Abstract
BACKGROUND:
Workplace smoking cessation programs can effectively assist employees to quit smoking. However, little is known about employees’ attitudes towards engagement in workplace smoking cessation programs.
OBJECTIVE:
This study aimed to address the limited understanding of the interaction between employee characteristics and their health beliefs toward engaging in a workplace smoking cessation program.
METHODS:
Self-report data was collected from 897 employees of a mining company operating in two remote towns in Australia. The majority of participants were male (73%), the mean age was 36.9 years (SD = 11.5). Chi square tests of independence were used to analyze relationships between employee characteristics and smoking cessation engagement attitudes. Engagement attitudes included: A desire to cease smoking; desire for assistance with the smoking cessation process; and intention to participate in a workplace smoking intervention.
RESULTS:
The findings from this study indicated that attitudes towards engagement in smoking cessation programs varied for mining employees according to gender, age, perceived severity, perceived self-efficacy, and stage of readiness to change.
CONCLUSIONS:
These findings provide insights that health promotion practitioners may apply to inform the design and marketing of effective workplace smoking cessation programs for similar employees.
Keywords
Introduction
Tobacco related disease and illness has been linked to the premature death of approximately 6 million people each year and costs the global economy in excess of half a trillion dollars through lost productivity and excess health-care [1]. Smoking increases the risk of chronic health conditions including: ischemic heart disease; stroke, type 2 diabetes; kidney disease; arthritis; osteoporosis; lung cancer; chronic obstructive pulmonary disease; asthma; and oral health [2]. Smokers can reduce most of their excess health risk by quitting smoking. Although greater health benefits are associated with ceasing smoking at younger ages rather than older ages, smoking cessation at any age is associated with meaningful increases in life expectancy [3, 4].
The majority of tobacco users who comprehend the health risks associated with tobacco use report a desire to cease smoking [4]. Participation in cessation interventions has been shown to result in substantially increased cessation rates [5]. Considerable research has investigated the efficacy of smoking cessation interventions. A recent comparison of intervention efficacy for programs targeting cessation of tobacco use in heavy smokers found higher rates of cessation are achieved for male participants in workplace cessation programs after one and six months compared to age-matched males who participated in a tobacco cessation clinic program [6]. In a synthesis of reviews and meta analyses, Fishwick and colleagues [7] concluded that effective smoking cessation interventions were likely to facilitate cessation regardless of whether they were implemented in clinical settings or workplaces. However, benefits associated with workplace based interventions, rather than clinical settings include: access to a large group of program participants; peer support; access to health and safety professionals to facilitate program delivery; and potential to opportunistically target males who traditionally have low rates of general practitioner consults [7, 8].
Based on consistent findings reported across several reviews and meta-analyses [7, 10], moderate evidence exists to suggest that the following interventions were effective in achieving smoking cessation when delivered in the workplace: pharmacological therapy, individual counseling and group behavioral interventions. Given the strong empirical support for the efficacy of workplace-based interventions to assist participants in smoking cessation, further research is required to determine how to encourage tobacco users to enroll and participate in smoking cessation programs. In a review of 11 studies of worksite-based smoking cessation programs, Leeks and colleagues[11] identified that the median program participation rate for eligible smokers was 28% (ranged from 12% to 84%).
Fishwick [7] reviewed 15 studies that investigated barriers to participation in workplace smoking cessation programs and found relatively robust evidence exists to conclude that efficacy of a workplace-based program, regardless of the type of tobacco cessation intervention, was strongly influenced by employees’ degree of readiness to cease smoking. Acceptable and convenient interventions were typically only effective when employees were personally ‘ready to change’. Based on this conclusion, it is critical to understand the factors that contribute to an individual’s readiness and willingness to participate in workplace smoking cessation programs. Individual contributing factors may include employee characteristics and beliefs. Knowledge of the contributing factors to program enrolment may be used to inform the design of scientifically valid client-centered workplace smoking cessation interventions that will encourage participation.
Employee characteristics related to workplace health program engagement
Previous research has revealed employee characteristics including: gender; age; lifestyle risk; and work absence, are related to levels of personnel engagement in broad workplace health promotion programs [12–15]. Several studies have found female employees to be more likely than male employees to enroll in corporate wellness programs [12–15]. Older rather than younger employees were typically more likely to engage in health coaching programs, although this has varied between organizations [12, 16]. A higher lifestyle risk level, determined by the number and severity of health risks, has also been identified as a significant predictor of enrolment in workplace wellness programs [12]. Participation in health and wellness programs has also been found to be associated with a reduced rate of work absence [17, 18]. The current study will investigate whether the predictors of workplace health program enrolment (gender, age, and absenteeism) apply to workplace smoking cessation program engagement.
Employee beliefs related to workplace health program engagement
Given that employee beliefs have been linked to voluntary smoking cessation program participation [7] the current study will compare two theoretical models related to health behavior change in order to identify key employee attitudes associated with engagement in workplace smoking cessation programs. Firstly, the Health Belief Model (HBM) may be applied to predict individual’s health behaviors [19–21]. The HBM posits that adoption of a health behavior relies on: (1) Perceived susceptibility of personally developing an illness or disease; (2) Perceived benefits for engaging in the behavior change; (3) Perceived barriers to engaging in the behavior change; (4) Perceived severity of the health problem for the individual; and (5) Self-efficacy representing the individual’s belief in their ability to perform the necessary behavioral change. In a meta-analysis using the health belief model to predict the change of health behaviors Carpenter (2010) reported perceived severity, barriers, and benefits were the most accurate predictors of behavioral change [22].
Secondly the Stages of Change model (which forms part of the broader Transtheoretical Model of Behavior Change) may be applied to predict individual’s readiness to change smoking behavior to achieve cessation [23, 24]. The model outlines six stages through which an individual progresses in readiness to change, including: pre-contemplation; contemplation; preparation; action; maintenance; and termination. Empirical studies have shown that that individual smokers vary in their readiness to cease smoking [25, 26]; and that readiness is positively correlated with cessation program enrolment and efficacy. For example, in a study by Biener and Abrams, employees who reported as thinking about changing their smoking patterns or taking action to quit smoking were more likely to cease smoking than employees who were not thinking about quitting smoking to enroll in a worksite smoking cessation program [27]. Additionally, smoking cessation communication tailored to an individual’s current stage of change has been found to be more effective in progressing an individual’s stage of readiness than non-matched communication [28].
Thus, empirical research suggests that the Health Belief Model and Stages of Change Model may provide insight to employee attitudes that are associated with engagement in a workplace smoking cessation intervention. In order to ensure health promotion programs for smoking cessation are appropriately targeted, this study will assess employee characteristics and beliefs that are most likely to predict an individual’s intention and desire to participate in a workplace smoking cessation program.
Method
Study design
This study was conducted as part of a larger health research project and received ethical clearance from the Uniting Care Health Human Research Ethics Committee (#2013.03.74). The study design adopted was cross-sectional.
Participants
Employees from two mining sites located in rural Australia were invited to participate in a survey. An a priori power analysis indicated that a total of 721 employees were required to participate in the health survey to achieve 80% power for detecting a medium sized effect (OR = 1.30) when employing the traditional 0.05 criterion of statistical significance [29]. A total of 897 workers voluntarily reported personal health and smoking data. Consistent with the organizations workforce demographics, the majority of participants were male (73%). The mean age of participants was 36.9 years(SD = 11.5).
Measures
Employee characteristics
Measures of age, gender, and health status replicated items from Government surveys [30, 31]. Health status response options included: ‘Excellent’; ‘Very good’; ‘Good’; ‘Fair’; or ‘Poor’. Survey items based on established Government and World Health Organization (WHO) measures of absenteeism and smoking status were condensed due to organizational time restrictions [30, 32]. Absenteeism was measured by ‘how many days in the last 4 weeks have you stayed away from work for more than half a day because of any illness or injury?’ Smoking status was measured by ‘how often do you currently smoke?’ Response options included: ‘Daily’; ‘At least weekly’; ‘Less often than weekly’; ‘I don’t currently smoke cigarettes or any tobacco products’; ‘I have NEVER smoked cigarettes or any tobacco products’.
Health beliefs
Due to time and survey length restrictions imposed by the mining organization, each health belief construct was measured by a single item. To increase the probability of capturing all relevant components of each construct and to reduce measurement error, the development of health belief measures was guided by construct definitions consistent with theoretical constructs [19, 33]. Items to assess the Health Belief Model constructs of severity, susceptibility, barriers, benefits, and self-efficacy were replicated from previous research that measured employees’ health beliefs [34]. Participants were presented with the list of health belief statements and asked to indicate the option that best described their opinion. For example, ‘My current behavior and lifestyle puts me at risk of getting a poor health condition or disease’ (susceptibility). Dependent variable outcomes were measured using a five-point Likert scale that ranged from one representing ‘strongly disagree’ to five representing ‘strongly agree’.
Stage of change
Employees’ stage of change was measured using a smoking adaptation of a single item measure that has previously been used to measure employees’ stage of change for sun protection and healthy weight behaviors [34, 35]. Participants were asked to select one of five statements in response to the following question. ‘How would you describe your approach to smoking?’ Response option statements were developed based on the transtheoretical model stage of change descriptions [36] and matched the five stages of precontemplative, contemplative, preparation, action, and maintenance. More specifically, smoking stage of change was measured by the selection of one of the following statements: precontemplative. “As far as I’m concerned my smoking habits don’t need changing”; contemplative “I’m seriously intending to reduce my smoking habits in the next 6 months”; preparation “I have definite plans to reduce my smoking”; action “I am doing something to reduce my smoking”; and maintenance “I took action more than 6 months ago to reduce my smoking and I’m working hard to maintain that change”.
Smoking cessation attitudes
Preference for an individual’s management of future smoking intentions, included: a desire to quit smoking; a desire for assistance with reducing or quitting smoking; and an intention to participate in smoking cessation programs. These measures were based on established Government and WHO survey items [30, 32].
Procedure
Due to organizational constraints it was not possible to randomly select individual employees throughout the company. Instead, three working units across two sites were nominated by the organization with the goal of obtaining a representative sample of employees. The study was advertised via information posters and announcements by mangers at daily work group meetings. All employees who were members of the selected work units and present during the data collection period were invited by a member of the research team to participate in a confidential survey. No other criterion was applied for participant selection. Managers were not aware of which employees voluntarily participated.
Data were screened for accuracy. One-way ANOVAs were used to test for demographic differences between current smokers and non-smokers. Chi square tests of independence were used to analyze relationships between independent variables and cessation preferences. All statistical test assumptions were met with the exception of a sufficient sample size for many of the planned chi-square tests. Two-tailed Fisher’s exact tests were conducted for all tests where the expected frequencies in each cell were below five. Standardized residuals were assessed to establish significant associations. An alpha level of 0.05 was used for all statistical tests. Significant associations are presented in tables.
Results
Of the 881 employees who reported their current smoking status, 23 percent reported smoking cigarettes or other tobacco products. This included: daily (20%); at least weekly (3%); and less often than weekly (1%). Seventy-six percent of participants identified as non-smokers. This included: not currently smoking (34%); and never having smoked (42%). The demographic distribution of the 204 employees that identified themselves as currently smoking at least weekly was consistent with the overall workforce sample of 897 employees. A majority of the current smokers were male (73%). The mean age of current smokers was 36.4 years (SD = 11.3). One-way ANOVAs were used to test for demographic differences between current smokers and non-smokers. Self-reported quality of life did not differ between the current smokers and non-smokers F(1, 874) = 0.16, p = 0.680. A majority of the current smokers (88%) perceived their current overall health status positively. Self-reported days absent from work in the last four weeks did not differ between the current smokers and non-smokers F(1, 820) = 0.670, p = 0.410. More specifically, 80 percent of current smokers reported no work absence for more than half a day because of any illness or injury. Thirteen percent reported one day of work absence and four percent reported two days of work absence. The remaining three percent of the current smokers reported work absences ranging from three to 14 days.
Desire to quit smoking
Within the sample of current smokers, 87 percent reported wanting to stop smoking. A series of chi-square tests of independence were performed to examine the relationships between demographic and health variables and a smoker’s preferences for ceasing smoking. A significant association between gender and preference for quitting smoking was identified, χ 2 (1, N= 204) = 7.09, p = 0.011, φ= –0.186. As can be seen by the frequencies cross tabulated in Table 1, based on the odds ratio, the odds of smokers wanting to cease smoking were 2.98 times higher if they were male than if they were female. The percentage of employees reporting a preference for quitting smoking did not differ by age group (p = 0.177, two-tailed Fisher’s exact test), or current overall health status (p = 0.174, two-tailed Fisher’s exact test). Work days absent approached significance, (p = 0.051, two-tailed Fisher’s exact test), however, the only cell that had a standardized residual above 1.96 consisted of one participant, who had 14 days off work due to illness, more than twice the number of days than the participant with the second most sick days.
Current smokers gender and their preference for ceasing smoking and for assistance with reducing or quitting smoking
Current smokers gender and their preference for ceasing smoking and for assistance with reducing or quitting smoking
Note. Standardized residuals are displayed in parentheses beside observed percentages.
A significant association was identified between smokers who reported a desire to cease smoking and their reported stage of change (p < 0.001, two-tailed Fisher’s exact test, Cramer’s V = 0.621). Sixty-nine percent of smokers who did not want to cease smoking reported being in the pre-contemplative phase of readiness for behavior change. As can be seen in Table 2, both pre-contemplative stage of change cells had standardized residuals greater than 1.96. This indicates pre-contemplative employees were significantly less likely than expected to want to cease smoking and significantly more likely than expected to not want to cease smoking. By comparison, the majority of smokers who did want to cease smoking reported being in the mid phases of readiness for behavior change, with 32 percent contemplating reducing their smoking, 27 percent planning to reduce their smoking, and 19 percent acting to reduce their smoking. The frequencies cross-tabulation in Table 2 revealed the likelihood of wanting to cease smoking was high for smokers at all stages of readiness for behavior change except the pre-contemplative phase.
Current smokers preference for ceasing smoking and their reported stage of change
Note. Standardized residual frequencies are displayed in parentheses below observed percentages.
The percentage of smokers reporting a desire to cease smoking did not differ with regard to the health belief model constructs of perceived: susceptibility (p = 0.993, two-tailed Fisher’s exact test); benefits (p = 0.249, two-tailed Fisher’s exact test); barriers (p = 0.736, two-tailed Fisher’s exact test); and self-efficacy (p = 0.964, two-tailed Fisher’s exact test). However, there was a significant association between reported cessation preference and perceived severity (p = 0.026, two-tailed Fisher’s exact test, Cramer’s V = 0.23). As can be seen in Table 3, standardized residuals indicate that participants who were unsure about the statement ‘A poor health condition or disease resulting from my current behaviors and lifestyle are likely to be severe’ were more likely than expected to not want to cease smoking, while those who agreed with the statement were less likely to not want to cease smoking. Moreover, 29 percent of smokers who wanted to cease smoking reported agreeing that their current behaviors and lifestyle could result in a severe health condition.
Current smokers agreement with the belief that a poor health condition or disease resulting from my current behaviors and lifestyle are likely to be severe and their preference for ceasing smoking, assistance and intending to participate in a smoking cessation program
Note. Standardized residual frequencies are displayed in parentheses beside observed percentages.
Within the sample of current smokers, 31 percent reported wanting assistance with reducing or quitting smoking. A series of chi-square tests of independence were performed to examine the relationships between demographic and health variables and smokers’ desires for assistance with reducing or quitting smoking. There was a significant association between gender and preference for assistance with reducing or quitting smoking (p = 0.027, two tailed Fisher’s exact test, φ= 0.161). As can be seen in Table 1, the odds of employees wanting assistance were 2.08 times higher for females than for males. A significant association was also identified between age group and preference for assistance with reducing or quitting smoking, (p = 0.027, two-tailed Fisher’s exact test, Cramer’s V = 0.223). Table 4 shows that reported wanting assistance with smoking reduction was significantly lower than expected for smokers aged 24 years and younger. The percentage of employees reporting a preference for assistance did not differ with regards to current overall health (p = 0.771, two-tailed Fisher’s exact test) or work days absent (p = 0.208, two-tailed Fisher’s exact test).
The percentage of smokers reporting wanting assistance did not differ with regards to their reported stage of change (p = 0.328, two-tailed Fisher’s exact test) or the health belief model constructs of perceived: susceptibility (p = 0.117, two-tailed Fisher’s exact test); benefits (p = 0.238, two-tailed Fisher’s exact test) and barriers, (p = 0.238, two-tailed Fisher’s exact test). However, there was a significant association between reported preference for assistance and perceived severity (p = 0.001, two-tailed Fisher’s exact test, Cramer’s V = 0.323). Eighty-three percent of smokers who did not want assistance reported not agreeing with the perceived severity statement. By comparison, 45 percent of smokers who desired assistance reported agreeing that their behaviors and lifestyle could result in a severe health condition.As shown in Table 3, reporting wanting assistance was highest (68.4%) for smokers who strongly believed that health conditions resulting from their behaviors would be severe. A significant association was also identified between assistance preference and perceived self-efficacy, (p < 0.041, two-tailed Fisher’s exact test, Cramer’s V = 0.23). Seventy-eight percent of smokers who did not want assistance agreed with the statement ‘I am able to successfully choose healthy lifestyle options’. Similarly, 68 percent of smokers who did want assistance agreed that they can choose healthy lifestyle options. As revealed by the standardized residuals in Table 5, wanting assistance was significantly higher (R > 1.96) for smokers who disagreed with the self-efficacy statement.
Current smokers age group and their preference for assistance in reducing or ceasing smoking
Current smokers age group and their preference for assistance in reducing or ceasing smoking
Note. Standardized residuals are displayed in parentheses beside observed percentages.
Current smokers agreement with the belief that I am able to successfully choose healthy lifestyle options and their preference for assistance in reducing or ceasing smoking
Note. Standardized residual frequencies are displayed in parentheses beside observed percentages.
Within the sample of current smokers, 20 percent reported that they would participate in a smoking cessation program if it was made available to staff and their family members. A series of chi-square tests of independence were performed to examine the relationships between demographic and health variables and smokers’ intentions to participate in a smoking cessation program. The percentage of employees reporting an intention to participate in a smoking cessation program did not differ by gender χ 2 (1, N = 203) = 3.70, p = 0.054, φ= 0.135), age group (p = 0.083, two-tailed Fisher’s exact test), current overall health status (p = 0.105, two-tailed Fisher’s exact test), or work days absent (p = 0.864, two-tailed Fisher’s exact test).
The percentage of smokers reporting participation intentions did not differ with regards to their reported stage of change (p = 0.392, two-tailed Fisher’s exact test) or the health belief model constructs of perceived: susceptibility (p = 0.061, two-tailed Fisher’s exact test); benefits (p = 0.274, two-tailed Fisher’s exact test); barriers (p = 0.797, two-tailed Fisher’s exact test); or self-efficacy (p = 0.074. two-tailed Fisher’s exact test). A significant association was found between smokers’ participation intentions and perceived severity of a condition resulting from smoking (p = 0.004, two-tailed Fisher’s exact test, Cramer’s V = 0.29). Eighty percent of smokers who did not intend to participate in a cessation program reported disagreement with the perceived severity statement. Comparatively, 50 percent of smokers who intended to participate reported agreeing with the severity statement. As can be seen from the standardized residuals in Table 3, intention to participate was significantly higher for smokers who agreed that health conditions resulting from their behaviors would be severe (R > 1.96).
Discussion
The majority of employees who identified themselves as smokers reported a desire to cease smoking tobacco within 12 months. Despite this, only one third of the smokers reported wanting assistance with cessation, and one fifth of smokers indicated an intention to participate in a workplace smoking cessation intervention. This may indicate that some employees are interested in, but not currently ready to, cease smoking tobacco; or that some employees would prefer to privately manage their cessation rather than accept assistance provided through their workplace.
Although males were more likely than females to report wanting to cease smoking, they were less likely than females to show an interest in assistance in achieving this aim, and while it just failed to reach significance, males intentions to participate in smoking cessation programs were similarly lower than females. This finding that males were less interested in participating in a corporate health promotion program is consistent with previous research conducted by Grossmeier (2013) which included employers from a range of industries such as retail, education, finance, utility and manufacturing [12]. With the addition of the mining sample in the current study, there appears to be considerable support for the finding that male employees were less likely to desire to quit smoking, or to privately manage their smoking cessation [12]. However, contrary to findings by Grossmeier (2013), age was not found to be significantly related to program participation intent [12]. Instead, age was only significantly related to the likelihood of wanting assistance to reduce smoking in the mining sample.
In contrast to the findings by Klesges and colleagues (1998) that identified perceived susceptibility to a health condition as a significant predictor of participation in a workplace smoking cessation program [37], the current study found that perceived susceptibility was not significantly related to smoking cessation engagement attitudes. However, perceived severity of a health condition and self-efficacy were found to be related to smoking cessation engagement attitudes. The likelihoods of wanting to cease smoking, wanting assistance, and intending to participate, were all higher for smokers who believed that health conditions would be severe in comparison to smokers who believed that health conditions would not be severe. Contrary to previous research findings that identified that the higher an individual’s self-efficacy was the more likely they were to participate in a cessation program [38], the current study found that preference for wanting to cease smoking and intention to participate in a workplace smoking cessation intervention did not differ with regards to perceived self-efficacy. Self-efficacy was only significantly related to preference for assistance with reducing or ceasing smoking. The finding that the likelihood of wanting assistance was highest for smokers who identified that they were not personally able to successfully choose healthy lifestyle options could indicate that smokers who had higher self-efficacy may have believed that they were able to independently cease smoking.
Consistent with previous research conducted by Biener and Abrams (1991), the current study found that the likelihood of wanting to cease smoking was high for smokers at all stages of readiness except those in the pre-contemplative stage [27]. Preference for wanting assistance with smoking cessation and intention to participate in a workplace smoking cessation intervention did not differ with regards to reported stage of change. This finding may suggest that although many employees in the pre-contemplation stage did not want to cease smoking immediately, they were not less likely than other employees to intend to participate in a smoking cessation program. Therefore, stage of change was not a useful indicator in this sample for targeting employees for smoking cessation program engagement.
Given the cross-sectional methodology and single industry workforce sample in the current study, it is unclear whether these findings can be generalized to workforces outside of the mining industry. Further research should progress this area of investigation using a longitudinal design, randomization techniques, a more diverse workforce sample, and include program enrolment and program completion outcome measures.
Conclusion
Although previous research has identified that corporate smoking cessation programs can assist employees in successfully ceasing smoking [8, 40], empowering employees to enroll in smoking cessation programs continues to provide a challenge for workplace health practitioners. In the current study, only 20 percent of smokers reported an intention to participate in a workplace smoking cessation intervention if it was made available to staff and their family members. In order to facilitate employee enrolment in corporate smoking cessation interventions, it is necessary to understand the relationship between employee variables and smoking cessation intentions. The current study found that employee attitudes towards engagement in smoking cessation varied according to gender, age, perceived severity of a health condition, perceived self-efficacy and stage of readiness to change. However, only perceived severity was significantly associated with intention to participate in a workplace smoking cessation program.
Importantly, the current research provides insight into how employee characteristics and health belief variables are related to intention to participate in a corporate smoking cessation program. Based on the findings it is recommended that practitioners target the promotion of smoking cessation programs to increase enrolment by employees who are at risk of tobacco related disease and unlikely to voluntarily participate in cessation strategies. More specifically, care should be taken to ensure that program promotion: is appropriate for engaging males; communicates the severity of health conditions associated with smoking tobacco; and that smoking cessation programs support and empower employees to successfully cease smoking behaviors. Health promotion practitioners should apply these recommendations to inform the design and marketing of smoking cessation programs to meet the needs of employees and to increase corporate program participation in male dominated workforces similar to the mining industry.
Conflict of interest
None to report.
Footnotes
Acknowledgments
The authors wish to acknowledge the generous corporate and community supporters who donated to Wesley Medical Research to advance health and medical research and fund this research.