Eliminating smoking from the workplace.

Nicotiana tabacum" (tobacco) was in use by American Indians when Columbus discovered America. The Indians believed tobacco had medicinal properties, and this was the main reason for its introduction into Europe. However, the contention that smoking is a health hazard is almost as old as the use of tobacco. In 1604 King James I issued the first official condemnation of tobacco, "A Counterblaste to Tobacco." [1] He called it "a custom loathsome to the eye, harmful to the brain, dangerous to the lungs, and in the black stinking fume thereof, nearest resembling the horrible stygian smoke of the pit that is bottomless." The first scientific article explicitly to link cigarette smoking to death and disease appeared in 1958. [2,3] Not much was done to address the hazards of smoking until 1964, when the Surgeon General ended a two-year study by reporting that cigarette smoking was associated with the 70 percent increase in the lung cancer death rate for American males from 1950 to 1960. [4] The report found that cigarette smoking was associate with lung cancer, coronary artery disease, chronic bronchitis, and emphysema. Ironically, in the same year, six tobacco companies gave the American Medical Association $10,000,000 for research. Now there are efforts afoot to have a smokefree America by the year 2000.

Laws mandating changes in smoking behavior both at work and in public places are being made. Forty-three states have clean indoor air acts ranging from nominal to extensive. Cigarette excise taxes range from 40 percent in Connecticut and Hawaii to lows of 2 percent in North Carolina and 2.5 percent in Virginia. [5] Beginning July 1, 1990, Virginia requires reasonable no smoking areas in hospitals, nursing homes and other health care facilities; educational facilities, including day care centers and colleges and universities; local and state government buildings; retail establishments with more than 15,000 square feet; and restaurants with more than 50 seats, making it the 26th state regulating smoking in restaurants. Smoking is prohibited in the cashier or service areas of all retail, government, or other businesses, regardless of size, as well as hospital emergency departments, common areas of schools, and school buses and elevators. [6]

The consequences of nonsmoking have three characteristics. First, the results are vague. Even though the smoker is at greater risk for lung diseases, cardiovascular disease, and cancer, these changes may not enter the smoker's awareness. Second, the consequences of smoking cessation tend to be delayed. Changes in the course of emphsema, altered likelihood of cancer or a heart attack, and even changes in lung function are delayed at least a number of months after the cessation of smoking. Third, removal or reduction of risk is the diminution of some disease state, rather than a positive event. Thus, the naturally occurring consequences of changes in smoking habits are vague and delayed and entail the reduction of unpleasant events. Research in psychology and experience in behavior therapy indicate that the consequences most effective in changing behavior are relatively immediate, are discrete or clear, and entail positive increases in desirable opportunities or processes. Behavior change is often most easily or surely accomplished and maintained if it is followed relatively immediately by a clearly identifiable and positive event. [7] Smoking cessation fails on all three counts. As a result, cessation rates may be high initially but do not last. The return to smoking is greatest within 90 days.

Behavior therapists may develop interventions with contingency plans that involve nonsmokers to prevent resentment by this group, especially if rewards are involved. Contingencies levied by peers or by unions appear to be accepted more readily than those levied by administration. Behavior traps may be considered (e.g., the worker who abstains from smoking may be allowed to enter an employer-sponsored lottery, along with nonsmokers, for a vacation, car, etc.). Another approach to reinforce cessation of smoking is a holistic approach (e.g., stop smoking, feel better, play tennis, lose weight.) Finally, positive reinforcement may be obtained through institutional policy or community support. Each workplace has its own characteristics and must develop its own program to stop smoking. General characteristics of programs for successful smoking cessation are direction, involvement, and commitmetn by top administration; follow-up; continuous adjustments; and widespread publicity. [8]

Analysis of implementation of a no smoking policy in a midwestern insurance company (603 employees) show: [9]

* There was an overall decrease in tobacco consumption by 33 percent of employees; 32 percent quit completely.

* Decreased consumption was greater in those smoking more than a pack per day.

* Among those who decreased tobacco consumption, 43 percent associated the decrease with the smoking policy.

* An inverse relationship existed between smokers' tobacco consumption and attitudes about the policy, which restricted smoking to one designated area.

In 1986, a similar smoking policy banned smoking in all but specially designated workplace areas for health and welfare employees in the National Capital Region in Canada. [10] Concurrently, employees were offered two self-help smoking cessation programs that were conducted by public service health nurses. One year following the smoking restriction, the prevalance of smoking in the employee population declined from 29 percent to 24 percent. The mean number of cigarettes smoked at work also declined. Data from the two surveys suggest that 46 percent of smokers tried to quit and 20 percent were not smoking at the time of the follow-up survey. Seven percent had quit for at least 6 months and three percent for at least a year. Continuous quit rates wre 12.5 percent at 6 weeks, 4 percent at 6 months, and 3.5 percent at one year.

Seven worksite smoking cessation programs that include support groups, incentives, and competition have been evaluated. [11] The average post-test cessation rate was 44.8 percent, with a rate at a 13-month follow-up of 36.1 percent.

Worksite smoking cessation programs clearly have a vital role to play in the national antismoking campaign. [12] Worksite programs include:

* Educational campaigns that convey information to employees about the risks of smoking and the benefits of quitting have been effective in getting smoking employees into cessation classes. Employees, however, are already either highly motivated to quit or may be defiant in the face of repeated warnings. Portable units for analyzing the CO content of expired alveolar air offer a noninvasive measure. Also, focusing on the benefits of cessation are more productive than emphasizing the bad effects of smoking.

* Worksite smoking restrictions that are voluntary are becoming mandatory in some states, especially in the health care industry sites. Some laws may address the fire hazard aspect.

* Self-help programs are preferred over face-to-face quit-smoking treatments. It is estimated that 95 percent of America's 32.6 million ex-smokers have quit on their own.

* Physical examination and physician advice constitute the next most intensive level of worksite intervention. Because these interventions require professional input and an expensive examination procedure, they are frequently reserved for high-risk groups.

* From one to three of businesses have offerd incentives to help their employees stop smoking. Most offer monetary rewards for quitting, avoiding verification of self-report of penalties for smoking relapse. Some companies extend reward contingencies to nonsmokers.

* Smoking cessation services programs are often underresearched, as biochemical monitoring is often not included in the follow up. It is of interest, however, that 70 percent of participants at one site surveyed reported they would not have sought out a program if one had not been offered to them at their place of work. Two research break-throughs have helped establish treatments with higher (30-50 percent) quit rates. [13] The first is aversive smoking and nicotine fading, and the second is noninvasive biochemical markers of the smoking status (carbon monoxide levels in alveolar breath samples, thiocyanate and continine levels in saliva samples), [14,15] allowing for objective verification of program results.

Industry and business have strong humanitarian, legal, and economic motives to establish worksite smoking control programs. Not only are smoking cessation programs important preventive measures to help the smoker quit or reduce cigarette utilization but they also are important in reducing on-the-job exposure to second-hand smoke by the nonsmoking employees. Recent surveys show that 15-19 percent of American businesses report incidents of nonsmoking employees claiming illnesses related to exposure to smoke on the job. In a landmark case, Donna Shrimp, a New Jersey Bell Telephone service representative who was allergic to tobacco smoke, successfully sued her employer for the right to work in a smokefree environment. [16] Second-hand smoke has been identified by the U.S. Surgeon General as a serious health hazard and is more carcinogenic than main stream smoke. There are approximately 5,000 deaths from lung cancer each year due to passive smoking. Many substances are found in much higher concentration in sidestream smoke than in mainstream smoke: two times as much tar and nicotine, five times more carbon monoxide, three times more benzopyrene, and fifty times more ammonia. [17]

The profit motive makes smoking cessation attractive to industry as well. Smoking-related medical care, absenteeism, accident,s and lost work output total an estimated $27.5 billion annually. Insurance companies, by offering premium reductions in life, health, fire, and casualty policies, offer the final proof that nonsmoking actually pays off. [18]

Worksite smoking cessation programs are a tangible expression of an organization's willingness to help smoking employees, many of who are eager to quit. Effective programs take many forms. The content covers the psychology of quitting; breaking addictive behaviors; using support systems; coping with smoker's nerves; smoking and nutrition, including avoiding weight gain, maintaining nonsmoking behavior, and exercise as a substitute for smoking. Techniques involve gradual waning, cold tukey, rapid smoking, hypnosis, and biofeed-back. Programs may employ group clasess, small groups, self-help materials, computer-assited instruction, or one-on-one counseling. Length and intensity of the programs may vary. Some program are open to spouses and family members for social support. Most programs use more than one medium, such as print material, audiovisuals, demonstration, skills training, lectures, and group discussion. Sources of vendors may be inhouse, community groups voluntary agencies, behavioral psychologists, hospitals, and for-profit programs. [19] Once a program is in effect, results need to be monitored with noninvasive biochemical markers (expired CO, salivary thiocyanate, and cotinine).

Smoking cessation programs have been found to be more effective if there is physician and management involvement. [20] The physician's contribution to smoking cessation in the workplace is multiple. Medical input is important when drawing up nonsmoking policies, as the medical department is considered neutral by both the employer and employees. Physicians can contribute substantially through direct clinical and diagnostic services in screening smokers and in counseling them individually about the risk related to smoking. They can monitor and iterpret carbon monoxide, thiocyanate, and continine meaures to permit reliable estimates of tobacco exposure. Physician also can coodinate the prescription and introduction of nicotine polacrilex for smoking cessation group classes or other cessation efforts.

Physicians themselves have decreased their smoking rate from 50 percent at one time to less then 17 percent now. [21] In the general population, 34 percent smoke. Ideally, by the year 2000 we will be a smokefree nation.

References

[1] O'Brien, C. "Sleep, Smoking and Performance." Ergonomics 32(10):i-ii, Oct. 1989.

[2] Hammond, E., and Horn, D. "Smoking and Death Rates--Report on Forty-four Months or Follow-up of 187,783 Men, I: Total Mortality." JAMA 166(10):1159-72, March 8, 1958.

[3] Hammond, E., and Horn, D. "Smoking and Death Rates--Report on Forty-four Months or Follow-up of 187,783 Men, II: Death Rates by Cause." JAMA 166(11):1294-308, March 15, 1958.

[4] Nett, M. "The Physician's Role in Smoking Cessation, a Present and Future Agenda." Chest 97(2):28S-32S, 1990.

[5] "Tobacco-Free America: State Legislated Actions on Tobacco Issues at-a-Glance." A public policy project sponsored by the American Cancer Society, the American Heart Association, and the American Lung Association.

[6] Virginia Indoor Clean Air Act, 15.1-291.1.

[7] Stuart, R. Adherence, Compliance and Generalization in Behavioral Medicine. New York, N.Y.: Brunner/Maze, 1982, pp. 145-68.

[8] Andrews, J. "Reducing Smoking in the Hospital, an Effective Model Program." Chest 84(2):206-9, Aug. 1983.

[9] Scott, C., and Gerberich, S. "Analysis of a Smoking Policy in the Workplace." Social Science and Medicine 21(3):299-305, 1985.

[10] Millar, W. "Evaluation of the Impact of Smoking Restrictions in a Government Work Setting." Canadian Journal of Public Health 79(5):379-82, Sept.-Oct. 1988.

[11] Jason, L., and others. "Incentives and Competition in a Worksite Smoking Cessation Intervention." American Journal of Public Health 80(2):205-6, Feb. 1990.

[12] Orleans, C., and Shipley, R. "Worksite Smoking Cessation Initiatives: Review and Recommendations." Addictive Behaviors 7(1):1-16, 1982.

[13] Orleans, C. "Understanding and Promoting Smoking Cessation: Overview and Guidelines for Physician Intervention. Ann. Rev. Med. 36:51-61, 1985.

[14] Matarazzo, J., and others. Behavioral Health. New York, N.Y.: John Wiley and Sons, 1984, pp. 729-54.

[15] Jarvis, M., and Russel, M. "Expired Air Carbon Monoxide: A Simple Breath Test of Tobacco Smoke Intake." British Medical Journal 281(6238):484-5, Aug. 16, 1990.

[16] "Establishing Smokefree Areas in the Workplace: Employee Guidelines." Richmond, Va.: American Lung Association of Virginia

[17] "Second-hand Smoke." Richmond, Va.: American Lung Association of Virginia.

[18] "Costs to American Economy for Cigarette-induced Major Illnesses." American Council on Science and Health, 1984.

[19] Danaher, B. "Smoking Cessation Programs in Occupational Settings." Public Health Reports 95(2):149-57, March-April 1980.

[20] Fisher, E., and others. "The Physician's Contribution to Smoking Cessation in the Workplace." Chest 93(2 Suppl.):56S-65S, Feb. 1988.

[21] Garfinkel, L., and Stellman, S. "Cigarette Smoking among Physicians, Dentists, and Nurses." CA-A Cancer Journal for Clinicians 36(1):2-8, Jan.-Feb. 1986.

Patricia K. Gomuwka, MD, is a plastic surgeon in private practice in Newport News, Va.