Smoking & Smoking Cessation in the Workplace
Table of Contents
Introduction p. 3
Purpose ... p. 3
The Effects of Smoke and Second-Hand Smoke ... p. 4
Do Non-smoking Policies Succeed? .. p. 5
Why do People Continue to Smoke? . p. 6
Promoting Smoking Cessation ... p. 9
Conclusion .. p. 15
Recommendations ... p. 15
References ... p. 17
Smoking & Smoking Cessation in the Workplace
The single most preventable factor that contributes to the major health problems facing Canadians today is the use of tobacco. The very mention of the word smoking can evoke an argument from the calmest of people, whether they are smokers or non-smokers. The former feel threatened, while the latter feel they may have the chance to bring an end to an activity they have long disliked and disapproved of. Workplaces across the country are adopting smoke-free policies in order to provide clean air and to protect employees and the public alike from the harmful, if not life-threatening effects of smoking. According to the American Lung Association (1997), 94 per cent of smokers and non-smokers now believe companies should either ban smoking totally in the workplace or restrict it to separately ventilated areas.
In response to an increased awareness of the dangers of smoking, there has been a growing interest in the introduction of smoking policies for the workplace. The purpose of this paper will be to outline some of the effects of smoking and the effectiveness of implementing smoking cessation programs. This paper also contains specific goals and strategic direction with which to achieve these goals and provides the groundwork for the formation of a committee to review the research and aid in implementing the recommendations. Well-designed and implemented programs and policies can aid in preventing the use and effects of tobacco and second-hand smoke.
The Effects of Smoking and Second Hand Smoke
The effects of the use of tobacco are well researched and well documented. Tobacco use poses a risk to both those who participate in the behavior, and to those who passively take in second-hand smoke. Stillman (1995) found that smoking is the leading cause of preventable death, and smoking related diseases are involved in more than one third of all hospital admissions. Fried (1994) reported that women who smoke are more often subject to infertility, miscarriage, spontaneous abortion, stillbirths, and underweight babies. Fried also found that crib death (sudden infant death syndrome, or SIDS) occurs 2.5 times more often in babies whose mothers smoke. Albrecht, Cassidy, Reynolds, Ketchem, and Abriola (1999) reported that more than 400,000 annual deaths are associated with tobacco use and the cost to health care and lost productivity is almost $100 billion per year. Moreover, maternal smoking in pregnancy has been linked to learning disabilities, hyperactivity, impulsivity, and soft neurological signs in school aged children. Albrecht et al (1999) also reported that maternal smoking and second hand smoke are associated with increased incidence of acute respiratory infections and more frequent hospitalization for severe bronchitis, pneumonia, asthma, and otitis media during the first year of infancy. Similarly, current estimates of the number of deaths attributed to smoking in Canada range as high as 38,000 per year (Albrecht et al, 1999). A large amount of deaths is also associated with involuntary exposure to the tobacco smoke.
According to Single, MacLennan and MacNeil (1994) in 1991, 46.8 billion cigarettes were sold legally in Canada. Thus, an estimated 35,717 deaths were attributed to smoking in Canada in 1990, a rate of 135.6 per 100,000. Single et al (1994) revealed that although Canadian men were once much more likely than women to smoke, men and women are now almost equally likely to be current smokers (31% vs. 28%). Also, men are more likely than women to be former smokers (39% vs. 31%). Meanwhile, smoking is highest among those aged 25 to 44 (35%) and lowest among those over 65 (15%).
The effects of smoking and second-hand smoke are many in number. Tobacco smoke represents the single most significant source of indoor air pollution. The smoke and second-hand smoke from tobacco contains over 4000 chemicals, both gas and particulate. The American Nurses' Association (ANA, 1998) researched and found that the gas phase of second-hand smoke contained such poisons and irritants as carbon monoxide, acrolein, ammonia, nitrogen oxides, benzene, pyridine, and hydrogen cyanide and the particulate phase contains nicotine and many known or probable carcinogens, which have no safe level for human exposure.
The seriously damaging health effects of tobacco smoke continue to be documented. ANA (1998) found that children and adults exposed to tobacco smoke experienced increased rates of respiratory illness, including lung cancer (approximately 3000 deaths per year in adults exposed to tobacco smoke), higher rates of respiratory tract infections (bronchitis and pneumonia), and exacerbation of asthma symptoms. The ANA (1998) also found that high exposure to tobacco smoke nearly doubles a woman's risk of heart attack, and also causes eye, nose, and throat irritation, leading to excess coughing, chest discomfort, and difficulty breathing.
Do Non-smoking Policies Succeed?
Joseph, Knapp, Nichol, and Pirie (1995) found that smoke-free hospital policies are designed to minimize patient, employee, and visitor exposure to secondhand smoke, encourage patients to quit smoking, and set an example for the community of institutional policies that reflect scientific knowledge about the health risks of smoking. David (1992) implemented a survey at a 38-bed hospice, where 119 staff is employed, as a preliminary way to introduce a no-smoking policy. The survey proved to be valuable in introducing staff to the concept of a policy, making them feel involved, and supplying the policy-makers with background information. Literature suggests that positive behavioral changes occur among employees after the introduction of a no-smoking policy. Shirres (1996) found in a study that the introduction of non-smoking policy and education programs induced positive behavioral and attitudinal changes in smoking. Martin (1998) states that providing a tobacco free environment that establishes nonuse of tobacco as a norm offers opportunities for positive role modeling. Joseph et al (1995) also found that having a person at the hospital dedicated to enforcing the no-smoking policy greatly improved the chances of success.
If a smoke-free work environment is to be achieved, greater efforts to assist smokers to quit will be necessary. Interventions to reduce smoking must become a priority for health care providers, as physicians and nurses come into and interact with a large number of smokers every year. Health promotion advocates must also communicate the cost savings and health benefits garnered from workplace smoking cessation programs.
Why do people continue to smoke?
Tobacco use, which occurs primarily through smoking, is a behavior influenced by pharmacological, psychological, social, and environmental factors (Fisher, Haire-Joshu, Morgan, Rehberg, & Rost, 1990). The U.S. Department of Health and Human Services (1988) state that nicotine, the major addictive agent in tobacco, provides both euphoric and sedating effects and serves as powerful pharmacological reinforcement for maintenance of the behavior. Christen and Christen (1994) suggested that recognizing tobacco use as an addiction is both critical for treating the tobacco user and for understanding why people continue to use tobacco despite the known health risks. Shiffman (1979) adds that in addition to its pharmacological effects, smoking involves a strong psychological dependence in that smokers report engaging in the behavior to soothe negative affective symptoms, such as tension, anxiety, boredom, and irritability. When these affective symptoms are reduced, it leads to an increased activity in the behavior.
Christen and Christen (1994) state that smoking is seldom a take-it-or-leave-it activity. Most smokers cannot choose to use tobacco one day and leave it alone the next. Most smokers admit that they would like to quit, but are unable to do so. Christen and Christen (1994) further argue that some individuals use nicotine as a tranquilizer: they believe that smoking keeps them on an even emotional keel and reduces their feelings of anger, fear, and frustration. In addition, Christen and Christen (1994) stated that smokers commonly reported smoking helps them to regulate their dysphoric moods or negative affect, and those who experience excessive stressors tend to increase their consumption. As mentioned, social and environmental conditions also influence tobacco use. McIntyre-Kingsolver, Lichenstein, & Mermelstein (1983) and Ockene, Benfari, Nuttall, Hurwitz, & Ockene (1983) state that a majority of smokers are surrounded by family members and friends who engage in the behavior, providing strong cues to continue smoking.
Albrecht et al (1999) found that adolescents are faced with lifestyle choices that are influenced by developmental level, cognitive understanding, decision-making skills, and social influences such as family values and peer pressure. Fried (1994) reported epidemiological data and study of psychological, biological, sociocultural, and physiological variables reveal a gender-related proclivity for females to initiate and maintain the tobacco habit. Young women appear to be more vulnerable to starting smoking and less amendable to stopping it. Fried (1994) reported a woman's fear of weight gain is a deterrent to cessation and an impetus to continue the tobacco habit. Women tend to report less confidence in their abilities to quit, perceive more barriers to abstinence, and anticipate negative consequences of quitting.
Fried (1994) suggested low income, poor housing, lack of education, single/divorced or separated marital status, unemployment, city dwelling, lack of independence, housewife, or single working parents are characteristics of a smoker. As mentioned, social and environmental conditions also influence tobacco use. These factors alone make it hard to resist and quit smoking, but when adolescents face smoking cessation, it can be even more difficult.
Christen and Christen (1994) state that smoking has both similarities to and differences from other addictions. Cigarette smoking, a special form of addiction with its own unique features, is incredibly resistant to long-term modification. Nicotine is addicting and smoking represents an addictive disorder, such as alcohol, cocaine, and heroin dependence. It is further argued that cigarette smoking is psychologically as well as physically addicting. Christen and Christen (1994) suggested that nicotine is now understood to be a strongly addictive mood-altering drug, with properties that clearly reinforce the continued use of tobacco products. They further argue that nicotine, as an ingestive disorder, compulsive nicotine intake causes physiological tolerance, tissue dependence, psychic dependence, and relatively well defined physical withdrawal symptoms.
Promotion Smoking Cessation
According to Blair (1995) one objective of wellness program activities is to foster employee health. However, workers whose health stands to gain the most from wellness programs are the least aware of their unhealthy lifestyles and the least motivated to change. According to Nagel, Mayton, and Walner (1995) since values are a central concept in understanding and predicting human behavior, health education aimed specifically at cigarette smoking or other habits treated singly rather than in relation to each other. Effective health promotion programs, that attempt to change negative behaviors while reinforcing existing positive behaviors must understand the attitudes and behavior of target audiences, are necessary. Mintz (1989) argued that for health promotion to be of any use in a practical sense, it must be put into the hands of those who can use it. Mintz (1989) suggested that the value of health information to society could only be fully realized if information is absorbed and acted upon to a significant degree by the audience that the information is intended to reach. According to Novelli (1997), successful utilization of health promotion is dependent upon understanding or identifying the target consumers' needs, expectations, satisfactions and dissatisfactions. Lefebvre and Rochlin (1997) and Wilson and Olds (1991) suggested that promotion of health products should consider the objectives of the promotion, the target audience, the desired effect, and the optimal reach and frequency.
Many serious public health and social problems of the day have their root in behaviors that begin in late childhood and adolescence. Nagel et al (1995) advised that drug education programs designed to keep adolescent from becoming daily users of tobacco (prevention) should be encouraged to focus on changing the value placed on health. According to Andreasen (1995), an extremely important task during the formative stages of the strategic planning process is to gain an understanding of the extent to which interpersonal influences are likely to be important for one or more target groups. When helping a smoker to quit, the smoking cessation facilitator needs to consider the smoking behaviors and attitudes of family members and significant others. Social support is an extremely important factor in any effort to change personal behaviors. Albrecht et al (1999) said aspects of development must be considered when developing health educational programs for adolescent females. They further advise that health providers must be aware of this educational barrier when counseling teens regarding health related behavior. Albrecht et al (1999) stated that adolescent development has a significant impact on strategies for health promotion. Behavioral experimentation is a common pattern in this age group and is related to the task of separation from family and identity development. They further indicated that rebelliousness and identification with peer groups influence adolescent behavior.
One of the most persistent findings is that children and adolescents are much more likely to participate in a particular high-risk behavior or activity if their friends also engage in that behavior or activity. Greenlund, Johnson, Webber, and Berenson (1997) found that from third grade through to sixth grade, there was five times the risk of an individual to smoke if a best friend also smoked. Grunberg, Winders & Wewers (1991) found that boys have decreased, but girls have increased, their likelihood to try cigarettes. Tobacco use in adolescent females is also associated with personal factors including self-image and self-esteem. Christen & Christen (1994) studied that tobacco use is learned and typically initiated during adolescence, when the need to achieve acceptance through peer conformity is particularly strong. They suggest that the desire to feel more grown-up and the drive to become self-defined and individuated can cause adolescents to rebel against the strict parental control or to challenge cultural and /or religious expectations. If social marketers are to develop effective health promotion programs to prevent the onset of high-risk behaviors in adolescents, such as smoking, it is crucial that they understand the exact role that social influence plays in this process.
According to Fried (1994), several variables in addition to gender are associated with the prevalence of cigarette smoking. These include socioeconomic status (SES), level of education, race, and occupational status. Fried further suggested that the difference in how young girls and young boys relate to their social contexts appear to create gender-distinct smoking behaviors and perceptions. Christen & Christen (1994) stated that the two major predictors of early cigarette use are experiencing peer pressure to smoke and having one or both parents whom smoke. Fried (1994) stated that a host of environmental factors predispose the adolescent female to tobacco use. The prime influencing factor is the tobacco industry's seductive advertising that depicts women smokers as powerful, glamorous, happy, successful, and attractive. Fried (1994) also suggested that the adolescent female, struggling with her negative body image and searching for beauty, views cigarette smoking as a means to achieve thinness and shape a feminine gender role. Fried (1994) found less educated adolescents females from lower socioeconomic strata are most likely to become one of the new smokers who start each day. In addition, 20 to 30 per cent of these adolescent smokers will become regular users by age 18.
Christen and Christen (1994) suggested, early in the cessation process, nonjudgmental and empathetic friends and family members can be enlisted to actively support recovering smokers. Likewise, healthy competition among recovering friends may also become a potent smoking cessation motivator. Tripp & Davenport (1989) suggested several strategies could be implemented in order to be successful in utilizing social marketing to promote smokers to reduce or cease smoking behaviors. These include:
1. Smokers don't want to be threatened. They don't want be bullied or made to feel ashamed of smoking.
2. A message that smoking causes death is not successful. All smokers know smoking causes health risks and that is it associated with a variety of health problems. Smokers know many people, who are healthy, yet have smoked regularly for many years. Smokers also know many people, who are sick, yet have never smoked a cigarette. Smokers also know many doctors, who surely know the facts, but are smokers.
3. Smokers need encouragement to quit. Many smokers have tried or know somebody who attempted to quit but could not. Smokers want more than punitive measures to help them stop smoking. The findings of these studies revealed that, supportive tone of the ads make the female smokers feel understood, reassured them that they were not failures and supported them in their efforts to quit. (Tripp & Davenport, 1989)
4. Smokers want realistic guidance about quitting. Smokers responded positively and were receptive to messages that revealed people often fail to quit in the first few attempts, and that kind of failure is normal. These messages gave smokers a reason for trying again and again.
Christen & Christen (1994) said recognizing tobacco use as an addiction is critical both for treating the tobacco user and for understanding why people continue to use tobacco despite the known health risks. They also suggested tobacco is a potent drug that exerts strong control over its regular users and reinforces the need to use and re-use. Albrecht et al (1999) stated that developmentally, adolescents focus on the present, the immediate effects of tobacco use, such as bad breath, stained teeth, and high cost of cigarettes, and this should be the focus of the education effort.
Christen and Christen (1994) reported that about 70 to 80 per cent of smokers who do quit are likely to relapse within the first 3 months of cessation. In addition, 50 per cent or more of patients who are recovering from surgery for a smoking related disease continue to smoke while they are hospitalized or resume smoking shortly after they are discharged. In essence, smoking is an extremely multifaceted, addictive behavior that involves pharmacological, environmental, cognitive, and affective factors.
Albrecht et al (1999) recommended programs that involve role modeling, peer resistance, and booster sessions, focused on attitude and behavior change, to achieve cessation while recognizing issues of adolescent development can be highly successful. They also suggested when working with teens, parents of the adolescent must be included in health promotion activities. Tripp & Davenport (1989) examined advertising directed at smokers found that fear tactics were a most ineffective means of encouraging smokers away from their smoking behavior. They found advertisements that provided information about the dangers of smoking and offered some suggestions that are effective methods to quit were effective. This study concluded positive ads seemed to motivate people to a moderate degree. Tripp & Davenport (1989) opposed the use of fear tactics to help teenage female smokers decide against initiation or cessation of smoking. They found that fear tactics failed to address the real concerns of female adolescent smokers, which center on the difficulties and frustration involved in breaking an addiction.
Albrecht et al (1999) further recommended the following steps as effective guidelines for smoking cessation for high-risk populations:
1. Awareness: understanding of the unique needs of the high-risk population.
2. Ask: inquire about lifestyle to assess high-risk areas to target cessation activities.
3. Advise: education should center around specific short and long-term effects smoking has on the high risk population and reversible effects that occur with cessation.
4. Assist: self-help educational material must be supplemental with counseling sessions that specifically address quit preparation, smoking triggers, and alternative coping responses that enhances lifestyle changes.
5. Arrange: follow-up appointments can be scheduled closely around quit date for reinforcement and support of cessation efforts.
6. Again: repeating process reinforces cessation efforts and addresses relapse issues.
A healthy and safe environment is a public health priority. Clean air, free from tobacco smoke, is particularly vital since researchers have documented the link between tobacco smoke and increased morbidity and mortality in both smokers and non-smokers. Health professionals can play an essential role in both clinical and community settings to reduce tobacco use, one of the leading causes of health problems in this country. Work site environments must have policies established and enforced that restrict or prohibit smoking. Health professionals must make it their duty to enhance public awareness and education about the hazards of tobacco smoke within the work setting, and the benefits
no-smoking policies as mechanisms for enhancing the health of both smokers and non-smokers.
A committee needs to be created to steer this organization to form and adopt a policy that satisfies all involved. The committee must include all employees representative and other stakeholders. We also advise, open procedures that motivate active decision making participation of all participants. The overall goals for the policy ensure that its scope of action is extensive.
These three goals are:
+ to protect the health and rights of non-smokers (protection);
+ to help non-smokers stay smoke free (prevention);
+ to aid and encourage those who want to quit smoking to do so (cessation).
To achieve this, the following six strategic directions have been identified:
+ access to information;
+ access to services and programs;
+ message promotion;
+ support for action;
+ Intersectoral policy coordination;
+ research and knowledge development
Albrecht, S., Cassidy, B., Reynolds, M. D., Ketchem, S. & Abriola, D. (1999). Developing guidelines for smoking cessation interventions for pregnant adolescents. Journal of Pediatric Nursing, 14(3), 150 - 156.
American Lung Association (1997). American lung association fact sheet - smoking policies in the workplace [On-line]. Available: http://www.lungusa.org/tobacco/smkworkfac.html
American Nurses Association (1998). American nurses association position statement. Environmental tobacco smoke. Tar Heel Nurse, 60(2), 14 - 5
Andreasen, A. (1995). Marketing social change: Changing behavior to promote, health, social development and the environment. San Francisco: Jossey-Bass.
Blair, J. E. (1995). Social marketing: Consumer focused health promotion. AAOHN Journal, 43(10), 527 - 531.
Christen, A. G. & Christen, J. A. (1994). Why is cigarette smoking so addicting? An overview of smoking as a chemical and process addiction. Health Values, 18(1),
17 - 24.
David, J. (1992). A survey of hospice staff smoking behavior and their opinions on smoking at work. Eurpoean Journal of Cancer Care, 1(5), 19 - 21.
Fisher, E. B., Haire-Joshu, D., Morgan, G. D. Rehberg, H., & Rost, K. (1990). Smoking and smoking cessation. American Review of Respiratory Disease, 142,
702 - 720.
Fried, J. L. (1994). Women and young girls high-risk populations for tobacco use. Health Values, 18(1), 33 - 40.
Greenlund, K., Johnson, C., Webber, L. & Berenson, G. (1997). Cigarette smoking attitudes and first use among third through sixth grade students: The bogalusa heart study. American Journal of Public Health, 87, 1345 - 48.
Grunberg, N. E., Winders, S. E. & Wewers, M. E. (1991). Gender differences in tobacco use. Health Psychology, 10(2), 143 - 153.
Joseph, A. M., Knapp, J. M., Nichol, K. L., & Pirie, P. L. (1995). Determinants of compliance with a national smoke-free hospital standard. Journal of the American Medical Association, 274(6), 491 - 495.
Lefebvre, R. C. & Rochlin, L. (1997). Social marketing. In K. Glanz, F. M. Lewis & B. K. Rimer (Eds), Health Behavior and Health Education: Theory, Research, and Practice (pp. 384 - 402). San Francisco: Jossey-Bass.
Martin, J. (1998). Nurses importance in tobacco use prevention, control. Nebraska Nurse, 31(3), 18.
McIntyre-Kingsolver, K. O., Lichenstien, E, & Mermelstein, R. J. (1983). Spouse training in a multicomponent smoking-cessation program. Journal of Consulting and Clinical Psychology, 51, 632 - 633.
Mintz, J. (1989). Social marketing new weapon in an old struggle. In Health Promotion. Canada: Health & Welfare Canada.
Nagel, L., Maynton, D. M. & Walner, T. (1995). Value differences across tobacco use levels. Health Values, 19(6), 39 - 44.
Novelli, W. D. (1997). Applying social marketing to health promotion and disease prevention. In K. Glanz, F. M. Lewis & B. K. Rimer (Eds), Health Behavior and Health Education: Theory, Research, and Practice (pp. 342 - 369). San Francisco: Jossey-Bass.
Ockene, J. K., Benfari, R. C., Nuttal, R. L., Hurwitz, I., & Ockene, I. S. (1982). Relationship of psychological factors to smoking behavior change in an intervention program. Preventative Medicine, 11, 13 - 28.
Shiffman, S. (1979). The tobacco withdrawal syndrome. National Institute of Drug abuse and Research Monograph, 23, 158 - 184.
Shirres, G. (1996). Successful implementation of a no-smoking policy. Collegian: Journal of the Royal Coleege of Nursing Australia, 3(4), 30 - 38.
Single, E., MacLennan, A. & MacNeil, P. (1994). Horizons 1994: Alcohol and other drug use in Canada. A Research Publication from the Studies Unit, Health Promotion Directorate. Ottawa: Health Canada.
Stillman, F. A. (1995). Smoking cessation for the hospitalized cardiac patient: rationale for and report of a model program. Journal of Cardiovascular Nursing, 9,
25 - 36.
Tripp, G. & Davenport, A. (1989). Fear advertising - it doesn't work! In Health Promotion. Canada: Health & Welfare Canada.
U. S. Department of Health and Human Services (1988). The health consequences of smoking: Nicotine addiction. A report of the surgeon general. Washington, DC: U. S.
Government Printing Office.
Wilson, M. & Olds, S. (1991). Application of the marketing mix to health promotion marketing. Journal of Health Education, 22(4), 254 - 259.