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

Worksite health promotion and social inequalities in health

It is well-documented that higher educated employees have better health than the lower educated. The workplace has been put forward as a contributor to this inequality. We extend previous work on workplace characteristics that could influence employee health by asking to what extent workplace health promotion (WHP) can account for the relation between education and health. Two ways in which WHP may relate to health inequalities are addressed: higher educated employees may be more likely to use WHP than lower educated employees and the effect of WHP on health may be stronger for higher educated than for lower educated employees. Using data from the European Sustainable Workforce Survey which contains information on over 11000 employees in 259 organisations, we test whether three types of WHP mediate or moderate the relation between education and health: healthy menus, sports facilities and health checks. We find that higher educated employees are in better health and that use of WHP positively relates to health. Use of healthy menus and sports facilities in the workplace can contribute to increasing health inequalities, as lower educated employees are less likely to make use of these. Health checks could contribute to diminishing health inequalities, as lower educated employees are more likely to use them compared to higher educated employees. The effect of WHP is not contingent on education. We advise stimulating lower educated employees to make more use of WHP, which can contribute to decreasing health inequalities.

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

Background

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

Methods

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

Results

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

Conclusions

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

Association between employer's knowledge and attitude towards smoking cessation and voluntary promotion in workplace: a survey study

Background

Workplace smoking cessation (SC) intervention is effective in increasing quit rate but little was known about the factors associated with voluntary SC promotion. Comprehensive smoke-free legislation, including banning smoking in all indoor area of workplaces, has been enforced in Hong Kong. This survey investigated the prevalence of company’s compliance with smoke-free legislation and examined the relation between voluntary SC promotion in workplace and employer’s knowledge of and attitude towards smoking and SC.

Methods

Half (50.3%, n = 292) of a convenience sample of companies completed a self-administered questionnaire on company’s voluntary SC promotion in the workplace. Factors investigated included company’s characteristics (size, type, and number of smoking employees); employers’ knowledge of smoking, second-hand smoke and SC effects on health; perceived responsibility in assisting employees to quit smoking and smoking prohibition in workplace (smoke free policy). Logistic regression yielded adjusted odds ratio (aOR) for voluntary SC promotion.

Results

A notable proportion of companies (14.7%) showed non-compliance with the smoke free workplace ordinance and only 10% voluntarily promoted SC. Perceived greater negative impact of smoking on the company (adjusted odds ratio[aOR] 1.94, 95% confidence interval [CI] 1.18-3.20) and better knowledge of smoking (aOR 1.40, 95%CI 1.00-1.94) were associated with voluntary SC promotion. Positive but non-significant associations were observed between perceived responsibility of assisting employees to quit, workplace smoke free policy and voluntary SC promotion. Company characteristics were generally not associated with voluntary SC promotion except white collar companies were less likely to promote SC (aOR 0.26, 95% CI 0.08-0.85).

Conclusions

This is the first survey on company’s SC promotion in the Chinese population. A notable proportion of companies was not compliant with the smoke-free workplace ordinance. Employers with a higher level of knowledge and perceived impact of smoking on companies and from blue-collar companies were more likely to promote SC in workplace. The findings inform future workplace intervention design and policy.

Trial registration

The study was retrospectively registered at ClinicalTrials.gov (NCT02179424) dated 27 June 2014.

Sex/Gender Differences in Cotinine Levels Among Daily Smokers in the Pennsylvania Adult Smoking Study

BACKGROUND

This study was conducted to determine sex/gender differences in smoke exposure and to quantify the role of potential predictors including puffing behaviors, nicotine dependence, and non-nicotinic factors.

METHODS

The Pennsylvania Adult Smoking Study (PASS) of 332 adult cigarette smokers utilized portable handheld topography devices to capture the smokers' profiles in a naturalistic environment. Sex/gender differences in salivary biomarkers were modeled using ANCOVA to account for measures of dependence (Fagerstrom Test for Nicotine Dependence, nicotine metabolite ratio [3-hydroxycotinine/cotinine]), and nondependence covariates including anthropomorphic factors and stress. The Blinder-Oaxaca method was used to decompose the sex/gender differences in nicotine uptake due to covariates.

RESULTS

Men had significantly higher cotinine levels (313.5 ng/mL vs. 255.8 ng/mL, p < 0.01), cotinine +3-hydroxycotinine levels, (0.0787 mol/L vs. 0.0675 mol/L, p = 0.01), puff volumes (52.95 mL vs. 44.77 mL, p < 0.01), and a lower nicotine metabolite ratio (0.396 vs. 0.475, p = 0.01) than women. The mean Fagerström Test for Nicotine Dependence score did not differ between men and women (p = 0.24). Women had a higher mean Hooked on Tobacco Checklist score than men (7.64 vs. 6.87, p < 0.01). In multivariate analysis, nicotine metabolite levels were not significantly different by sex. Decomposition results show that ten predictors can explain 83% of the sex/gender differences in cotinine uptake. Height was the greatest contributor to these differences, followed by average puff volume. Conclusion and Impact: The higher levels of nicotine metabolites in men, compared to women, can be explained by height, weight, puff volume, and nicotine metabolism.

Realizing the Potential of Cancer Prevention - The Role of Implementation Science

In the past two decades, we and others have estimated that more than half of cancers could have been prevented by applying knowledge that we already have. Tobacco use, inactivity, and obesity are modifiable causes of cancer,^– and evidence now suggests that vaccination against the human papillomavirus, the use of aspirin and selective estrogen-receptor modulators, and participation in screening programs further reduce the risk of specific cancers.^, The effect of these strategies on cancer-related outcomes in the general population is significant. A 62% reduction in lung-cancer mortality is associated with smoking cessation at age 50, and environmental and policy strategies are effective at increasing cessation.^– A 95% reduction in mortality is associated with screening for cervical cancer, a 100% reduction in mortality is associated with vaccination against the human papillomavirus, ^– and a 90% reduction in mortality related to chronic liver disease and liver cancer is associated with vaccination against hepatitis B virus. There is also benefit for those at high risk for cancer. Lung-cancer screening is associated with a 20% reduction in mortality among smokers at high risk, salpingo-oophorectomy reduces the risk of breast and ovarian cancer among women with a BRCA1/2 mutation,^, and treatment with selective estrogen receptor modulators reduces the incidence of breast cancer by 50% among women at high risk.^, Screening, diagnosis, and treatment of hepatitis C virus infection reduces the risk of all-cause mortality by 50% among those with infection. Our ability to prevent cancer has improved significantly.

The Praise! Project:

Cancer prevention research has inadequately reached the African American community despite a higher risk for cancer and many other chronic diseases. Reasons for this failure include historical mistrust of research and medical institutions; lack of culturally relevant interventions; and a failure to design and implement interventions that “give back” to the community. The Partnership to Reach African Americans to Increase Smart Eating (PRAISE!) project is a National Cancer Institute-funded study that developed and tested a nutrition intervention program in partnership with African American churches. Sixty churches and over 1300 individuals participated in this 5 year randomized controlled trial. In this article, the authors describe the design and implementation of the PRAISE! intervention, building on the strengths of the African American church to create a community-university partnership to enhance cultural relevance of the intervention and foster the potential for long term sustainability and diffusion in the African American community.

Boosting healthy heart employer-sponsored health dissemination efforts: identification and information-sharing intentions

Health information dissemination options have expanded to include workplaces and employer-sponsored efforts. This study focuses on a core relational concept found in workplaces, organizational identification-the feeling of belongingness-and the impact of partnering with employers and health clinics in health information dissemination. We use social-identity theory and multiple identification to test our predictions from a sample of working adults representing more than 100 different employers. We found that when people strongly identify with their employer, they have increased health behavioral intentions and they intend to talk about the health information with coworkers. The significant models explain more than 50% and 30% of the variance in these two outcomes. The experimental results examining single and multiple organizational sources revealed no differences on any outcomes. These findings offer a contribution to health information dissemination research by articulating how identification with an employer functions to affect behavioral intentions.

Workplace interventions for smoking cessation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The relationship between sun protection policies and practices in schools with primary-age students: the role of school demographics, policy comprehensiveness and SunSmart membership

Schools can implement evidence-based sun protection policies that guide practices to help protect children from harmful sun exposure. This national study assessed the relationship between the existence and comprehensiveness of written policies and the comprehensiveness of sun protection practices. The impact of school demographics on the strength of the relationship was also examined, as was the possibility that 'SunSmart' membership would have an additional impact on practices, beyond having any formal policy. In 2011-12, staff members of 1573 schools catering to primary-age students completed a self-administered survey about sun protection policies and practices (response rate of 57%). Results showed that schools with a written policy had more comprehensive practices than schools without a written policy. The relationship between having a written policy and sun protection practices was stronger for remote schools compared with metropolitan and regional schools, and for schools catering to both primary and secondary students compared with primary students only. In addition, policy comprehensiveness was associated with practice comprehensiveness, and SunSmart membership was indirectly related to practice comprehensiveness via policy comprehensiveness. These results indicate that written policies relate to practice comprehensiveness, but the strength of the association can vary according to the characteristics of the organization.

Systems antecedents for dissemination and implementation: a review and analysis of measures

There is a growing emphasis on the role of organizations as settings for dissemination and implementation. Only recently has the field begun to consider features of organizations that affect dissemination and implementation of evidence-based interventions. This manuscript identifies and evaluates available measures for five key organizational-level constructs: (a) leadership, (b) vision, (c) managerial relations, (d) climate, and (e) absorptive capacity. Overall the picture was the same across the five constructs--no measure was used in more than one study, many studies did not report the psychometric properties of the measures, some assessments were based on a single response per unit, and the level of the instrument and analysis did not always match. One must seriously consider the development and evaluation of a robust set of measures that will serve as the basis of building the field, allow for comparisons across organizational types and intervention topics, and allow a robust area of dissemination and implementation research to develop.

Implementing state tobacco treatment services: lessons from the Massachusetts experience

This case study was conducted between 2000 and 2003 to examine the implementation of community based tobacco treatment programs funded by the Massachusetts Department of Public Health Tobacco Control Program (MTCP). Four dimensions of implementation, drawn from several models of program evaluation are explored: (a) quantity of services, (b) quality of services, (c) implementation/use of systems, and (d) sustainability. The quantity of services delivered was high, reflecting MTCP's focus on increasing availability of services, particularly in underserved populations. The quality of physician-delivered tobacco intervention did not meet national benchmarks for delivery of all 5As (Ask, Advise, Assess, Assist, Arrange follow-up) and only about half of organizations reported routine systems for auditing tobacco use documentation. Implementation of systems to identify tobacco users and deliver tobacco treatment varied widely by community health settings, with low rates of tobacco use documentation found. Finally, in an era of greater competition for scarce prevention dollars, sustainability of services over time must be planned for from the outset, as indicated by the success of programs that sustained services by proactively and creatively incorporating tobacco treatment into their organizations. This case study can inform states' policies in their design of tobacco treatment services in community health settings.

Organizational factors and the attitude toward health promotion in German ICT-companies

This study takes a first step toward examining the relationship between organizational characteristics and the perceived attitude toward health promotion in companies from the perspective of chief executive officers (CEOs). Data for the cross-sectional study were collected through telephone interviews with one CEO from randomly selected companies within the German information and communication technology (ICT) sector. Multivariate logistic regression analysis (LRA) was performed, and further LRA was conducted after stratifying on company size. LRA of data from a total of n = 522 interviews found significant associations between the attitude toward health promotion and the company's market position, its number of hierarchical levels, the percentage of permanent positions and the percentage of employees with an academic education. After stratification on company size, the association between the attitude toward health promotion and both market position and the percentage of employees with an academic education was still present in small companies. There were no significant relationships between the attitude toward health promotion and the structural characteristics of medium-sized and large companies. The preliminary results of the study indicate that a perceived attitude toward health promotion in companies can be explained, to a certain degree, by the intraorganizational characteristics analyzed. Our key findings highlight that efforts toward establishing a positive attitude toward health promotion should focus on small companies with a lower market position and a greater number of employees with a lower education level.

Worksite tobacco prevention in the Canton of Zurich: stages of change, predictors, and outcomes

OBJECTIVES

This study provides information about the prevalence of tobacco prevention (TP) and the stages of change with respect to the introduction of TP among companies in the Canton of Zurich (n = 1,648). It explores the factors that predict restrictiveness of smoking policies, number of individual support measures, interest in services to promote TP, and the relationship between TP and health outcomes.

METHODS

Data were gathered by means of a written questionnaire and analysed using ordinal regression models.

RESULTS

Whereas many companies maintain smoke-free policies, only few provide cessation-courses. Health and welfare organisations have strictest, and building and hospitality companies have least strict policies. Company size predicts number of individual support measures but not policy restrictiveness. Both measures are predicted by personal concern of the representative. Interest in services is predicted by tobacco-related problems and medium stages of change. Finally, stricter policies are associated with lower proportion of smokers and less tobacco-related problems.

CONCLUSIONS

Health professionals should support less advanced companies in their endeavour to implement TP. The findings provide a baseline to evaluate the implementation of the forthcoming smoke-free legislation.

Using organization theory to understand the determinants of effective implementation of worksite health promotion programs

The field of worksite health promotion has moved toward the development and testing of comprehensive programs that target health behaviors with interventions operating at multiple levels of influence. Yet, observational and process evaluation studies indicate that such programs are challenging for worksites to implement effectively. Research has identified several organizational factors that promote or inhibit effective implementation of comprehensive worksite health promotion programs. However, no integrated theory of implementation has emerged from this research. This article describes a theory of the organizational determinants of effective implementation of comprehensive worksite health promotion programs. The model is adapted from theory and research on the implementation of complex innovations in manufacturing, education and health care settings. The article uses the Working Well Trial to illustrate the model's theoretical constructs. Although the article focuses on comprehensive worksite health promotion programs, the conceptual model may also apply to other types of complex health promotion programs. An organization-level theory of the determinants of effective implementation of worksite health promotion programs.

Workplace interventions for smoking cessation

BACKGROUND

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

OBJECTIVES

To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2008, MEDLINE (1966 - April 2008), EMBASE (1985 - Feb 2008) and PsycINFO (to March 2008). We searched abstracts from international conferences on tobacco and the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one author and checked by another. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

We include 51 studies covering 53 interventions in this updated review. We found 37 studies of workplace interventions aimed at individual workers, covering group therapy, individual counselling, self-help materials, nicotine replacement therapy and social support. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective. We also found 16 studies testing interventions applied to the workplace as a whole. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Incentive schemes increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting.

AUTHORS' CONCLUSIONS

1. We found strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include individual and group counselling and pharmacological treatment to overcome nicotine addiction. All these interventions show similar effects whether offered in the workplace or elsewhere. Self-help interventions and social support are less effective. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low.2. There was limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer.3. We failed to detect an effect of comprehensive programmes in reducing the prevalence of smoking.

Translating science to practice: community and academic perspectives

While evidence Reviews inform practice and policy guidelines, the gap between guidelines and implementation may be growing. We place dissemination and implementation Research in the context of other changes needed to drive Research into practice. Multilevel approaches to Research and dissemination are needed as are metrics to inform academic appointment and promotions. Moving beyond funding that stops and starts with grant cycles is a key issue from the community perspective to ensure continuity and improved health. Transdisciplinary approaches that cut across disciplinary boundaries to develop shared conceptual frameworks may help speed the integration of Research with practice. Identifying and implementing structural changes to develop and support transdisciplinary teams may further facilitate this process. Changes in the approaches used to structure and implement scientific advances into practice will help achieve the enormous potential to advance the health of the population.

Utilization of prevention research: searching for evidence

OBJECTIVE

Understanding the process of translating prevention research into practice calls for systematic efforts to assess the state of the published literature on the utilization of prevention research in public health programs and policy. This review describes the search strategy, methods, results, and challenges in identifying and reviewing literature relevant to this objective.

METHODS

Systematic searches of topics related to prevention research in literature published in 1995-2002 revealed 86 empiric articles in 12 public health areas.

RESULTS

A lack of uniform terminology, variation in publication sources, and limited descriptions of the stages of research utilization (e.g., adoption and implementation) in the published literature posed major challenges to identifying articles that met study criteria. Most accepted articles assessed the adoption or implementation of prevention research; four examined long-term sustainability. There was approximately equal distribution of reported research set in either health services or public health settings. Few of the articles contained search terms reflecting all four concept areas (prevention, public health, research, and use) targeted by the literature search.

CONCLUSIONS

Refining terms used in prevention research and research utilization could address lack of shared and unique definitions. Expanded reporting of research utilization stages in reports of prevention research could lead to improved literature searches and contribute to more successful adoption, implementation, and further use of prevention research products.

Adoption and implementation of strategies for diabetes management in primary care practices

BACKGROUND

Secondary and tertiary prevention of chronic illness is a major challenge for the United States healthcare system. Controlled studies show that interventions can enhance secondary prevention in primary care practices, but they shed little light on implementation of secondary prevention outside the experimental context. This study examines the adoption and implementation of an important set of secondary and tertiary prevention efforts--diabetes management strategies--for type 2 diabetes in the everyday clinical practice of primary care. It explores whether adoption and implementation processes differ by type of strategy or prevalence of diabetes among patients in the practice.

METHODS

Holistic case studies (those used to assess a single analytic unit, in this case, the physician group practice, as opposed to multiple embedded subunits) were conducted in 2001-2002 on six primary care practices in North Carolina identified from a statewide physician survey on strategies for diabetes management. Practices were selected by prevalence of diabetes and type of strategy for diabetes management--patient oriented (focused on self-management) versus biomedical (focused on secondary prevention practices). Results were derived from thematic analysis of interviews and secondary documents.

RESULTS

Adoption and implementation did not differ by diabetes prevalence or type of diabetes strategy. All practices had a routine forum for vetting new strategies, and most used traditional channels for identifying them. Implementation often required adaptation of the strategy and the organization. Sustained use of a diabetes strategy depended on favorable organizational policies and procedures (e.g., training, job redesign) and ongoing commitment of resources.

CONCLUSIONS

Diabetes management strategies are often complex and require adoption and implementation processes different from those described by classic innovation diffusion models. Alternative conceptual models that consider organizational process, structure, and culture are needed.

Diffusion of clean indoor air ordinances in the southwestern United States

The authors investigate the process through which clean indoor air ordinances were considered in 10 communities in the southwestern United States and key factors that influenced diffusion and adoption. Clean indoor air ordinances, which ban smoking in public places, were adopted in approximately 1,409 U.S. communities from 1986 to April 2004. The authors gathered data from 10 communities in New Mexico and Texas by means of face-to-face interview, e-mail, and telephone interviews and by analyzing archival materials. Important influences on the adoption or rejection of clean indoor air ordinances were (a) personal experiences of policy champions, (b) local framing of the ordinance as a public health issue versus as an economic/ business or an individual rights issue, and (c) interpersonal networks connecting a community to previously adopting communities. The policies that were adopted ranged in comprehensiveness, with each community of study reinventing model policies obtained from other communities.

Availability of smoking prevention and cessation services for childhood cancer survivors

OBJECTIVE

To characterize the smoking-related services available to childhood cancer survivors and describe organizational characteristics that were related to institutions' capacity to provide smoking services.

METHODS

Institutions affiliated with the Children's Oncology Group were surveyed from 2003 to 2004.

RESULTS

Of the 132 responding institutions, 85% assessed the smoking status of their cancer survivors intermittingly, but only 3% assessed smoking status at every visit, as recommended by the PHS guidelines. A minority of sites offered either smoking prevention (39%) or cessation (25%) services; 58% of sites had a mechanism in place to refer survivors for cessation services. In multivariate analyses, the most parsimonious model predicting capacity for smoking service delivery included barriers, respondents' attitudes, complexity, and institutional stability.

CONCLUSIONS

These data highlight an important need to improve the availability of smoking services for childhood cancer survivors. Additionally, these findings will inform the development of future interventions that are sensitive to barriers and facilitators to providing prevention services.

Participation rates in worksite-based intervention studies: health promotion context as a crucial quality criterion

Recently, a set of specific quality evaluation criteria for health promotion research has been proposed in this journal. One of the quality criteria identified is the 'health promotion context'. With this paper we would like to contribute to the dialogue by specifying the importance of this criterion on the basis of our on experience with worksite-based obesity prevention interventions. We advocate the reporting of participation rates among approached worksites in publications on worksite intervention effects. Such information will help to draw conclusions on the practical relevance of the shown effectiveness of the intervention. Health promotion practice is advised to adopt and disseminate evidence-based interventions, accompanied by a diffusion study with a minimal research burden for participants.

Factors related to participatory employee advisory boards in small, blue-collar worksites

PURPOSE

To identify factors related to formation, participation, and characteristics of employee advisory boards (EABs) in blue-collar worksites.

DESIGN

This study used a nonexperimental qualitative design to assess EAB formation, activity, and enthusiasm levels and examined those factors relative to employee participation in worksite-wide health promotion activities.

SETTING

Twenty-two blue-collar worksites with a total of 113 EAB members in the greater Seattle area.

SUBJECTS

Individuals who agreed to serve on EABs in the intervention worksites.

INTERVENTION

Participants received training in involving employees in the 5-A-Day project intervention activities.

MEASURES

Measures include type of worksite, number of EAB members, method of EAB recruitment, and variables describing EAB functioning, including attendance at meetings, assistance at project activities, and level of enthusiasm.

RESULTS

All worksites formed EABs. There was no association between the way the EAB was formed and subsequent EAB attendance at meetings, participation in project activities, representativeness of the EAB, or level of EAB enthusiasm. Enthusiasm of the EAB was associated with employee participation, and EABs with a higher level of enthusiasm showed more participation by employees than worksites with less enthusiastic EABs.

CONCLUSIONS

It is possible to develop participatory structures in small, blue-collar worksites. More information is needed about factors related to levels of enthusiasm of EABs.

Workplace interventions for smoking cessation

BACKGROUND

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

OBJECTIVES

To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register in October 2004, MEDLINE (1966 - October 2004), EMBASE (1985 - October 2004) and PsycINFO (to October 2004). We searched abstracts from international conferences on tobacco and we checked the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

We categorized interventions into two groups: a) Interventions aimed at the individual to promote smoking cessation and b) interventions aimed at the workplace as a whole. We applied different inclusion criteria for the different types of study. For interventions aimed at helping individuals to stop smoking, we included only randomized controlled trials allocating individuals, workplaces or companies to intervention or control conditions. For studies of smoking restrictions and bans in the workplace, we also included controlled trials with baseline and post-intervention outcomes and interrupted times series studies.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one author and checked by two others. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

Workplace interventions aimed at helping individuals to stop smoking included ten studies of group therapy, seven studies of individual counselling, nine studies of self-help materials and five studies of nicotine replacement therapy. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective.Workplace interventions aimed at the workforce as a whole included 14 studies of tobacco bans, two studies of social support, four studies of environmental support, five studies of incentives, and eight studies of comprehensive (multi-component) programmes. Tobacco bans decreased cigarette consumption during the working day but their effect on total consumption was less certain. We failed to detect an increase in quit rates from adding social and environmental support to these programmes. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Competitions and incentives increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting.

AUTHORS' CONCLUSIONS

We found: 1. Strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include advice from a health professional, individual and group counselling and pharmacological treatment to overcome nicotine addiction. Self-help interventions are less effective. All these interventions are effective whether offered in the workplace or elsewhere. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low. 2. Limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer. 3. Consistent evidence that workplace tobacco policies and bans can decrease cigarette consumption during the working day by smokers and exposure of non-smoking employees to environmental tobacco smoke at work, but conflicting evidence about whether they decrease prevalence of smoking or overall consumption of tobacco by smokers. 4. A lack of evidence that comprehensive approaches reduce the prevalence of smoking, despite the strong theoretical rationale for their use. 5. A lack of evidence about the cost-effectiveness of workplace programmes.

Lessons learned from community-based cancer screening intervention research

Behaviors associated with cancer screening have been the focus of intensive research over the past 2 decades, primarily in the form of intervention trials to improve screening based in both clinical and community settings. Meta-analyses and literature reviews have synthesized and organized the resulting literature. From the accumulated work, this review distilled lessons learned from cancer screening intervention research in community settings. The authors posed the question, "What do we know about the development of effective community-based interventions (the level of good over harm achieved in real-world conditions)?" Framed around the concept of focal points (the simultaneous combination of target population, behavioral objective, and setting for an intervention), 13 lessons were derived. One lesson was cross-cutting, and the other lessons addressed the three focal-point components and the major intervention categories (access-enhancing strategies, mass media, small media, one-on-one and small-group education, and combinations of these categories). To build more systematically on existing research, recommendations are made for new directions in basic behavioral and intervention research.

Reducing occupation-based disparities related to tobacco: roles for occupational health and organized labor

BACKGROUND

Persistent and growing occupation-based disparities related to tobacco pose a serious public health challenge. Tobacco exacts a disproportionate toll on individuals employed in working class occupations, due to higher prevalence of smoking and exposure to secondhand smoke among these workers compared to others.

METHODS

We provide an overview of recent advances that may help to reduce these disparities, including research findings on a successful social contextual intervention model that integrates smoking cessation and occupational health and safety, and a new national effort to link labor unions and tobacco control organizations around their shared interest in reducing tobacco's threat to workers' health.

CONCLUSIONS

Implications of these efforts for future research and action are discussed.

Reducing social disparities in tobacco use: a social-contextual model for reducing tobacco use among blue-collar workers

In the United States in 1997, the smoking prevalence among blue-collar workers was nearly double that among white-collar workers, underscoring the need for new approaches to reduce social disparities in tobacco use. These inequalities reflect larger structural forces that shape the social context of workers' lives. Drawing from a range of social and behavioral theories and lessons from social epidemiology, we articulate a social-contextual model for understanding ways in which socioeconomic position, particularly occupation, influences smoking patterns. We present applications of this model to worksite-based smoking cessation interventions among blue-collar workers and provide empirical support for this model. We also propose avenues for future research guided by this model.

Challenges to improving the impact of worksite cancer prevention programs: comparing reach, enrollment, and attrition using active versus passive recruitment strategies

OBJECTIVE

The impact of worksite intervention studies is maximized when reach and enrollment are high and attrition is low. Differences in reach, enrollment, and retention were investigated by comparing 2 different employee recruitment methods for a home-based cancer-prevention intervention study.

METHODS

Twenty-two worksites (N = 10,014 employees) chose either active or passive methods to recruit employees into a home-based intervention study. Reach (e.g., number of employees who gave permission to be called at home), Enrollment (e.g., number of employees who joined the home intervention study), and Attrition (e.g., number who did not complete the 12- and 24-month follow-ups) were determined. Analysis at the cluster level assessed differences between worksites that selected active (n = 12) versus passive (n = 10) recruitment methods on key outcomes of interest. Employees recruited by passive methods had significantly higher reach (74.5% vs. 24.4% for active) but significantly lower enrollment (41% vs. 78%) and retention (54% vs. 70%) rates (all ps < .0001). Passive methods also successfully enrolled a more diverse, high-risk employee sample. Passive (vs. active) recruitment methods hold advantages for increased reach and the ability to retain a more representative employee sample. Implications of these results for the design of future worksite studies that involve multilevel recruitment methods are discussed.

Ethical dilemmas and human rights considerations arising from the evaluation of a smoking policy in a health promoting setting

One of the key challenges in managing the Health Promoting Workplace is the development of an effective policy for the control of environmental tobacco smoke (ETS). This paper explores the ethical consequences raised when the implementation of such a policy was evaluated in a large multi-campus university. In a three-stage evaluation, the first stage involved a qualitative enquiry with the Health and Safety Committee to obtain the management perspective on the working of the policy. A survey of the perception of the ETS policy and smoking behaviours with a representative sample of staff and students constituted the second stage. In the final stage the Health and Safety Committee was engaged with the findings of stages 1 and 2 to develop a response to the evaluation. The ethical implications which arise from this evaluation centre, firstly, on the underlying reasons for undertaking an evaluation. Secondly, consideration is given to the consequences of applying utilitarian principles to smoking policy for the minority who smoke and thus find their work or study patterns affected by a smoking ban. Such a ban limits their autonomy and while it may be helpful (beneficent) in terms of their longer-term physical health, it may have harmful (maleficent) effects on their psychological wellbeing and the potential for negative consequences if they choose to contravene the ban on smoking. The implications of addressing this situation are explored.

Making youth tobacco control programs more ecological: organizational and professional profiles

PURPOSE

To identify the organizational and professional correlates of the integration of the ecological approach in Canadian public health organizations' tobacco control programs for youth.

DESIGN

Cross-sectional survey.

SETTING

Canadian public health organizations.

SUBJECTS

One hundred and ten tobacco control programs implemented in 90 organizations. The response rate for the organizations was 87%.

MEASURES

Descriptions of programs were obtained by telephone interviews. An analytical procedure was applied to the program data to identify intervention settings, targets and strategies for each program. Using this information, a summary score of the integration of the ecological approach was estimated for each program. Organizational and professional variables were assessed by self-administered questionnaires to managers and professionals involved in these programs.

RESULTS

The level of integration of the ecological approach in programs was related to organizational (frequency of contacts and collaborations with external partners, team composition) and extraorganizational factors (size of the city in which the public health unit is located). Cognitive attributes of the practitioners (knowledge and beliefs) also emerged as significant predictors. Finally, positive associations were observed between practitioners' personal characteristics (educational achievement, working status in health promotion [full vs. part-time], previous experience, gender, and disciplinary/professional background) and cognitive predictors.

CONCLUSIONS

Organizational environment and staff preparation play a critical role in the adoption of the ecological approach in tobacco control programs.

Using theory to understand the multiple determinants of low participation in worksite health promotion programs

Low participation at the employee or worksite level limits the potential public health impact of worksite-based interventions. Ecological models suggest that multiple levels of influence operate to determine participation patterns in worksite health promotion programs. Most investigations into the determinants of low participation study the intrapersonal, interpersonal, and institutional influences on employee participation. Community- and policy-level influences have not received attention, nor has consideration been given to worksite-level participation issues. The purpose of this article is to discuss one macrosocial theoretical perspective--political economy of health--that may guide practitioners and researchers interested in addressing the community- and policy-level determinants of participation in worksite health promotion programs. The authors argue that using theory to investigate the full spectrum of determinants offers a more complete range of intervention and research options for maximizing employee and worksite levels of participation.

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

BACKGROUND AND OBJECTIVES

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

RESEARCH DESIGN

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

RESULTS

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

CONCLUSION

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