Effects of workplace smoking bans on cigarette consumption

Employed adolescents and beliefs about self-efficacy to avoid smoking

This paper examines self-efficacy to avoid cigarette smoking and its association with smoking and quitting behavior, peer and worksite influences, nicotine dependence, and socio-demographic variables among employed adolescents. A cross-sectional survey was used to collect data from employed adolescents ages 15-18 who worked in 10 participating grocery stores in Massachusetts. Eighty-three percent of workers (n=379) completed the survey. Results from the multivariate model indicate that daily smokers were less confident in their ability to avoid smoking than those who smoked less frequently. As nicotine dependence increased, self-efficacy beliefs decreased. In addition, as friends' encouragement to quit increased, self-efficacy beliefs also increased. Work-related variables were not associated with self-efficacy beliefs among smokers. This study suggests that smoking frequency, nicotine dependence, and friends' encouragement to quit are associated with self-efficacy to avoid smoking. Researchers may tailor interventions for daily and less-than-daily smokers, build on peer networks that encourage quitting and help smokers resist pressures to smoke, and enhance strategies for coping with nicotine dependence in high-risk situations.

Effect of smoke-free workplaces on smoking behaviour: systematic review

OBJECTIVE

To quantify the effects of smoke-free workplaces on smoking in employees and compare these effects to those achieved through tax increases.

DESIGN

Systematic review with a random effects meta-analysis.

STUDY SELECTION

26 studies on the effects of smoke-free workplaces.

SETTING

Workplaces in the United States, Australia, Canada, and Germany.

PARTICIPANTS

Employees in unrestricted and totally smoke-free workplaces.

MAIN OUTCOME MEASURES

Daily cigarette consumption (per smoker and per employee) and smoking prevalence.

RESULTS

Totally smoke-free workplaces are associated with reductions in prevalence of smoking of 3.8% (95% confidence interval 2.8% to 4.7%) and 3.1 (2.4 to 3.8) fewer cigarettes smoked per day per continuing smoker. Combination of the effects of reduced prevalence and lower consumption per continuing smoker yields a mean reduction of 1.3 cigarettes per day per employee, which corresponds to a relative reduction of 29%. To achieve similar reductions the tax on a pack of cigarettes would have to increase from $0.76 to $3.05 (0.78 euro to 3.14 euro) in the United States and from 3.44 pounds sterling to 6.59 pounds sterling (5.32 euro to 10.20 euro) in the United Kingdom. If all workplaces became smoke-free, consumption per capita in the entire population would drop by 4.5% in the United States and 7.6% in the United Kingdom, costing the tobacco industry $1.7 billion and 310 million pounds sterling annually in lost sales. To achieve similar reductions tax per pack would have to increase to $1.11 and 4.26 pounds sterling.

CONCLUSIONS

Smoke-free workplaces not only protect non-smokers from the dangers of passive smoking, they also encourage smokers to quit or to reduce consumption.

[Evaluation of a workplace anti-smoking program at a company with 640 employees]

OBJECTIVES

Awareness of the health risks of passive smoking for non-smokers has led to the development of workplace interventions for smokers, although they are still few in our setting. The objective of this study was to evaluate the efficacy of an anti-smoking program among the workers of a company, in function of changes in the pre- and post-intervention prevalence of smoking in the study population.

METHOD

A pre-intervention questionnaire on smoking (prevalence and attitudes) was administered at a company with 640 employees (92% men, 8% women). An anti-smoking program was carried out inside the company during working hours over the next nine months. The questionnaire was then repeated (post-intervention) in order to evaluate its efficacy based on changes. For employees who answered both questionnaires, paired variables were analyzed.

RESULTS

The pre-intervention questionnaire was answered by 388 employees (60%), 357 men (92%) and 31 women (8%); their mean age was 48.4 years (SD 9.36). The prevalence of smoking was 55%, including daily smokers, sporadic smokers and others. The mean number of cigarettes per day was 17.86 (SD 2.45). The mean level of nicotine dependence measured by the Fagerström test was 3.3 (SD 2.8) out of 10. The post-intervention questionnaire was answered by 206 employees (32%). Among employees who answered both questionnaires (83), analysis of paired data showed a decrease in the prevalence of smoking of 4% and in the number of cigarettes per day from 17.4 (pre-intervention) to 16.4 (post-intervention). The differences were not statistically significant.

CONCLUSIONS

Although the workplace is an appropriate setting for anti-smoking interventions that would contribute to improving the health of smokers, such programs are currently underutilized.

Checklist of Health Promotion Environments at Worksites (CHEW): development and measurement characteristics

PURPOSE

Health promotion policy frameworks, recent theorizing, and research all emphasize understanding and mobilizing environmental influences to change particular health-related behaviors in specific settings. The workplace is a key environmental setting. The Checklist of Health Promotion Environments at Worksites (CHEW) was designed as a direct observation instrument to assess characteristics of worksite environments that are known to influence health-related behaviors.

METHODS

The CHEW is a 112-item checklist of workplace environmental features hypothesized to be associated, both positively and negatively, with physical activity, healthy eating, alcohol consumption, and smoking. The three environmental domains assessed are (1) physical characteristics of the worksite, (2) features of the information environment, and (3) characteristics of the immediate neighborhood around the workplace. The conceptual rationale and development studies for the CHEW are described, and data from observational studies of 20 worksites are reported.

RESULTS

The data on CHEW-derived environmental attributes showed generally good reliability and identified meaningful sets of variables that plausibly may influence health-related behaviors. With the exception of one information environment attribute, intraclass correlation coefficients ranged from 0.80 to 1.00. Descriptive statistics on selected physical and information environment characteristics indicated that vending machines, showers, bulletin boards, and signs prohibiting smoking were common across worksites. Bicycle racks, visible stairways, and signs related to alcohol consumption, nutrition, and health promotion were relatively uncommon.

CONCLUSIONS

These findings illustrate the types of data on environmental attributes that can be derived, their relevance for program planning, and how they can characterize variability across worksites. The CHEW is a promising observational measure that has the potential to assess environmental influences on health behaviors and to evaluate workplace health promotion programs.

Health and behavior: the interplay of biological, behavioral, and social influences: summary of an Institute of Medicine report

An Institute of Medicine committee was convened to explore the links between biological, psychosocial, and behavioral factors and health and to review effective applications of behavioral interventions. Based on the evidence about interactions of the physiological responses to stress, behavioral choices, and social influences, the committee encouraged additional research efforts to explore the integration of these variables and to evaluate their mechanisms. An understanding of the social factors influencing behavior is growing and should be considered in programs and policies for public health, in addition to individual behavior and physiological status. Interventions to change behaviors have been directed toward individuals, communities, and society. Many intervention trials have documented the capacity of interventions to modify risk factors. However, more trials that include measures of morbidity and mortality to determine if the strategy has the desired health effects are needed. Behavior can be changed and new behaviors can be taught. Maintaining behavior changes is a greater challenge. Although short-term changes in behavior following interventions are encouraging, long-duration efforts are needed to improve health outcomes and to provide long-term assessments of effectiveness. Interventions aimed at any level can influence behavior change; however, existing research suggests that concurrent interventions at multiple levels are most likely to sustain behavior change and should be encouraged.

How many deaths are caused by second hand cigarette smoke?

OBJECTIVES

To estimate the number of deaths attributable to second hand smoke (SHS), to distinguish attributable and potentially avoidable burdens of mortality, and to identify the most important sources of uncertainty in these estimates.

METHOD

A case study approach, using exposure and mortality data for New Zealand.

RESULTS

In New Zealand, deaths caused by past exposures to second hand smoke currently number about 347 per year. On the basis of present exposures, we estimate there will be about 325 potentially avoidable deaths caused by SHS in New Zealand each year in the future. We have explored the effect of varying certain assumptions on which the calculations are based, and suggest a plausible range (174-490 avoidable deaths per year).

CONCLUSION

Attributable risk estimates provide an indication for policy makers and health educators of the magnitude of a health problem; they are not precise predictions. As a cause of death in New Zealand, we estimate that second hand smoke lies between melanoma of the skin (200 deaths per year) and road crashes (about 500 deaths per year).

Policy makers' perspectives on tobacco control advocates' roles in regulation development

OBJECTIVE

To identify, from policy makers' perspectives, strategies that enhance tobacco control advocates' effectiveness in the regulatory arena.

DESIGN

Key informant interview component of a comparative case study of regulatory agencies in the USA.

SUBJECTS

Policy makers involved in the development of four regulatory tobacco control policies (three state and one federal).

METHODS

Interviews of policy makers, field notes, and deliberation minutes were coded inductively.

RESULTS

Policy makers considered both written commentary and public testimony when developing tobacco control regulations. They triaged written commentary based upon whether the document was from a peer reviewed journal, a summary of research evidence, or from a source considered credible. They coped with in-person testimony by avoiding being diverted from the scientific evidence, and by assessing the presenters' credibility. Policy makers suggested that tobacco control advocates should: present science in a format that is well organised and easily absorbed; engage scientific experts to participate in the regulatory process; and lobby to support the tobacco control efforts of the regulatory agency.

CONCLUSIONS

There is an important role for tobacco control advocates in the policy development process in regulatory agencies.

A prospective investigation of the impact of smoking bans on tobacco cessation and relapse

BACKGROUND AND OBJECTIVES

To examine the long term impact of workplace smoking bans on employee smoking cessation and relapse. Over three years we studied a total of 1033 current or former smokers (intervention group) employed in smoke-free hospitals and 816 current or former smokers (comparison group) employed in non-smoke-free workplaces. The design of this natural experiment is a prospective cohort study. We randomly selected both hospitals and employees from 12 strata based on hospital size and state tobacco regulations, and sampled employees in the same communities. Main outcome measures were post-ban quit ratio and relapse rate.

RESEARCH DESIGN

Between groups comparisons were conducted using the Cochran-Mantel-Haenszel statistic for general association, stratified Cox proportional hazards models, and the CMH analysis of variance statistic based on ranks. McNemar's test and the sign test were used to test for changes over time within each group.

RESULTS

Differences in the post-ban quit ratio were observed between intervention and comparison groups (p < or = 0.02). For employees whose bans were implemented at least seven years before survey, the post-ban quit ratio was estimated at 0.256, compared with 0.142 for employees in non-smoke-free workplaces (p = 0.02). After controlling for a variety of factors, time to quit smoking was shorter for the hospital employees (p < 0.001), with an overall relative risk of quitting of 2.3. Contrary to expectations, relapse rates were similar between the groups.

CONCLUSION

Employees in workplaces with smoking bans have higher rates of smoking cessation than employees where smoking is permitted, but relapse is similar between these two groups of employees. The results of this investigation have international applicability for policy makers, clinicians, employers, and employees. Countries should review smoking policies in workplaces in light of their own smoking patterns and efforts to deal with environmental tobacco smoke.

Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke

This report presents the results of systematic reviews of effectiveness, applicability, other effects, economic evaluations, and barriers to use of selected population-based interventions intended to reduce tobacco use and exposure to environmental tobacco smoke. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis of recommendations by the Task Force on Community Preventive Services (TFCPS) regarding the use of these selected interventions. The TFCPS recommendations are presented on page 67 of this supplement.

The relationship between home smoking bans and exposure to state tobacco control efforts and smoking behaviors

PURPOSE

To examine the relationship between home smoking bans and adult smokers' exposure to the statewide California Tobacco Control Program (TCP) and their cigarette smoking behavior.

DESIGN

Cross-sectional survey that was part of the statewide Independent Evaluation of the California Tobacco Control, Prevention and Education Program.

SETTING

Random telephone interviews within 18 California counties.

SUBJECTS

A representative sample of 1315 adult smokers, aged 25 years and older.

MEASURES

The telephone survey included questions about smoking behavior, quitting smoking, exposure to tobacco control program components, home smoking rules, and attitudes related to tobacco use and environmental tobacco smoke (ETS).

RESULTS

Smokers with a home smoking ban were twice as likely (OR = 2.29; 95% CI 1.22, 4.29) to have heard of TCP community programs and three times more likely (OR = 3.18; 95% CI 1.34, 7.57) to have seen and talked about the ETS media spot than smokers with no home smoking policy. Multivariate regression models indicated that having a home smoking ban was related to smoking fewer cigarettes per day and greater interest in quitting smoking compared with smokers with no smoking rules in the home (p < .05).

CONCLUSIONS

These findings suggest that smokers reporting exposure to the California TCP were more likely to have restrictive home smoking policies and that more restrictive home smoking policies were associated with reduced smoking behavior.

The relationship between organizational characteristics and the adoption of workplace smoking policies

Organizational-level variables that are hypothesized to influence the level of smoking policy restrictions and the prevalence of smoking control activities were tested in a sample of 1 14 worksites that participated in the Working Well Trial, a national trial of worksite health promotion. Predictors related to more restrictive policies included smaller size, larger percentage of white-collar workers, larger number of complaints about environmental tobacco smoke, less complexity, more formalization, and having a CEO who valued health and employees' well-being. The number of smoking control activities offered in a worksite was predicted by having a larger blue-collar workforce, a higher percentage of female employees, higher levels of workforce stability, and a CEO who valued health and employees' well-being. Efforts to identify predictors of companies' adoption and implementation of workplace-based policies and interventions are an important part of tobacco control efforts and will enhance future intervention and research efforts.

Effect of an eight week smoking ban on women at US navy recruit training command

OBJECTIVE

To examine the effect of a unique organisational smoking ban on female United States Navy recruits, a population with historically high smoking rates.

SETTING AND DESIGN

Study participants were female recruits (n = 5503) entering the Navy recruit training command between March 1996 and March 1997 (12 consecutive months). Participants completed smoking surveys at entry to recruit training (baseline) and again at graduation from training after exposure to an eight week, 24 hour a day smoking ban. Effects of the ban on baseline to graduation changes in perceptions of being a smoker were examined, and relapse rates among baseline ever smokers was assessed three months after leaving recruit training.

RESULTS

Among all recruits, 41.4% reported being smokers at entry (that is, reported any smoking in the 30 days before entering recruit training). As a result of the ban, there was a significant reduction (from about 41% to 25%, p < 0.001) in the percentage of all women recruits who reported themselves as smokers, a much larger change than expected had no ban been in place. Relapse at the three month follow up varied according to the type of smoker at entry into the Navy, with rates ranging from 89% relapse among baseline daily smokers to 31% among baseline experimenters.

CONCLUSIONS

Findings suggest that the ban provides some smokers who desire to quit with an external impetus and support to do so. However, high relapse rates indicate that more than an organisationally mandated smoking ban during recruit training is needed to help younger smokers, more regular smokers, and those who intend to continue smoking to quit after joining the Navy.

Effect of workplace smoking policies on smoking cessation: results of a longitudinal study

Studies of worksite smoking bans often find that they fail to increase the rate of smoking cessation. To see whether duration of exposure to restrictive policies was an important element, we surveyed workers by phone to examine the effect of being continuously employed at a smokefree worksite for 3 years. Results showed that worksite policy was unrelated to smoking cessation. However, 12% of respondents at smokefree worksites reported that smoking had taken place in their work area, and over 20% reported at least 2 hours of worksite environmental tobacco smoke (ETS) exposure during the prior week. When minimal ETS exposure is used as an indicator of an effectively enforced smoking ban, logistic regression demonstrates that continuous employment at such a worksite strongly predicts smoking cessation. Failure to demonstrate a significant impact of worksite smoking bans on cessation in this and other studies may be due to poor enforcement of smoking policies.

Short-term impact of a university based smoke free campaign

STUDY OBJECTIVE

The aim of this study was to evaluate the impact of a smoke free programme implemented at the University of Geneva, Switzerland, in 1996. This programme included a prohibition to smoke in university buildings everywhere except in limited areas, and a smoking cessation counselling service.

METHODS

Surveys were conducted before and four months after the programme was implemented, in representative samples of programme participants (n = 833) and university members not exposed to the programme (n = 1023).

RESULTS

In retrospective assessments, participants reported being less bothered by environmental tobacco smoke after programme implementation, but no between group difference was detected in prospective assessments. Relationships between smokers and non-smokers improved moderately in the intervention group and remained unchanged in the comparison group (between group p = 0.001). Proportions of smokers who attempted to quit smoking in the past four months increased from 2.0% to 3.8% in the intervention group and remained unchanged at 3.5% in the comparison group (between group difference: p = 0.048). No impact on smoking prevalence (25%) was detected. The programme was appreciated by university members, although some of its modalities were criticised.

CONCLUSION

A regulation prohibiting smoking everywhere but in limited areas of university buildings was acceptable and reduced the perception of bother by environmental tobacco smoke. It did not, however, influence smoking habits or attitudes toward smoking.

The effects of household and workplace smoking restrictions on quitting behaviours

OBJECTIVE

To assess the association of household and workplace smoking restrictions with quit attempts, six month cessation, and light smoking.

DESIGN

Logistic regressions identified the association of household and workplace smoking restrictions with attempts to quit, six month cessation, and light smoking.

SETTING

Large population surveys, United States.

SUBJECTS

Respondents (n = 48,584) smoked during the year before interview in 1992-1993, lived with at least one other person, and were either current daily smokers or were former smokers when interviewed.

MAIN OUTCOME MEASURES

The outcome measures were an attempt to quit during the last 12 months, cessation for at least six months among those who made an attempt to quit, and light smoking (< 15 cigarettes a day).

RESULTS

Smokers who lived (odds ratio (OR) = 3.86; 95% confidence interval (CI) = 3.57 to 4.18) or worked (OR = 1.14; 95% CI = 1.05 to 1.24) under a total smoking ban were more likely to report a quit attempt in the previous year. Among those who made an attempt, those who lived (OR = 1.65, 95% CI = 1.43 to 1.91) or worked (OR = 1.21, 95% CI = 1.003 to 1.45) under a total smoking ban were more likely to be in cessation for at least six months. Current daily smokers who lived (OR = 2.73, 95% CI = 2.46 to 3.04) or worked (OR = 1.53, 95% CI = 1.38 to 1.70) under a total smoking ban were more likely to be light smokers.

CONCLUSIONS

Both workplace and household smoking restrictions were associated with higher rates of cessation attempts, lower rates of relapse in smokers who attempt to quit, and higher rates of light smoking among current daily smokers.

Promoting reduced smoking rates in the context of workplace smoking bans

A randomized study was conducted in 41 workplaces to determine the potential of self-help and group-based programs to encourage reduced smoking in workplaces that have implemented smoking bans. The trial had limited success in recruiting smokers, attrition was an important limitation, and the study outcomes were modest. The authors conclude that more research is needed on effective strategies that help smokers minimize smoking at work.

Impact of the Working Well Trial on the worksite smoking and nutrition environment

This article reports the effect of a worksite cancer control intervention on aspects of the physical and social environment related to dietary and smoking behaviors of employees. Data are from 111 intervention and control worksites that participated in the Working Well Trial. Employee surveys and interviews with key organizational informants assessed environmental and normative changes relevant to nutrition and tobacco use. Results indicated significant effects of the intervention on all nutrition outcomes: access to healthy food, nutritional information at work, and social norms regarding dietary choice. Significant benefits were not found for smoking norms or smoking policies. However, changes occurred in both the control and intervention sites on these variables. This first large analysis of environmental and normative effects of a worksite intervention is consistent with the employee behavior change findings for the trial and serves as a model for future analyses of multilevel worksite health promotion programs.

The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States

OBJECTIVES

This study estimates the contribution of smoke-free workplaces to the recent national declines in cigarette consumption in Australia and the United States.

METHODS

Nineteen studies of the impact of smoke-free workplaces on workday cigarette consumption were reviewed. The number and cost of cigarettes forgone were calculated and extrapolated to a scenario in which all indoor work areas were smoke-free.

RESULTS

Of the 19 studies, 18 reported declines in daily smoking rates, and 17 reported declines in smoking prevalence. Smoke-free workplaces are currently responsible for an annual reduction of some 602 million cigarettes, or 1.8% of all cigarettes that might otherwise be consumed, in Australia, and an annual reduction of 9.7 billion cigarettes (2%) in the United States. Approximately 22.3% of the 2.7 billion decrease in cigarette consumption in Australia between 1988 and 1995 can be attributed to smoke-free workplaces, as can 12.7% of the 76.5 billion decrease in the United States between 1988 and 1994.

CONCLUSIONS

If workplaces were universally smoke-free, the number of cigarettes forgone annually would increase to 1.14 billion (3.4%) in Australia and 20.9 billion (4.1%) in the United States.

A review of the health impact of smoking control at the workplace

PURPOSE

To summarize and provide a critical review of worksite health promotion program evaluations published between 1968 and 1994 that addressed the health impact of worksite smoking cessation programs and smoking policies.

METHODS

A comprehensive literature search conducted under the auspices of the Centers for Disease Control and Prevention identified 53 smoking cessation program evaluation reports, of which 41 covered worksite single-topic cessation programs. Nine additional reports were located through manual search of citations from published reports and reviews. These 50 reports covered 52 original data-based studies of cessation programs. The search produced 19 reports for tobacco policy evaluations, of which 12 addressed health impact. An additional 17 reports were located by the authors. These 29 reports covered 29 studies of policy impact.

SUMMARY OF IMPORTANT FINDINGS

Smoking cessation group programs were found to be more effective than minimal treatment programs, although less intensive treatment, when combined with high participation rates, can influence the total population. Tobacco policies were found to reduce cigarette consumption at work and worksite environmental tobacco smoke (ETS) exposure.

CONCLUSIONS

The literature is rated suggestive for group and incentive interventions; indicative for minimal interventions, competitions, and medical interventions; and acceptable for the testing of incremental effects. Because of the lack of experimental control, the smoking policy literature is rated as weak, although there is strong consistency in results for reduced cigarette consumption and decreased exposure to ETS at work.

Screening for unhealthy lifestyle factors in the workplace

OBJECTIVE

To examine (1) the prevalence of four lifestyle behaviours among Australia Post employees and (2) employees' perceptions of the role of the workplace in promotion of lifestyle change.

DESIGN

A cross-sectional survey using a self-administered questionnaire involved 688 employees working in Australia Post throughout metropolitan Sydney.

MAIN OUTCOME MEASURES

Prevalence related to age and sex of alcohol consumption, cigarette smoking, inadequate exercise, perception of excessive weight.

RESULTS

36% of men and 11% of women reported drinking alcohol at levels considered hazardous or harmful; 33% of men and 25% of women reported smoking; 51% of men and 62% of women thought they were overweight; 30% of men and 39% of women did not exercise regularly. Younger respondents were more likely to report drinking hazardously or harmfully, were smokers and had multiple risk factors. A majority of respondents thought that their employer should be interested in employee's lifestyle issues, particularly excessive drinking (63%). However, few considered seeking advice from the workplace regarding smoking (16%), weight (25%) and excessive alcohol consumption (12%).

CONCLUSIONS

These results show that many of Australia Post employees have unhealthy lifestyle behaviours. While employees perceive that the workplace has an important role in promoting healthy lifestyles among staff, few are presently willing to seek advice from the workplace regarding these issues. Promotion of healthy lifestyles in Australian workplaces is a potentially important public health advance that could reduce the incidence of diseases associated with high-risk lifestyle behaviours.

Association of the health-promoting workplace with trade unionism and other industrial factors

PURPOSE

The study examines associations of five healthy workplace attributes with trade unionism and nine other industrial and sociodemographic factors. The aims were to illustrate the measurement of workplace health promotion indicators in Western Australia and to identify associations leading to a better understanding of determinants of the healthy workplace.

DESIGN

Personal and telephone cross-sectional surveys were performed using population-based sampling frames. The overall response rate was 72%.

SETTING

Workplaces in Western Australia.

SUBJECTS

Random samples of household respondents aged 16 to 69 years in 1992 (n = 1310) and 1994 (n = 1113).

MEASURES

Measures of association between healthy workplace attributes and trade unionism were adjusted for workplace location, size, sector, and industrial classification.

RESULTS

Trade unionism was strongly associated with healthy catering practices (adjusted OR 2.05; 95% CI 1.30 to 3.23), sun protection practices (2.66; 1.69 to 4.17), disability access (1.47; 1.10 to 1.95), and worksite health promotion programs (2.56; 2.07 to 3.17). A weak and nonsignificant association was observed with restrictive smoking policies (1.21; .95 to 1.55). Generally, healthy workplace attributes were reported less often by respondents working in rural locations, in the private sector, and at small worksites. There was no consistent relationship with sociodemographic factors, including an index of social disadvantage, but members of blue-collar occupations experienced a low prevalence of restrictive smoking policies.

CONCLUSIONS

The study raises the hypothesis, but cannot confirm, that trade unions could provide a means for employees to pursue the creation of a health-promoting workplace. Small business represents an excellent target for health promotion activities.

Qualified nurse smokers' attitudes towards a hospital smoking ban and its influence on their smoking behaviour

This study explored the effects of a complete smoking ban in a large British teaching hospital on nurses' smoking behaviour and their attitudes and views on the current policy and compliance with it. Questionnaires were distributed to a convenience sample of nurse smokers and ex-smokers 9 months after the introduction of the smoking ban. A response rate of 64.7% (n = 33) was achieved. The reported reduction in work-time cigarette consumption following the ban was not statistically significant (Wilcoxon test: P = 0.069). No reduction outside work was recorded. Six (21.4%) smokers claimed that the ban had been a reason for them to try to give up smoking. Two of three ex-smokers reported that the ban had played a role in their giving up. The respondents showed considerable agreement with their health educator and role model function. Support for the policy was, however, very limited and compliance with it was reported to be poor among patients as well as staff. Twenty (76.9%) of current smokers indicated their wish to give up, 11 (39.3%) of them believed their own determination to be an effective way to achieve this. These results would seem to indicate that smoking policies currently have limited impact on smoking behaviour. It is suggested that in future policies should aim at strengthening nurses' determination to give up as well as secure their support for the restrictions in order to assist them in changing their smoking behaviour.

Prevalence of workplace smoking bans in Victoria

Restrictions on smoking in the Victorian workplace have been measured since 1988. This paper investigates whether the trend of increasing prevalence of total bans found between 1988 and 1992 has continued. Estimates are based on workers' reports of the restrictions on smoking that apply at their workplaces. For indoor workers a total ban on smoking restrictions in the workplace has increased from 58% in 1992 to 66% in 1995. White collar workers continue to enjoy a higher rate of protection than blue collar workers. Factories, warehouses, hotels and restaurants are the worksites least likely to have restrictions. Bans result in considerable exiled smoking: half the smokers reported going out to smoke during working hours on their last work day.

Recruiting worksites to participate in a health promotion research study

PURPOSE

In this study, the type and size of participating and nonparticipating worksites in a health promotion research trial were examined.

DESIGN

In-person and telephone contacts were made with representatives from a random sample of eligible worksites recruited to participate in a research trial to increase fruit and vegetable consumption.

SETTING

Worksites that had 250 to 2000 employees and a worksite cafeteria were recruited.

SUBJECTS

Eighty-one worksites were contacted.

MEASURES

A census of eligible worksites (N = 109) formed the recruitment base, and a random selection of worksites (N = 81) was personally contacted and asked to participate in the research. Information on size, type of worksite, and a worksite representative was obtained from a privately compiled list covering the greater Puget Sound area. Eligibility for the project included the presence of an onsite cafeteria at the worksite as assessed by a brief telephone call.

RESULTS

Thirty-six of the contacted worksites (44.5%) agreed to participate. There were no significant differences in participation by type or size of worksite.

DISCUSSION

Worksites can be recruited to participate in research trials. No particular type or size of worksite is more likely to participate. Instituting pre-randomization participation conditions may reduce post-randomization dropout by ascertaining compliance with research requirements before randomization.

Environmental tobacco smoke: health effects and policies to reduce exposure

The health hazards due to exposure to environmental tobacco smoke (ETS) are increasingly established. ETS contains thousands of chemicals including 43 known carcinogens. Known health effects of ETS exposure are lung cancer in nonsmokers, childhood disorders such as bronchitis, and perhaps, heart disease. Workplace exposure to ETS is widespread and is influenced strongly by the type of smoking policy in the workplace. To decrease ETS exposure, efforts to restrict public smoking have proliferated over the past decade. These restrictions have emanated from government as well as voluntary measures by various private industries. Bans on public smoking are effective in reducing nonsmokers' exposure to ETS. Workplace smoking bans also influence the intensity of smoking among employees and may increase quit smoking rates. In addition to the health benefits from smoke-free workplaces, there are likely cost savings to employers who implement such policies.

Passive smoking and health: should we believe Philip Morris's "experts"?

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Successful implementation of a no-smoking policy

Literature suggests that positive behavioural changes occur among employees after the introduction of a no-smoking policy (NSP). This paper reports successful results following the introduction of a revised NSP at Hawker de Havilland Victoria (HDHV) Limited, an aerospace component manufacturing company. In February, 1994 a poll survey indicated that 86 of the 480 employees smoked. In April, 1994 all 480 employees were surveyed, to assess smoking behaviour and attitudes. Education programs and company-sponsored Fresh Start Quit courses were conducted on-site. In August, 1994 a second survey was distributed, to the smokers only, to assess smoking habits, behaviour, satisfaction with the NSP and whether education programs influenced them to change their smoking habits. Findings in this study suggest that the introduction of the NSP and education programs induced positive behavioural and attitudinal changes to smoking. In August, 1994 the key results of the second smoking survey indicated that 5 per cent of employees quit smoking, 43 per cent reduced the number of cigarettes smoked per day, 1.6 per cent smoked more and 30 per cent reported no change. These results show that a short-term multifaceted smoking cessation program implemented over 5 months can produce a decrease in cigarette smoking.

Cigarette smoking at hire as a predictor of employment outcome

We have reported that cigarette smoking at the time of hire is associated with elevated rates of accidents, injuries, absence, discipline, and firing among US postal workers. We followed this cohort of 2537 for a second year to assess whether these associations would change with time in a workplace with active smoking cessation programs. Smokers' elevated risks for accidents, injuries, and discipline decreased after the first year. Risk for involuntary turnover was slightly higher in the 2-year analysis. The elevation in the rate of absence for smokers remained comparable in both periods. Although it is possible that the decline in the relative risk of accidents, injuries, and discipline may reflect changes in smoking status, we were unable to obtain follow-up data on smoking status to test this hypothesis.

Community based health education: general practitioners' perceptions of their role and willingness to participate

This study aimed to: 1. determine general practitioners' perceptions of their appropriateness to conduct community based health education; 2. assess the proportion of general practitioners who had undertaken group health education in the previous 12 months, and identify the factors that discourage and encourage this activity; and 3. identify appropriate health areas and the community groups that general practitioners would be prepared to address if provided with educational packages on the topic. A random sample of 181 general practitioners (66.5 per cent response rate) completed a mailed questionnaire. General practitioners rated health promotion officers (32.6 per cent) and general practitioners (30.9 per cent) as the most appropriate health care providers to undertake community based health education activities. Of the general practitioners, 38 per cent had undertaken community health education in the previous 12 months, with lack of time, lack of earnings while away from the practice, and lack of confidence in public speaking being the main reasons for not undertaking this activity. Being specifically invited to address groups, being provided with an information package on the topic, and being paid for their time were the three factors most likely to encourage this activity. Skin, cervical and breast cancer, blood pressure and cholesterol, and asthma were the topics general practitioners were most willing to speak on. Although this survey suggests that general practitioners would be willing to undertake this community health education, research is needed on whether they are the most appropriate and effective group for this.

Tobacco control

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Can psychiatric and chemical dependency treatment units be smoke free?

The feasibility and appropriateness of establishing smoke-free psychiatric and chemical dependency treatment units are topics of recent interest. This paper reviews the literature on the implementation of smoke-free policies in psychiatric and chemical dependency treatment units. Several issues are addressed including (a) the concerns raised by treatment staff regarding the implementation of a smoke-free policy, (b) the effects of involuntary smoking cessation or reduction on the treatment and/or recovery of patients, (c) the utilization of smoking cessation interventions by patients and staff, and (d) the effects of a smoke-free environment on the smoking behavior of patients and staff. It is concluded that a smoke-free environment is a reasonable and achievable goal in these settings. However, the implementation of a smoke-free policy in chemical dependency treatment units has met with several more problems than those observed in psychiatric settings. Recommendations for further clinical research and program implementation are offered.

Community attitudes to bans on smoking in licensed premises

Information about public attitudes to the restriction of smoking in licensed premises could provide an impetus for a campaign to address the failure of the industry to improve the health of its employees and the public. A probability sample of 816 people was surveyed to determine community attitudes to the introduction of bans on smoking in licensed premises. A total ban on smoking was supported by 20 per cent and provision of special smoking areas by 65 per cent, and 15 per cent wanted no bans. More-educated people, white-collar workers, nonsmokers and those who went to licensed premises less than weekly were more likely to support bans than were the less educated, blue-collar workers, smokers, and those who went to licensed premises at least weekly. The less educated, smokers and those who went to licensed premises at least weekly were most likely to perceive that the introduction of smoking bands would reduce their patronage of licensed premises. Nonsmokers and those with more than 12 years of education were more likely to report that their patronage would increase if bands were introduced than were smokers and the less educated. The introduction of bans on smoking in licensed premises would result in only a small loss of patronage after accounting for potential increases from supporters of bans. The effect of the bans is likely to be felt most strongly among the less educated, smokers and regular patrons.

Smoking-related beliefs and behaviour of South Australians with diabetes

Data cumulated from three representative population surveys (n = 9402) in South Australia were used to determine smoking prevalence of those aged 15 years or over with and without self-reported medically confirmed diabetes. Overall, smoking prevalence in the two groups did not differ. However, among those aged under 40 years with self-reported diabetes, smoking prevalence approached 55 per cent, which was significantly higher than in young respondents without diabetes (32 per cent). Diabetic smokers were no more likely than were nondiabetic smokers to have tried to quit or to be ready to quit; one-quarter of diabetic smokers had no thought of quitting or of modifying their habit. Smokers with diabetes were significantly more likely to be heavy smokers (43.5 per cent) than were nondiabetic smokers (23.4 per cent). Fewer smokers with diabetes tended to believe that smoking causes or aggravates heart disease or circulatory problems than did other smokers, although these differences did not reach statistical significance. Additional effort is required to find methods to assist people with diabetes to refrain from smoking.

School policy in COMMIT: a promising strategy to reduce smoking by youth

Organizational smoking policy has been identified as a potentially effective way to influence health behavior, particularly in worksites. Examining the elements of existing school smoking policies for both students and employees can provide insight into the potential effectiveness of these policies in changing young people's smoking behavior. This paper examines selected components of existing school smoking policies in a national sample of schools at all levels of education as part of the Community Intervention Trial for Smoking Cessation. Schools were questioned about their school smoking policies, related resources, and compliance. The data show much variation in the elements of school tobacco use policy to change smoking behavior. Existing policies in schools differ among grade levels, thus providing different messages about the appropriateness of smoking. Policies differ for students and adults, providing another opportunity for confusion about the messages that policy can deliver. In general, resources available to support existing policies are lacking. Many schools offer classes on knowledge of negative health effects of smoking but do not teach the psychosocial skills necessary to resist tobacco use. In its present forms, school policy has great potential for an effective tool for health promotion, but considerable reform is needed to overcome current barriers.

Creating a smoke-free hospital: attitudes and smoking behaviors of nurses and physicians

PURPOSE

To assess smoking prevalence and attitudes of physicians and nurses before a smoking ban. The relationship between pre-ban attitudes and post-ban smoking behavior was also studied.

DESIGN

This is a prospective descriptive study of a cohort of nurses and physicians who were surveyed six months before and six months after a ban on smoking was implemented.

SETTING

A large, 1,000-bed teaching hospital in the Northeast of the United States.

SUBJECTS

All full-time members of the medical (n = 1,496) and nursing staff (n = 1,500) were surveyed. The overall response rate for the cohort was 41% for physicians and 39% for nurses.

MEASURES

Surveys included standardized questions on current smoking behavior, and sociodemographic variables. Attitudes toward quitting and the smoking policy and attitudes about implementation and enforcement of the smoking ban were included.

RESULTS

Both physicians and nurses were supportive of a smoke-free policy, but the two groups differed significantly on attitudes related to implementation and enforcement, with nurses being more accommodating toward smoking and less likely to enforce a ban on smoking. Physicians were more likely than nurses to quit smoking after implementation of the ban. Pre-ban attitudes were not predictive of post-ban changes in smoking behavior.

CONCLUSIONS

Physicians and nurses agreed with establishing a smoke-free environment but disagreed over the efforts needed to maintain the smoke-free environment. Quitting behavior was not influenced by pre-ban attitudes.

Effects of a restricted work-site smoking policy on employees who smoke

OBJECTIVES

This study evaluated the biological and subjective consequences observed in individual smokers after implementation of a workplace smoking-restriction policy.

METHODS

Employees were evaluated for 4 weeks before and 4 weeks after their workplace became smoke-free (n = 34). A comparison group of smokers whose work-site smoking was unrestricted served as controls (n = 33). Daily exposure to tobacco constituents and withdrawal effects were measured.

RESULTS

Smokers at the restricted site had verified smoking reduction (mean = four cigarettes per day) and significantly reduced nicotine and carbon monoxide during the work shift. There were increases in ratings of some common withdrawal symptoms (cravings/urges, concentration difficulties, increased eating, depression). No evidence of compensatory smoking during nonwork hours was found. Overall tobacco exposure, as measured in saliva cotinine, showed a nonsignificant 15% decline.

CONCLUSIONS

Workplace smoking restriction markedly altered smoking patterns (i.e., reduced daytime smoking) and reduced cotinine levels to an amount consistent with cigarette reduction. Thus, work-site smoking restriction may promote meaningful, albeit limited, reductions in tobacco exposure and consequent health risks.

Smoking control in restaurants: the effectiveness of self-regulation in Australia

OBJECTIVES

The provision of smoke-free areas in restaurants has been a controversial issue; the restaurant industry largely opts for a self-regulation approach. This study aimed to examine the effectiveness of self-regulation as a strategy in meeting the industry's and customers' perceived needs.

METHODS

Restaurateur and customer perspectives on the provision of smoke-free areas in restaurants were examined by survey among 365 restaurateurs and 1327 customers in New South Wales, Australia.

RESULTS

Less than 2% of restaurants were totally smoke-free; 22% provided some smoke-free areas. Customers were much more likely than owners to think that smoke-free areas should be provided. Owners appeared to be unaware of customers' views about smoke-free areas in restaurants.

CONCLUSIONS

Little evidence was found to support the effectiveness of the self-regulation policy adopted by the restaurant industry. Characteristics of restaurants and owners associated with the provision of smoke-free areas are presented and implications of the findings are discussed.

Unravelling gossamer with boxing gloves: problems in explaining the decline in smoking

For about three decades countries such as Australia, Great Britain, and the United States have been turning up the heat on tobacco advertising. Encouraging, sometimes dramatic falls in consumption have followed. On any given day in 1993 smokers in such countries are exposed to a welter of news, information, persuasion, and policies designed to turn them off smoking. For a long time explanations and evaluations of the effects of these policies and interventions have been tied to oversimplified causal models when the reality is rather more messy and complicated. Four factors largely explain the reluctance of researchers to move beyond these models: the reductionist tradition of science; the explanatory privileging of recent events and factors; pragmatic concern for policy "tractable" factors; and the relation of funding to the evaluative process. Broader research approaches to understanding changes in complex behaviours such as smoking are required--for example, qualitative methods.

Total indoor smoking ban and smoker behavior

METHODS

To assess smoking policy support and effects, 1,083 hospital employees (203 smokers) were surveyed by anonymous questionnaire 1 year after the announcement (5 months after implementation) of a new total indoor smoking ban. A second follow-up, limited to smoker respondents only, was conducted 2 years postannouncement.

RESULTS

A total indoor smoking ban was supported by the vast majority of nonsmokers (89%) and ex-smokers (86%) and by nearly half of the then-smoking population (45%). Consistent with previous reports, the smoking ban was associated with a significant decrease in cigarette use during work hours, particularly among moderate to heavy smokers. However, the ban did not result in increased institutional quit rates. Light smokers (< 10 cig/day), compared with heavy smokers (> or = 30 cig/day), were more likely to support the no-smoking policy and had fewer problems observing the ban. They were also less apt to report a decrease in work productivity.

CONCLUSION

A total indoor smoking ban had little effect on overall institutional quit rates. Heavy smokers will, predictably, experience the greatest difficulty complying with a total indoor nonsmoking policy.

Tobacco in Australia—An Overview

Tobacco smoking is the largest preventable cause of death and disease in Australia, and the major cause of drug death. Under a third of adults smoke, male rates having declined significantly following the Second World War. The publication of international reports during the 1960s causally linking tobacco with death and disease stimulated action by Australian health professionals, although governments remained unresponsive. In the 1970s, advertising bans in the broadcast media were introduced, but quickly circumvented by the tobacco companies through sport sponsorships. However, the 1980s brought increased public awareness about health issues, and legislation concerning advertising restrictions and other aspects of tobacco control. Importantly, unequivocal evidence about the effects of passive smoking also become available in this decade, signalling a battle between public health interests and the tobacco industry, which the industry can now be said to have lost. Although consumption and disease rates are falling, priority areas for action still remain.

[Restrictions to smoking at the workplace and smoking habits: a literature review]

Based on a critical review of the literature, we assess the consequences of restrictive smoking policies at the worksite on smoking habits of active smokers. The majority of the fourteen studies reported to date (eleven studies from the United States, one study from Canada, one from Australia and one from the FRG) suggest that restrictive smoking policies might have a major impact on reduction of cigarette smoking and eventual smoking cessation of active smokers. However, most of the studies suffer from serious methodologic limitations, and more stringent scientific investigations should be carried out. Nevertheless, implementation of restrictive smoking policies at the worksite appears to be a reasonable measure of nonsmoker protection, even before definitive evaluation of the impact on smoking behavior of active smokers. Such implementation should take place without discrimination of smokers in the context of comprehensive worksite prevention programs and should be accompanied by thorough scientific evaluation.

Characteristics of heavy smokers

BACKGROUND

Heavy smokers (those who smoke greater than or equal to 25 or more cigarettes a day) are a subgroup who place themselves and others at risk for harmful health consequences and also are those least likely to achieve cessation. Despite this, heavy smokers are not well described as a segment of the smoking population.

METHODS

We used representative population data on 1,048 smokers to examine differences between heavy and lighter smokers (less than or equal to 24 cigarettes per day).

RESULTS

Heavy smokers constituted 26.7% of all cigarette smokers. Compared with lighter smokers, heavy smokers were significantly more likely to be male, to be age 30 years or older, to smoke their first cigarette of the day within 30 min of waking, to perceive quitting as very difficult, to have little confidence in their ability to quit, to be less likely to report variation in their rate of smoking between work and leisure days, and to be less likely to be employed.

CONCLUSIONS

Public health strategies which may particularly assist heavy smokers include stronger restrictions on smoking in public places, nicotine replacement therapies, and the use of segmentation research to more carefully target campaign messages to influence quit attempts and confidence.

[Prevalence of smoking in hospital personnel and future teachers]

We have surveyed the prevalence of smoking habits and the opinions about it's regulation among 192 students in two different schools (a teachers' and a nursing school) and among 320 employees of the University Hospital of Geneva. Smoking prevalence varies depending on the profession and sex, and remains high considering the level of education of the surveyed population. Among the future school teachers 23% are smokers. In the hospital, the smoking prevalence is 25% in the health professionals and 32% in the administrative and technical staff. As many as 46% of the future nurses are smoking. Obviously much still needs to be done in order to decrease the number of smokers among the health professionals. The majority of the employees questioned, both smokers and non-smokers, were in favor of regulating smoking in the workplace. 91% of the hospital staff, and 86% of the smokers among them, favored a smoke free hospital policy. Restriction of tobacco use in the workplace should be implemented particularly when it is the wish of a majority of employees.

Smoking prohibition in the workplace and smoking cessation in the Federal Republic of Germany

BACKGROUND

The relationship between prohibition of smoking at the workplace and smoking cessation was assessed in a national sample survey conducted in the Federal Republic of Germany in 1987.

METHODS

Four hundred thirty-nine men and women ages 21 to 65, who were actively engaged in the workforce for at least 20 hr per week and were either current or former smokers, were included in the study.

RESULTS

Quit ratios were substantially higher among women who worked at worksites designated as smokefree compared with women who were allowed to smoke at their workplace. Among men, there were only minor differences between both types of worksites. After simultaneously controlling for age, marital status, and level of education by multiple logistic regression, the odds ratio of being a current smoker (vs former smoker) was 0.80 (95% confidence interval, 0.44-1.45) for men and 0.22 (95% confidence interval, 0.09-0.50) for women working at places where smoking was prohibited (compared with men and women who were allowed to smoke at the workplace).

CONCLUSION

These results suggest that prohibition of smoking at the workplace may help a substantial proportion of smokers, particularly female smokers, to quit. Prohibition of smoking at the workplace might therefore be a particularly cost-effective public health measure.

Public policy for the control of tobacco-related disease

Public policies concerning tobacco shape the environment of the smoker and nonsmoker alike. These policies use diverse means to achieve the common goal of reducing tobacco use and its attendant health consequences. Educational interventions such as warning labels, school curricula, and public service announcements serve to inform the public about the hazards of tobacco smoke. These are countered by the pervasive marketing of tobacco products by the tobacco industry, despite a ban on tobacco advertising on radio and television. Further restrictions on tobacco advertising and promotion have been proposed and await action. Cigarette excise taxes and smoker-nonsmoker insurance premium differentials discourage smoking by making it more costly to purchase cigarettes. Conversely, health insurance reimbursement for smoking cessation programs could reduce the cost of giving up the habit and might encourage cessation. Restricting or banning smoking in public places and workplaces decreases a smoker's opportunities to smoke, further inhibiting this behavior. Reducing the availability of cigarettes to children and adolescents may help to prevent them from starting to smoke. The environment of the smoker is conditioned by this pastiche of influences. Physicians who become involved in tobacco-control issues have the opportunity to alter the environmental influences on their patients. This is likely to be synergistic with physicians' efforts inside the office to encourage individual smokers to quit. As a first step toward advocacy outside the office, physicians can help to create a smoke-free health-care facility in their own institution. Beyond that, advocacy groups or the voluntary health organizations (e.g., American Lung Association) provide avenues for physicians to take a stand on community issues relevant to tobacco control. Physicians who take these steps to alter the environment of smokers beyond the office are likely to magnify the effect of their work with individual patients who smoke.