demographic variables such as morals or religious beliefs which intervene. Organizational constraints include characteristics of the organization itself, supervision, work-group and the task at hand. Environmental constraints lie outside the organization and characterize the larger socio-cultural setting in which the employee functions. They include legal, cultural and economic constraints. Our discussion in this study is limited to organizational constraints.
Organizational Factors Affecting Smoking at Work
DISTANCING FORCES Supervisory characteristics Work group characteristics Job characteristics Organizational characteristics Work role stress Occupational obsolecence
• . CONSTRAINTS
Individual contjaints Personality characteristics Background characteristics Oramnizational constraints Organizational characteristics Supervisory characteristics Work group characteristics Job characteristics Environmental constraints Cultural constraints Legal constraints Economic constraints
MINUS
117
Z ATTRACTIONS Organizational rewards
(e.g., salary, •nge benefits security, intrinsic rewards) Job satisfaction
LEVELOF DISTANCING NECESSARY
v
SUBSTANCE USE
Fig. 1. Conceptual framework for examination of smoking as a response to the work environment, Adapted from Gupta, N. and Jenkins, G. D. (1984).
When the total distancing force outweighs total attractions, the expected consequence is that employees will distance themselves either physically or psychologically from work. T h e individual, being thrown off balance, attempts to regain it by adapting her/his behavior. Adaptive behaviors can be directed outward. They can be positive, i.e. discussing the problem or learning new skills, or negative i.e. complaining and accusing others or calling in sick. The intensity of the adaptive behavior depends on the level of distancing necessary. Substance use which is one of many behaviors, emerges to the degree that institutionalized constraints allow. The aim of this study was to identify organizational factors that might have influenced implementation of restrictive smoking policies at two social welfare districts utilizing the Gupta-Jenkins model as a framework.
118
Pucci and Haglund
BACKGROUND
In 1988 the Personal Policy Board of the city of Stockholm approved new guidelines for smoking control at municipal work sites and assigned its administrative agency the task of facilitating policy implementation in the city's agencies and organizations (R6kfritt ar naturligt, 1988). Briefly, the policy recommended prohibiting smoking in all municipal places of employment. In situations where ordinary ventilation did not protect employees from exposure to environmental tobacco smoke (ETS), either ventilated smoking lounges with direct external exhaust or total ban on smoking was recommended. Whenever smoking restrictions were introduced, smoking cessation programs were to be offered employees during working hours. The Personnel Policy Board's two-year intervention, N A T U R A L L Y SMOKE-FREE, targeted all local governmental agencies and municipal organizations in the city of Stockholm. It was conducted between May 1988 and November 1990. The intervention included community organizational components intended to help identify common problems or goals, mobilize resources and in other ways develop and implement strategies for attaining the specified goals (Minkler, 1990). These included conferences, seminars and workshops. Health education materials and analytical tools were also developed and training programs for smoking cessation group leaders were conducted (Pucci and Haglund, 1992a). All agencies and organizations in the municipality including the city's 18 social welfare districts, were tracked from November 1986 to November 1990.
MATERIAL AND METHOD Settings and Subjects The subjects for our focus group interviews were recruited by district wellness coordinators and by the moderator. Only smokers and former smokers were invited to participate in the interviews. All participants were women employed either as home helpers or as child care workers. The cooperating sights were the two social welfare districts that had been surveyed earlier (Pucci and Haglund, 1992b). They will be referred to as District A and District B in the rest of this paper. Seven focus groups varying in size from two to six members were conducted.
Organizational Factors Affecting Smoking at Work
119
The Focus Group Discussion A series of focus group interviews examining 1) smokers' and exsmokers' perception and understanding of the new regulations, 2) their own smoking behavior, and 3) organizational factors impacting on policy implemention was conducted. The interviews provided access to a narrower sample than in the survey and at the same time allowed us to address the issues in more depth. The m e t h o d o l o g y incorporated s t a n d a r d focus group f o r m a t (Kruegar, 1989; Morgan 1988;) around a set of questions aimed at eliciting reactions to the policy itself as well as providing information about smoking behavior at work and smoking as it related to professional role. A discussion guide was developed in which questions were presented in a logical order. The groups were moderated by the first author (LGP) between April and June 1991. Focus groups were conducted in the respective facilities of the host organizations. The moderator explained that the purpose of the group interview was to obtain smokers' and former smokers' views and ideas about the new smoking regulations. An assistant took notes during the interviews. Consent was obtained from participants to tape-record the sessions. Discussion topics began with the policy itself and proceeded to smoking behavior as it related to work and professional roles. The interview procedure included asking the group a general question, obtaining several responses, then probing further with more specific questions until all relevant views had been expressed. Each session lasted approximately one and one-half hours. After the discussion, the moderator listened to the recorded tapes, made additional notes and made comparisons with the assistant's notes. Transcripts of the tapes were used together with the notes in order to complete the moderator's impression and to facilitate analysis. The responses were categorized, specific information was extracted, compiled and summarized.
RESULTS Procedures suggested by Morgan (1988) and Kruegar (1989) were adapted in examining the responses. The process consisted of generating categories of concerns from key words, phrases and verbatim quotes. Each category was examined for subtopics. The most useful quotes and illustrations were then selected for the various categories.
120
Pucci and Haglund
The focus groups provided valuable information about policy awareness, adherence, changes in smoking status, smoking in the work setting and disruptions in work as a result of the newly implemented policy. Policy Awareness Discussions about policy content and implementation provided two distinctly different patterns at the two districts. Participants at District A knew the exact date when the smoking control policy went into effect. They also knew locations of designated smoking areas. H o m e helpers identified designated smoking areas in centers for the elderly. F u r t h e r m o r e participants reported how the "smoking control policy" had gone into effect and were able to describe steps taken by the district for preparing employees for the policy change. One participant provided the following account: "..a program was endorsed in the fall of '90. We inspected the various worksites and made suggestions for where designated smoking areas should be located" In contrast, participants from District B had only a vague recollection of the "ban on smoking" as they called it, and were unable to give details about its content or implementation. "There never were any rules about smoking, there aren't any now." "I think we're supposed to keep the doors closed when we smoke."
Adherence Discussions about adherence to new smoking regulations also revealed differences between the two districts. W h e n relating what had happened during policy implementation, participants at Districts A discussed specific changes in the physical environment often citing designated smoking areas. In contrast, participants from District B discussed how supervisor's smoking behavior might affect "eventual" policy implementation. "'As long as.......(supervisor) smokes, it's alright to smoke at work "'
Changes in Smoking Status One section of the focus group interview brought out factors affecting smoking behavior. Since participants were smokers and ex-smokers, we were interested in eliciting factors in the work setting that facilitated or
Organizational Factors Affecting Smoking at Work
121
impeded their quitting smoking. Participants at both districts reported the positive effects of co-worker/client support and how they were encouraged to quit smoking. Several remarked that quitting smoking was "contagious", i.e. when one person quit, others followed suit. "I decided, I wasn't going to quit (smoking), but when everyone else was doing it, I t h o u g h t 'why not!'."
The temptation to start smoking after having quit, was also discussed at length. Again, responses from the two districts were similar. The smell of cigarette smoke and co-workers who smoked had negative effects on those who had quit or were trying to. Several participants mentioned that their relationship to cigarettes was similar to alcoholics relationship to alcohol. "Once an alcoholic, always an alcoholic." Participants revealed that they often took up smoking as a response to job pressures. They also associated smoking with comradery, which made it easy to start smoking after they had quit. "Sometimes its just to have fun. Your buddies say, c'mon, let's take a break. It's fun ...the whole gang jokes and smokes."
Smoking and Work This section of the focus group interviews brought out how smoking behavior was impacted by the work setting. The discussion turned to the topic of taking cigarette breaks. Home helpers adapted their smoking breaks to the task at hand, while child care workers integrated smoking into their work day. Home helpers revealed that they smoked mostly when they went to shop for their clients. They considered it natural to take the opportunity to smoke when they were outdoors, they also reported that they smoked during lunch and coffee breaks. There were other times when they really wanted to smoke, for example: when they had a problem, to quiet their nerves, or when the pressure was on. Participants revealed that for them, smoking was a way of coping with work pressures. "I meet people e v e ~ day, new people in new situations. I have to pace myself, get to know people and their homes. It's the clients who count. I'm not important. So l have to shift gears (take a smoke) three or four times a day."
The home helpers also described smoking as an integral part of their duties. In cases where clients smoked, it was natural for them to sit and talk over a cup of coffee and a cigarette. In this sense smoking fulfilled their professional responsibilities of providing company for their clients.
122
Pucci and Haglund "It's like when they offer you coffee and a roll and you say, no thanks, I'm trying to lose weight. They always say, take just one, you won't get fat.' And, you do it because you want to keep them company. The same goes for smoking."
Child care w o r k e r ' s smoking b e h a v i o r in relationship to the w o r k situation, differed s o m e w h a t from t h a t o f the h o m e helpers. T h e child care w o r k e r s described smoking as an integral part o f the w o r k day. T h e y b e g a n and e n d e d their day with a cigarette. S m o k i n g was a "given" during lunch and regular breaks. O n e participant gave the following account: "At morning coffee I go with the other smokers to the smoking lounge. I don't smoke anymore before lunch. Now, if things are pretty quiet, I mean not total chaos, I might have a cigg before lunch...or if I've got to discuss something with someone. I might say, can we discuss it while we take a smoke? Then I smoke after lunch and at afternoon coffee break. Maybe there's even time for one between. And, then right before I go home. I guess about 20 in all." Child care workers also indicated that s m o k i n g was a way o f coping with w o r k stress. T h e y s m o k e d m o r e w h e n they were tired, when they were u n d e r pressure, w h e n the kids w e r e rowdy and the p a r e n t s complained. "Sometimes when I feel I just can't satisfy everyone....parents have unreasonable expectations...that's when I start smoking. It's hard working with people." F o r child care workers, discussions during focus interviews emphasized conflict between their smoking and their professional behavior. T h e y didn't want the children to know they s m o k e d o r to see t h e m with a cigarette. Disruption of Work It was primarily in child care settings that the restrictive smoking policy disrupted work. Child care w o r k e r s w h o s m o k e d , left the premises between existing breaktimes. Participants readily a d m i t t e d that five-minute breaks were often drawn out and that w h e n several s m o k e r s took breaks together, their non-smoking colleagues were left to carry on alone. Participants were in a g r e e m e n t that n o n - s m o k e r s got fewer breaks. O n e p e r s o n r e p o r t e d that "extra" breaktime was often the topic of discussion during focus groups. O n e ex-smoker expressed her dismay: " S m o k e r s get m o r e breaks. If non smokers sit down to read the paper, it's not the same thing, The)' think we're shirking our d u ~ . "
DISCUSSION W e f o u n d g r e a t e r policy awareness at District A than at District B, which is consistent with earlier results f r o m p r o g r a m evaluation of the two
Organizational Factors Affecting Smoking at Work
123
districts. Pucci and Haglund (1992b) attributed this difference to District A's active dissemination of information and the fact that District A had followed the prescribed model and in the recommended time framework (Pucci, 1991). In contrast, District B had compromised the time table by trying to do everything at one point in time. In addition implementation (information) had stagnated on the administrative level at District B. However, differences in policy awareness at the two districts did not seem to be associated with patterns of smoking behavior at work, or support for/barriers to quitting smoking. Instead, specific patterns associating work stress and work norms with smoking at work emerged for home helpers and childcare workers. Investigations of smoking policy implementation at places of employment have concentrated on smoker's behavior and measured success/failure of the implementation in terms of changing that behavior (Pucci 1991). Earlier investigations have, however identified a need for addressing work environmental factors that affect employee health behavior. LaRocco, House and French, (1980) pointed out that occupational task structure and environment may play a central role in determining which sources of support are most salient for altering health behaviors. Emont and Cummings (1990) assessed the effects of worksite-level factors on clinic participation and smoking cessation at multiple work settings and concluded that, in addition to intervention efforts focused on employee behavior, manager and worksite characteristics should also be addressed. Gupta and Jenkins' model (1984), although developed as a tool for discussing substance use at work, is also appropriate to our discussion of smoking policy/behavior, since nicotine is a drug with immediate psychoneurological and physiological effects (Golding et al. 1982; Taveira Da Silva et al., 1982). Furthermore it has been suggested that on-the-job smoking is one way of coping with or adapting to work induced stress (Conway et al., 1981; Hatch, 1983; Crutchfietd, 1984). Applying the Gupta-Jenkins model (Figure 1) to our interview results allows us to systematically examine organizational characteristics as they relate to smoking behavior at work. Distancing Forces Distancing forces that were identified by participants included job characteristics and work role stress. As one child-care worker put it, "Sometimes when I feel I just can't satisfy everyone, parents have unreasonable expectations, that's when I start smoking. Its hard working with people". Home helpers found that smoking helped them disengage from one client
124
Pucci and Haglund
and prepare to meet the next. These findings are consistent with earlier investigations (Conway, 1981; Crutchfield et al., 1984). Attractions
Attractions, which are both intrinsic and intrinsic rewards, were also mentioned by participants. Child-care workers both smokers and ex-smokers clearly saw smoking as a reward for smokers since it allowed them to leave the worksite at will. In addition the comradery that smokers experienced at morning report, during breaktimes and at the end of the day had intrinsic social value for them. Participants described how smoking behavior was inadvertently encouraged. Cigarette breaks were viewed by smokers as an entitlement, by non-smokers as a fringe benefit. Home helpers saw smoking as an expected part of their job and indirectly the source of job satisfaction. ("You keep them company"). Smoking behavior was, in Gupta & Jenkins' words, "an attraction which pulled employees toward the organization". Organizational Constraints
Of the three categories of constraints that would have otherwise mediated on-the-job smoking, individual constraints and environmental constraints lie beyond the realm of this discussion. For our purposes we will restrict our comments to the various organizational constraints.
General organizational characteristics, i.e. formal policies and procedures: At the two social welfare districts, formal worksite smoking control policies had been endorsed by management and labor. Opportunity for employees to attend smoking cessation groups during working hours was an integrated component in the policy. However, the policy lacked guidelines for enforcement. This together with the fact that employees interpreted the policy as "only recommendations" seemed to engender confusion and served to weaken it as a potential organizational constraint. Supervisor characteristics: According to Gupta and Jenkins, supervisors' characteristics affect the extent to which substance use is a viable option on the premises since supervisors vau in their tolerance of substance use by subordinates. This is also the case for cigarette smoking, since as one participant pointed out, "If the boss smokes, it's okay to smoke wherever...if the supervisors smoke it's even okay to take a cigarette break on the worksite". Emont and Cummings (1990) reported participation rates were slightly higher for worksites at which the manager was willing to restrict smoking or promote a smoking cessation clinic. Gottleib et al (1992)
Organizational Factors Affecting Smoking at Work
125
emphasize that the role of middle management supervisors in policy implementation was a critical factor in implementation success. These earlier findings lend credence to ours. Work group characteristics: Participants provided a picture of childcare workers who found time to enjoy the company of their co-workers, to plan their work and to review the day over a cigarette and coffee, which is also consistent with earlier findings (Emurian et al., 1982; Schilling, 1985, Gottleib et al., 1992). Home helpers considered smoking with clients as • legitimate and an integral part of their professional role. Job characteristics: Earlier studies have reported smoking control policy implementation in medical settings (Rigotti, 1986; Biener, 1989; Hurt, 1989). It is only logical that the health education message in these interventions included an appeal to professional pride. From our findings, we sense an opening with regard to child-care workers who express guilt about their smoking. Their professional role which includes being a role model for health behavior, could be a potential organizational constraint against on-the-job smoking.
CONCLUSIONS Findings in this study represent the two districts in question and cannot be applied generally. Nevertheless they draw our attention to important areas for future research. Occupational groups represented here fit what Schiller (1985) calls stress-associated model (quantitative overload, qualitative underload, lack of control and lack of social support). A great deal of attention has been devoted to work role stress (Levi, Frankenhauser & Gardell, 1980, Theorell, 1990). There is reason for stress and substance use to be positively related. By definition, stress is aversive. People generally avoid aversive situations. The presence of stressful (hence aversive) work environment is likely to motivate employees to avoid the environment physically or psychologically hence distancing forces. (Gupta & Jenkins, 1984). At the same time, existing attractions encourage on-the-job smoking at the two districts and organizational constraints against smoking at work as well as adherence to restrictive smoking policies are weak. In order to implement smoking control policies in work settings, there should be a clear formulation of what the policy is intended to accomplish such as protecting nonsmokers, helping smokers quit (Gottlib et al., 1992). Furthermore, there should be a shift from recommendations to regulations in which breaktimes are clearly defined. (Fielding, 1991, Gottleib et al., 1992). Health education initiatives that emphasize on-the-job smoking as
126
Pucci and Haglund
a work environment issue rather than an individual right and that target middle managers and supervisors are also indicated (Emont 8,: Cummings, 1990, Gottleib 1992). And finally, Weinstein (1989) reminds us that to be successful, worksite health promotion strategies (vis it vis smoking control policies) must focus attention upon the work itself, not only on the worker. Creating a work environment that enhances healthy behavior requires an understanding of management practices, job characteristics, as well as how professional and/or occupational roles relate to smoking.
REFERENCES Beiner, L. Abrams, D. B., Follick, M. J., Dean, L. (1989). A comparative evaluation of restrictive smoking policy in a general hospital. Am J Public Health 79:192-195. Conway, T. L., Vickers, R. R., Ward, H. W., Rahe, R. H. (1981). Occupational stress and variation in cigarette, coffee and alcohol consumption. Journal of Health and Social Behavior 22 (6): 155-165. Cotton, T. J. et al. (19~z3). Effects of grain dust exposure and smoking on symptoms and lung function. J. Oeeup. Med. 25: 131-141. Covey, L. S. & Wynder, E. L. (1981). Smoking habits and occupational status. J. Occup. Med. 23:531-542. Crutchfield, R. D. & Gove, W. R. (1984). Determinants of drug use a test of the coping hypothesis. Soc. Sci. Med. 18:503-509. Emont, S. L., Cummings, K. M. (1990). Organizational factors affecting participation in a smoking cessation program and abstinence among 68 auto dealers. Am. J. Health Promot. 5(2):107-114. Emurian, H. H., Nelis, M. J. Brady, J. V. and Ray, R. L. (1982). Event time-series relationship between cigarette smoking and coffee drinking. Addict Behav. 7: 441-444. Fielding; J. E. (1991). Smoking control at the workplace. Annual Review of Public Health 12:209-234. Glasgow, R. E. (1989). Assessment of smoking behavior in relation to worksite smoking policies. NY State J. Med. 89(1):31-34. Golding, J. F. & Mangan, G. L. (1982). Effects of cigarette smoking on measures of arousal response suppression and excitation/inhibition balance. Int. J. Addict. 17: 793-804. Gottlieb, N. H., Lovato, C. Y., Weinstein, R., Green, L. W., Eriksen, M. P. (1992). The implementation of a restrictive worksite smoking policy in a large decentralized organization. Health Education Quarterly 19(1): 77-100. Gupta, N. & Jenkins, G. D. (~984). Substance use as an employee response to the work environment. Journal of "v~cational Behavior 24:$4-93. Hatch, J P.. Biener, S. M. and Fischer, J. G. (1983). The effects of smoking ,rod cigarette nicotine content on smokcrs' preparation and pcrlormancc of psychosociall_,, stressful tasks. J. Behav. Med. 6: 207-216. Hurt, R. D., Bergc, K. G., Oflord, K P. et al. (t989) The making of a smoking-free medical center. JAMA 261(1):95-97. Kruegar, R. A. (1989). Focus groups - a practical guide for applied research, Sage Publications, London. LaRocco, J. M., House, J. S. French, J. R. P jr. (1980). Social support, occupational stress, and health. Journal of Health and Social Behavior 21:202-218.
Organizational Factors Affecting Smoking at Work
127
Levi, L., Frankenhaeuser, M., Gardell, B. (1981). Report on work stress related to social structures and processes. In: Elliot, G. R. & Eisendorf, C (eds) Research on Stress and Human Health. Springer Publishers. New York. Minkler, M. (1990). Improving health through community organization In: Glanz, K., Lewis E. M., Rimer, B. K. (eds) Health behavior and health education. Jossey-Bass Publishers, San Francisco. Morgan, D. L. (1988). Focus groups as qualitative research, Qualitative Research Methods Series 16. A Sage Publication, London. Nellis, M. J., Emurian, H. H., Brady, J. V. and Ray, R. L. (1982). Behavior and analysis of cigarette smoking. Pavlovian J. Biol. Sci. 17:140-149. Orleans, C. S. and Shipley, R. H. (1982). Worksite smoking cessation initiatives: review and recommendations. Addict Behav. 7:1-16. Pearle, J. L. (1982). Smoking and duration of asbestos exposure in the production of functional and roentgenographic abnormalities in shipyard workers. J. Occup. Med. 24:37-40. Pucci, L. G. (I991). Implementing restrictive smoking policies and smoking behavior at places of employment - commentary on current evidence. European Journal of Public Health 1:105-109. Pucci, L. G., Haglund, B. J. A. (1992a). Focus groups: a tool for developing better health education materials and approaches for smoking intervention. Health Promotion International 7(1): 11-15. Pucci, L. G. Haglund, B. J. A. (1992b). Restricting smoking at places of employment - program evaluation at two social welfare districts. (Submitted for publication). Rigotti, N. A., Hill Pilk, B., Cleary, P., Singer D. T., Mulley, A. G. (1986). The impact of banning smoking on a hospital ward. Clinical Research 34(2):833A. Rosen, M., Wall, S., Hanning, M., Lindberg, G., Nystr6m, L. (1987). Smoking habits and their confounding effects among occupational groups in Sweden. Scand J. Soc. Med. 15:233-240. Rosenstock, I. M., Stergachis, A., Heany, C. (1986). Evaluation of smoking prohibition policy in a health maintenance organization. Am. J. Pub. Health (Public Health Briefs) 76 1014-1015. R6kfritt ar naturligt Naturally smoke free (author's translation) - en information fr~n Dilsooch milj6politiska enheten -Personal och organisations F6rvaltning, (1988). Stockholm (in Swedish). Schiling, R. F. III, Gilchrist, L. D., Schinke, S. P. (1985). Smoking in the workplace - review of critical issues. Public Health Rep 100:473-477. Sorensen, G., Pachacek, T. and Pallonen, M. (1986). Occupational and worksite norms and attitudes about smoking cessation. AJPH 76(5): 544-549. Theorell, T. (1989). Personal control at work and health: a review of epidemiological studies .in Sweden. In: Steptoe, A & Appels, A. (eds) Stress, Personal Control and Health. Wiley. Taveira Da Silva, A. M. & Hamosh, P. (1982). Effect of smoking a cigarette on the density dependence of maximal expiratory flow. Respiration 43: 258-263. Waldron, I. and Lye D. (1989). Employment, unemployment, occupation and smoking. Am. J. Prey. Med. 5(3): 142-149, Weinstein, M. S. (1989). Lifestyle, stress and work: strategies lor hcalth promotion. In: Federal Centrc for Health Education (ed). Hcalth Promolion in the Working World. Springer-Verlag, Berlin.
