Introduction

Over the last few decades, the health risk appraisal (HRA), also known as a health hazard appraisal or a health risk assessment, has become increasingly popular, primarily in the United States, as an instrument for promoting health awareness and motivating behavioral change. It is also used as an introduction to periodic health screening or as a substitute for it and, when aggregated for a group of individuals, as the basis for identifying targets for a health education or health promotion program to be designed for them. It is based on the following concept:

• Ostensibly healthy, asymptomatic individuals may be at risk of developing a disease process that can cause morbidity in the future and may lead to premature death.
• Factors that lead to such risk can be identified.
• Some of those risk factors can be eliminated or controlled thereby preventing or attenuating the disease process and preventing or delaying the morbidity and mortality.

The development of the HRA in the 1940s and 1950s is credited to Dr. Lewis Robbins, working at the Framingham prospective study of heart disease and later at the National Cancer Institute (Beery et al. 1986). The 1960s saw additional models developed and, in 1970, Robbins and Hall produced the seminal work that defined the technique, described the survey instruments and the risk computations, and outlined the patient feedback strategy (Robbins and Hall 1970).

Interest in HRA and health promotion in general was stimulated by a growing awareness of the importance of risk factor control as a basis element in health promotion, the evolving use of computers for data compilation and analysis and, especially in the United States, increasing concern over the escalating cost of health care and the hope that preventing illness might slow its upward spiral of growth. By 1982, Edward Wagner and his colleagues at the University of North Carolina were able to identify 217 public and private HRA vendors in the United States (Wagner et al. 1982). A good many of these have since faded from the scene but they have been replaced, at least to a limited extent, by new entrants into the marketplace. According to a 1989 report of a survey of a random sample of US worksites, 29.5% have conducted HRA activities; for worksites with more than 750 employees, this figure rose to 66% (Fielding 1989). HRA use in other countries has lagged considerably.

What is the HRA?

For purposes of this article, an HRA is defined as a tool for assessing health risks that has three essential elements:

1. A self-administered questionnaire inquiring about the individual’s demographic profile, medical background, family history, personal habits and lifestyle. This information is frequently supplemented by biomedical measurements such as height, weight, blood pressure, and skin-fold thickness, and data regarding the results of urinalysis, blood cholesterol level and other laboratory tests, either as reported by the individual or taken as part of the process.
2. A quantitative estimation of the individual’s future risk of death or other adverse outcomes from specific causes based on a comparison of the individual’s responses to epidemiological data, national mortality statistics and actuarial calculations. Some questionnaires are self-scored: points are assigned to the response to each question and then added to derive a risk score. With the appropriate computer software, the responses may be entered into a microcomputer that will calculate the score. Most often the completed questionnaires are forwarded to a central point for batch processing and the individual results are mailed or delivered to the participants.
3. Feedback to the individual with suggestions for changes in lifestyle and other actions that would improve well-being and reduce the risk of disease or premature death.

Originally, the total risk estimate was presented as a single number that could be targeted for reduction to a “normal” value or even to lower-than-normal values (vis-à-vis the general population) by implementing the suggested behavioral changes. To make the results more graphic and compelling, the risk is now sometimes expressed as a “health age” or “risk age” to be compared with the individual’s chronological age, and an “achievable age” as the target for the interventions. For example, a report might say, “Your present age is 35 but you have the life expectancy of a person aged 42. By following these recommendations, you could reduce your risk age to 32, thereby adding ten years to your projected life span.”

Instead of comparing the individual’s health status with the “norm” for the general population, some HRAs offer an “optimal health” score: the best attainable score that might be achieved by following all of the recommendations. This approach appears to be particularly useful in guiding young people, who may not yet have accumulated significant health risks, to an optimally desirable lifestyle.

The use of a “risk age” or a single number to represent the individual’s composite risk status may be misleading: a significant risk factor may be statistically offset by “good” scores on most other areas and lead to a false sense of security. For example, a person with normal blood pressure, a low blood cholesterol level, and a good family history who exercises and wears automobile seat belts may earn a good risk score despite the fact that he smokes cigarettes. This suggests the desirability of focusing on each “greater than average” risk item instead of relying on the composite score alone.

The HRA is not to be confused with health status questionnaires that are used to classify the eligibility of patients for particular treatments or to evaluate their outcomes, nor with the variety of instruments used to assess degree of disability, mental health, health distress or social functioning, although such scales are sometimes incorporated into some HRAs.

HRA Questionnaire

Although the HRA is sometimes used as a prelude to or part of a periodic, pre-employment or pre-placement medical examination, it is usually offered independently as a voluntary exercise. Many varieties of HRA questionnaires are in use. Some are limited to core questions that feed directly into the risk age calculations. In others, these core questions are interspersed with additional medical and behavioral topics: more extensive medical history; stress perceptions; scales to measure anxiety, depression and other psychological disorders; nutrition; use of preventive services; personal habits and even interpersonal relationships. Some vendors allow purchasers to add questions to the questionnaire, although responses to these are not usually incorporated into the health-risk computations.

Almost all HRAs now use forms with boxes to be checked or filled in by pencil for computer entry by hand or by an optical scanner device. As a rule, the completed questionnaires are collected and batch-processed, either in-house or by the HRA vendor. To encourage trust in the confidentiality of the program, completed questionnaires are sometimes mailed directly to the vendor for processing and the reports are mailed to the participants’ homes. In some programs, only “normal” results are mailed to participants, while those employees with results calling for intervention are invited for private interviews with trained staff persons who interpret them and outline the corrective actions that are indicated. Greater access to personal computers and more widespread familiarity with their use have led to the development of interactive software programs that allow direct entry of the responses into a microcomputer and immediate calculation and feedback of the results along with risk reduction recommendations. This approach leaves it up to the individual to take the initiative of seeking help from a staff person when clarification of the results and their implications is needed. Except when the software program allows storage of the data or their transfer to a centralized data bank, this approach does not provide information for systematic follow-up and it precludes the development of aggregate reports.

Managing the Program

Responsibility for managing the HRA program is usually assigned to the respective directors of the employee health service, the wellness program or, less frequently, the employee assistance program. Quite often, however, it is arranged and supervised by the personnel/human resources staff. In some instances, an advisory committee is created, often with employee or labor union participation. Programs incorporated into the organization’s operating routine appear to run more smoothly than those that exist as somewhat isolated projects (Beery et al. 1986). The organizational location of the program may be a factor in its acceptance by employees, particularly when confidentiality of personal health information is an issue. To preclude such a concern, the completed questionnaire is usually mailed in a sealed envelope to the vendor, who processes the data and mails the individual report (also in a sealed envelope) directly to the participant’s home.

To enhance participation in the program, most organizations publicize the program through preliminary hand-outs, posters and articles in the company newsletter. Occasionally, incentives (e.g., T-shirts, books and other prizes) are offered for completion of the exercise and there may even be monetary awards (e.g., reduction in the employee’s contribution to health insurance premiums) for successful reduction of excess risk. Some organizations schedule meetings where employees are told about the program’s purposes and procedures and are instructed in completing the questionnaire. Some, however, simply distribute a questionnaire with written instructions to each employee (and, if included in the program, to each dependant). In some instances, one or more reminders to complete and mail the questionnaire are distributed in order to increase participation. In any case, it is important to have a designated resource person, either in the organization or with the HRA program provider, to whom questions can be directed in person or by telephone. It may be important to note that, even when the questionnaire is not completed and returned, merely reading it can reinforce information from other sources and foster a health consciousness that may favorably influence future behavior.

Many of the forms call for clinical information that the respondent may or may not have. In some organizations, the program staff actually measures height, weight, blood pressure and skin-fold thickness and collects blood and urine samples for laboratory analysis. The results are then integrated with the questionnaire responses; where such data are not entered, the computer processing program may automatically insert figures representing the “norms” for persons of the same sex and age.

Turnaround time (the time between completing the questionnaire and receiving the results) may be a significant factor in the value of the program. Most vendors promise delivery of the results in ten days to two weeks, but batch processing and post office delays may extend this period. By the time the reports are received, some participants may have forgotten how they responded and may have disassociated themselves from the process; to obviate this possibility, some vendors either return the completed questionnaire or include key responses of the individual in the report.

Reports to the Individual

The reports may vary from a single-page statement of results and recommendations to a more than 20-page brochure replete with multicolor graphs and illustrations and extended explanations of the relevance of the results and the importance of the recommendations. Some rely almost entirely on preprinted general information while in others the computer generates an entirely individualized report. In some programs where the exercise has been repeated and the earlier data have been retained, comparisons of current results with those recorded earlier are provided; this may provide a sense of gratification that can serve as further motivation for behavior modification.

A key to the success of a program is the availability of a health professional or trained counselor who can explain the importance of the findings and offer an individualized program of interventions. Such personalized counseling can be extremely useful in allaying needless anxiety that may have been generated by misinterpretation of the results, in helping individuals establish behavioral change priorities, and in referring them to resources for implementation.

Reports to the Organization

In most programs, the individual results are summarized in an aggregate report sent to the employer or sponsoring organization. Such reports tabulate the demography of the participants, sometimes by geographic location and job classification, and analyze the range and levels of health risks discovered. A number of HRA vendors include projections of the increased health care costs likely to be incurred by high-risk employees. These data are extremely valuable in designing elements for the organization’s wellness and health promotion program and in stimulating consideration of changes in job structure, work environment and workplace culture that will promote the health and well-being of the workforce.

It should be noted that the validity of the aggregate report depends on the number of employees and the level of participation in the HRA program. Participants in the program tend to be more health conscious and, when their number is relatively small, their scores may not accurately reflect the characteristics of the entire workforce.

Follow-up and Evaluation

The effectiveness of the HRA program may be enhanced by a system of follow-up to remind participants of the recommendations and encourage compliance with them. This can involve individually addressed memoranda, one-on-one counseling by a physician, nurse or health educator, or group meetings. Such follow-up is particularly important for high-risk individuals.

HRA program evaluation should start with a tabulation of the level of participation, preferably analyzed by such characteristics as age, sex, geographic location or work unit, job and educational level. Such data may identify differences in acceptance of the program that might suggest changes in the way it is presented and publicized.

Increased participation in risk-reduction elements of the wellness program (e.g., a fitness program, smoking cessation courses, stress management seminars) may indicate that HRA recommendations are being heeded. Ultimately, however, evaluation will involve determination of changes in risk status. This may involve analyzing the results of the follow-up of high-risk individuals or repetition of the program after an appropriate interval. Such data may be fortified by correlation with data such as utilization of health benefits, absenteeism or productivity measures. Appropriate recognition, however, should be given to other factors that may have been involved (e.g., bias reflecting the sort of person who returns for retest, regression to the mean, and secular trends); truly scientific evaluation of the program impact requires a randomized prospective clinical trial (Schoenbach 1987; DeFriese and Fielding 1990).

Validity and Utility of the HRA

Factors that may affect the accuracy and validity of an HRA have been discussed elsewhere (Beery et al. 1986; Schoenbach 1987; DeFriese and Fielding 1990) and will only be listed here. They represent a checklist for workplace decision makers evaluating different instruments, and include the following:

• accuracy and consistency of self-reported information
• completeness and quality of the epidemiological and actuarial data on which the risk estimates are based
• limitations of the statistical methods for calculating risk, including combining risk factors for different problems into a single composite score and the distortions produced by substituting “average” values either for missing responses in the questionnaire or for measurements not taken
• reliability of the method for calculating the benefits of risk reduction
• applicability of the same mortality calculations to the young whose death rates are low and to older individuals for whom age alone may be the most significant factor in mortality. Furthermore, the validity of the HRA when applied to populations different from those on whom most of the research has been done (i.e., women, minorities, people of different educational and cultural backgrounds) must be regarded from a critical point of view.

Questions have also been raised about the utility of the HRA based on considerations such as the following:

1. The primary focus of HRA is on life expectancy. Until recently, little or no attention has been paid to factors primarily influencing morbidity from conditions that are not usually fatal but which may have an even greater impact on well-being, productivity and health-related costs (e.g., arthritis, mental disorders, and long-term effects of treatments intended to reduce specific risks). The problem is the lack of good morbidity databases for the general population, to say nothing of subgroups defined by age, sex, race or ethnicity.
2. Concern has been expressed about the ill effects of anxiety generated by reports of high-risk status reflecting factors which the individual is unable to modify (e.g., age, heredity, and past medical history), and about the possibility that reports of “normal” or low-risk status may lead individuals to ignore potentially significant signs and symptoms that were not reported or which developed after the HRA was completed.
3. Participation in an HRA programme is usually voluntary, but allegations of coercion to participate or to follow the recommendations have been made.
4. Charges of “blaming the victim” have rightfully been levelled at employers who offer HRA as part of a health promotion programme but do little or nothing to control health risks in the work environment.
5. Confidentiality of personal information is an ever-present concern, especially when an HRA is conducted as an in-house programme and abnormal findings appear to be a trigger for discriminatory actions.PP9

Evidence of the value of health-risk reduction has been accumulating. For example, Fielding and his associates at Johnson and Johnson Health Management, Inc., found that the 18,000 employees who had completed the HRA provided through their employers used preventive services at a considerably higher rate than a comparable population responding to the National Health Interview Survey (Fielding et al. 1991). A five-year study of almost 46,000 DuPont employees demonstrated that those with any of the six behavioral cardiovascular risk factors identified by an HRA (e.g., cigarette smoking, high blood pressure, high cholesterol levels, lack of exercise) had significantly higher rates of absenteeism and use of health care benefits as compared to those without such risk factors (Bertera 1991). Furthermore, applying multivariate regression models to 12 health-related measures taken mainly from an HRA allowed Yen and his colleagues at the University of Michigan Fitness Research Center to predict which employees would generate higher costs for the employer for medical claims and absenteeism (Yen, Edington and Witting 1991).

Implementing an HRA Program

Implementing an HRA program is not a casual exercise and should not be undertaken without careful consideration and planning. The costs of an individual questionnaire and its processing may not be great but the aggregate costs to the organization may be considerable when such items as staff time for planning, implementation and follow-up, employee time for completing the questionnaires, and adjunct health-promotion programs are included. Some factors to be considered in implementation are presented in figure 1.

Figure 1. Checklist for health risk appraisal (HRA) implementation.

Should we have an HRA program?

An increasing number of companies, at least in the United States, are answering this question in the affirmative, abetted by the growing number of vendors energetically marketing HRA programs. The popular media and “trade” publications are replete with anecdotes describing “successful” programs, while in comparison there is a paucity of articles in professional journals offering scientific evidence of the accuracy of their results, their practical reliability and their scientific validity.

It seems clear that defining one’s health risk status is a necessary basis for risk reduction. But, some ask, does one need a formal exercise like the HRA to do this? By now, virtually everyone who persists in cigarette smoking has been exposed to evidence of the potential of adverse health effects, and the benefits of proper nutrition and physical fitness have been well publicized. Proponents of HRA counter by pointing out that receiving an HRA report personalizes and dramatizes the risk information, creating a “teachable moment” that can motivate individuals to take appropriate action. Further, they add, it can highlight risk factors of which the participants may have been unaware, allowing them to see just what their risk reduction opportunities are and to develop priorities for addressing them.

There is general agreement that HRA has limited value when used as a stand-alone exercise (i.e., in the absence of other modalities) and that its utility is fully realized only when it is part of an integrated health promotion program. That program should offer not only individualized explanations and counseling but also access to intervention programs that address the risk factors that were identified (these interventions may be provided in-house or in the community). Thus, the commitment to offer HRA must be broadened (and perhaps may become more costly) by offering or making available such activities as smoking cessation courses, fitness activities and nutrition counseling. Such a broad commitment should be made explicitly in the statement of objectives for the program and the budget allocation requested to support it.

In planning an HRA program, one must decide whether to offer it to the entire workforce or only to certain segments (e.g., to salaried or hourly workers, to both, or to workers of specified ages, lengths of service or in specified locations or job categories); and whether to extend the program to include spouses and other dependants (who, as a rule, account for more than half of the utilization of health benefits). A critical factor is the need to secure the availability of at least one person in the organization sufficiently knowledgeable and appropriately positioned to supervise the design and implementation of the program and the performance of both the vendor and the in-house staff involved.

In some organizations in which full-scale annual medical examinations are being eliminated or offered less frequently, HRA has been offered as a replacement either alone or in combination with selected health screening tests. This strategy has merit in terms of enhancing the cost/benefit ratio of a health promotion program, but sometimes it is based not so much on the intrinsic value of the HRA but on the desire to avoid the ill-will that might be generated by what could be perceived as elimination of an established employee benefit.

Conclusion

Despite its limitations and the paucity of scientific research that confirms the claims for its validity and utility, the use of HRA continues to grow in the United States and, much less rapidly, elsewhere. DeFriese and Fielding, whose studies have made them authorities on HRA, see a bright future for it based on their prediction of new sources of risk-relevant information and new technological developments such as improvements in computer hardware and software that will permit direct computer entry of questionnaire responses, allow modeling of the effects of changes in health behavior, and produce more effective full-color reports and graphics (DeFriese and Fielding 1990).

HRA should be used as an element in a well-conceived, continuing program of wellness or health promotion. It conveys an implicit commitment to provide activities and changes in the workplace culture that offer opportunities to help control the risk factors it will identify. Management should be aware of such a commitment and be willing to make the requisite budget allocations.

While much research remains to be done, many organizations will find HRA a useful adjunct to their efforts to improve the health of their employees. The implicit scientific authority of the information it provides, the use of computer technology, and the personalized impact of the results in terms of chronological versus risk age seem to enhance its power to motivate participants to adopt healthy, risk-reducing behaviors. Evidence is accumulating to show that employees and dependants who maintain healthy risk profiles have less absenteeism, demonstrate enhanced productivity, and use less medical care, all of which have a positive effect on the organization’s “bottom line”.

Back

Physical training and fitness programs are generally the most frequently encountered element in worksite health promotion and protection programs. They are successful when they contribute to the goals of the organization, promote the health of employees, and remain pleasing and useful to those participating (Dishman 1988). Because organizations around the world have widely diverse goals, workforces and resources, physical training and fitness programs vary greatly in how they are organized and in what services they provide.

This article is concerned with the reasons for which organizations offer physical training and fitness programs, how such programs fit within an administrative structure, the typical services offered to participants, the specialized personnel who offer these services, and the issues most often involved in worksite fitness programming, including the needs of special populations within the workforce. It will focus primarily on programs conducted onsite in the workplace.

Quality and Fitness Programming

Today’s global economy shapes the goals and business strategies of tens of thousands of employers and affects millions of workers around the world. Intense international competition requires organizations to offer products and services of higher value at ever lower costs, that is, to pursue so-called “quality” as a goal. Quality-driven organizations expect workers to be “customer oriented,” to work energetically, enthusiastically and accurately throughout the entire day, to continually train and improve themselves professionally and personally, and to take responsibility for both their workplace behavior and their personal well-being.

Physical training and fitness programs can play a role in quality-driven organizations by helping workers to achieve a high level of “wellness”. This is particularly important in “white-collar” industries, where employees are sedentary. In manufacturing and heavier industries, strength and flexibility training can enhance work capacity and endurance and protect workers from occupational injuries. In addition to physical improvement, fitness activities offer relief from stress and carry a personal sense of responsibility for health into other aspects of lifestyle such as nutrition and weight control, avoidance of alcohol and drug abuse, and smoking cessation.

Aerobic conditioning, relaxation and stretching exercises, strength training, adventure and challenge opportunities and sports competitions are typically offered in quality-driven organizations. These offerings are often structured within the organization’s wellness initiatives—“wellness” involves helping people to actualize their full potential while leading a lifestyle that promotes health—and they are based on the awareness that, since sedentary living is a well-demonstrated risk factor, regular exercise is an important habit to foster.

Basic Fitness Services

Participants in fitness programs should be instructed in the rudiments of fitness training. The instruction includes the following components:

• a minimum number of exercise sessions per week to achieve fitness and good health (three or four times a week for 30 to 60 minutes per session)
• learning how to warm up, exercise and cool down
• learning how to monitor heart rate and how to safely raise one’s heart rate to a training level appropriate for one’s age and fitness level
• graduating training from light to heavy to ultimately achieve a high level of fitness
• techniques for cross training
• The principles of strength training, including resistance and overload, and combining repetitions and sets to achieve strengthening goals
• strategic rest and safe lifting techniques
• relaxation and stretching as an integral part of a total fitness programme
• learning how to customize workouts to suit one’s personal interests and lifestyle
• achieving an awareness of the role that nutrition plays in fitness and overall good health.

Besides instruction, fitness services include fitness assessment and exercise prescription, orientation to the facility and training in the use of the equipment, structured aerobic classes and activities, relaxation and stretching classes, and back-pain prevention classes. Some organizations offer one-on-one training, but this can be quite expensive since it is so staff-intensive.

Some programs offer special “work hardening” or “conditioning,” that is, training to enhance workers’ capacities to perform repetitive or rigorous tasks and to rehabilitate those recovering from injuries and illnesses. They often feature work breaks for special exercises to relax and stretch overused muscles and strengthen antagonistic sets of muscles to prevent overuse and repetitive injury syndromes. When advisable, they include suggestions for modifying the job content and/or the equipment used.

Physical Training and Fitness Personnel

Exercise physiologists, physical educators, and recreational specialists make up the majority of the professionals working in worksite physical fitness programs. Health educators and rehabilitation specialists also participate in these programs.

The exercise physiologist designs personalized exercise regimens for individuals based on a fitness assessment which generally includes a health history, a health risk screening, assessment of fitness levels and exercise capacity (essential for those with handicaps or recovering from injury), and confirmation of their fitness goals. The fitness assessment includes the determination of resting heart rate and blood pressure, body composition. muscle strength and flexibility, cardiovascular efficiency and, often, blood lipid profiles. Typically, the findings are compared with norms for people of the same sex and age.

None of the services offered by the physiologist are meant to diagnose disease; employees are referred to the employee health service or their personal physicians when abnormalities are found. In fact, many organizations require that a prospective applicant obtain clearance from a physician before joining the program. In the case of employees recovering from injuries or illness, the physiologist will work closely with their personal physicians and rehabilitation counselors.

Physical educators have been trained to lead exercise sessions, to teach the principles of healthy and safe exercise, to demonstrate and coach various athletic skills, and to organize and administer a multifaceted fitness program. Many have been trained to perform fitness assessments although, in this age of specialization, that task is performed more often by the exercise physiologist.

Recreational specialists carry out surveys of participants’ needs and interests to determine their lifestyles and their recreational requirements and preferences. They may conduct exercise classes but generally focus on arranging trips, contests and activities that instruct, physically challenge and motivate participants to engage in wholesome physical activity.

Verifying the training and competence of physical training and fitness personnel often presents problems to organizations seeking to staff a program. In the United States, Japan and many other countries, government agencies require academic credentials and supervised experience of physical educators who teach in school systems. Most governments do not require certification of exercise professionals; for example, in the United States, Wisconsin is the only state that has enacted legislation dealing with fitness instructors. In considering an involvement with health clubs in the community, whether voluntary like the YMCAs or commercial, special caution should be taken to verify the competence of the trainers they provide since many are staffed by volunteers or poorly trained individuals.

A number of professional associations offer certification for those working in the adult fitness field. For example, the American College of Sports Medicine offers a certificate for exercise instructors and the International Dance Education Association offers a certificate for aerobics instructors. These certificates, however, represent indicators of experience and advanced training rather than licenses to practice.

Fitness Programs and the Organization’s Structure

As a rule, only medium-sized to large-sized organizations (500 to 700 employees is generally considered the minimum) can undertake the task of providing physical training facilities for their employees at the worksite. Major considerations other than size include the ability and willingness to make the necessary budgetary allocations and availability of space to house the facility and whatever equipment it may require, including dressing and shower rooms.

Administrative placement of the program within the organization usually reflects the goals set for it. For example, if the goals are primarily health-related (e.g., cardiovascular risk reduction, reducing illness absences, prevention and rehabilitation of injuries, or contributing to stress management) the program will usually be found in the medical department or as a supplement to the employee health service. When the primary goals relate to employee morale and recreation, it will usually be found in the human resources or employee relations department. Since human resources departments are usually charged with implementing quality improvement programs, fitness programs with a wellness and quality focus will often be located there.

Training departments rarely are assigned responsibility for physical training and fitness programs since their mission is usually limited to specific skill development and job training. However, some training departments offer outdoor adventure and challenge opportunities to employees as ways to create a sense of teamwork, build self-confidence and explore ways to overcome adversity. When jobs involve physical activity, the training program may be responsible for teaching proper work techniques. Such training units will often be found in police, fire and rescue organizations, trucking and delivery firms, mining operations, oil exploration and drilling companies, diving and salvage organizations, construction firms, and the like.

Onsite or Community-based Fitness Programs

When space and economic considerations do not allow comprehensive exercise facilities, limited programs may still be conducted in the workplace. When not in use for their designed purposes, lunch and meeting rooms, lobbies and parking areas may be used for exercise classes. One New York City-based insurance company created an indoor jogging track in a large storage area by arranging a path between banks of filing cabinets containing important but infrequently consulted documents. In many organizations around the world, work breaks are regularly scheduled during which employees stand at their work stations and do calisthenics and other simple exercises.

When onsite fitness facilities are not feasible (or when they are too small to accommodate all the employees who would use them), organizations turn to community-based settings such as commercial health clubs, schools and colleges, churches, community centers, clubs and YMCAs, town- or union-sponsored recreation centers, and so on. Some industrial parks house an exercise facility shared by the corporate tenants.

On another level, fitness programs may consist of uncomplicated physical activities practiced in or about the home. Recent research has established that even low to moderate levels of daily activity may have protective health effects. Activities like recreational walking, biking or stair-climbing which require the person to dynamically exercise large muscle groups for 30 minutes five times a week, may prevent or delay the advance of cardiovascular disease while providing a pleasant respite from daily stress. Programs that encourage walking and bicycling to work can be developed for even very small companies and they cost very little to implement.

In some countries, workers are entitled to leaves that may be spent at spas or health resorts which offer a comprehensive program of rest, relaxation, exercise, healthful diet, massage and other forms of restorative therapy. The aim, of course, is to have them maintain such a healthful lifestyle after they return to their homes and jobs.

Exercise for Special Populations

Older workers, the obese and especially those who have been sedentary for long can be offered low-impact and low-intensity exercise programs in order to avert orthopedic injuries and cardiovascular emergencies. In onsite facilities, special times or separate workout spaces may be arranged to protect the privacy and dignity of these populations.

Pregnant women who have been physically active may continue to work or exercise with the advice and consent of their personal physicians, keeping in mind the medical guidelines concerning exercise during pregnancy (American College of Obstetricians and Gynecologists 1994). Some organizations offer special reconditioning exercise programs for women returning to work after delivery.

Physically challenged or handicapped workers should be invited to participate in the fitness program both as a matter of equity and because they may accrue even greater benefits from the exercise. Program staff, however, should be alert to conditions that may entail greater risk of injury or even death, such as Marfan’s syndrome (a congenital disorder) or certain forms of heart disease. For such individuals, preliminary medical evaluation and fitness assessment is particularly important, as is careful monitoring while exercising.

Setting Goals for the Exercise Program

The goals selected for an exercise program should complement and support those of the organization. Figure 1 presents a checklist of potential program goals which, when ranked in order of importance to a particular organization and aggregated, will help in shaping the program.

Figure 1. Suggested organizational goals for a fitness and exercise programme.

Eligibility for the Exercise Program

Since the demand may exceed both the program’s budget allocation and the available space and time, organizations have to carefully consider who should be eligible to participate. It is prudent to know in advance why this benefit is being offered and how many employees are likely to take advantage of it. Lack of preparation in this regard may lead to embarrassment and ill will when those who desire to exercise cannot be accommodated.

Particularly when providing an onsite facility, some organizations limit eligibility to managers above a certain level in the organization chart. They rationalize this by arguing that, since such individuals are paid more, their time is more valuable and it is proper to give them priority of access. The program then becomes a special privilege, like the executive dining room or a conveniently located parking space. Other organizations are more even-handed and offer the program to all on a first-come, first-served basis. Where demand exceeds the facility’s capacity, some use length of service as a criterion of priority. Rules setting minimum monthly use are sometimes used to help manage the space problem by discouraging the casual or episodic participant from continuing as a member.

Recruiting and Retaining Program Participants

One problem is that the convenience and low cost of the facility may make it particularly attractive to those already committed to exercise, who may leave little room for those who may need it much more. Most of the former will probably continue to exercise anyway while many of the latter will be discouraged by difficulties or delays in entering the program. Accordingly, an important adjunct to recruiting participants is simplifying and facilitating the enrolment process.

Active efforts to attract participants are usually necessary, at least when the program is initiated. They include in-house publicity via posters, flyers and announcements in available intramural communications media, as well as open visits to the exercise facility and the offer of experimental or trial memberships.

The problem of dropout is an important challenge to program administrators. Employees cite boredom with exercise, muscular aches and pains induced by exercise, and time pressure as the major reasons for dropping out. To counter this, facilities entertain members with music, videotapes and television programs, motivational games, special events, awards such as T-shirts and other gifts and certificates for attendance or reaching individual fitness goals. Properly designed and supervised exercise regimens will minimize injuries and aches and pains and, at the same time, make the sessions efficient and less time-consuming. Some facilities offer newspapers and business publications as well as business and training programs on television and videotape to be accessed while exercising to help justify the time spent in the facility.

Safety and Supervision

Organizations offering worksite fitness programs must do so in a safe manner. Potential members must be screened for medical conditions that might be affected adversely by exercise. Only well-designed and well-maintained equipment should be available and participants must be properly instructed in its use. Safety signs and rules on the appropriate use of the facility should be posted and enforced, and all staff should be trained in emergency procedures, including cardiopulmonary resuscitation. A trained exercise professional should oversee the operation of the facility.

Record Keeping and Confidentiality

Individual records containing information about health and physical status, fitness assessment and exercise prescription, fitness goals and progress toward their accomplishment and any relevant notes should be maintained. In many programs, the participant is allowed to chart for himself or herself what was done on each visit. At a minimum, the content of records should be kept secure from all but the individual participant and members of the program staff. Except for the staff of the employee health service, who are bound to the same rules of confidentiality and, in an emergency, the participant’s personal physician, details of the individual’s participation and progress should not be revealed to anyone without the individual’s express consent.

Program staff may be required to make periodic reports to management presenting aggregate data regarding participation in the program and the results.

Whose Time, Who Pays?

Since most worksite exercise programs are voluntary and established to benefit the worker, they are considered an extra benefit or privilege. Accordingly, the organization traditionally offers the program on the worker’s own time (during lunch time or after hours) and he or she is expected to pay all or part of the cost. This is generally applicable also to programs provided offsite in community facilities. In some organizations, the employees’ contributions are indexed to salary level and some offer “scholarships” to those who are low paid or those with financial problems.

Many employers allow participation during working hours, usually for higher-level employees, and pick up most if not all of the cost. Some refund employees’ contributions if certain attendance or fitness goals are attained.

When program participation is mandatory, as in training to prevent potential work injuries or to condition workers to perform certain tasks, government regulations and/or labor union agreements require it to be provided during work hours with all costs borne by the employer.

Managing Participants’ Aches and Pains

Many people believe that exercise must be painful in order to be beneficial. This is frequently expressed by the motto “No pain, no gain”. It is incumbent on the program staff to counter this erroneous belief by changing the perception of exercise through awareness campaigns and educational sessions and by ensuring that the intensity of the exercises is graduated so that they remain pain-free and enjoyable while still improving the participant’s level of fitness.

If participants complain of aches and pains, they should be encouraged to continue to exercise at a lower level of intensity or simply to rest until healed. They should be taught “RICE,” the acronym for the principles of treating sports injuries: Rest; Ice down the injury; Compress any swelling; and Elevate the injured body part.

Sports Programs

Many organizations encourage employees to participate in company-sponsored athletic events. These may range from softball or football games at the yearly company picnic, to intramural league play in a variety of sports, to inter-company competitions such as the Chemical Bank’s Corporate Challenge, a competitive distance run for teams of employees from participating organizations that originated in New York City and now has spread to other areas, with many more corporations joining as sponsors.

The key concept for sports programs is risk management. While the gains from competitive sports can be considerable, including better morale and stronger “team” feelings, they inevitably entail some risks. When workers engage in competition, they may bring to the game work-related psychological “baggage” that can cause problems, particularly if they are not in good physical condition. Examples include the middle-aged, out-of-shape manager who, seeking to impress younger subordinates, may be injured by exceeding his or her physical capabilities, and the worker who, feeling challenged by another in competing for status in the organization, may convert what is meant to be a friendly game into a dangerous, bruising mêlée.

The organization wishing to offer involvement in competitive sports should seriously consider the following advice:

• Be sure that participants understand the purpose of the event and remind them that they are employees of the organization and not professional athletes.
• Establish firm rules and guidelines governing safe and fair play.
• Although signed informed consent and waiver forms do not always protect the organization from liability in the event of injury, they help participants to comprehend the extent of the risk associated with the sport.
• Offer conditioning clinics and practice sessions prior to the opening of the competition so that participants can be in good physical shape when they begin to play.
• Require, or at least encourage, a complete physical examination by the employee’s personal physician if not available in the employee health service. (Note: the organization may have to accept financial responsibility for this.)
• Perform a safety inspection of the athletic field and all of the sports equipment. Provide or require personal protective equipment such as helmets, clothing, safety pads and goggles.
• Make sure that referees and security personnel as needed are on hand for the event.
• Have first aid supplies on hand and a pre-arranged plan for emergency medical care and evacuation if needed.
• Be sure that the organization’s liability and disability insurance coverage covers such events and that it is adequate and in force. (Note: it should cover employees and others who attend as spectators as well as those on the team.)

For some companies, sports competition is a major source of employee disability. The above recommendations indicate that the risk may be “managed,” but serious thought should be given to the net contribution that sports activities can reasonably be expected to provide to the physical fitness and training program.

Conclusion

Well-designed, professionally managed workplace exercise programs benefit employees by enhancing their health, well-being, morale and work performance. They benefit organizations by improving productivity qualitatively and quantitatively, preventing work-related injuries, accelerating employees’ recovery from illness and injury, and reducing absenteeism. The design and implementation of each program should be individualized in accord with the characteristics of the organization and its workforce, with the community in which it operates, and with the resources that can be made available for it. It should be managed or at least supervised by a qualified fitness professional who will consistently be mindful of what the program contributes to its participants and to the organization and who will be ready to modify it as new needs and challenges arise.

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Diet, physical activity and other lifestyle practices such as not smoking cigarettes and reduction of stress are important in the prevention of chronic diseases. Proper nutrition and other healthy lifestyle practices also aid in maintaining individual well-being and productivity. The worksite is an ideal place to teach people about good health habits, including sound nutrition, weight control and exercise practices. It is an excellent forum for efficiently disseminating information and monitoring and reinforcing changes that have been made (Kaplan and Brinkman-Kaplan 1994). Nutrition programs rank among the most commonly included activities in wellness programs sponsored by employers, labor unions and, sometimes, jointly. In addition to formal classes and programs, other supportive educational efforts such as newsletters, memos, payroll inserts, posters, bulletin boards, and electronic mail (e-mail) can be offered. Nutrition education materials can also reach employees’ dependants through mailings to the home and making classes and seminars available to homemakers who are the gatekeepers of their families’ food intake practices and habits. These approaches provide useful information that can be applied easily both at the worksite and elsewhere and can help reinforce formal instruction and encourage workers to enroll in programs or make informed and profitable use of worksite facilities (such as the cafeteria). Moreover, carefully targeted materials and classes can have a very significant impact on many people, including the families of workers, especially their children, who can learn and adopt good nutrition practices that will last a lifetime and be passed on to future generations.

Successful worksite intervention programs require a supportive environment that enables workers to act on nutrition messages. In this context, it is essential that employees have access to appropriate foods in cafeterias and vending machines that facilitate adherence to a recommended diet. For those whose lunches depend on “brown bags” or lunch boxes, worksite arrangements for storing the lunch bags or boxes are part of a supportive environment. In addition, employer-provided or entrepreneurial lunch wagons can offer nourishing food on the spot at field worksites remote from feeding facilities. Facilities for light personal washing before eating are also important. These employer-sponsored activities express a strong commitment to the health and well-being of their employees.

In-plant Catering Programs, Vending Machines, and Coffee and Tea Breaks

Many employers subsidize in-plant food services partially or totally, making them attractive as well as convenient. Even where there is only one shift, many cafeterias serve breakfasts and dinners as well as lunches and refreshments at breaks; this is of particular value to those who live alone or whose food preparation in the home may be less than adequate. Some worksite cafeterias are open to employees’ friends and families to encourage “lunching-in” rather than using more expensive and often less nutritionally desirable facilities in the community.

Modifying foods that are offered at the worksite provides support and encouragement of healthy eating patterns (Glanz and Mullis 1988). In fact, cafeteria interventions are one of the most popular worksite nutrition programs as they allow point-of-choice nutrition information to be readily made available (Glanz and Rogers 1994). Other interventions include modifying menu choices to provide low-fat, low-calorie and high-fiber foods or to highlight “heart healthy” foods (Richmond 1986). Worksites also can implement healthy catering policies and offer nutrient-dense foods that are low in fat, cholesterol and sodium (American Dietetic Association 1994). Negotiations can be conducted with food service vendors to also provide low-fat food items, including fruit, in vending machines. One such program resulted in a greater selection by employees of low-calorie foods (Wilber 1983). Food service management, caterers and vendors may realize greater sales and increased participation in the food service activities at the worksite especially when tasty, attractive, healthy foods are served (American Dietetic Association 1994).

Coffee and tea breaks with nutrient-dense snack foods available can help employees meet nutritional needs. Many “lunch hours” are only 30 or 40 minutes long and because some employees use that time for shopping, socializing or personal business, they skip eating. A supportive environment may require lengthening the lunch period. Moreover, maintaining proper hygiene in the in-plant catering facility and ensuring the health and proper training of all food service personnel (even when the facility is operated under contract with an outside vendor) demonstrates the worksite’s commitment to employee health, thereby increasing workers’ interest in supporting the onsite food service establishments as well as other programs.

General Nutrition Guidance

The basic dietary recommendations that have been issued by government agencies of different countries encourage health promotion and the prevention of diet-related, noncommunicable diseases (FAO and WHO 1992). The dietary guidelines adopted include the following principles:

• Adjust energy intake to meet energy expenditure in order to achieve and maintain desirable body weight.
• Avoid excessive fat intake and, especially, intake of saturated fat and cholesterol.
• Increase intake of complex carbohydrates and dietary fibre and limit sugar intake to moderate levels.
• Limit salt intake to a moderate level.
• Limit alcohol intake.
• Offer a variety of foods from all food groups.

There is compelling scientific evidence to support these dietary recommendations. Not only is abnormal body weight a risk factor for many chronic diseases, but fat distribution is also important to health (Bray 1989). Android obesity, or excess fat in the abdomen, is a greater health risk than gynoid obesity, the presence of excess weight below the waist (i.e., in the hips and thighs). A waist-to-hip ratio close to or above one is associated with a greater risk of hypertension, hyperlipidaemia, diabetes and insulin resistance (Seidell 1992). Thus, both body mass index (BMI)—that is, body weight (kilograms) divided by height (meters) squared—and the waist-to-hip ratio are useful in assessing weight status and the need to lose weight. Figure 1 presents BMI classifications of underweight, desirable weight, overweight and obesity.

Figure 1. Body mass index (BMI) classifications.

Essentially everyone, even individuals who are at an ideal body weight, would benefit from nutrition guidance aimed at preventing the weight gain that typically occurs with ageing. An effective weight control program integrates nutrition, exercise, and behavior modification principles and techniques.

A diet that provides less than 30% of calories from fat, less than 10% of calories from saturated fat, and less than 300 milligrams of cholesterol daily is typically recommended to help maintain a desirable blood cholesterol level (i.e., <200 mg/dl) (National Institutes of Health 1993b). Saturated fat and cholesterol raise blood cholesterol levels. A diet relatively low in total fat facilitates achieving the saturated fat recommendation. A 2,000-calorie diet can include 67 grams of total fat and less than 22 grams of saturated fat per day. A diet low in total fat also facilitates reducing calories for weight management and may be implemented by including a variety of foods in the diet so that nutrient needs are met without exceeding calorie needs.

Diets high in complex carbohydrates (the sort of carbohydrate found in grains, legumes, vegetables, and, to some extent, fruits) are also high in many other nutrients (including B vitamins, vitamins A and C, zinc and iron) and low in fat. The recommendation to use sugar in moderation has been made because sugar, despite being a source of energy, has limited nutrient value. Thus, for persons with low calorie needs, sugar should be used sparingly. In contrast, sugar can be used as a source of calories, in moderation, in higher calorie (nutritionally adequate) diets. Although sugar promotes dental caries, it is less cariogenic when consumed with meals than when consumed in frequent between-meal snacks.

Because of the association between sodium intake and systolic hypertension, dietary salt and sodium are recommended only in moderation. A diet that provides not more than 2,400 milligrams of sodium daily is recommended for the prevention of hypertension (National Institutes of Health 1993a). A high-sodium diet also has been shown to promote calcium excretion and, thus, may contribute to the development of osteoporosis, a female-predominant risk (Anderson 1992). The major sources of sodium in the diet include processed foods and salt (or high-sodium condiments such as soy sauce) added to food during cooking or at the table.

If alcohol is consumed, it should be used in moderation. This is because excessive alcohol consumption may cause liver and pancreatic disease, hypertension and damage to the brain and heart. Further adverse consequences associated with heavy alcohol consumption include addiction, increased risk of accidents and impaired job performance.

Another common recommendation is to consume a variety of foods from all food groups. More than 40 different nutrients are required for good health. Since no single food provides all nutrients, including a variety of foods facilitates achieving a nutritionally adequate diet. A typical food guide provides recommendations for the number of “servings” of foods from the different food groups (figure 2). The range of servings listed represents the minimum that should be consumed daily. As energy needs increase, the range should increase correspondingly.

Figure 2. Example of a good daily nutrition guide.

Other specific dietary recommendations have been made by different countries. Some countries recommend water fluoridation, breastfeeding, and iodine supplementation. Many also recommend that protein intake be adequate but that excess protein be avoided. Some have guidelines for the relative proportion of animal to vegetable protein in the diet. Others have emphasized vitamin C and calcium intake. Implicit to these country-specific recommendations is that they are targeted to the special needs identified for a particular area. Other nutritional issues that are important and relevant to individuals worldwide include those relating to calcium, hydration, and antioxidant vitamins and minerals.

An adequate calcium intake is important throughout life to build a strong skeleton and achieve a maximum peak bone mass (bone mass peaks between the ages of 18 and 30) and help retard age-associated bone mass loss that often leads to osteoporosis. At least 800 milligrams of calcium daily is recommended from age one year through old age. For adolescents, when bones are growing rapidly, 1,200 milligrams of calcium per day are recommended. Some authorities believe that young adults, postmenopausal women and men over 65 years of age need 1,500 milligrams of calcium per day and that the diet of all other adults should provide 1,000 milligrams. Pregnant and lactating women need 1,200 milligrams of calcium per day. Dairy products are rich sources of calcium. Low fat dairy products are recommended to control blood cholesterol levels.

Maintaining adequate hydration is essential for achieving maximal work performance. One serious consequence of dehydration is an inability to dissipate heat effectively, with a consequent increase in body temperature. Thirst usually is a good indicator of hydration status, except during heavy physical exertion. Workers always should respond to thirst and drink fluids liberally. Cool, dilute fluids replace water losses fastest. Laborers also should drink fluids liberally; for every 0.5 kilogram of weight lost per day due to exertion, one-half liter of water is recommended to replace the water lost via sweat.

Antioxidants have received a great deal of attention lately because of the growing evidence that suggests they may protect against the development of cancer, heart disease, cataracts and even slow the ageing process. The antioxidant vitamins are beta-carotene and vitamins A, E, and C. The mineral selenium also is an antioxidant. Antioxidants are thought to prevent the formation of harmful free radicals which destroy cell structures over time in a process that leads to the development of various diseases. The evidence to date suggests that antioxidants may protect against the development of cancer, heart disease and cataracts, although a causal relationship has not been established. Food sources of beta-carotene and vitamin A include green leafy vegetables, and red, orange and yellow fruits and vegetables. Grains and fish are significant sources of selenium. Citrus fruits are important sources of vitamin C, and vitamin E is found in sources of polyunsaturated fat, including nuts, seeds, vegetable oil and wheat germ.

The remarkable similarity in the dietary recommendations made by different countries underscores the consensus among nutritionists about the ideal diet for promoting health and well being. The challenge that lies before the nutrition community now is to implement these population-based dietary recommendations and assure proper nutrition globally. This will require not only providing a safe and adequate food supply to all persons everywhere, but also necessitates developing and implementing nutrition education programs worldwide that will teach virtually everyone the principles of a healthy diet.

Cultural and Ethnic Approaches to Foods and Diet

Effective nutrition education approaches must address cultural issues and ethnic food habits. Cultural sensitivity is important in planning nutrition intervention programs and in eliminating barriers to effective communication in individual counseling, as well. Given the current emphasis on cultural diversity, exposure to different cultures in the worksite, and a keen interest among individuals to learn about other cultures, pace-setting nutrition programs that embrace cultural differences should be well received.

Societies have vastly different beliefs about the prevention, cause, and treatment of disease. The value placed on good health and nutrition is highly variable. Helping people adopt healthy nutrition and lifestyle practices requires an understanding of their beliefs, culture and values (US Department of Health and Human Services 1990). Nutrition messages must be targeted to the specific practices of an ethnic population or group. Moreover, the intervention approach must be planned to address widely held beliefs about health and nutrition practices. For example, some cultures disapprove of alcohol whereas others consider it to be an essential part of the diet even when taken with meals eaten at the worksite. Thus, nutrition interventions must be specialized not only to meet the particular needs of a target group, but to embrace the values and beliefs that are unique to their culture.

Overweight

The key environmental factors that contribute to the development of overweight and obesity are principally caloric excess and lack of physical activity.

Overweight and obesity are most often classified on the basis of BMI, which is correlated with body composition (r = 0.7–0.8). Weight status classifications according to BMI for men and women less than 35 and greater than 35 years of age are presented in Figure 10. The health risks associated with overweight and obesity are clear. Data from a number of studies have shown a J-shape relationship between body weight and all-cause mortality. Although the mortality rate increases when BMI exceeds 25, there is a pronounced increase when BMI is greater than 30. Interestingly, underweight also increases risk of mortality, albeit not to the extent as does overweight. Whereas overweight and obese individuals are at higher risk of death due to cardiovascular disease, gallbladder disease and diabetes mellitus, underweight persons are at higher risk for the development of digestive and pulmonary diseases (Lew and Garfinkel 1979). The incidence of overweight and obesity in some developed countries may be as high as 25 to 30% of the population; it is even higher in certain ethnic groups and in groups of low socioeconomic status.

A low caloric diet that leads to a weight loss of 0.2 to 0.9 kilograms (0.5 to 2 pounds) per week is recommended for weight reduction. A low-fat diet (about 30% of calories from fat or lower) that is also high in fiber (15 grams per 1000 calories) is recommended to facilitate decreasing calories and providing bulk for satiety. A weight loss program should include both exercise and behavior modification. A slow, steady weight loss is recommended to successfully modify eating behaviors in order to maintain weight loss. Guidelines for a sound weight-reduction program appear in figure 3.

Figure 3. Guidelines for a sound weight-reduction programme.

A random-digit telephone survey of 60,589 adults across the United States revealed that approximately 38% of women and 24% of men were actively trying to lose weight. Reflecting the marketing efforts of what has become a veritable weight-reduction industry, the methods employed ranged from periodic fasting, participating in organized weight-reduction programs, often with commercially prepared foods and special supplements, and taking diet pills. Only half of those trying to lose weight reported using the recommended method of calorie restriction combined with exercise demonstrating the importance of worksite nutrition education programs (Serdula, Williamson et al. 1994).

Weight loss in overweight or obese persons beneficially affects various chronic disease risk factors (NIH 1993a). Weight loss leads to reductions in blood pressure, plasma lipids and lipoproteins (i.e., total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides) and increases high density lipoprotein (HDL) cholesterol, all of which are major risk factors for coronary heart disease (figure 4). Furthermore, blood glucose, insulin and glycosylated haemoglobin levels are favorably affected. With weight losses as modest as about four kilograms, even when some excess weight is regained, improvements in these parameters have been observed.

Figure 4. Major coronary heart-disease risk factors.

Weight control is essential for reducing chronic disease morbidity and mortality. This has formed the basis of the dietary recommendations of many groups worldwide to achieve and maintain a healthy body weight. These recommendations have been made mainly for developed countries where overweight and obesity are major public health concerns. While diet, exercise, and behavior modification are recommended for weight loss, the key to reducing the incidence of overweight and obesity is to implement effective prevention programs.

Underweight

Underweight (defined as a body weight of 15 to 20% or more below accepted weight standards) is a serious condition that results in a loss of energy and an increased susceptibility to injury and infection. It is caused by an insufficient food intake, excessive activity, malabsorption and poor utilization of food, wasting diseases or psychological stress. High-energy diets are recommended for a gradual, steady weight gain. A diet that provides 30 to 35% of calories from fat and an additional 500 to 1,000 calories per day is recommended. Underweight persons can be encouraged to eat calorie-dense meals and snacks at the worksite by offering them access to a wide variety of palatable, popular foods.

Special Diets

Special diets are prescribed for the treatment of certain diseases and conditions. In addition, dietary modifications should accompany preventive lifestyle and nutrition programs and should be implemented during various stages of the life cycle, such as during pregnancy and lactation. An important aspect of successfully implementing special diets is recognizing that a number of different strategies can be utilized to achieve the nutrient specifications of the special diet. Thus, individualizing diet plans to meet the unique needs of persons is essential for attaining long-term dietary adherence and, thereby, realizing the health benefits of the diet.

Low-fat, low-saturated fat, low-cholesterol diet

The recommended diets for the treatment of an elevated blood cholesterol level are the Step-One diet (<30% of calories from fat, 8 to 10% of calories from saturated fat and <300 milligrams of cholesterol) and the Step-Two diet (<30% of calories from fat, <7% of calories from saturated fat, and <200 milligrams of cholesterol) (NIH 1993b). These diets are designed to progressively reduce intake of saturated fat and cholesterol and to decrease total fat intake. The major sources of fat in the diet are meat, poultry; full-fat dairy products and fats and oils. In general, for most persons in developed countries, adherence to a Step-One diet requires reducing total fat and saturated fat by about 20 to 25%, whereas following a Step-Two diet requires decreasing total fat similarly but decreasing saturated fat by approximately 50%. A Step-One diet can be achieved rather easily by applying one or more fat reduction strategies to the diet, such as substituting lean meat, poultry and fish for higher-fat varieties, substituting low-fat and skim milk products for full-fat dairy products, using less fat in food preparation and adding less fat to food prior to consumption (e.g., butter, margarine or salad dressing) (Smith-Schneider, Sigman-Grant and Kris-Etherton 1992). A Step-Two diet requires more careful diet planning and the intensive nutrition education efforts of a qualified nutritionist.

Very low-fat diet

A diet that provides 20% or less of calories from fat is recommended by some nutritionists for the prevention of certain cancers that have been associated with diets high in fat (Henderson, Ross and Pike 1991). This diet is rich in fruits and vegetables, grains, cereals, legumes and skim milk dairy products. Red meat can be used sparingly, as can fats and oils. Foods are prepared with little or no added fat and are cooked by baking, steaming, boiling or poaching.

A diet that provides minimal amounts of saturated fat (3% of calories) and total fat (10% of calories), together with major lifestyle changes (smoking cessation, exercise and meditation) has been shown to result in the regression of atherosclerosis (Ornish et al. 1990). This particular diet requires major lifestyle changes (i.e., a change in habitual cuisine), including adopting a largely vegetarian diet and using meat, fish and poultry as a condiment, if at all, and emphasizing grains, legumes, fruits, vegetables, and skim milk dairy products. Adherence to this diet can require the purchase of special foods (fat-free products) while avoiding most commercially prepared foods. While this regimen is an option for some persons at high risk for cardiovascular disease, especially as an alternative to drug therapy, it requires a very high level of motivation and commitment.

Diet for workers with diabetes

An individually developed dietary prescription based on metabolic, nutrition, and lifestyle requirements is recommended (American Dietetic Association 1994). In general, dietary protein provides 10 to 20% of calories. Saturated fat should account for less than 10% of total caloric intake. The distribution of remaining energy from carbohydrate and fat varies according to the patient’s condition and reflects the specific glucose, lipid and weight outcomes chosen for him or her. For those who are at or close to ideal weight, 30% of calories from fat is recommended. For overweight persons, a reduction in total fat facilitates reducing calories, resulting in a corresponding weight loss. For persons who have an elevated triglyceride level, a diet higher in total fat, and, in particular, monounsaturated fat is recommended, together with close supervision; the higher-fat diet may perpetuate or aggravate obesity. The new model for the medical nutrition therapy for diabetes includes assessment of the individual’s metabolic and lifestyle parameters, an intervention plan and monitoring therapeutic outcomes.

Diet for pregnancy and lactation

Pregnancy and lactation represent periods when both energy and nutrient demands are high. For pregnancy, a diet should provide sufficient calories for adequate weight gain (National Research Council 1989). The calories and nutrients needed to maximally support pregnancy and lactation for as long as several years during multiple pregnancies and lengthy lactation periods can be obtained from a diet that includes the basic food groups. Other recommendations for both pregnant and lactating women include selecting a variety of foods from each food group, consuming regular meals and snacks, and including ample dietary fiber and fluid. Alcoholic beverages should be avoided or at least markedly restricted by pregnant and lactating women. Salt to taste is also recommended for pregnant women. An adequate diet during pregnancy and lactation is essential to assure normal fetal and infant growth and development and maternal health and well-being, and should be emphasized in worksite nutrition education programs and catering facilities.

Lactose Intolerance and Gluten Sensitivity

Many adults, especially those of certain ethnic groups, must restrict lactose in their diet due to a lactase deficiency. The major source of lactose in the diet is dairy products and foods prepared with them. It is important to note that the excipient in many medications is lactose, a circumstance that could pose problems to those who take a number of medications. For the small number of people who have a gluten sensitivity (coeliac disease), foods containing gluten must be eliminated from the diet. Sources of gluten in the diet include wheat, rye, barley and oats. Whereas many individuals with a lactose intolerance can tolerate small amounts of lactose, especially when eaten with foods that do not contain lactose, persons with a gluten sensitivity must avoid any food that contains gluten. Worksite catering facilities should have appropriate foods available if there are employees with these special conditions.

Summary

The worksite is an ideal setting for implementing nutrition programs aimed at teaching the principles of good nutrition and their application. There is a variety of programs that can be developed for the worksite. In addition to providing classes and nutrition education materials for all employees, special programs can be targeted to workers at high risk for different chronic diseases or for selected groups based on ethnic or demographic characteristics. Chronic disease risk reduction requires a long-term commitment by both workers and their employers. Effective worksite nutrition programs are beneficial in reducing the risk of chronic diseases in countries worldwide.

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Introduction

Awareness of the adverse effects associated with cigarette smoking has increased since the 1960s when the first US Surgeon General’s report on this topic was released. Since that time, attitudes towards cigarette smoking have steadily grown towards the negative, with warning labels being required on cigarette packages and advertisements, bans on television advertising of cigarettes in some countries, the institution of non-smoking areas in some public places and the complete prohibition of smoking in others. Well-founded public health messages describing the dangers of tobacco products are increasingly widespread despite the tobacco industry’s attempts to deny that a problem exists. Many millions of dollars are spent each year by people trying to “kick the habit”. Books, tapes, group therapy, nicotine gum and skin patches, and even pocket computers have all been used with varying degrees of success in aiding those with nicotine addiction. Validation of the carcinogenic effects of passive, “second-hand” smoking has added impetus to the growing efforts to control the use of tobacco.

With this background, it is natural that smoking in the workplace should become a growing concern for employers and employees. On the most basic level, smoking represents a fire hazard. From a productivity standpoint, smoking represents either a distraction or an annoyance, depending on whether the employee is a smoker or a non-smoker. Smoking is a significant cause of morbidity in the workforce. It represents a drain in productivity in the form of the loss of work days due to illness, as well as a financial drain on an organization’s resources in terms of health-related costs. Furthermore, smoking has either an additive or multiplicative interaction with environmental hazards found in certain workplaces increasing significantly the risk of many occupational diseases (figure 1).

Figure 1. Examples of interactions between occupation and cigarette smoking causing disease.

This article will concern itself with the rationale for smoking control in the workplace and suggest a practical attitude and approach to managing it, recognizing that mere exhortation is not enough. At the same time, the terrible, addictive nature of nicotine and the human difficulties associated with quitting will not be underestimated. One hopes that it represents a more realistic approach to this complicated problem than some of those taken in the past.

Smoking in the Workplace

Organizations are increasingly associating unhealthy habits such as smoking with higher operating costs, and employers are taking measures to reduce the excess costs associated with employees who smoke. People who smoke one or more packs of cigarettes a day account for 18% higher medical claim costs than non-smokers, according to a study of the impact of various lifestyle risks compiled by the Ceridian Corporation, a technology services company based in Minneapolis, Minnesota. Heavy smokers spend 25% more days as inpatients in hospitals and are 29% more likely than non-smokers to have annual health care claims costs that exceed US$5,000, the study shows (Lesmes 1993).

The impact of smoking on the health of the population and the health care system is unparalleled (US Department of Health and Human Services 1989). According to the World Health Association (1992), tobacco kills at least 3 million people each year worldwide: in countries where smoking has been a long-established behavior, it is responsible for about 90% of all lung cancer deaths; 30% of all cancers; over 80% of cases of chronic bronchitis and emphysema; and some 20 to 25% of coronary heart disease and stroke deaths. Numerous other adverse health conditions, including respiratory diseases, peptic ulcers and pregnancy complications, are also attributable to smoking. Smoking remains the leading cause of avoidable death in many countries, so pervasive that it is responsible for about one sixth of deaths from all causes in the United States, for example (Davis 1987).

The combined effect of smoking and occupational hazards has been demonstrated by the significant differences in morbidity of smokers and non-smokers in many occupations. The interaction of the two types of hazards increases the risk of many diseases, particularly the chronic obstructive pulmonary diseases, lung cancer, cardiovascular diseases, as well as disabilities (figure 1).

Well-recognized complications resulting from exposure to tobacco-related hazards are outlined in great detail throughout the technical literature. Recent attention has focused on the following:

• Female risks. Changes in oestrogen metabolism, menstrual disorders, early menopause, delayed conception or infertility, cancer of the cervix.
• Maternal and pregnancy risks. Spontaneous abortion, ectopic pregnancy, placental irregularities, placenta praevia, abruptio placentae, vaginal bleeding, foetal mortality, preterm birth, retardation of foetal development, low birth weight, congenital anomalies and chronic hypoxia.
• Childhood complications. Increased neonatal mortality, sudden infant death syndrome (SIDS), impaired physical and intellectual development.

Environmental Tobacco Smoke (ETS)

Tobacco smoking is not only dangerous to the smoker but to non-smokers as well. ETS (“passive smoking” and “second-hand smoke”) is a unique risk for people, such as office workers, working in a closed environment. In developed countries, the World Health Organization (1992) points out, tobacco smoke is the most common pollutant of indoor air and is usually present at higher concentrations than other air pollutants. Besides the acute effects of eye and throat irritation, ETS increases the risk of lung cancer and possibly of cardiovascular disease. It is particularly troublesome to individuals with pre-existing health conditions, such as asthma, bronchitis, cardiovascular disease, allergies and upper respiratory infections, and also is a vexatious challenge to those who have recently given up smoking and are struggling to maintain their abstinence.

The US National Institute for Occupational Safety and Health, NIOSH, concluded that (1991):

• ETS is a potential carcinogen.
• Exposure to ETS should be reduced to the lowest possible concentration.
• Employers should minimize occupational exposure to ETS by using all available control measures.
• Worker exposure to ETS is most efficiently and completely controlled by simply eliminating tobacco smoke from the workplace.
• Employers should prohibit smoking at the workplace and provide sufficient disincentives for those who do not comply.

Except where legislation has mandated the smoke-free workplace, the protection of non-smoking employees from the health risks associated with exposure to ETS remains a formidable challenge for many public and private sector employees. Smokers, with encouragement from the tobacco industry, have maintained that continuation of smoking is inherently an individual right, despite the fact that eliminating tobacco smoke from the workplace has required innovations in ventilation engineering and expense by the employer. Legal precedents have established a clear duty for employers to provide workplaces free from hazards such as ETS and courts of law in some countries have found employers liable for the adverse health effects of ETS exposure on the job.

Surveys of public knowledge and attitudes about the risks of ETS and the desirability of workplace smoking restrictions show widespread concern about this sort of exposure and increasingly strong support for significant restrictions among both non-smokers and smokers (American Lung Association 1992). Governments have adopted an increasing number of ordinances and regulations limiting smoking in public and private workplaces (Corporate Health Policies Group 1993).

Impact of Smoking on Employers’ Costs

Historically, employers’ efforts to reduce smoking in the workplace have been driven by issues of cost and productivity losses related to smoking behavior. A number of studies have compared employers’ costs associated with smoking and non-smoking employees. For example, in one study of employees in a large-scale group health insurance plan, tobacco users had higher average outpatient medical care costs ($122 versus $75), higher average insured medical costs ($1,145 versus $762), more hospital admissions per 1,000 employees (174 versus 76), more hospital days per 1,000 employees (800 versus 381), and longer average lengths of hospital stay (6.47 versus 5.03 days) (Penner and Penner 1990).

Another study, undertaken over a period of three and one-half years by the Dow Chemical Company and covering 1,400 employees (Fishbeck 1979), showed that smokers were absent 5.5 days more per year than non-smokers, costing Dow over $650,000 annually in excess wages alone. This figure did not include extra health care costs. In addition, smokers had 17.4 disability days per year compared with 9.7 days for non-smokers. Smokers also had twice the frequency of circulatory disease problems, three times more pneumonia, 41% more bronchitis and emphysema, and 76% more respiratory diseases of all types. For every two non-smokers who died during the study period, seven smokers died.

A study by the United States Steel Corporation found that employees who smoke have more work-loss days than those who have never smoked. It also showed that in every age group, as the number of cigarettes smoked per day by confirmed smokers increased, so did the number of absences due to illness. Additionally, male smokers of more than two packs per day had nearly twice as much absence as their non-smoking counterparts. In a study on how much individual behavioral risk factors contribute to the total disability and health care costs of a large, multi-location industrial company, smokers had 32% greater absenteeism and $960 excess average annual illness costs per employee (Bertera 1991).

The annual report of the Kansas State Employees Health Care Commission found that smokers incurred 33% more hospital admissions than non-smokers (106.5 versus 71.06 hospital admissions per 1,000 persons). The total average claim payment per employee was $282.62 more for smokers than for non-smokers.

Results like these have prompted some US employers to add a “surcharge” to their smoking employees’ share of group health insurance premiums to cover the higher claims payments associated with this population. The Resinoid Engineering Corporation stopped hiring smokers in its Ohio plant because their health care claims were $6,000 higher per employee per year for smokers than for non-smokers; a similar move by a Chicago, Illinois company was barred because the state law prohibits discriminatory hiring on the basis of lifestyle.

Other employers, using the “carrot” rather than the “stick” approach, have offered inducements such as monetary or other types of awards to employees who successfully quit smoking. A popular approach is to refund the tuition required for participating in a smoking cessation program to those who complete the course or, more strictly, to those who remain abstinent for a defined period following the completion of the course.

In addition to increased health care costs and costs associated with lost productivity due to sickness among smokers, there are other increased costs associated with smoking, namely those arising from lost productivity during smoking breaks, higher fire and life insurance costs, and higher general cleaning costs related to smoking. For example, Air Canada identified savings of about US$700,000 per year by not having to clean ashtrays and being able to extend the frequency of deep cleaning of its planes from six to nine months after implementing its tobacco-free policy (WHO 1992). A study by Kristein (1983) designed to take into account all of the increased costs due to smoking estimated the total to be $1,300 per smoker per year (adjusted to 1993 dollars). He also discussed other areas of excess cost, including, in particular, the costs of higher levels of maintenance for computers and other sensitive equipment, and for installing and maintaining ventilation systems. Furthermore, he added that other costs result from the “inefficiency and errors based on the established literature as to the effects of higher carbon monoxide levels in smokers, eye irritation, measured lower attentiveness, cognitive and exercise capacity function”.

Smoking Policies and Regulations

In the 1980s, laws and voluntary policies to restrict smoking at the workplace increased in number and strength. Some pertain only to government worksites which, together with places of work where children are present, have often taken the lead. Others affect both government and private worksites. They are characterized by banning smoking altogether (“smoke-free” worksites); restricting smoking in common areas such as cafeterias and meeting rooms; allowing smoking only in special smoking areas; and requiring accommodation of the interests of smokers and non-smokers, with primacy given to the wishes of the latter.

Some programs regulate smoking in worksites where certain hazardous materials are present. For example, in 1976 Norway issued rules prohibiting the assignment of persons who smoke to areas where they may be exposed to asbestos. In 1988, Spain prohibited smoking in any place where the combination of smoking and occupational hazards results in greater risk to the health of workers. Spain also prohibits smoking in any worksite where pregnant women work. Other countries that have taken legislative measures to restrict smoking in the workplace include Costa Rica, Cuba, Denmark, Iceland and Israel (WHO 1992).

Increasingly, legislation restricting smoking at the worksite is part of a broader regulation covering public places. New Zealand, Norway and Sweden have enacted such legislation while Belgium, the Netherlands and Ireland have passed laws prohibiting smoking in most public places. The 1991 French law prohibits smoking in all places designed for collective use, notably schools and public transportation (WHO 1992).

In the United States and Canada, although federal agencies have adopted smoking control policies, legislation has been limited to states and provinces and to municipalities. By 1989, 45 US states had enacted laws restricting smoking in public places, while 19 states and the District of Columbia had adopted ordinances restricting smoking in private workplaces (Bureau of National Affairs 1989). The state of California has a bill pending that would totally ban smoking in all indoor employment areas and would also obligate an employer to take reasonable steps to prevent visitors from smoking (Maskin, Connelly and Noonan 1993). For some time, the Occupational Safety and Health Administration (OSHA) in the US Department of Labor has been considering the regulation of ETS in the workplace both as an independent toxicant and as a component of indoor air (Corporate Health Policies Group 1993).

Another incentive for employers to reduce smoking in the workplace comes from cases of disability stemming from exposure to ETS that have won worker’s compensation awards. In 1982, a federal appellate court found an employee eligible for disability retirement because she had been forced to work in a smoke-filled environment (Parodi vs. Veterans Administration 1982). Similarly, employees have been awarded worker’s compensation payments because of adverse reactions to tobacco smoke on the job. Indeed, William Reilly, the former administrator of the US Environmental Protection Agency (EPA) has expressed the hope that the threat of employer liability raised by the recent release of the EPA’s designation of EST as a significant health hazard would obviate the necessity of additional federal government regulations (Noah 1993).

Another factor favoring the establishment of policies curbing workplace smoking is the change in public attitudes reflecting (1) recognition of the mounting scientific evidence of the risks of cigarette smoke to smokers and non-smokers alike, (2) a decline in the prevalence of smoking, (3) a decline in the social acceptability of smoking and (4) a heightened awareness of the rights of non-smokers. The American Lung Association (1992) reported consistent increases in the overall percentage of adults who favor workplace smoking restrictions, from 81% in 1983 to 94% in 1992, while in the same period, those favoring a total ban increased from 17% to 30% and those favoring no restrictions fell from 15% to 5%.

Labor unions are also increasingly supportive of non-smoking policies (Corporate Health Policies Group 1993).

Recent US surveys have shown a marked trend towards not only increased adoption of smoking restrictions but also their increasing stringency (Bureau of National Affairs 1986, 1991). The percentage of companies with such policies rose from 36% in 1986 to 85% in 1991 while, in the same period, there was a sixteen-fold increase in the percentage with total bans or “smoke-free” policies (Bureau of National Affairs 1991; Coalition on Smoking and Health 1992).

Smoking Cessation Programs

Worksites are becoming increasingly common settings for health education and promotion efforts. Of several cited studies (Coalition on Smoking and Health 1992), one survey indicates that 35.6% of companies offer some kind of smoking cessation assistance. Another study shows that non-smoking policies may also provide environmental support to individuals attempting to quit smoking. Thus, a non-smoking policy may also be considered an important element in a smoking cessation program.

Smoking cessation methods are divided into two categories:

• Unassisted methods, which include going “cold turkey” (i.e., just stopping without recourse to any special techniques); gradually reducing the number of cigarettes smoked per day; using low-tar or low-nicotine cigarettes; quitting with friends, relatives or acquaintances; using special cigarette filters or holders; using other nonprescription products; or substituting another tobacco product for cigarettes (snuff, chewing tobacco, pipes or cigars).
• Assisted methods, which include attending a programme or a course with or without a fee; consulting a mental health professional; hypnosis; acupuncture; and using nicotine gum or nicotine skin patches.

The efficacy of these various methods is the subject of much controversy largely due to the difficulties and costs associated with long-term follow-up and the obvious self-interest of the vendors of programs and products. Another serious limitation relates to the ability to verify the smoking status of program participants (Elixhauser 1990). Saliva tests measuring cotinine, a metabolite of nicotine, are an effective objective indicator of whether an individual has recently been smoking, but they are moderately complicated and expensive and, thus. not widely used. Accordingly, one is forced to depend on the questionable reliability of the individual’s self-reports of success in either quitting or cutting down on the amount smoked. These problems make it extremely difficult to compare various methods to one another or even to make proper use of a control group.

Despite these encumbrances, two general conclusions can be drawn. First, those individuals most successful in permanently quitting do so largely on their own, often after numerous attempts to do so. Secondly, barring the individual “cold turkey” approach, multiple interventions in combination appear to enhance the effectiveness of efforts to quit, especially when accompanied by support in maintaining abstinence and reinforcement of the quit-smoking message (Bureau of National Affairs 1991). The importance of the latter is confirmed by a study (Sorenson, Lando and Pechacek 1993) which found that the highest overall cessation rate was achieved by smokers who worked among a high proportion of non-smokers and who were frequently asked not to smoke. Still, the six-month quitting rate was only 12%, compared to a rate of 9% among the control group. Obviously, cessation programs in general must not be expected to produce dramatic positive results but, instead, must be viewed as requiring a persistent, patient effort towards the goal of quitting smoking.

Some workplace smoking cessation programs have been overly simple or naive in their approach, while others have lacked long-term determination and commitment. Companies have tried everything from simply restricting smoking to specified areas of the worksite or autocratically making a sudden announcement banning all smoking, to providing expensive and intensive (but often short-lived) programs offered by outside consultants. The problem and the challenge is to successfully accomplish the transition to a smoke-free workplace without sacrificing worker morale or productivity.

The following section will present an approach that incorporates our present knowledge of the difficulties individuals face in quitting and the employer attitude necessary to best achieve the goal of non-smoking in the workplace.

An Alternative Approach to Achievinga Smoke-free Workplace

Past experience has shown that simply offering smoking cessation programs to volunteers does not advance the goal of a smoke-free workplace because the majority of smokers will not participate in them. At any given time, only about 20% of smokers are ready to quit and only a minority of this group will sign up for a cessation program. For the other 80% of smokers who don’t want to quit or who don’t believe they can quit when the enterprise goes smoke-free, instituting a ban on smoking in the workplace will just tend to cause them to move their smoking during working hours “out the door” to a designated smoking area or somewhere outside the building. This “80% problem”—the problem that 80% of the smokers are not going to be helped or even consider participating in the program if only smoking cessation programs are offered—has numerous consequent negative effects on employee relations, productivity, operating costs and health-related costs.

An alternative, and successful, approach has been developed by Addiction Management Systems, an organization based in Toronto, Canada. This approach is based on the knowledge that change and the modification of behavior is a process which can be planned and managed using organizational and behavioral techniques. It involves dealing with control of smoking in the workplace in the same way as any other major policy or procedural change for the company, with informed decisions made by management after input from representative employee groups. A controlled change is made by supporting those managers responsible for overseeing the change and making all smokers positive participants in the change by providing them with the “tools” to accommodate to the new non-smoking environment without requiring them to quit smoking. The focus is on communications and team-building by involving and educating all of those affected by the policy change.

The actual process of the transition to a smoke-free workplace begins with the announcement of the policy change and the start of a transition period of several months’ duration before the policy goes into effect. In behavioral terms, the upcoming policy change to becoming smoke-free acts as a “stimulus to change” and creates a new environment in which it is in the interest of all smokers to seek a means of successfully adapting to the new environment.

The announcement of this policy change is followed by a communication program aimed at all employees, but focused on two important groups: the supervisors who must implement and oversee the new non-smoking policy, and the smokers who need to learn to adapt to the new environment. An important part of the communication program is making smokers aware that, while they will not be required to quit smoking unless they so choose, they must nonetheless adhere to the new policy forbidding smoking in the workplace during the workday. All employees receive the communications about the policy and upcoming changes.

During the transition period, supervisors are provided with communications materials and a training program to enable them to understand the policy change and to anticipate questions, problems or other concerns which may come up during or after the change. As the group most directly affected when the policy goes into effect, smokers are consulted about their specific needs and also receive their own training program. The special focus of the latter is to acquaint them with a voluntary self-help “smoking control” program that contains a number of options and choices which allow the smokers to understand the program and to learn to modify their smoking behavior in order to refrain from smoking during the workday as required once the new policy goes into effect. This allows each smoker to personalize his or her own program, with “success” defined by the individual, whether it be quitting altogether or just learning how not to smoke during the workday. Accordingly, resentment is neutralized and the change to the smoke-free workplace becomes a positive motivating factor for the smoker.

The end result of this approach is that when the effective date of the policy arrives, the transition to a smoke-free workplace becomes a “non-event”—it simply happens, and it is successful. The reason this occurs is that the groundwork has been laid, the communications have been carried out, and all of those persons involved understand what needs to happen and have the means to make a successful transition.

What is important from an organizational standpoint is that the change is one which tends to be self-maintaining, with only minimal ongoing input from management. Also important is the effect that once successful in learning to “manage” their smoking problem, the smokers in the “80% group” tend to build on their success and to progress towards quitting completely. Finally, in addition to the beneficial effect on the well-being and morale of employees who are positively involved in the transition to a smoke-free environment, the organization accrues over time benefits in terms of higher productivity and reduced costs related to health care.

Evaluation of Effectiveness

In evaluating the effectiveness of the program, there are two separate criteria that must be considered. The first is whether the workplace truly becomes a smoke-free environment. Success with respect to this goal is relatively easy to measure: it is based on regular supervisors’ reports on violations of the policy within their work areas; monitoring complaints from other employees; and the results of unannounced spot checks of the workplace to reveal the presence or absence of cigarette butts, ashes and smoke-laden air.

The second measure of success, and more difficult to determine, is the number of employees who actually quit smoking and maintain their smoke-free status. While perhaps the most practical position to take is to be concerned only with worksite smoking, such a limited success will bring about fewer long-term benefits, especially with respect to decreasing illness and health care costs. While periodic mandatory saliva tests for cotinine to identify those who continue to smoke would be the best and most objective method for evaluating long-term program success, this is not only complicated and expensive but also is fraught with numerous legal and ethical questions regarding employee privacy. A compromise is the use of annual or semi-annual anonymous questionnaires that ask how individuals’ smoking habits have changed and how long abstinence from smoking has been maintained and that, at the same time, probe changes in employees’ attitudes toward the policy and the program. Such questionnaires have the added advantage of being a means of reinforcing the non-smoking message and of keeping the door open for those still smoking to reconsider dropping the habit.

A final long-term outcome evaluation involves monitoring employee absenteeism, illnesses and health care costs. Any changes would at first be subtle, but over a number of years they should be cumulatively significant. Death benefits paid prior to normal retirement age could be another long-term reflection of the success of the program. Of course, it is important to adjust such data for such factors as changes in the work force, employee characteristics such as age and sex, and other factors affecting the organization. Analysis of these data is manifestly subject to the rules of statistics and would probably be valid only in organizations with a large and stable workforce and adequate data collection, storage and analysis capabilities.

Smoking Control Worldwide

There is a growing worldwide unwillingness to continue to bear the burdens of cigarette smoking and nicotine addiction in terms of their effects on human well-being and productivity, on health and health care costs, and on the economic health of work organizations and nations. This is exemplified by the expanding participation in World No-Tobacco Day that has been spearheaded by the World Health Organization in May of each year since 1987 (WHO 1992).

The aim of this event is not only to ask people to stop smoking for one day but also to trigger interest in controlling smoking among public and private organizations and to promote pressure for the passage of laws, by-laws or regulations advancing the cause of tobacco-free societies. It is also hoped that the relevant agencies will be stimulated to initiate research on specific themes, publish information or initiate action. To this end, each World No-Tobacco Day is assigned a specific theme (table 1); of particular interest to readers of this article is the 1992 Day which addressed “Tobacco-free workplaces: safer and healthier”.

1992    Tobacco Free Workplaces: safer and healthier

1993    Health Services: our window to a tobacco-free world

1994    The Media and Tobacco: getting the health message across

1995    The Economics of Tobacco: tobacco costs more than you think

1996    Sports and the Arts

1997    United Nations and Specialized Agencies against Tobacco

A problem beginning to be recognized is the increase in cigarette smoking in developing countries where, prompted by the marketing blandishments of the tobacco industry, populations are being encouraged to view smoking as a hallmark of social advancement and sophistication.

Conclusion

The adverse effects of cigarette smoking on individuals and societies are increasingly being recognized and understood (except by the tobacco industry). Nevertheless, smoking continues to enjoy social acceptability and widespread use. A special problem is that many young people become addicted to nicotine years before they are old enough to work.

The workplace is an exceptionally useful arena for combating this health hazard. Workplace policies and programs can have a strong positive influence over the behavior of employees who smoke, abetted by peer pressure from non-smoking coworkers. The wise organization will not only appreciate that control of workplace smoking is something that serves its own self-interest in terms of legal liabilities, absenteeism, production and health-related costs, but will also recognize that it can be a matter of life and death for its employees.

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