Workplace interventions for smoking cessation

Smoking Habits and Workplace Health Promotion among University Students in Southern Italy: A Cross-Sectional Pilot Investigation

The study aimed to investigate the tobacco smoking prevalence, habits and awareness among a cohort of healthcare students from a university hospital in southern Italy and the associations with socio-demographic determinants. A secondary outcome was to estimate the educational needs to receive information on smoking-related risk factors. Five hundred and forty-nine students completed a self-administered questionnaire (180 male and 369 female, average age 25 yo, ±5.9 SD), enrolled from October 2018 to November 2019 at the University of Naples 'Luigi Vanvitelli', and the collected data were analysed by descriptive and inferential statistical analysis. The sample's prevalence of current smokers was 25.3%, without a significant sex difference. The multiple logistic regression model showed the link between smoking habits and alcoholic beverage consumption (p < 0.001) and living with smokers (p = 0.003). The enrolled cohort does not seem to need more information about the risks of cigarette smoking (p = 0.028). The data analysis and the comparison with the current literature allowed the authors to hypothesise a training model to be adopted within a workplace health promotion programme managed by an occupational physician. This model included targeted training for smoking dissuasion, focusing on sex and gender, cohabitant's influence, and combined addiction management. Further research will focus on the effectiveness of these proposed models.

Hospital as a smoke-free workplace

OBJECTIVES

The primary aim of a hospital is to promote/improve and restore health, thus smoking, whether in its passive or active form, should be banned in all hospital premises for the benefit of employees and patients alike. The Global Network for Tobacco Free Healthcare Services (GNTH) is an international non-profit association formed in 1999. The GNTH's mission is to implement tobacco-free policies to create a healthy workplace and patients' environment; help physicians, nurses, and other healthcare workers to stop smoking; and educate all caregivers about tobacco dependence treatment and support them in providing smoking cessation interventions.

METHODS

Implementation standards and a system of their self-audit for all participating hospitals were developed by the GNTH. We describe both the international and Czech networks, recommended methods for programme implementation and results of self-audit questionnaires completed by Czech participating hospitals.

RESULTS

Worldwide, there are 19 national networks with 1,672 members including 56 gold forum members. To date, the largest network has been formed in France (670 members), followed by Spain (580) and Taiwan (209). After the first Czech institution (Prague-based General University Hospital) joined GNTH in 2010, the Czech Republic established its national network in 2017 currently comprising 10 members, of this number 1 gold, 3 silver and 6 bronze national certification level members. The main barriers to better outcomes in the Czech Republic include smoking on outdoor hospital grounds, lack of pharmacotherapy reimbursement and time, and inadequate staff education in the field of tobacco dependence treatment.

CONCLUSIONS

The Global Network's mission is to advocate, recruit and enable healthcare services and professionals to implement and sustain effective tobacco management and cessation policies in accordance with the WHO Framework Convention on Tobacco Control (FCTC). A systematic approach supports the quality of care and treatment outcomes for patients as well as healthy workplace conditions for the staff.

Socioeconomic inequalities in effectiveness of and compliance to workplace health promotion programs: an individual participant data (IPD) meta-analysis

BACKGROUND

This individual patient data (IPD) meta-analysis aimed to investigate socioeconomic inequalities in effectiveness on healthy behavior of, and compliance to, workplace health promotion programs.

METHODS

Dutch (randomized) controlled trials were identified and original IPD were retrieved and harmonized. A two-stage meta-analysis was conducted where linear mixed models were performed per study (stage 1), after which individual study effects were pooled (stage 2). All models were adjusted for baseline values of the outcomes, age and gender. Intervention effects were assessed on physical activity, diet, alcohol use, and smoking. Also, we assessed whether effects differed between participants with low and high program compliance and. All analyses were stratified by socioeconomic position.

RESULTS

Data from 15 studies (n = 8709) were harmonized. Except for fruit intake (beta: 0·12 [95% CI 0·08 0·15]), no effects were found on health behaviors, nor did these effects differ across socioeconomic groups. Only participants with high compliance showed significant improvements in vigorous and moderate-to-vigorous physical activity, and in more fruit and less snack intake. There were no differences in compliance across socioeconomic groups.

CONCLUSIONS

Workplace health promotion programs were in general not effective. Neither effectiveness nor compliance differed across socioeconomic groups (operationalized by educational level). Even though stronger effects on health behavior were found for participations with high compliance, effects remained small. The results of the current study emphasize the need for new directions in health promotion programs to improve healthy behavior among workers, in particular for those in lower socioeconomic position.

Occupational health check-ups and health-promoting programs and asthma

Background

The focus in occupational health check-ups is in work and health, but they offer also a possibility to assess health behavior and give guidance e.g. on weight control. We wanted to study whether having occupational health checks-up, receiving physicians’ advice to change health behavior or participation in health promotion programs had an effect on obesity in a five-year follow-up from 1998 to 2003 in asthmatic and non-asthmatic workers.

Methods

Altogether 23,220 individuals aged 20–54 years were picked up from a randomized Finnish population sample. Univariate and multivariate logistic regression analysis was used to calculate the risk for obesity in 2003. The variables used in the modelling were gender, age, smoking, asthma, depression, and physical workload.

Results

Both asthmatic and non-asthmatic workers gained weight during the follow-up. Of the asthmatics 48 and 47% of the non-asthmatics had occupational health-check-up in the last 5 years. Of the asthmatics 18 and 14% of the non-asthmatics had received physician’s advice to change their health behavior (p < 0.001). Associated factors for obesity (BMI > 30) in 2003 were gender (men OR 1.19), older age (OR 1.25), smoking (OR 1.07) or depression (OR 1.44).

Conclusions

Results show that having occupational health checks-up or receiving physicians’ advice to change health behavior or participation in health promotion programs did not stop gain of weight during a five-year follow-up. Asthmatic workers did not differ from non-asthmatics. Male gender, older age, smoking, and depression were associated with obesity but not the physical workload.

Development of an Evidence and Gap Map (EGM) of interventions to increase smoking cessation: A study protocol

Smoking remains one of the leading risk factors contributing to the global burden of disease. Sub-optimal implementation of evidence-based tobacco control and smoking cessation practice is a major challenge despite a substantial evidence base for interventions to increase smoking cessation globally. We aim to develop an Evidence and Gap Map (EGM) to collate the existing evidence and identify the gap in research on interventions to increase smoking cessation worldwide. A conceptual framework was developed followed by the formulation of a search strategy with key search terms and search period (1970 - date of search). The search will be conducted in relevant bibliographic databases (e.g. MEDLINE, Embase, SCOPUS), systematic reviews databases (e.g. Cochrane Library, Joanna Briggs systematic reviews, EPPI-Reviewer) and impact evaluation databases (e.g. 3ie Impact Evaluation repository and Cochrane tobacco addiction group specialized register) with support from a research librarian. Subsequently, two coders will screen and retrieve systematic reviews and individual impact evaluation studies. The adapted SURE (Supporting the Use of Research Evidence) checklist will be used to evaluate the quality of the included systematic reviews. A narrative synthesis from the systematic review findings and line listing of the impact evaluations will form the basis of this EGM. The EGM report will be presented in an interactive visual format. The proposed EGM will organise the pieces of evidence generated in systematic reviews and impact evaluations on smoking cessation interventions and identify the current research gaps, if any. The findings will inform evidence-based practice and future research.

A randomized controlled trial to compare group motivational interviewing to very brief advice for the effectiveness of a workplace smoking cessation counseling intervention

BACKGROUND

Studies show that smokers have a lower work performance due to time spent smoking, increased fatigue perception and are more absent from work due to smoking-related diseases. The workplace could represent an important location to promote smoking cessation.

METHODS

This study is a multi-center, controlled trial for smoking cessation counseling at the participants' workplace, where 656 randomized participants received four sessions of group motivational interviewing or four sessions of very brief advice and were followed up for 52 weeks.

RESULTS

The Continuous Quit Rate (CQR) was higher for the smoking cessation counseling group than for the very brief advice group during weeks 9 to 12 (17.5% vs. 3.6%) weeks 9 to 24 (13.4% vs. 3.4%) and weeks 9 to 52 (10.3% vs. 3.1%).

CONCLUSIONS

This study demonstrated that motivational interviewing is an efficacious smoking cessation approach for smokers at their workplace. The short-term and long-term cessation rate of the intervention of the smoking cessation counseling group exceeded that of very brief advice.

Ambulatory Smoking Habits Investigation based on Physiology and Context (ASSIST) using wearable sensors and mobile phones: protocol for an observational study

INTRODUCTION

Smoking prevalence continues to be high over the world and smoking-induced diseases impose a heavy burden on the medical care system. As believed by many researchers, a promising way to promote healthcare and well-being at low cost for the large vulnerable smoking population is through eHealth solutions by providing self-help information about smoking cessation. But in the absence of first-hand knowledge about smoking habits in daily life settings, systems built on these methods often fail to deliver proactive and tailored interventions for different users and situations over time, thus resulting in low efficacy. To fill the gap, an observational study has been developed on the theme of objective and non-biased monitoring of smoking habits in a longitudinal and ambulatory mode. This paper presents the study protocol. The primary objective of the study is to reveal the contextual and physiological pattern of different smoking behaviours using wearable sensors and mobile phones. The secondary objectives are to (1) analyse cue factors and contextual situations of smoking events; (2) describe smoking types with regard to users' characteristics and (3) compare smoking types between and within subjects.

METHODS AND ANALYSES

This is an observational study aimed at reaching 100 participants. Inclusion criteria are adults aged between 18 and 65 years, current smoker and office worker. The primary outcome is a collection of a diverse and inclusive data set representing the daily smoking habits of the general smoking population from similar social context. Data analysation will revolve around our primary and secondary objectives. First, linear regression and linear mixed model will be used to estimate whether a factor or pattern have consistent (p value<0.05) correlation with smoking. Furthermore, multivariate multilevel analysis will be used to examine the influence of smokers' characteristics (sex, age, education, socioeconomic status, nicotine dependence, attitudes towards smoking, quit attempts, etc), contextual factors, and physical and emotional statuses on their smoking habits. Most recent machine learning techniques will also be explored to combine heterogeneous data for classification of smoking events and prediction of craving.

ETHICS AND DISSEMINATION

The study was designed together by an interdisciplinary group of researchers, including psychologist, psychiatrist, engineer and user involvement coordinator. The protocol was reviewed and approved by the ethical review board of UZ Leuven on 18 April 2016, with an approval number S60078. The study will allow us to characterise the types of smokers and triggering events. These findings will be disseminated through peer-reviewed articles.

Organizational culture and the adoption of anti-smoking initiatives at small to very small workplaces: An organizational level analysis

INTRODUCTION

Many workplaces have adopted anti-smoking initiatives to reduce smoking behavior, but small workplaces are less likely to adopt these initiatives. One factor that could influence adoption is organizational culture, defined as the values and assumptions shared by members of an organization. The aim of this study was to examine the types of organizational culture associated with smoking policy strength and adoption of smoking cessation activities at small (20–99 employees) and very small (<20 employees) workplaces. Two study hypotheses were made: An increase in clan culture (characterized by participation in decision-making and human resources development) will be associated with an increase in smoking policy strength (H1) and higher odds of having cessation activities in the workplace (H2).

METHODS

Between June and October 2017, executives and employees coming from small and very small workplaces participated in separate surveys. Executives answered questions about their workplace’s anti-smoking initiatives, while employees completed a 12-item questionnaire about organizational culture. We aggregated employee data to perform linear and logistic regression at the organizational level.

RESULTS

Organizational culture was not significantly associated with smoking policy strength, therefore H1 was not supported. Counter to H2, an increase in clan culture was associated with lower odds of offering smoking cessation activities (OR=0.06; 95% CI: 0.01–0.58).

CONCLUSIONS

We did not find support for the hypothesized relationships. External factors and additional cultural characteristics may explain study findings. Continued research on culture and ways to improve tobacco control within smaller workplaces is needed.

Tobacco product use among workers in the construction industry, United States, 2014-2016

BACKGROUND

Although cigarette smoking has declined among U.S. workers, smoking remains high among construction workers. This study assessed tobacco product use among U.S. construction workers.

METHODS

The 2014-2016 National Health Interview Survey data for U.S. working adults were analyzed.

RESULTS

Of the 10.2 (6.3% of working adults) million construction workers, 35.1% used any tobacco product; 24.4% were cigarette smokers, 8.3% were cigar, cigarillo, pipe or hookah smokers, 7.8% were smokeless tobacco users, 4.4% were e-cigarette users, and 7.6% used ≥2 tobacco product users. Tobacco use varied by worker characteristics, with highest tobacco use (>35%) among those reporting ≤5 years on the job, temporary work status, job insecurity, or an unsafe workplace. Construction workers had higher odds of tobacco product use than non-construction workers.

CONCLUSIONS

Over one-third of U.S. construction workers use tobacco products and disparities exist across sub-groups. Workplace tobacco control strategies could reduce tobacco use among this population.

Evaluation of a Workplace Health and Wellbeing Training Course Delivered Online and Face-To-Face

Organisations may benefit from training champions to promote healthy workplace environments and initiatives. This study compared the perceived usefulness and relative effectiveness of an employee training course offered via online and face-to-face formats. Individuals who took part in the training course were assessed on their perceived competence and confidence to implement changes pre- and post-training. Repeated measures Analysis of Variance (ANOVA) and a t-test were conducted to test for significant differences between pre- and post-training scores and/or mode of training, respectively. Although the face-to-face training course was rated as slightly more useful, there were no significant differences between the two modes of training for the other dependent variables, and both modes led to significantly greater perceived competence and confidence post-training. These findings demonstrate the potential benefits of training employees to implement changes in their workplaces.

A qualitative assessment of the smoking policies and cessation activities at smaller workplaces

Background

To reduce the negative consequences of smoking, workplaces have adopted and implemented anti-smoking initiatives. Compared to large workplaces, less research exists about these initiatives at smaller workplaces, which are more likely to hire low-wage workers with higher rates of smoking. The purpose of this study was to describe and compare the smoking policies and smoking cessation activities at small (20–99 employees) and very small (< 20 employees) workplaces.

Methods

Thirty-two key informants coming from small and very small workplaces in Iowa completed qualitative telephone interviews. Data collection occurred between October 2016 and February 2017. Participants gave descriptions of the anti-smoking initiatives at their workplace. Additional interview topics included questions on enforcement, reasons for adoption, and barriers and facilitators to adoption and implementation. The data were analyzed using counts and content and thematic analysis.

Results

Workplace smoking policies were nearly universal (n = 31, 97%), and most workplaces (n = 21, 66%) offered activities to help employees quit smoking. Reasons for adoption included the Iowa Smokefree Air Act, to improve employee health, and organizational benefits (e.g., reduced insurance costs). Few challenges existed to adoption and implementation. Commonly cited facilitators included the Iowa Smokefree Air Act, no issues with compliance, and support from others. Compared to small workplaces, very small workplaces offered cessation activities less often and had fewer tobacco policy restrictions.

Conclusions

This study showed well-established tobacco control efforts in small workplaces, but very small workplaces lagged behind. To reduce potential health disparities in smoking, future research and intervention efforts in tobacco control should focus on very small workplaces.

Ups and downs of a peer-based smoking cessation intervention help tailored to hospital-employees with low socioeconomic status: The RESPEKT Study

INTRODUCTION

Smoking is one of the most important determinants of socioeconomic inequality in mortality. Few studies have tested which interventions are effective in smokers with low socioeconomic status (SES).

METHODS

All hospitals in the Capital Region of Denmark were included and randomized to intervention or control groups. The target-group was smokers with low SES. Intervention hospitals: smokers in the target-group assisted researchers to tailor a group-based smoking cessation intervention. Further they helped recruiting smoking colleagues and motivating them to stay abstinent. Control hospitals: ‘as usual’. Unforeseen organizational challenges led to a change of study design; the hospital-level assessment was reduced to two cross-sectional surveys.

RESULTS

Response rates in hospitals’ smoking status survey were very low. Smoking status was reported by 1876 out of 7003 employees at baseline and 2280 out of 7496 employees at 1-year follow-up. Two cross-sectional surveys showed no significant difference in self-reported smoking at 1-year follow-up between intervention and control hospitals (p=0.262). We recruited 100 smokers in the group-based smoking cessation intervention tailored to smokers with low SES (corresponding to approx. 10% of smokers in target-group); 32.4% of these were validated as continuously abstinent at 6 months follow-up.

CONCLUSIONS

Involving smokers with low SES as partners at an early stage of study design facilitated both recruitment and development of the intervention. Despite high validated long-term abstinence rates in smoking cessation groups in the intervention hospitals we found no apparent effect of the intervention at hospital-level after one year. However, larger involvement of the target-group seems feasible and is recommended.

Unaided Smoking Cessation in Healthy Employees

BACKGROUND

According to guidelines, behavioral and pharmacological assistance should be offered to all smokers willing to quit. However, a large proportion of ex-cigarette smokers are self-quitters.

OBJECTIVES

To identify characteristics of long-term, unaided self-quitters, as compared to recurrent smokers among health care employees.

METHODS

University hospital employees (n = 5,218) were addressed through a 17-question questionnaire inquiring about past and current smoking behavior. Questions included daily cigarette consumption, pack-years, previous quit attempts, smoking-free period, and utilization of pharmacological therapies and counseling.

RESULTS

2,574 (49.3%) questionnaires were returned. 791 subjects declared to have successfully quit smoking. A complete data set was available for 763 cases. Patients remained smoking free for a mean period of 11.8 ± 9.7 years. The most common smoking cessation method in these subjects was unaided (77.2%), followed by alternative approaches (15.4%), nicotine replacement therapy (4.5%), counseling (1.7%), and bupropion (1.2%). Smoking cessation was achieved with 1 attempt in 53% of the cases, 2 in 19%, 3 in 13%, and more than 3 attempts in 15%, respectively. On average, 2.4 ± 3.02 attempts led to successful smoking cessation. After 2 or more unsuccessful attempts, the odds ratio for a further unsuccessful smoking cessation was 2.58 (95% CI 1.94-3.45).

CONCLUSION

The majority of the ex-smokers quitted smoking without any behavioral or pharmacological support. The chance to successfully quit smoking without any help in a first or second attempt is considerably high. The risk for smoking recurrence after 2 ineffective quit attempts is markedly increased (OR 2.58).

Outcome of tobacco cessation in workplace and clinic settings: A comparative study

Aims and Objectives:

Several biological, social, and cultural factors contribute to the poor outcome of tobacco cessation interventions. Inability to engage large number of participants is one of the major identifiable factors. The objective of this study was to compare the outcome of tobacco cessation interventions in the clinical and workplace settings.

Materials and Methods:

In the present study, we recruited 100 participants in tobacco cessation clinic (TCC) group and workplace group (50 participants in each). Both the groups were regularly intervened and were followed up regularly at 2 weeks, 4 weeks, 3 months, and 6 months. Active interventions in the form of awareness lectures, focused group discussions, and if needed, pharmacotherapy (nicotine/non-nicotine replacement therapy) was carried out for all participants. The outcome was assessed as no change, harm reduction (>50% reduction), complete cessation, and drop out. Statistical analysis of the data was done using the Statistical Package for the Social Sciences version 21.0.

Results:

At the end of 1 month, there was higher tobacco cessation rate in the workplace group versus TCC group (n = 22, 44% vs n = 9, 18%; P < 0.0001). The tobacco cessation rate was maintained even after 6 months of intervention (n = 30, 60% vs n = 12, 24%; P = 0.002) and dropout rate was also lower among the workplace group than the TCC group (n = 14, 28% vs n = 27, 54%; P < 0.0001).

Conclusions:

Our study findings suggest that the workplace setting has superior outcome in tobacco cessation and harm reduction than clinical setting. In addition, it is associated with low dropout rate and the cessation effect is maintained over a period of 6 months.

Cigarette Smoking Prevalence Among Adults Working in the Health Care and Social Assistance Sector, 2008 to 2012

OBJECTIVE

The primary objective of this study was to estimate current smoking among workers in the health care and social assistance sector.

METHODS

We analyzed the 2008 to 2012 National Health Interview Survey data for adults (age 18 years or more) working in health care and social assistance sector who reported current cigarette smoking.

RESULTS

Of the approximately 18.9 million health care and social assistance workers, 16.0% were current cigarette smokers. Smoking prevalence was highest in women (16.9%) and among workers: age 25 to 44 years (17.7%); with a high school education or less (24.4%); with income less than $35,000 (19.5%); with no health insurance (28.5%); in the nursing and residential care facilities (26.9%) industry; and in the material recording, scheduling, dispatching, and distributing (34.7%) occupations.

CONCLUSIONS

These findings suggest that specific group of workers in the health care and social assistance sector might particularly benefit from cessation programs and incentives to quit smoking.

Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data)

BACKGROUND

Meeting global health challenges requires effective behaviour change interventions (BCIs). This depends on advancing the science of behaviour change which, in turn, depends on accurate intervention reporting. Current reporting often lacks detail, preventing accurate replication and implementation. Recent developments have specified intervention content into behaviour change techniques (BCTs) - the 'active ingredients', for example goal-setting, self-monitoring of behaviour. BCTs are 'the smallest components compatible with retaining the postulated active ingredients, i.e. the proposed mechanisms of change. They can be used alone or in combination with other BCTs' (Michie S, Johnston M. Theories and techniques of behaviour change: developing a cumulative science of behaviour change. Health Psychol Rev 2012;6:1-6). Domain-specific taxonomies of BCTs have been developed, for example healthy eating and physical activity, smoking cessation and alcohol consumption. We need to build on these to develop an internationally shared language for specifying and developing interventions. This technology can be used for synthesising evidence, implementing effective interventions and testing theory. It has enormous potential added value for science and global health.

OBJECTIVE

(1) To develop a method of specifying content of BCIs in terms of component BCTs; (2) to lay a foundation for a comprehensive methodology applicable to different types of complex interventions; (3) to develop resources to support application of the taxonomy; and (4) to achieve multidisciplinary and international acceptance for future development.

DESIGN AND PARTICIPANTS

Four hundred participants (systematic reviewers, researchers, practitioners, policy-makers) from 12 countries engaged in investigating, designing and/or delivering BCIs. Development of the taxonomy involved a Delphi procedure, an iterative process of revisions and consultation with 41 international experts; hierarchical structure of the list was developed using inductive 'bottom-up' and theory-driven 'top-down' open-sort procedures (n = 36); training in use of the taxonomy (1-day workshops and distance group tutorials) (n = 161) was evaluated by changes in intercoder reliability and validity (agreement with expert consensus); evaluating the taxonomy for coding interventions was assessed by reliability (intercoder; test-retest) and validity (n = 40 trained coders); and evaluating the taxonomy for writing descriptions was assessed by reliability (intercoder; test-retest) and by experimentally testing its value (n = 190).

RESULTS

Ninety-three distinct, non-overlapping BCTs with clear labels and definitions formed Behaviour Change Technique Taxonomy version 1 (BCTTv1). BCTs clustered into 16 groupings using a 'bottom-up' open-sort procedure; there was overlap between these and groupings produced by a theory-driven, 'top-down' procedure. Both training methods improved validity (both p < 0.05), doubled the proportion of coders achieving competence and improved confidence in identifying BCTs in workshops (both p < 0.001) but did not improve intercoder reliability. Good intercoder reliability was observed for 80 of the 93 BCTs. Good within-coder agreement was observed after 1 month (p < 0.001). Validity was good for 14 of 15 BCTs in the descriptions. The usefulness of BCTTv1 to report descriptions of observed interventions had mixed results.

CONCLUSIONS

The developed taxonomy (BCTTv1) provides a methodology for identifying content of complex BCIs and a foundation for international cross-disciplinary collaboration for developing more effective interventions to improve health. Further work is needed to examine its usefulness for reporting interventions.

FUNDING

This project was funded by the Medical Research Council Ref: G0901474/1. Funding also came from the Peninsula Collaboration for Leadership in Applied Health Research and Care.

Health Promotion Methods for Smoking Prevention and Cessation: A Comprehensive Review of Effectiveness and the Way Forward

Tobacco smoking is one of the greatest causes of mortality in the world, responsible for over 5 million deaths per annum. The prevalence of smoking is over 1 billion people, with the majority coming from low or middle income countries. Yet, the incidence of smoking varies vastly between many countries. Some countries have been able to decline the smoking and tobacco related morbidity and mortality through the introduction of health promotion initiatives and effective policies in order to combat tobacco usage. However, on the other hand, in some countries, the incidence of smoking is increasing still further. With the growing body of evidence of detriment of tobacco to health, many control policies have been implemented as health promotion actions. Such methods include taxation of smoking, mass advertising campaigns in the media, peer education programs, community mobilization, motivational interviewing, health warnings on tobacco products, marketing restrictions, and banning smoking in public places. However, the review of the effectiveness of various health promotion methods used for smoking prevention and cessation is lacking. Therefore, the aim of this review is to identify and critically review the effectiveness of health promotion methods used for smoking prevention and cessation. All available studies and reports published were considered. Searches were conducted using PubMed, MEDLINE, Ovid, Karger, ProQuest, Sage Journals, Science Direct, Springer, Taylor and Francis, EMBASE, CINAHL, and Cochrane and Wiley Online Library. Various relevant search terms and keywords were used. After considering the inclusion and exclusion criteria, we selected 23 articles for the present review.

Identifying the effects of environmental and policy change interventions on healthy eating

Obesity has been characterized as a disease. Strategies to change the incidence and prevalence of this disease include a focus on changing physical and social environments, over and above individual-level strategies, using a multilevel or systems approach. We focus our attention on evidence published between 2008 and 2013 on the effectiveness of interventions in nutrition environments, i.e., environmental interventions designed to influence the intake of healthful foods and amount of energy consumed. An overarching socioecological framework that has guided much of this research was used to characterize different types of environmental strategies. Intervention examples in each area of the framework are provided with a discussion of key findings and related conceptual and methodological issues. The emphasis in this review is on adults, but clearly this literature is only one part of the picture. Much research has been focused on child-specific interventions, including environmental interventions. Some evidence suggests effectiveness of policy-based or other types of interventions that aim to regulate or restructure environments to promote healthy dietary choices, and these strategies would apply to both children and adults. Opportunities to evaluate these policy changes in adults' social and physical environments are rare. Much of the existing research has been with children. As conceptual and methodological issues continue to be identified and resolved, we hope that future research in this domain will identify environmental strategies that can be included in intervention toolboxes to build healthy nutrition environments for both adults and children.

Gender differences in smoking among U.S. working adults

BACKGROUND

Cigarette smoking remains a leading cause of morbidity and mortality. Although gender differences in cigarette smoking in the U.S. population have been documented, information on these differences among working adults is limited.

PURPOSE

To describe the current smoking prevalence by gender among working U.S. adults and examine gender differences in smoking by occupation.

METHODS

The 2004-2011 National Health Interview Survey data for adults aged ≥18 years that were working in the week prior to the interview (N=132,215) were analyzed in 2013. Current cigarette smokers were those who smoked at least 100 cigarettes in their lifetime and currently smoke every day or some days.

RESULTS

During 2004-2011, an estimated 22.8% of men workers and 18.3% of women workers were current smokers. Of the current smokers, women workers had higher odds of being an everyday smoker (prevalence OR [POR]=1.17, 95% CI=1.09, 1.26); having poor self-rated emotional health (POR=1.28, 95% CI=1.15, 1.41); and having chronic obstructive pulmonary disease (POR=2.45, 95% CI=2.14, 2.80), heart disease (POR=1.27, 95% CI=1.12, 1.45), and current asthma (POR=2.21, 95% CI=1.96, 2.49) compared with men workers. Women in "supervisors, construction, and extraction" (38.9%) occupations and men in "extraction" (40.5%) occupations had the highest smoking prevalence.

CONCLUSION

Among working adults, women had lower prevalence of smoking than men, yet women who smoke were more likely than men to have adverse health outcomes, including self-rated poorer physical and emotional health.

A risk prediction model for smoking experimentation in Mexican American youth

BACKGROUND

Smoking experimentation in Mexican American youth is problematic. In light of the research showing that preventing smoking experimentation is a valid strategy for smoking prevention, there is a need to identify Mexican American youth at high risk for experimentation.

METHODS

A prospective population-based cohort of 1,179 adolescents of Mexican descent was followed for 5 years starting in 2005-06. Participants completed a baseline interview at a home visit followed by three telephone interviews at intervals of approximately 6 months and additional interviews at two home visits in 2008-09 and 2010-11. The primary endpoint of interest in this study was smoking experimentation. Information about social, cultural, and behavioral factors (e.g., acculturation, susceptibility to experimentation, home characteristics, and household influences) was collected at baseline using validated questionnaires.

RESULTS

Age, sex, cognitive susceptibility, household smoking behavior, peer influence, neighborhood influence, acculturation, work characteristics, positive outcome expectations, family cohesion, degree of tension, ability to concentrate, and school discipline were found to be associated with smoking experimentation. In a validation dataset, the proposed risk prediction model had an area under the receiver operating characteristic curve (AUC) of 0.719 (95% confidence interval, 0.637-0.801) for predicting absolute risk for smoking experimentation within 1 year.

CONCLUSIONS

The proposed risk prediction model is able to quantify the risk of smoking experimentation in Mexican American adolescents.

IMPACT

Accurately identifying Mexican American adolescents who are at higher risk for smoking experimentation who can be intervened will substantially reduce the incidence of smoking and thereby subsequent health risks.

Weight gain prevention in the school worksite setting: results of a multi-level cluster randomized trial

OBJECTIVE

To describe the effectiveness, reach and implementation of a weight gain prevention intervention among public school employees.

METHOD

A multi-level intervention was tested in a cluster randomized trial among 782 employees in 12 central Massachusetts public high schools from 2009 to 2012. The intervention targeted the nutrition and physical activity environment and policies, the social environment and individual knowledge, attitudes and skills. The intervention was compared to a materials only condition. The primary outcome measures were change in weight and body mass index (BMI) at 24-month follow-up. Implementation of physical environment, policy and social environment strategies at the school and interpersonal levels, and intervention participation at the individual level were assessed.

RESULTS

At 24-month follow-up, there was a net change (difference of the difference) of -3.03 pounds (p=.04) and of -.48 BMI units (p=.05) between intervention and comparison conditions. The majority of intervention strategies were successfully implemented by all intervention schools, although establishing formal policies was challenging. Employee participation in programs targeting the physical and social environment was maintained over time.

CONCLUSION

This study supports that a multi-level intervention integrated within the organizational culture can be successfully implemented and prevent weight gain in public high school employees.

Workplace interventions for smoking cessation

BACKGROUND

The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation.

OBJECTIVES

1. To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking.2. To collect and evaluate data on costs and cost effectiveness associated with workplace interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register (July 2013), MEDLINE (1966 - July 2013), EMBASE (1985 - June 2013), and PsycINFO (to June 2013), amongst others. We searched abstracts from international conferences on tobacco and the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

We selected interventions conducted in the workplace to promote smoking cessation. We included only randomized and quasi-randomized controlled trials allocating individuals, workplaces, or companies to intervention or control conditions.

DATA COLLECTION AND ANALYSIS

One author extracted information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the studies, and a second author checked them. For this update we have conducted meta-analyses of the main interventions, using the generic inverse variance method to generate odds ratios and 95% confidence intervals.

MAIN RESULTS

We include 57 studies (61 comparisons) in this updated review. We found 31 studies of workplace interventions aimed at individual workers, covering group therapy, individual counselling, self-help materials, nicotine replacement therapy, and social support, and 30 studies testing interventions applied to the workplace as a whole, i.e. environmental cues, incentives, and comprehensive programmes. The trials were generally of moderate to high quality, with results that were consistent with those found in other settings. Group therapy programmes (odds ratio (OR) for cessation 1.71, 95% confidence interval (CI) 1.05 to 2.80; eight trials, 1309 participants), individual counselling (OR 1.96, 95% CI 1.51 to 2.54; eight trials, 3516 participants), pharmacotherapies (OR 1.98, 95% CI 1.26 to 3.11; five trials, 1092 participants), and multiple intervention programmes aimed mainly or solely at smoking cessation (OR 1.55, 95% CI 1.13 to 2.13; six trials, 5018 participants) all increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective (OR 1.16, 95% CI 0.74 to 1.82; six trials, 1906 participants), and two relapse prevention programmes (484 participants) did not help to sustain long-term abstinence. Incentives did not appear to improve the odds of quitting, apart from one study which found a sustained positive benefit. There was a lack of evidence that comprehensive programmes targeting multiple risk factors reduced the prevalence of smoking.

AUTHORS' CONCLUSIONS

1. We found strong evidence that some interventions directed towards individual smokers increase the likelihood of quitting smoking. These include individual and group counselling, pharmacological treatment to overcome nicotine addiction, and multiple interventions targeting smoking cessation as the primary or only outcome. All these interventions show similar effects whether offered in the workplace or elsewhere. Self-help interventions and social support are less effective. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low.2. We failed to detect an effect of comprehensive programmes targeting multiple risk factors in reducing the prevalence of smoking, although this finding was not based on meta-analysed data. 3. There was limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer, although one trial demonstrated a sustained effect of financial rewards for attending a smoking cessation course and for long-term quitting. Further research is needed to establish which components of this trial contributed to the improvement in success rates.4. Further research would be valuable in low-income and developing countries, where high rates of smoking prevail and smoke-free legislation is not widely accepted or enforced.

A systematic review of internet-based worksite wellness approaches for cardiovascular disease risk management: outcomes, challenges & opportunities

Context

The internet is gaining popularity as a means of delivering employee-based cardiovascular (CV) wellness interventions though little is known about the cardiovascular health outcomes of these programs. In this review, we examined the effectiveness of internet-based employee cardiovascular wellness and prevention programs.

Evidence Acquisition

We conducted a systematic review by searching PubMed, Web of Science and Cochrane library for all published studies on internet-based programs aimed at improving CV health among employees up to November 2012. We grouped the outcomes according to the American Heart Association (AHA) indicators of cardiovascular wellbeing – weight, BP, lipids, smoking, physical activity, diet, and blood glucose.

Evidence Synthesis

A total of 18 randomized trials and 11 follow-up studies met our inclusion/exclusion criteria. Follow-up duration ranged from 6 – 24 months. There were significant differences in intervention types and number of components in each intervention. Modest improvements were observed in more than half of the studies with weight related outcomes while no improvement was seen in virtually all the studies with physical activity outcome. In general, internet-based programs were more successful if the interventions also included some physical contact and environmental modification, and if they were targeted at specific disease entities such as hypertension. Only a few of the studies were conducted in persons at-risk for CVD, none in blue-collar workers or low-income earners.

Conclusion

Internet based programs hold promise for improving the cardiovascular wellness among employees however much work is required to fully understand its utility and long term impact especially in special/at-risk populations.

Health promotion in the Danish maritime setting: challenges and possibilities for changing lifestyle behavior and health among seafarers

BACKGROUND

Seafaring is a risky occupation when compared to land-based industries as incidence rates of mortality and morbidity are higher. This trend is partly due to a higher number of accidents but also higher incidence of lifestyle-related diseases like cardiovascular disease and lung cancer. In Denmark, the proportion of smokers as well as of overweight and obese persons is higher among seafarers compared to the general population. This high burden of risk indicates that this occupational group might be a growing challenge at sea in regard to safety and health issues and there is a need to further our understanding of the health promotion approaches that work.

METHODS

A single-group pre-post design was conducted in 2008-2009 in order to identify changes in lifestyle related behaviors and health risk factors among seafarers (N: 606) in two Danish shipping companies after implementing two structural health promotion interventions (healthy cooking courses for ship cooks and improvement of fitness facilities) as well as health education interventions (smoking cessation courses, individual exercise guidance and extra health check-ups) at the maritime workplace. Baseline and follow-up data were collected with a self-administrated standardized questionnaire and individual health profiling assessing parameters such as physical health and physical fitness. In addition, qualitative interviews with participants and non-participants were conducted in order to gain in-depth information on experiences with the intervention processes.

RESULTS

Significant changes were identified for levels of fitness, daily sugar intake and metabolic syndrome. However, these results were not associated with participating in the health educational interventions. One possible explanation for the improved fitness rate could be the upgrading of fitness equipment onboard the ships provided by the management level. The decrease in daily sugar intake and prevalence of seafarers with metabolic syndrome might be associated with the cooking course intervention which aimed at providing healthier daily meals on board.

CONCLUSION

The findings suggest that a multicomponent health promotion intervention program has the potential to achieve change in seafarers' health behavior and health parameters. In the future, studies with more rigorous designs, separately testing the contribution of different types of interventions are needed.

A qualitative evidence synthesis of employees' views of workplace smoking reduction or cessation interventions

BACKGROUND

The need to reduce smoking rates is a recognised public health policy issue in many countries. The workplace offers a potential context for offering smokers' programmes and interventions to assist smoking cessation or reduction. A qualitative evidence synthesis of employees' views about such programmes might explain why some interventions appear effective and others not, and can be used to develop evidence-based interventions for this population and setting.

METHODS

A qualitative evidence synthesis of primary research exploring employees' views about workplace interventions to encourage smoking cessation, including both voluntary programmes and passive interventions, such as restrictions or bans. The method used was theory-based "best fit" framework synthesis.

RESULTS

Five relevant theories on workplace smoking cessation were identified and used as the basis for an a priori framework. A comprehensive literature search, including interrogation of eight databases, retrieved 747 unique citations for the review. Fifteen primary research studies of qualitative evidence were found to satisfy the inclusion criteria. The synthesis produced an evidence-based conceptual model explaining employees' experiences of, and preferences regarding, workplace smoking interventions.

CONCLUSION

The synthesis suggests that workplace interventions should employ a range of different elements if they are to prove effective in reducing smoking among employees. This is because an employee who feels ready and able to change their behaviour has different needs and preferences from an employee who is not at that stage. Only a multi-faceted intervention can satisfy the requirements of all employees.

Participatory workplace interventions can reduce sedentary time for office workers--a randomised controlled trial

BACKGROUND

Occupational sedentary behaviour is an important contributor to overall sedentary risk. There is limited evidence for effective workplace interventions to reduce occupational sedentary time and increase light activity during work hours. The purpose of the study was to determine if participatory workplace interventions could reduce total sedentary time, sustained sedentary time (bouts >30 minutes), increase the frequency of breaks in sedentary time and promote light intensity activity and moderate/vigorous activity (MVPA) during work hours.

METHODS

A randomised controlled trial (ANZCTR NUMBER: ACTN12612000743864) was conducted using clerical, call centre and data processing workers (n = 62, aged 25-59 years) in 3 large government organisations in Perth, Australia. Three groups developed interventions with a participatory approach: 'Active office' (n = 19), 'Active Workstation' and promotion of incidental office activity; 'Traditional physical activity' (n = 14), pedometer challenge to increase activity between productive work time and 'Office ergonomics' (n = 29), computer workstation design and breaking up computer tasks. Accelerometer (ActiGraph GT3X, 7 days) determined sedentary time, sustained sedentary time, breaks in sedentary time, light intensity activity and MVPA on work days and during work hours were measured before and following a 12 week intervention period.

RESULTS

For all participants there was a significant reduction in sedentary time on work days (-1.6%, p = 0.006) and during work hours (-1.7%, p = 0.014) and a significant increase in number of breaks/sedentary hour on work days (0.64, p = 0.005) and during work hours (0.72, p = 0.015); there was a concurrent significant increase in light activity during work hours (1.5%, p = 0.012) and MVPA on work days (0.6%, p = 0.012).

CONCLUSIONS

This study explored novel ways to modify work practices to reduce occupational sedentary behaviour. Participatory workplace interventions can reduce sedentary time, increase the frequency of breaks and improve light activity and MVPA of office workers by using a variety of interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTN12612000743864.

The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions

BACKGROUND

CONSORT guidelines call for precise reporting of behavior change interventions: we need rigorous methods of characterizing active content of interventions with precision and specificity.

OBJECTIVES

The objective of this study is to develop an extensive, consensually agreed hierarchically structured taxonomy of techniques [behavior change techniques (BCTs)] used in behavior change interventions.

METHODS

In a Delphi-type exercise, 14 experts rated labels and definitions of 124 BCTs from six published classification systems. Another 18 experts grouped BCTs according to similarity of active ingredients in an open-sort task. Inter-rater agreement amongst six researchers coding 85 intervention descriptions by BCTs was assessed.

RESULTS

This resulted in 93 BCTs clustered into 16 groups. Of the 26 BCTs occurring at least five times, 23 had adjusted kappas of 0.60 or above.

CONCLUSIONS

"BCT taxonomy v1," an extensive taxonomy of 93 consensually agreed, distinct BCTs, offers a step change as a method for specifying interventions, but we anticipate further development and evaluation based on international, interdisciplinary consensus.

Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews

BACKGROUND AND AIMS

The Cochrane Collaboration is an international not-for-profit organization which produces and disseminates systematic reviews of health-care interventions. This paper is the first in a series of annual updates of Cochrane reviews on tobacco addiction interventions. It also provides an up-to-date overview of review findings in this area to date and summary statistics for cessation reviews in which meta-analyses were conducted.

METHODS

In 2012, the Group published seven new reviews and updated 13 others. This update summarizes and comments on these reviews. It also summarizes key findings from all the other reviews in this area.

RESULTS

New reviews in 2012 found that in smokers using pharmacotherapy, behavioural support improves success rates [risk ratio (RR) 1.16, 95% confidence interval (CI) = 1.09-1.24], and that combining behavioural support and pharmacotherapy aids cessation (RR 1.82, 95% CI = 1.66-2.00). Updated reviews established mobile phones as potentially helpful in aiding cessation (RR 1.71, 95% CI = 1.47-1.99), found that cytisine (RR 3.98, 95% CI = 2.01-7.87) and low-dose varenicline (RR 2.09, 95% CI = 1.56-2.78) aid smoking cessation, and found that training health professionals in smoking cessation improves patient cessation rates (RR 1.60, 95% CI = 1.26-2.03). The updated reviews confirmed the benefits of nicotine replacement therapy, standard dose varenicline and providing cessation treatment free of charge. Lack of demonstrated efficacy remained for partner support, expired-air carbon monoxide feedback and lung function feedback.

CONCLUSIONS

Cochrane systematic review evidence for the first time establishes the efficacy of behavioural support over and above pharmacotherapy, as well as the efficacy of cytisine, mobile phone technology, low-dose varenicline and health professional training in promoting smoking cessation.

Development and evaluation of an intervention aiming to reduce fatigue in airline pilots: design of a randomised controlled trial

Background

A considerable percentage of flight crew reports to be fatigued regularly. This is partly caused by irregular and long working hours and the crossing of time zones. It has been shown that persistent fatigue can lead to health problems, impaired performance during work, and a decreased work-private life balance. It is hypothesized that an intervention consisting of tailored advice regarding exposure to daylight, optimising sleep, physical activity, and nutrition will lead to a reduction of fatigue in airline pilots compared to a control group, which receives a minimal intervention with standard available information.

Methods/design

The study population will consist of pilots of a large airline company. All pilots who posses a smartphone or tablet, and who are not on sick leave for more than four weeks at the moment of recruitment, will be eligible for participation.

In a two-armed randomised controlled trial, participants will be allocated to an intervention group that will receive the tailored advice to optimise exposure to daylight, sleep, physical activity and nutrition, and a control group that will receive standard available information. The intervention will be applied using a smartphone application and a website, and will be tailored on flight- and participant-specific characteristics. The primary outcome of the study is perceived fatigue. Secondary outcomes are need for recovery, duration and quality of sleep, dietary and physical activity behaviours, work-private life balance, general health, and sickness absence. A process evaluation will be conducted as well. Outcomes will be measured at baseline and at three and six months after baseline.

Discussion

This paper describes the development of an intervention for airline pilots, consisting of tailored advice (on exposure to daylight and sleep-, physical activity, and nutrition) applied into a smartphone application. Further, the paper describes the design of the randomised controlled trial evaluating the effect of the intervention on fatigue, health and sickness absence. If proven effective, the intervention can be applied as a new and practical tool in fatigue management. Results are expected at the end of 2013.

Trial registration

Netherlands Trial Register: NTR2722

Socioeconomic variations in access to smoking cessation interventions in UK primary care: insights using the Mosaic classification in a large dataset of primary care records

BACKGROUND

Smoking prevalence is particularly high amongst more deprived social groups. This cross-sectional study uses the Mosaic classification to explore socioeconomic variations in the delivery and/or uptake of cessation interventions in UK primary care.

METHODS

Data from 460,938 smokers registered in The Health Improvement Network between 2008 and 2010 were analysed. Logistic regression was used to calculate odds ratios for smokers having a record of receiving cessation advice or a prescription for a cessation medication during the study period by Townsend quintile and for each of the 11 Mosaic groups and 61 Mosaic types. Both of these measures are area-level indicators of deprivation. Profiles of Mosaic categories were used to suggest ways to target specific groups to increase the provision of cessation support.

RESULTS

Odds ratios for smokers having a record of advice or a prescription increased with increasing Townsend deprivation quintile. Similarly, smokers in more deprived Mosaic groups and types were more likely to have a documented cessation intervention. The odds of smokers receiving cessation advice if they have uncertain employment and live in social housing in deprived areas were 35% higher than the odds for successful professionals living in desirable areas (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.20-1.52; absolute risks 57.2% and 50.1% respectively), and those in low-income families living in estate-based social housing were 50% more likely to receive a prescription than these successful professionals (OR 1.50, 95% CI 1.31-1.73; absolute risks 19.5% and 13% respectively). Smokers who did not receive interventions were generally well educated, financially successful, married with no children, read broadsheet newspapers and had broadband internet access.

CONCLUSIONS

Wide socioeconomic variations exist in the delivery and/or uptake of smoking cessation interventions in UK primary care, though encouragingly the direction of this variation may help to reduce smoking prevalence-related socioeconomic inequalities in health. Groups with particularly low intervention rates may be best targeted through broadsheet media, the internet and perhaps workplace-based interventions in order to increase the delivery and uptake of effective quit support.

Promoting health and wellness in the workplace: a unique opportunity to establish primary and extended secondary cardiovascular risk reduction programs

Given the burden of cardiovascular disease (CVD), increasing the prevalence of healthy lifestyle choices is a global imperative. Currently, cardiac rehabilitation programs are a primary way that modifiable risk factors are addressed in the secondary prevention setting after a cardiovascular (CV) event/diagnosis. Even so, there is wide consensus that primary prevention of CVD is an effective and worthwhile pursuit. Moreover, continual engagement with individuals who have already been diagnosed as having CVD would be beneficial. Implementing health and wellness programs in the workplace allows for the opportunity to continually engage a group of individuals with the intent of effecting a positive and sustainable change in lifestyle choices. Current evidence indicates that health and wellness programs in the workplace provide numerous benefits with respect to altering CV risk factor profiles in apparently healthy individuals and in those at high risk for or already diagnosed as having CVD. This review presents the current body of evidence demonstrating the efficacy of worksite health and wellness programs and discusses key considerations for the development and implementation of such programs, whose primary intent is to reduce the incidence and prevalence of CVD and to prevent subsequent CV events. Supporting evidence for this review was obtained from PubMed, with no date limitations, using the following search terms: worksite health and wellness, employee health and wellness, employee health risk assessments, and return on investment. The choice of references to include in this review was based on study quality and relevance.

Pharmacological interventions for smoking cessation: an overview and network meta-analysis

BACKGROUND

Smoking is the leading preventable cause of illness and premature death worldwide. Some medications have been proven to help people to quit, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness.

OBJECTIVES

How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long-term abstinence (six months or longer)? How do the remaining treatments compare with placebo in achieving long-term abstinence? How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits?

METHODS

The overview is restricted to Cochrane reviews, all of which include randomised trials. Participants are usually adult smokers, but we exclude reviews of smoking cessation for pregnant women and in particular disease groups or specific settings. We cover nicotine replacement therapy (NRT), antidepressants (bupropion and nortriptyline), nicotine receptor partial agonists (varenicline and cytisine), anxiolytics, selective type 1 cannabinoid receptor antagonists (rimonabant), clonidine, lobeline, dianicline, mecamylamine, Nicobrevin, opioid antagonists, nicotine vaccines, and silver acetate. Our outcome for benefit is continuous or prolonged abstinence at least six months from the start of treatment. Our outcome for harms is the incidence of serious adverse events associated with each of the treatments. We searched the Cochrane Database of Systematic Reviews (CDSR) in The Cochrane Library, for any reviews with 'smoking' in the title, abstract or keyword fields. The last search was conducted in November 2012. We assessed methodological quality using a revised version of the AMSTAR scale. For NRT, bupropion and varenicline we conducted network meta-analyses, comparing each with the others and with placebo for benefit, and varenicline and bupropion for risks of serious adverse events.

MAIN RESULTS

We identified 12 treatment-specific reviews. The analyses covered 267 studies, involving 101,804 participants. Both NRT and bupropion were superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, and 1.82; 95% CredI 1.60 to 2.06 respectively). Varenicline increased the odds of quitting compared with placebo (OR 2.88; 95% CredI 2.40 to 3.47). Head-to-head comparisons between bupropion and NRT showed equal efficacy (OR 0.99; 95% CredI 0.86 to 1.13). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91), and to bupropion (OR 1.59; 95% CredI 1.29 to 1.96). Varenicline was more effective than nicotine patch (OR 1.51; 95% CredI 1.22 to 1.87), than nicotine gum (OR 1.72; 95% CredI 1.38 to 2.13), and than 'other' NRT (inhaler, spray, tablets, lozenges; OR 1.42; 95% CredI 1.12 to 1.79), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46). Cytisine (a nicotine receptor partial agonist) returned positive findings (risk ratio (RR) 3.98; 95% CI 2.01 to 7.87), without significant adverse events or SAEs. Across the 82 included and excluded bupropion trials, our estimate of six seizures in the bupropion arms versus none in the placebo arms was lower than the expected rate (1:1000), at about 1:1500. SAE meta-analysis of the bupropion studies demonstrated no excess of neuropsychiatric (RR 0.88; 95% CI 0.31 to 2.50) or cardiovascular events (RR 0.77; 95% CI 0.37 to 1.59). SAE meta-analysis of 14 varenicline trials found no difference between the varenicline and placebo arms (RR 1.06; 95% CI 0.72 to 1.55), and subgroup analyses detected no significant excess of neuropsychiatric events (RR 0.53; 95% CI 0.17 to 1.67), or of cardiac events (RR 1.26; 95% CI 0.62 to 2.56). Nortriptyline increased the chances of quitting (RR 2.03; 95% CI 1.48 to 2.78). Neither nortriptyline nor bupropion were shown to enhance the effect of NRT compared with NRT alone. Clonidine increased the chances of quitting (RR 1.63; 95% CI 1.22 to 2.18), but this was offset by a dose-dependent rise in adverse events. Mecamylamine in combination with NRT may increase the chances of quitting, but the current evidence is inconclusive. Other treatments failed to demonstrate a benefit compared with placebo. Nicotine vaccines are not yet licensed for use as an aid to smoking cessation or relapse prevention. Nicobrevin's UK license is now revoked, and the manufacturers of rimonabant, taranabant and dianicline are no longer supporting the development or testing of these treatments.

AUTHORS' CONCLUSIONS

NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use. Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT.

Predictors of success for smoking cessation at the workplace: a longitudinal study

BACKGROUND

The effectiveness of worksite interventions to reduce smoking is debatable.

OBJECTIVES

A comprehensive smoking cessation intervention was implemented in a community of more than 17,000 employees at three different health care companies. The primary endpoint was abstinence at 24 months (self-reported and confirmed by exhaled carbon monoxide ≤ 6 parts per million). Predictors of long-term abstinence were analysed by multivariable regression analysis.

METHODS

The study was designed as an investigator-initiated and investigator-driven, open, multicentre, cohort study; 887 smokers were enrolled in the programme. The intervention included intensive individual counselling as well as nicotine replacement and/or bupropion according to individual preferences. Re-interventions for relapse were offered during the 24-month follow-up.

RESULTS

The abstinence rate was 37% at 24 months and did not differ among the various medication groups (p > 0.05 for all). Predictors of successful cessation were higher age (odds ratio, OR 1.47, 95% confidence interval, CI 1.08-2.00, p < 0.01), breathlessness on exertion (OR 2.26, 95% CI 1.1-4.9, p = 0.03), and a higher educational level (OR 1.81, 95% CI 1.06-3.09, p = 0.03). Higher Fagerström (OR 0.76, 95% CI 0.59-0.97, p < 0.01) and craving scores (OR 0.75, 95% CI 0.63-0.89, p < 0.01), chronic sputum production (OR 0.52, 95% CI 0.31-0.87, p = 0.01) and use of antidepressants (OR 0.54, 95% CI 0.32-0.91, p = 0.02) were associated with ongoing smoking.

CONCLUSION

A comprehensive smoking cessation intervention at the workplace achieves high, stable, long-term abstinence rates. Elderly, well-educated employees with breathlessness on exertion have higher odds of quitting smoking. In contrast, those with high physical dependency and more intense craving, and those reporting use of antidepressant medication or sputum production have poorer chances to quit.

The contribution of office work to sedentary behaviour associated risk

BACKGROUND

Sedentary time has been found to be independently associated with poor health and mortality. Further, a greater proportion of the workforce is now employed in low activity occupations such as office work. To date, there is no research that specifically examines the contribution of sedentary work to overall sedentary exposure and thus risk. The purpose of the study was to determine the total exposure and exposure pattern for sedentary time, light activity and moderate/vigorous physical activity (MVPA) of office workers during work and non-work time.

METHODS

50 office workers from Perth, Australia wore an Actical (Phillips, Respironics) accelerometer during waking hours for 7 days (in 2008-2009). Participants recorded wear time, waking hours, work hours and daily activities in an activity diary. Time in activity levels (as percentage of wear time) during work and non-work time were analysed using paired t-tests and Pearson's correlations.

RESULTS

Sedentary time accounted for 81.8% of work hours (light activity 15.3% and MVPA 2.9%), which was significantly greater than sedentary time during non-work time (68.9% p < 0.001). Office workers experienced significantly more sustained sedentary time (bouts >30 minutes) and significantly less brief duration (0-10 minutes) light intensity activity during work hours compared to non-work time (p < 0.001). Further, office workers had fewer breaks in sedentary time during work hours compared to non-work time (p < 0.001).

CONCLUSIONS

Office work is characterised by sustained sedentary time and contributes significantly to overall sedentary exposure of office workers.

“Hike up yer skirt, and quit.” what motivates and supports smoking cessation in builders and renovators

Construction-related occupations have very high smoking prevalence rates and are an identified priority population for efforts to promote cessation. This study sought to identify the smoking cessation supports and services which best suited this workforce group, and to identify gaps in reach of preventive health services. We performed qualitative text analysis on pre-existing conversations about smoking cessation among workers in this sector. The material appeared on a discussion forum about residential construction from 1998 and 2011. Roughly 250 unique user names appeared in these discussions. The qualitative analysis addressed knowledge, motivation, environmental influences, and positive and negative experiences with supports for cessation. Self-identified smokers tended to want to quit and described little social value in smoking. Actual quit attempts were attributed to aging and tangible changes in health and fitness. Peer-to-peer social support for cessation was evident. Advice given was to avoid cigarettes and smokers, to focus on personal skills, personal commitment, and the benefits of cessation (beyond the harms from smoking). Many discussants had received medical support for cessation, but behavioural counselling services appeared underutilized. Our findings support efforts toward more complete bans on workplace smoking and increased promotion of available behavioural support services among dispersed blue-collar workers.

The use of financial incentives in promoting smoking cessation

OBJECTIVE

Cigarette smoking is the leading cause of preventable death in the United States and world. Despite the availability of numerous therapies for smoking cessation, additional efficacious interventions are greatly needed. We provide a narrative review of published studies evaluating financial incentives for smoking cessation and discuss the parameters important for ensuring the efficacy of incentive interventions for smoking cessation.

METHODS

Published studies that evaluated the impact of incentives to promote smoking cessation and included an appropriate control or comparison condition were identified and reviewed.

RESULTS

Incentives are efficacious for promoting smoking abstinence across the general population of smokers as well as substance abusers, adolescents, patients with pulmonary disease, patients with serious mental illness and other challenging subgroups. To develop and implement an effective incentive treatment for smoking, special attention should be paid to biochemical verification of smoking status, incentive magnitude and the schedule of incentive delivery.

CONCLUSION

Consistent with the extensive literature showing that incentives are effective in reducing illicit drug use, a large body of evidence supports their effectiveness in reducing smoking. Continued efforts are warranted to further develop and disseminate incentive-based treatments for smoking cessation across clinical settings and populations.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Tobacco use and impact of tobacco-free policy on university employees in an environment of high tobacco use and production

OBJECTIVE

To assess occupational tobacco use and the impact of a tobacco-free policy in the Central Appalachia, an environment characterized by high tobacco use and production.

METHODS

This study was an Internet-based survey conducted on 2,318 university employees. Descriptive, chi-square, and logistic regression statistics were performed. Unadjusted and adjusted odds ratios (AOR) with respective 95 % confidence intervals (CI) were reported.

RESULTS

The survey response rate was 50.8 %; of the respondents, 9.0 % were current smokers. Smoking prevalence among faculty, administrators/professionals, and clerical/support staff was 6.1, 8.1, and 13.1 %, respectively. While those respondents aged 30-39 years showed a significantly increased likelihood of being a current smoker (AOR 5.64, 95 % CI 1.31-9.26), knowledge that secondhand smoke is harmful (AOR 0.22, 95 % CI 0.07-0.70) and support for tobacco-free policy (AOR 0.11, 95 % CI 0.04-0.27) decreased the likelihood.

CONCLUSION

Low tobacco use among faculty and administrators confirmed the relationship between tobacco use and socio-economic status, even in a tobacco-producing environment. Disaggregation of tobacco use data assists the public health community in the efficient allocation of efforts and resources for cessation programs to reduce tobacco use in such environments.

Implementation of workplace-based smoking cessation support activities and smoking cessation among employees: the Finnish Public Sector Study

OBJECTIVES

We investigated the relationship between implementation of workplace smoking cessation support activities and employee smoking cessation.

METHODS

In 2 cohort studies, participants were 6179 Finnish public-sector employees who self-reported as smokers at baseline in 2004 (study 1) or 2008 (study 2) and responded to follow-up surveys in 2008 (study 1; n=3298; response rate = 71%) or 2010 (study 2; n=2881; response rate=83%). Supervisors' reports were used to assess workplace smoking cessation support activities. We conducted multilevel logistic regression analyses to examine changes in smoking status.

RESULTS

After adjustment for sociodemographic characteristics, number of cigarettes smoked per day, work unit size, shift work, type of job contract, health status, and health behaviors, baseline smokers whose supervisors reported that the employing agency had offered pharmacological treatments or financial incentives were more likely than those in workplaces that did not offer such support to have quit smoking. In general, associations were stronger among moderate or heavy smokers (≥ 10 cigarettes/day) than among light smokers (<10 cigarettes/day).

CONCLUSIONS

Cessation activities offered by employers may encourage smokers, particularly moderate or heavy smokers, to quit smoking.

Short and long term effects of a lifestyle intervention for construction workers at risk for cardiovascular disease: a randomized controlled trial

BACKGROUND

The prevalence of overweight and elevated cardiovascular disease (CVD) risk among workers in the construction industry is relatively high. Improving lifestyle lowers CVD risk and may have work-related benefits. The purpose of the study was to evaluate the effects on physical activity (PA), diet, and smoking of a lifestyle intervention consisting of individual counseling among male workers in the construction industry with an elevated risk of cardiovascular disease (CVD).

METHODS

In a randomized controlled trial including 816 male blue- and white-collar workers in the construction industry with an elevated risk of CVD, usual care was compared to a 6-month lifestyle intervention. The intervention consisted of individual counseling using motivational interviewing techniques, and was delivered by an occupational physician or occupational nurse. In three face to face and four telephone contacts, the participant's risk profile, personal determinants, and barriers for behavior change were discussed, and personal goals were set. Participants chose to aim at either diet and PA, or smoking. Data were collected at baseline and after six and 12 months, by means of a questionnaire. To analyse the data, linear and logistic regression analyses were performed.

RESULTS

The intervention had a statistically significant beneficial effect on snack intake (β-1.9, 95%CI -3.7; -0.02) and fruit intake (β 1.7, 95%CI 0.6; 2.9) at 6 months. The effect on snack intake was sustained until 12 months; 6 months after the intervention had ended (β -1.9, 95%CI -3.6; -0.2). The intervention effects on leisure time PA and metabolic equivalent-minutes were not statistically significant. The beneficial effect on smoking was statistically significant at 6 (OR smoking 0.3, 95%CI 0.1;0.7), but not at 12 months (OR 0.8, 95%CI 0.4; 1.6).

CONCLUSIONS

Beneficial effects on smoking, fruit, and snack intake can be achieved by an individual-based lifestyle intervention among male construction workers with an elevated risk of CVD. Future research should be done on strategies to improve leisure time PA and on determinants of maintenance of changed behavior. Considering the rising prevalence of unhealthy lifestyle and CVD, especially in the aging population, implementation of this intervention in the occupational health care setting is recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN60545588

Tabagismo: a percepção dos fumantes em um grupo de educação em saúde

Estudo qualitativo, que objetivou compreender o significado dos grupos antitabagismo desenvolvidos em uma unidade de Saúde da Família do município de Montes Claros, em Minas Gerais. Utilizou-se como referencial teórico-metodológico a pesquisa-ação. Os sujeitos foram usuários tabagistas que vivenciaram as sessões do grupo de educação em saúde. Os instrumentos para coleta de dados foram: observação não-participante, observação participante e entrevistas semiestruturadas. Os dados foram submetidos à técnica da análise do discurso com identificação de duas categorias: o significado do tabagismo e o significado dos grupos de apoio antitabagismo na percepção dos sujeitos participantes do grupo. Emergiram as ideias e os sentimentos dos fumantes, bem como a representatividade do cigarro para os sujeitos. O estudo demonstrou a relevância dos grupos de apoio, durante o processo de cessação do tabagismo, e a necessidade de melhor capacitação profissional e estruturação dos serviços para o enfrentamento do problema. Este estudo também se constituiu numa forma de divulgação do tratamento do tabagismo na rede pública de saúde e do seu impacto na população beneficiada, servindo de parâmetro e estímulo a outros cenários.

Non-smoking worksites in the residential construction sector: using an online forum to study perspectives and practices

Objectives

Blue-collar workers are a recognised priority for tobacco control. Construction workers have very high smoking rates and are difficult to study and reach with interventions promoting smoke-free workplaces and cessation. The objectives of this study were to explore the smoking-related social climate in the North American residential construction sector and to identify potential barriers and facilitators to creating smokefree worksites.

Methods

The data source used was a popular internet forum on home building. Participants included a broad and unselected population of employers, employees and freelance tradespersons working in residential construction. The forum archive contained 10 years of discourse on the subjects of smoking, workplace secondhand smoke and smoking restrictions on construction sites. Qualitative data analysis methods were used to describe major and minor discussion themes relevant to workplace smoking culture and policies in this sector.

Results

Participants described considerable tension between smoking and non-smoking tradespersons, but there was also much interpersonal support for cessation and support for non-smokers' rights. Employers and employees described efforts to make construction sites smoke free, and a movement towards preferential hiring of non-smoking tradespersons was discussed. Board participants wanted detailed scientific evidence on secondhand smoke exposure levels and risk thresholds, particularly in open-air workplaces.

Conclusions

Experience with success of smoking bans in other challenging workplaces can be applied to the construction sector. Potential movement of smokers out of the workforce represents a challenge for public health systems to ensure equitable access to cessation supports and services.

The effectiveness of interventions to change six health behaviours: a review of reviews

BACKGROUND

Several World Health Organisation reports over recent years have highlighted the high incidence of chronic diseases such as diabetes, coronary heart disease and cancer. Contributory factors include unhealthy diets, alcohol and tobacco use and sedentary lifestyles. This paper reports the findings of a review of reviews of behavioural change interventions to reduce unhealthy behaviours or promote healthy behaviours. We included six different health-related behaviours in the review: healthy eating, physical exercise, smoking, alcohol misuse, sexual risk taking (in young people) and illicit drug use. We excluded reviews which focussed on pharmacological treatments or those which required intensive treatments (e.g. for drug or alcohol dependency).

METHODS

The Cochrane Library, Database of Abstracts of Reviews of Effectiveness (DARE) and several Ovid databases were searched for systematic reviews of interventions for the six behaviours (updated search 2008). Two reviewers applied the inclusion criteria, extracted data and assessed the quality of the reviews. The results were discussed in a narrative synthesis.

RESULTS

We included 103 reviews published between 1995 and 2008. The focus of interventions varied, but those targeting specific individuals were generally designed to change an existing behaviour (e.g. cigarette smoking, alcohol misuse), whilst those aimed at the general population or groups such as school children were designed to promote positive behaviours (e.g. healthy eating). Almost 50% (n = 48) of the reviews focussed on smoking (either prevention or cessation). Interventions that were most effective across a range of health behaviours included physician advice or individual counselling, and workplace- and school-based activities. Mass media campaigns and legislative interventions also showed small to moderate effects in changing health behaviours.Generally, the evidence related to short-term effects rather than sustained/longer-term impact and there was a relative lack of evidence on how best to address inequalities.

CONCLUSIONS

Despite limitations of the review of reviews approach, it is encouraging that there are interventions that are effective in achieving behavioural change. Further emphasis in both primary studies and secondary analysis (e.g. systematic reviews) should be placed on assessing the differential effectiveness of interventions across different population subgroups to ensure that health inequalities are addressed.

Tobacco use cessation and weight management among motor freight workers: results of the gear up for health study

OBJECTIVES

To present the results of a study of a worksite-based intervention to promote tobacco use cessation and improve weight management among motor freight workers.

METHODS

This study used a pre-test/post-test, non-randomized design to assess the effectiveness of a four-month intervention that addressed the social context of the work setting. We evaluated 7-day tobacco quit prevalence among baseline tobacco users, and successful weight management, defined as no weight gain in workers with BMI <25 at baseline and any weight loss among overweight and obese workers.

RESULTS

At baseline, 40% were current tobacco users, and 88% had a BMI of 25 or greater. Of 542 workers invited to participate, 227 agreed to participate and received at least the first telephone call (42%). Ten-month post-baseline, baseline tobacco users who participated in the intervention were more likely to have quit using tobacco than non-participants: 23.8% vs. 9.1% (p = 0.02). There was no significant improvement in weight management.

CONCLUSIONS

Incorporating work experiences and job conditions into messages of health behavior change resulted in significant tobacco use cessation among participating motor freight workers.

Postgraduate education for doctors in smoking cessation

INTRODUCTION AND AIMS

Smoking cessation advice from doctors helps improve quit rates but the opportunity to provide this advice is often missed. Postgraduate education is one strategy to improve the amount and quality of cessation support provided. This paper describes a sample of postgraduate education programs for doctors in smoking cessation and suggests future directions to improve reach and quality.

DESIGN AND METHODS

Survey of key informants identified through tobacco control listserves supplemented by a review of the published literature on education programs since 2000. Programs and publications from Europe were not included as these are covered in another paper in this Special Issue.

RESULTS

Responses were received from only 21 key informants from eight countries. Two further training programs were identified from the literature review. The following components were present in the majority of programs: 5 As (Ask, Advise, Assess, Assist and Arrange) approach (72%), stage of change (64%), motivational interviewing (72%), pharmacotherapies (84%). Reference to clinical practice guidelines was very common (84%). The most common model of delivery of training was face to face. Lack of interest from doctors and lack of funding were identified as the main barriers to uptake and sustainability of training programs.

DISCUSSION AND CONCLUSIONS

Identifying programs proved difficult and only a limited number were identified by the methods used. There was a high level of consistency in program content and a strong link to clinical practice guidelines. Key informants identified limited reach into the medical profession as an important issue. New approaches are needed to expand the availability and uptake of postgraduate education in smoking cessation

Worksite interventions for preventing physical deterioration among employees in job-groups with high physical work demands: background, design and conceptual model of FINALE

BACKGROUND

A mismatch between individual physical capacities and physical work demands enhance the risk for musculoskeletal disorders, poor work ability and sickness absence, termed physical deterioration. However, effective intervention strategies for preventing physical deterioration in job groups with high physical demands remains to be established. This paper describes the background, design and conceptual model of the FINALE programme, a framework for health promoting interventions at 4 Danish job groups (i.e. cleaners, health-care workers, construction workers and industrial workers) characterized by high physical work demands, musculoskeletal disorders, poor work ability and sickness absence.

METHODS/DESIGN

A novel approach of the FINALE programme is that the interventions, i.e. 3 randomized controlled trials (RCT) and 1 exploratory case-control study are tailored to the physical work demands, physical capacities and health profile of workers in each job-group. The RCT among cleaners, characterized by repetitive work tasks and musculoskeletal disorders, aims at making the cleaners less susceptible to musculoskeletal disorders by physical coordination training or cognitive behavioral theory based training (CBTr). Because health-care workers are reported to have high prevalence of overweight and heavy lifts, the aim of the RCT is long-term weight-loss by combined physical exercise training, CBTr and diet. Construction work, characterized by heavy lifting, pushing and pulling, the RCT aims at improving physical capacity and promoting musculoskeletal and cardiovascular health. At the industrial work-place characterized by repetitive work tasks, the intervention aims at reducing physical exertion and musculoskeletal disorders by combined physical exercise training, CBTr and participatory ergonomics. The overall aim of the FINALE programme is to improve the safety margin between individual resources (i.e. physical capacities, and cognitive and behavioral skills) and physical work demands, and thereby reduce the physical deterioration in a long term perspective by interventions tailored for each respective job-group.

DISCUSSION

The FINALE programme has the potential to provide evidence-based knowledge of significant importance for public health policy and health promotion strategies for employees at high risk for physical deterioration.

TRIAL REGISTRATIONS

ISRCTN96241850, NCT01015716 and NCT01007669.