Worksite smoking cessation initiatives: Review and recommendations

AddicfiveBehaviors, Vol. 7, pp. I-16, 1982 Printed in the US.4. All rights reserved.

WORKSITE

0306~4603/82/010001-16$03.00/O Copyright c 1982 Pergamon Press Ltd

SMOKING

REVIEW

AND

CESSATION

INITIATIVES:

RECOMMENDATIONS

CAROLE

S. ORLEANS*

Duke University

Medical Center

and ROBERT

H. SHIPLEY

Duke University Medical Center and Durham VA Medical Center

Abstract-Offering health lifestyle change assistance in the workplace represents a major challenge for behavioral scientists and behavior therapists in the 1980s. Business and industry are showing special interest in employee smoking cessation. This paper reviews a wide range of worksite smoking cessation activities and related research. Six types of intervention are discussed: educational campaigns: policies restricting workplace smoking: self-help programs; physical examination and physician advice: incentive programs; and actual smoking cessation services. Existing research is critically reviewed. Practical recommendations for improving and systematically evaluating worksite quit smoking initiatives are presented.

From a behavioral science perspective. worksite smoking cessation programs have a clearly vital role to play in the national anti-smoking campaign. Worksite programs have a unique potential to reach the 50% of America’s blue-collar workers who both smoke (Gallup, 1974; (Houpt, Orleans, George, & Brodie, 1979). Sterling& Weinkam, 1976) and underutilize existing smoking cessation services. Also, workplace social supports can provide nonsmoking norms and reinforcers to help maintain lasting change in smoking behavior (McDill, 1975). Ad hoc group smoking cessation treatments often try to simulate supportive networks like those that exist naturally in the workplace (e.g., Hamilton & Bornstein. 1979). From a different perspective, business and industry have strong humanitarian, legal and economic motives to establish worksite smoking control programs. Anti-smoking programs represent a major contribution to the health and productivity of valued employees. Helping the smoker quit or reduce smoking is an important preventive health initiative. Also. industries are increasingly concerned to protect the health of nonsmokers, with recent surveys showing 150/c-19% of American businesses reporting incidents of nonsmoking employees claiming illnesses related to on-the-job exposure to second-hand smoke (Dartnell. 1977. NICSH. Note I). In some cases, nonsmoking employees have resorted to legal action (Shimp, 1978; USDHEW. 1977). In a landmark case, Donna Shimp. a New Jersey Bell Telephone service representative who was allergic to tobacco smoke, successfully sued her employer for rights to work in a smoke-free environment. The New Jersey Superior Court ruling argued that second-hand smoke posed a clear danger to the health of smoking and nonsmoking employees, and pointed out that a company prohibiting smoking near sensitive equipment, as Bell Telephone did, owed at least as much respect to *Requesrs for reprints should be addressed to Carole S. Orleans. Box 3837. Duke University Durham. North Carolina 27710.

Medical Center.

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S. ORLEANS

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H. SHIPLEY

its employees. The movement to protect nonsmokers’ rights in the workplace will pick up momentum from new findings that healthy nonsmokers exposed to tobacco smoke in the workplace show small airways dysfunction similar to that of light smokers (White & Froeb, 1980). Finally, the profit motive makes smoking cessation attractive. Smoking-related medical care, absenteeism. accidents, and lost work output total an estimated $27.5 billion annually (Lute & Schweitzer, 1978). Costs of decreased on-the-job productivity (Shimp, 1978), accident costs (Glantz & Rosenberg, Note 2), and housekeeping expenses (Kelliher, 1978) add to the financial burdens of smoking-related illnesses. Although fewer than one percent of U.S. Businesses have calculated costs related to employee smoking (NICSH, Note I), calculations which have been done show substantial, even staggering, costs to some individual employers (e.g., Glantz & Rosenberg, Note 2; Kelliher, 1978). Given these varied and powerful rationales, it is little wonder that businesses are showing increased interest in workplace anti-smoking programs (Dartnell. 1977; NICSH, Note 1). A recent (1978-79) survey conducted by the National Interagency Council on Smoking and Health (NISCH, Note 1) shows that almost half of a representative sample of U.S. businesses have a policy restricting or prohibiting workplace smoking, that lS’%offer some form of anti-smoking education or promotion program, and that 33% want to expand or develop a smoking cessation program. With 70% of the businesses wishing to develop or expand services expressing an interest in outside assistance, behavioral scientists and behavior therapists will be called on increasingly for help. This paper reviews existing surveys and research evaluating workplace smoking cessation activities to guide the behavioral scientist. Workplace programs are arranged and discussed hierarchically beginning with anti-smoking educational campaigns, including policies limiting or banning smoking, and ending with actual smoking cessation services. Different types of workplace programs are briefly described and controlled or objective research evaluating them is reviewed. Resources to aid the behavioral science consultant are indicated along with practical recommendations for designing and evaluating worksite programs. OVERVIEW

OF

WORKSITE

PROGRAMS

Educational campaigns

Anti-smoking educational campaigns usually teach employees about the risks of smoking and the benefits of quitting. They have ranged from disseminating educational materials to extensive lectures by health professionals (NICSH, Note 1). For instance, the Texas Division of Dow Chemical Company prefaced an incentive programs with an intensive educational campaign: American Cancer Society materials were widely disseminated, anti-smoking films were shown to the vast majority of employees and many family members, and regular safety meetings incorporated teaching about the health hazards of smoking. Dow carefully monitored the impact of these efforts. finding, for instance, that 97% of 7,200 affected employees and many of their family members viewed one or more anti-smoking films (Dow Chemical Company, 1976). Medically- and occupationally-highrisk groups (e.g., asbestos workers. uranium miners, coronary heart disease-prone employees) often receive specialized health education amplifying their unique health risks. For instance, the Johns-Mansville Corporation distributed literature on the smoking-asbestoslung cancer relationship to all supervisors and employees at its asbestos-using sites and conducted small group presentations and discussions of this literature (Cooper, 1978; Ellis, 1978a). Workplace health education programs have not been systematically evaluated. However. related behavioral science research has shown that health risk education typically improves knowledge and motivation to change without producing actual or lasting

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behavior change (e.g.. Houpt et al.. 1979; Roberts, 1975: Thompson, 1978). Moreover. health risk education may not always be appropriate or even helpful. Smokers who have already heard multiple warnings about smoking and are already highly motivated to quit may be immune to further communications. Or, worse, they may be defiant or reactive in the face of repeated warnings causing a boomerang or “communication innoculation effect” (Green & Green, 1977). As part of needed studies of educational efforts at the worksite, measures of knowledge, attitudes and motivation regarding smoking should accompany measures of smoking behavior. Comprehensive measures could help management design useful educational campaigns and evaluate their diverse outcomes. In the absence of guiding research. we must look to related findings in designing effective educational approaches. One promising approach involves giving smokers feedback of the immediate, reversible effects of smoking. This approach has had a marked deterrent value in helping adolescents avoid becoming regular smokers (Evans, Rozelle, Mittlemark, Hansen, Bane, & Havis, 1978). Feedback of carbon monoxide levels along with a brief explanation of the harmful effects of carbon monoxide elevations is one “biofeedback” method that seems especially practical at the worksite. Portable units for analyzing the CO content of expired alveolar air offer a noninvasive measure (Hughes, Frederiksen, & Frazier, 1978). This form of biofeedback has been successfully applied to motivating employees to enroll in worksite smoking cessation activities (e.g.. Dickey, Note 3) and seems especially appropriate for smokers immune to, or possibly overly fearful about, warnings and advice concerning future chronic smoking-related illness. Other research suggests that educational campaigns could benefit from a focus on the benefits of cessation, downplaying the harms of continuing to smoke. An expectation of quitting benefits, and a motivation to improve one’s health, rather than a fear of smoking harms, seem to predict success in quitting (e.g., Eisinger, 1971, 1972; Mausner, 1973). Useful summaries of the health benefits of the smoking cessation are offered in Houpt et al. (1979) and Schuman (1971). Finally, educational campaigns could focus on the effects of passive smoking and address issues of nonsmokers’ rights and their tactful enforcement in the workplace. Recently, Shor and Williams (1978, 1979) documented that nonsmokers frequently experienced adverse physiological and psychological reactions to second-hand smoke, but often hid their true feelings and failed to request changes in smokers’ behavior. Assertiveness training for nonsmokers (e.g., Pachman & Frederiksen, 1979) could assist reticent nonsmokers to defend their rights. Action on Smoking and Health (ASH), a non-profit nonsmokers* rights group based in Washington, DC., provides useful reference materials on passive smoking (ASH, Note 4). Other materials are described by Shimp, Blumrosen. and Finifter (1976). Worksite smoking restrictions Worksite smoking restrictions are the most common anti-smoking step taken by U.S. businesses with the recent NICSH (Note 1) showing that about 50% of companies have adopted restrictive smoking policies. At a minimum, restrictions involve limiting smoking to designated areas with greater restrictions in blue-collar work areas consistent with safety and health concerns. Some employees have taken the extreme measure of totally banning smoking. For instance, the Alexandria, Virginia Fire Department adopted a no-smoking policy because smoking raises the normal occupational risks of smoke exposure, and because Virginia State law requires duty-disability support for any firefighter developing a smoke-related illness but free of respiratory and coronary problems when hired (Robyn, Note 5). Likewise, Johns-Manville prohibited smoking in all its asbestos-using sites because asbestos workers who smoke have 92 times the normal risk of lung cancer

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S. ORLEANS

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H. SHIPLEY

(Cooper. 1978: Ellis, 1978a). In both instances, bans extend to prospective employees and require written no-smoking pledges. Many resources offer guidelines for worksite smoking restrictions (American Cancer Society. 1978; ASH. Note 6). Commonly, they suggest prohibiting smoking in small enclosed areas (e.g., elevators, shuttle vehicles, etc.), medical care facilities and meeting rooms. and establishing nonsmoking areas in dining, recreational and common facilities on the basis of actual usage and conforming to state laws and regulations. The Department of Health. Education and Welfare and Center for Disease Control publish an annual summary of bills and resolutions on smoking restrictions introduced to state legislatures during the previous year, including those passed into law (USDHEW, 1979). Shimp et al. (1976) offer more concrete guidelines, and include references to model workplace restrictions. The Occupational Safety and Health Administration should be consulted to determine that workplace standards conform to established workplace exposure standards. To date. evaulations of worksite restrictions and smoking bans have been limited to surveys of employee opinion. For example. one nationwide survey showed that 757~ of all adult respondents. and 70% of smokers, felt that management should have the right to restrict smoking. Over two-thirds of those who approved restrictions said management should have this right whether or not smoking represented a safety hazard (USPHS. 1976). As a counterpoint, Dartnell’s (1977) survey found that 13% of responding companies reported that some workers had complained about unfair policies violating their rights fo smoke. (A slightly greater number, 15% reported that some of their nonsmoking employees had complained of smoking-related illness). No evaluations of workplace restrictions have, to our knowledge, collected data concerning the effects of workplace smoking restrictions on smoking attitudes and behavior on and off the job, employee morale and smoker-nonsmoker relationships. Consistent with goals to provide support for nonsmoking, restrictive policies should be acceptable to smokers and nonsmokers. Recently, questionnaires have been developed to survey smokers and nonsmokers about smoking policies (Shor & Williams, 1978. 1979). Preliminary results have been surprising; smokers generally ignore nonsmoking signs. responding more favorably to polite requests to refrain from smoking. Unfortunately nonsmokers are frequently inhibited from making such requests because they fear being seen as “oddballs, spoil sports. or troublemakers” (Shor & Williams, 1978). These survey instruments could be used to help management avoid smoking restrictions that cause unnecessary friction between smokers and nonsmokers. There are important ethical issues to consider when implementing any smokmg cessatron program. but particularly coercive programs like absolute bans. Robyn (Note 5) reasons that such a policy is most equitable and economically efficient in industries where smoking interacts synergistically with other occupational hazards. After a helpful analysis. she concludes that private employers are within their legal rights in refusing to hire smokers especially in occupations where the employee health risks are very great. and where fellow employees are taxpayers who must bear the burden of smoking-related illness or disability. The employee is best served even in this instance when she he is given access to effective quitting methods. Union opposition to the Johns-Manville ban emphasized that smoking and other stress-related lifestyle risks are adaptations to alientating workplace conditions (Ellis. 1978b). Instituting workplace smoking prohibitions should not detract from any other efforts to assure employees a safe. positive work environment.

Survevs have found that. cost aside. most smokers prefer self-help methods (e.g.. books. printed instructions. TV clinics) over face-to-face quit-smoking treatments (Gallup. 1971:

Workslle

smoking

cessation

5

Schwartz & Dubitzsky. 1967). In fact. an estimated 95% of America’s 32.6 million exsmokers have quit on their own (Horn. 1978). Since one-year quit rates for self-guided quit attempts are only 16-207~ (e.g., Guilford. 1968: Horn, 1978; Moss, 1979). smokers using self-help methods might profit from materials and programs to assist them. Workpiace self-help programs are thus potentially popular and cost-effective. Over half of the 15% of the U.S. businesses offering employee quit smoking programs distribute “how to quit” materials-mainly those developed by the voluntary health organizations (NlCSH. Note 1). None of the workplace programs using these and similar materials have been objectively evaluated (e.g. Dow. 1976; Ellis. 1978b). In the absence of such evaluations. we can only extrapolate from related findings. The few behavioral quitsmoking manuals which have been evaluated have shown modest success (e.g., Conway, 1977; Glasgow. 1978). Self-help programs offered through the m il. through prerecorded phone messages or via audiotaped instructions have also been prib mising (Dubren, 1977, 1978; Jeffrey, Danaher, Killen, Kinnier, & Farquahr, Note 7). Televised and videotaped quit smoking clinics, which could be easily adapted to the worksite have received only preliminary evaluation (Dubren. 1977; Shewchuk, 1976; Best, Note 8). But, one variant of the broadcast quit clinic that looks especially promising seems particularly suited to workplace propams. It involves using pretaped presentations by professionals amplified by lay leaders in a group setting (McAlister. 1978). Behavioral scientists have much to contribute in designing and evaluating self-help workplace programs given that so little .is known. Many questions need study. For instance, it is likely that the most effective self-help method would incorporate the most effective treatment procedures (e.g., aversive smoking and behavioral self-control procedures). It may be that smokers who use self-help programs are a special subset of all smokers wishing to quit on their own. Defining this population could help industries target and develop self-help programs with wide appeal in their worksite. Also, outside aids could

be selected to best enhance a strong sense of self-efficacy, .expectations for a positive outcome. self-reinforcement practices and the use of a generic problem-solving approach since these characteristics tend to distinguish successful unaided quitters (e.g., Perri, Richards, & Schulthuis, 1977; Rozensky & Bellak. 1974: DiClemente, Note 9). Since many self-help methods are associated with high dropout rates and low relative success rates, self-help programs might succeed particularly well at the worksite with corporate incentives and social support to help motiviate and sustain self-guided quitting. Physical examination and physician advice Physical examination and individualized risk assessment and health education constitute the next most intensive level of worksite intervention (Ellis. 1978a; lnsell & Chadwick, 1977). Because these interventions require professional input and expensive examination procedures, they are frequently reserved for high-risk groups. Fully one-third of the companies surveyed by the NJCSH (Note 1) that offered any smoking control program, offered counseling by physicians on the staff and/or counseling from outside health professionals. Preliminary objective evaluations suggest that such counseling has substantial impact. At Varian Corporation in Palo Alto, California, high CHD-risk subjects were selected from men,aged 35 to 55 for further on-site examinations and individual physician advice. Twelve employees were randomly designated to receive physician advice alone, and were compared with 24 employees randomly designated to receive either additional health counseling or additional behavioral treatment (Meyer & Henderson, 1974). In one 20minute consultation. an outside physician summarized the individual’s risks of cardiovascular disease and prescribed weight loss. smoking cessation. increased physical activity

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S. ORLEAhS

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H. SHIPLEY

and/or dietary changes. This procedure closely resembles risk profiling and the Health Harzard Appraisal and advice used by large federal agencies and corporations (e.g., Robbins & Hall, 1970). After six months, 15% of employees receiving only physician advice had quit smoking. This quit rate did not differ significantly from quit rates among employees who went on to receive extended health counseling or behavioral treatment for lifestyle change, probably because additional treatment did not offer training in effective self-control or quitting methods. Richmond (1977) reported similar results for annual onsite physical examinations for middle-aged management personnel of Cummins Engine Company in Columbus, Ohio. Over a fifteen-year period, 98% of eligible employees took advantage of an annual health screen in which a physician discussed the personal risks of smoking and strongly advised cessation. About 20% of the 543 smokers participating in the health screen claimed to have been persuaded to cease smoking entirely for at least a year. Fifteen of these 118 smokers resumed smoking after a year or more of abstinence, dropping the long-term success rate to a still substantial 19%. Rates of CHD morbidity and mortality favored ex-smokers over current smokers. Related studies examining physician advice for at-risk employees seen in the medical sector show that brief physician feedback and counseling significantly boost quitting rates (Rose & Hamilton, 1978). Physician advice and personalized risk assessment represent powerful intervention tactics. Preliminary data suggest that the long-term quit rates for workplace advice are similar to those of more intensive treatment procedures (e.g., quit clinics)-a remarkable result because the samples, include all smokers. rather than just smokers motivated for treatment. Controlled experimental research is now needed to replicate these long-term results with a wider range of employee populations and to examine the impact of population and setting variables on outcomes. For example, available data suggest that physician advice is strongest when delivered in the context of personal health care, in faceto-face interactions, when tied to knowledge of personal vulnerability for a serious smoking-related illness, and with follow-up attention (e.g., Rose & Hamilton, 1978; Russell, Wilson, Taylor, & Baker, 1979). Twenty to thirty percent one-year quit rates are common for smokers who know themselves “at risk” for coronary heart disease, and for smokers with existing cardiorespiratory illnesses: 50-60% one-year quit rate characterize post-MI smokers advised to quit (Lichtenstein & Danaher, 1978; Orleans, 1980). On the other hand. for predominantly healthy smokers. quit-smoking advice generally produces 5-8% one-year quit rates (e.g.. Russell et al., 1979: Shipley & Orleans, Note 10). The better results from the workplace programs described above may be due to the higher socioeconomic status and health motivation of smokers in the management occupations studied. interactions of outcomes with these factors should be explored. Low-risk smokers in general might profit from risk education which is not diseaseoriented. As noted in discussing educational campaigns. feedback of CO levels, along with education about CO and health. constitutes a promising cost-effective method. For instance. Dickey (Note 3) employing a carbon monoxide analyzer to screen 662 employees as part of a worksite health improvement program reported a 17% sign-up rate for on-site quit smoking services. This rate compared very favorably to the usual 1OCcenlistment. National surveys have shown American physicians reluctant to advise their healthy patients not to smoke because they doubt the value of this advice. and are skeptical about any treatment offering much help to smokers (Green & Horn. 1968; USPHS. 1976). Helping worksite health professionals set reasonable goals for their interventions might counteract this pessimism. Likewise. intervention guidelines and materials developed expressly for primary care physicians could be used at the workplace. including the “Helping Smokers Quit Kit” developed and distributed by the National Cancer lnstitute

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and currently being evaluated (Bratic & Ellis. Note I 1). Other guidelines are also available (e.g.. Lichtenstein & Danaher. 1979; Robbins & Hall, 1970; Shipley & Orleans. Note 10. Research into worksite physician intervention would be greatly improved by studies using experimental research designs and examining subject-treatment interactions. and by incorporating physiological measures that could be easiiy added to examination procedures to verify smokers’ self-report and furnish health risk data (Vogt, Selvin, Widdowson, & Hulley, 1977). Only one large-scale investigation (Rose & Hamilton, 1978) has employed measures of general physical functioning, total mortality, and sickness-related work absence, finding improvement in general functioning, and reductions in mortality and absence rates for advised versus nonadvised subjects. Incentive program

From 1% to 3% of businesses have offered incentives to help their employees kick the smoking habit (Dartnell, 1977; NICSH, Note 1). A variety of such programs are described in an “Employer’s Kit” compiled by Action for Smoking and Health (ASH, Note 8). Most offer monetary rewards for quitting, avoiding verification of self-report or penalties for smoking relapse. Few companies extend reward contingencies to nonsmokers and never.smokers. Examples selected below to illustrate typical programs were taken from the “Employer’s Kit” (ASH, Note 8) and a related report (Kelliher, 1978). The Texas Division of Dow Chemical Company pioneered on-site incentives for nonsmokers, allotting quitters raffle tickets for each month they remained off cigarettes (Dow, 1976). Nonsmoking employees who recruited quitters into its program were also allotted tickets for a year-end raffle of an outdoor motor boat. Following this incentive program (and previous health education campaigns). 24Ycof the Division’s 1638 smokers enrolled as pledges in the program during its first 4 months (meaning they stopped smoking for some period of time), with only 3% of enrollees backsliding during this 4month recruitment period. Unfortunately, followup data are not available. lntermatic, Inc. in Spring Grove, Illinois, opened an “I Quit Smoking” window covering bets up to $100 from employees who bet they could quit. The company doubled their bets if they succeeded, and added additional bonuses. The Austad Company in Sioux Falls, South Dakota and Cybertek Computer Products in Los Angeles, California offer cash bonuses of $100 and $500, respectively, to employees who quit for a year. Speedcall Corporation in Hayward, California and Leslie Manufacturing and Supply Company in Minneapolis offer ex-smokers $7 per week, the estimated cost of two-pack-a-day habit. Speedcall offered an identical bonus to nonsmokers. Speedcall’s president who employed 24 smokers prior to the incentive program, reported a 54% quit rate after bonuses were introduced (Kelliher, 1978). Only one incentive program has been objectively evaluated by outside consultants (Rosen & Lichtenstein, 1977). Sixteen smokers and 15 nonsmokers of the EugeneSpringfield Ambulance Service in Eugene, Oregon were offered $5 per month for not smoking at work, the year’s savings to be matched in Christmas bonuses. All but four employees volunteered, agreeing that violation of the nonsmoking policy by any one employee would result in all employees losing that month’s bonuses. Two months after the program was initiated, 59% of smokers stated they were not smoking at work. Even the four nonparticipating smokers reported reduced rates. At the end of one year, 33%, of participating smokers and 25% of all smokers claimed abstinence at work, reporting no increase in smoking outside of work. Participants rated their work performance and employees’ friendliness as improving, with the exception that group penalties for individual infractions of the no-smoking rule led to friction between employees.

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Without controlled studies of worksite nonsmoking incentives. we must look to related research showing that positive reinforcement (tangible or social) for nonsmoking used alone is generally less effective than other behavioral cessation techniques, but is valuable as a treatment adjunct (e.g., Bernstein& McAlister, 1976; Brockway, Kleinmann. Edelson, & Gruenewald, 1977; Halimton & Bornstein, 1979; Lando, 1976). Workplace nonsmoking incentives may not produce high quit rates, but might raise motivation to quit and rally social support for quitting efforts. Incentives represent an especially attractive vehicle for industry to exploit its unique therapeutic resource-potentially strong social supports for nonsmoking. In order to instigate the highest levels of workplace social support, incentives ought to reward nonsmoking by all employees, not just new exsmokers, using a pledge system like Dow’s or spreading nonsmoking profits to all employees. Adding family benefits could strengthen outside supports for quitting. Likewise, group penalties for individual infractions which can undermine morale and support (Rosen & Lichtenstein, 1977) should be avoided. Expecting incentives alone to produce high abstinence levels is inappropriate. Corporations offering incentives may realize the greatest return on this investment if they also provide access to effective quitting methods-even if only through referral to treatments available outside the workplace. Future studies of incentive programs should definitely use physiological measures to verify self-report and monitor smokers’ health status, since incentives more than other interventions may cause smokers to report more success than they achieve. Also, since smokers who don’t smoke at work may compensate by smoking more in other settings, noninvasive physiological measures, like alveolar CO, that can assess the health effects of incentive-related changes in employees’ smoking habits are important (e.g., Hughes et al., 1978). Needed controlled evaluations should also examine participation and drop out rates, long-term outcomes, effects on employees who do not enroll (smokers and nonsmokers). and program cost-effectiveness. Given industry’s profit-motives for cessation programs, it is remarkable that so few businesses have calculated smoking-related costs (NICSH, Note I), or determined the cost-effectiveness of incentive programs. Finally, since incentives may boost motivation to quit and support for nonsmoking, these variables should be monitored along with behavior change in any program evaluation. Smoking

cessation services

Many industries offer quit-smoking programs some paid for in part or in full by management (ASH. Note 6; NICSH, Note I). Programs vary greatly. The NICSH (Note 1) survey found that 23% of companies with smoking control programs offered singlesession clinics, and 32% offered multi-session clinics. The ASH (Note 6) “Employers’ Kit” describes five different corporate smoking cessation programs. Most companies sponsor onsite quit-clinics organized by outside commercial or noncommercial agencies. Danaher (1980) describes two businesses employing outside consultants (Campbell Soup, Camden. N.J. and the Boeing Aircraft Company) and one industry, Ford Motor Company, using outside consultants to organize in-house smoking cessation services through its Corporate Health Education Program. However, only five published reports evaluate worksite smoking cessation programs. Meyer and Henderson (1974) studied a worksite cardiac risk-reduction program conducted at Varian Corporation in Palo Alto, California. As described earlier, 36 middleaged male employees judged at high-risk for coronary heart disease were randomly designated to receive physician advice alone. or with either extended individual health counseling or a group behavior modification treatment. Extended health counseling recapitulated physician advice without suggesting behavior change strategies and involved two and one-half hours of contact over I1 weeks. Group behavioral smoking cessation

Work\ite

smoktnp cessation

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techniques offered over an 1l-week period included self-monitoring with relatively ineffective gradual cutdown and stimulus control procedures. End-of-treatment results favored behavioral group treatment. but group differences disappeared by a three-month followup. At a three-month follow-up. IS&. 10% and 97’ of participants were abstinent following physician advice. extended health counseling and behavior modification, respectively. Two studies report on SmokEnders worksite clinics. SmokEnders, the largest proprietary program offering on-site clinics. combines nonaversive smoking control methods (e.g., cut-down. find substitutes) with group encouragement and support. and employs many techniques to instill self-mastery motivation and reinforce success expectations (Rogers, 1977). A “buddy system” is set up within each worksite to capitalize on existing social support networks. but no formal maintenance program is introduced (Schwartz & Rider, 1978). Kanzler. Zeidenberg. and Jaffe (1976) conducted an independent study of SmokEnders’ corporate program. In a staff poll at the New York State Psychiatric Institute, where 42% of employees smoked, 48% of smokers said they would be willing to attend a stop smoking clinic. and 18% said they would be willing to pay a fee-most suggesting $5 a week. However, despite wide publicity only 4% actually enrolled in a clinic costing only $6.00 per session. To increase group size. members of smokers’ families were included. Participants were mostly female white-collar workers with several years of college education who smoked over a pack a day. However, in comparison with SmokEnders national client sample, these smokers had smoked less and for fewer years than national participants. The dropout rate of participants who actually began the program was quite low-seven percent. Including these dropouts as failures, 67% of the participants were abstinent at the end of the clinic, This figure is very close to the 70% national quit-rate claimed by SmokEnders (Kanzler, Zeidenberg, & Jaffe. 1976). Initial abstinence rates were verified by measuring plasma cotinine, a nicotine metabolite (Zeidenberg. Jaffe, Kanzler, Levitt, Langone. & Vunakis, 1977). At six months. the abstinence rate had fallen to 437~ levelling at one year to 40%. Unfortunately, no physiological measures were repeated at follow-up contacts. Replicating these long-term results with a more representative employee sample and with verification of self-report would establish SmokEnders as a relatively effective program. Similar preliminary results have been reported by Johns-Manville which launched a multi-pronged anti-smoking campaign at 14 of its asbestos-using sites. Seven thousand employees, approximately 507~ of whom were smokers, were involved in the JohnsManville effort. An educational campaign was followed by on-site SmokEnders clinics and absolute worksite smoking bans. Quit dates of the SmokEnders programs were arranged to coincide with the first days of smoking bans. Johns-Manville paid half of the enrollment fee. with the remainder reimbursed to employees who attended all sessions and were abstinent through the six-month follow-up (Cooper, 1978). Management reports show that only 15 to 20% of employees participated in the quit-clinics overall (Sell. Note 12). In one plant, only 14 of 125 smokers enrolled (Robyn. Note 5). The dropout rate is not currently known. According to management preliminary data from II plants involving approximately 5200 employees suggest a 757~ end-of-treatment abstinence rate, but no objective reports have been published (Sell, Note 12). A fourth study conducted at Bell Laboratories in Murray Hill, New Jersey examined videotaped smoking clinic offered to 87 volunteers in five consective clinics (Bauer, 1978). On-site leadership was provided by a briefly trained employee. Each clinic consisted of five consecutive daily sessions, with one hour spent viewing a professional’s videotaped review of smoking health hazards and quitting instructions. followed by a half-hour of group

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discussion. A “buddy system” was used but no maintenance sessions were offered. End of treatment abstinence, including dropouts, averaged over 83%. The abstinence rate dropped to 36% at three months and to 28% at six months. Finally, Danaher (1980) has reported preliminary results for Ford Motor Company’s cardiovascular risk-reduction programs. Smokers formed self-help groups based on shared interests in regular-paced aversive smoking plus self-control training (n = 26. six groups). abrupt quitting (n = 22, four groups) and/ or gradual quitting (n = 10, four groups) each using contingency contracting and self-control training. Group members selected leaders who directed use of self-help materials and guidelines. Preliminary results showed highest six-month abstinence rates (20%) for the aversive smoking procedures-a pattern conforming to general findings showing the relative superiority of treatment incorporating aversive smoking (e.g., Bernstein & McAlister, 1976). Available findings offer little to guide the industry wishing to invest in an effective employee smoking cessation program. Evaluations of worksite quitting services have lacked experimental methods, clear definitions of independent variables and adequate measurement of dependent variables. Only one of the five studies reviewed employed an experimental design, and even this study confounded procedural differences with differences in treatment intensity and duration (Meyer & Hendersen, 1974). Most cessation treatments occurred after educational campaigns and/ or corporate pressures or incentives for quitting had been introduced. Thus, it’s impossible to judge effectiveness of the treatment outside of this context. Most studies involve select subsamples of motivated, white-collar or medically- or occupationally-high-risk participants. Only one study sought any verification of self-report data or compared corporate results with results of similar interventions in the field (e.g., Kanzler et al., 1976; Zeidenberg et al., 1977). No study included measures of employer costs and benefits, effects of treatment on self-efficacy, health, job satisfaction or performance, or assessments of positive and negative “sideeffects” of quitting smoking (i.e., did quitters start jogging? gain weight?). Creative use of experimental research designs, improved reporting of intervention techniques and multiple measures of treatment outcome will greatly advance our knowledge of these worksite interventions. A recent study of worksite relaxation training by Peters, Benson, and Porter (1977) offers a useful model for a rigorous and comprehensive evaluation. Notwithstanding these serious methodological problems, we can tenatively conclude that the efficacy of cessation techniques in the workplace and in the field are similar when populations and recruitment techniques are similar (Kanzler et al., 1976). If true, this conclusion has two important implications. First. worksite programs should incorporate procedures shown most effective in other settings-namely comprehensive behavioral programs employing some form of smoke aversion (e.g., Bernstein & McAlister, 1976: Danaher, 1977: Lando. 1977). It is surprising that so few programs have done so. Second, results in the workplace would be expected to exceed general results only if special steps were taken to harness and exploit the worksite’s chief therapeutic resource-a cohesive support network and corporate contingencies reinforcing nonsmoking. Again. it is surprising that more firms have not capitalized on these “natural resources.” Behavioral scientists could contribute to understanding and improving comprehensive worksite programs not only through better controlled research but also through consultation to improve cessation services. Although the research on smoking cessation techniques now offers solid groundwork for developing new programs, proven techniques are seldom applied in workplace settings. Likewise, newer findings suggesting cost-effective service delivery models particularly suited to the workplace should be reviewed. For instance. Bell Laboratories obtained excellent end-of-treatment outcomes combining a videotaped expert leader with a supportive group directed by a lay leader (Bauer. 1978). McAlister

H’orksire smoking cessation

11

(1978) has recently reported impressive 50”,C six-month quit rates for similar groups (nonworksite) - rates which did not differ significantly from those of in vivo expert-led groups. The low cost videotaped~closed circuit television mode1 deserves careful evaluation. In a related vein. behavior science technology can be appled to help industry address problems of low participation rates. and the selective participation of white-collar workers. Recruitment techniques, like CO feedback and incentives, must be used to boost employee participation rates, and self-help methods should be offered to those shunning face-to-face treatment (Danaher, 1980). To reach the blue-collar worker who is more at risk to smoke. more likely to compound smoking risks with occupational risks, and more likely to suffer preventable smoking-related illness (Gallup, 1974; Houpt et al.. 1979; Sterling & Weinkham, 1976). incentive systems, and cost-sharing or released time for smoking cessation activities could be offered. Finally. since industry frequently turns to outside agencies for quit-smoking clinic services. behavioral scientists can assist by helping companies select and evaluate such services. A recent consumer’s guide to common non-commercial (e.g., American Heart Association. American Lung Association) and proprietary (e.g., SmokEnders. Schick) clinics might be helpful to industry and consultants (Shipley & Orleans, Note 10). This guide summarizes organizational reports and results of controlled outside evaluations and points to shortcomings in evaluation methods. Combined

strategies

Many industries have combined several strategies in an aggressive multi-component antismoking campaign. The ambitious pioneering Tyler (Texas) Asbestos Workers Program, for instance, combined free on-site semiannual physical examinations. individualized personalized physician advice reinforced by letters to employees and their family members. educational presentations, and both face-to-face and telephone quit-smoking clinic services (Ellis. 1978a. 3978b). Preliminary evaluations included measures of smoking behavior and employees’ knowledge and attitudes concerning cigarette smoking. Likewise. Dow Chemical Company (Dow Chemical Company. Note 3) and Johns-Manville (Cooper, 1978; Sell, Note 12) included a variety of antismoking tactics in their programs. The authors are working with representatives of the Johnson and Johnson Live for Life Institute in New Brunswick. New Jersey to carefully pilot-test a broad-spectrum employee health promotion program including physical examination and risk profiling, CO feedback, smoking restrictions, incentives for nonsmoking. and both self-help and group treatments for smokers motivated to quit. Results of ongoing objective evaluations will be quite valuable. Multiple component programs make sense for industry. Incentives. restrictions, and educational campaigns serve chiefly to raise motivation to quit. individualized physician examination and advice are more powerful motivators and offer more help. Self-help programs and smoking cessation services can teach nonsmoking skills to smokers motivated to quit. Controlled evaluations to find out how combined strategies influence smoking behavior, attitudes and knowledge have not yet been done. Studies to determine the best combination of different strategies. or to tailor particular combinations to particular work settings or employee groups. represent an ideal not even approached. CONCLC!SIOh’S

Research

limitations

ASD

RECOMMENDAT~IONS

and recommendations

Workplace smoking cessation programs are woefuhy under-researched. The NICSH (Note I) poll showed that only 15% of the minority of American businesses with

CAROLE

12

S. ORLEANS

and ROBERT

H. SHIPLEY

antismoking programs had conducted evaluations. The handful of published evaluations seldom meet minimum methodological standards for controlled research. Research has been chiefly atheoretical rather than oriented towards hypothesis testing. Little is known about relative program effects except for a few findings suggesting that the relative efficacy of different approaches is similar in the workplace and in the field. Likewise, component analyses have not been undertaken to determine the independent effects of separate components of multicomponent antismoking initiatives (e.g., an informational campaign plus incentives plus a volunteer quit clinic). If we know little about worksite program results, we know even less about the setting and participant characteristics that influence results. Participant characteristics are often poorly described, and never examined as predictors of outcome. For instance, the majority of worksite quit clinic volunteers have been white-collar workers (Barco, Note 13; Kanzler et al., 1976). but the blue-collar worker is most likely to smoke (Sterling, 1978; Sterling & Weinkham, 1976). Procedures effective for white-collar workers might not be equally effective for blue-collar workers given potentially lower motivation and fewer social supports for quitting. Also. many worksite programs have been evaluated with occupationally- or medically-high-risk smokers. We know, for example, that physician advice is more than twice as effective with high-risk smokers (Shipley& Orleans, Note IO), and similar results would be expected in the workplace. There are no data on setting characteristics influencing workplace program outcomes. Another research problem concerns self-reported smoking, the chief outcome measure in the few evaluations .published. Rosen and Lichtenstein (1977) found that smokers did not candidly report their smoking levels at work when incentives included group penalties for individual infractions. Future worksite research should include a strategy for verifying selfreport involving either asking participants for the names of work associates who would agree to supply data about participants’ smoking levels, or measuring physiological correlates of smoking behavior (e.g., Brockway et al., 1977; Vogt et al., 1978). Physiological measures are particularly valuable since they are likely to increase the honesty of selfreport (Evans, 1976; Ohlin, Lundh, & Westling, 1976), can detect compensation for changed smoking behavior at work. and would reflect changes in health risks. Only if multiple outcomes are evaluated can we evaluate and understand the full impact of worksite anti-smoking initiatives. In addition to improving measures of smoking behavior. measures of health knowledge, attitudes, and; or motivation are needed. Restrictions and other salient corporate initiatives have not been evaluated for their effects on employee morale. well-being and job satisfication. Likewise. no study has attempted to quantify the degree to which a worksite program succeeds in reaching people who might not otherwise seek treatment. Subjective and objective health consequences have been examined in only a few studies (Ellis, 1978a. 1978b: Richmond, 1977). and no general formulae for determining overall cost-effectiveness have been advanced. Finally, smokers have been the focus of all evaluations. Benefits to nonsmoking employees have not been assessed. Program

potentials

and recommendations

The NICSH (Note I) survey showed that 70% of the U.S. businesses wishing to develop or expand smoking cessation programs were interested in outside assistance. This review has suggested several forms that such assistance could take. Workplace smoking control programs have. by and large. been developed without the benefit of behavioral science input. Educational campaigns have emphasized traditional risk education, rather than more innovative approaches involving CO feedback and emphasis on benefits of quitting. Self-help campaigns have not made use of promising self-help materials and approaches.

Worksite

smoktng cessation

13

Incentive programs have encountered avoidable friction and self-report problems. Overall. evaluations have been sketchy. This review has pinpointed areas where behavioral knowledge could be productively applied to highlight potential benefits of greater collaboration between industry and behavioral scientists. Likewise, this review has culled existing research to highlight evidence for promising programs and approaches to stimulate program consultation. Helping industry develop, implement and evaluate smoking cessation and related health-lifestyle change programs represents a major challenge for behavioral scientists and behavior therapists in the 1980s. We hope this interim review offers useful guidelines and practical resources to help meet this challenge. Ackno~ledgemenr-Preparation of this report was supported in part by a grant from the Live Life Institute at Johnson and Johnson in New Brunswick. New Jersey.

REFERENCE

NOTES

Interagency Council on Smoking and Health. Smoking and rhc workplace. National Interagency Council on Smoking and Health business survev. (291 Broadway. Suite 1005, New York. New York 10007). January. 1980. of the Clean Indoor Air AU 2. Glantz. S.. Rosenberg. S.P.. & Lovedav, P. An economic onulvsis of ” the effects . qf 1978 on Cuffforniu governmenrs. Unpublished manuscript, 1979. (Available from S. Glantz. Department of Medicine. Universitv of California or San Francisco, San Francisco, California.) report to H.W. Tomhnson, ladec inc., Albany. N.Y. 12205, February I. 1978. 3. Dickey. 1. Unpublished 4. Action on Smoking and Health (ASH). Passive Kir. no date. (Available from ASH. 2000 H Street N.M’.. 1. National

Washington. DC. 20006.) 5. Robyn. D.L. Should emplovers

6. 7.

8.

9. IO.

II.

12. 13.

be allowed (required) 10 refuse to hire smokers.? Unpublished manuscript. 1979. (Available from D.L. Robyn. University of California at Berkeley, Boah Hall. School of Law. Berkeley. California.) Action on Smoking and Health (ASH) Emplover‘s Kir. no date. (Available from ASH, 2000 H Street. N.W.. Washington, D.C. 20006). Jeffrey, R.W.. Danaher. B.G.. Killen. J.. Kinnier, R. & Farquahr, J.D. Mediated programs .for heal/h behovior change: smoking cessorion and weighr reduction b? mail. Paper presented at the meeting of the Association for Advancement of Behavior Therapy, San Francisco, December. 1979. Best. J.A. Effecriveness of 4 relevisionlprini clinic for smoking cessarion. Paper presented at the meeting of the Association for the Advancement of Behavior Therapy, Chicago, November, 1978. (J. Allan Best. Department of Psychology, University of British Columbia, Vancouver, British Columbia. Canada V6T IWS). DiClemente. C.C. Self-efficacy and smoking cessation moinrenance. Unpublished manuscript, 1979. (Available from C. DiClemente. Texas Research Institute of Mental Sciences. Houston, Texas.) Shipley. R.. & Orleans. C.S. Smoking cessorion. In P.A. Boudewyns & F.J. Keefe (Eds.). Behoviorul medicinefor rheprimorv corephysician. New York: Addison-Wesley. in press. (Available from R.H. Shipley. Chief, Psychology Service, Durham VA Medical Center, Durham, N.C. 27710). Bratic, E., & Ellis, B.H. An approach to utilizing thephysician to help smokers quit. Paper presented at the Fourth World Conference on Smoking and Health. Stockholm, June, 1979. (Elaine Bratic. Office of Cancer Communications, National Cancer Institute. Bethesda, Md. 20205). Sell, W. Personal communication, August, 1979. (Johns-Manville Corporation. Denver, Colorado). Barco. E. Personal communication. August. 1979. (SmokEnders, Inc., Phillipsburg, N.J.).

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