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.

Back

In 1990, the US Government demonstrated strong support for workplace health promotion programs with the publication of Healthy People 2000, setting forth the National Health Promotion and Disease Prevention Objectives for the Year 2000 (US Public Health Service 1991). One of these objectives calls for an increase in the percentage of worksites offering health promotion activities for their employees by the year 2000, “preferably as part of a comprehensive employee health promotion program” (Objective 8.6). Two objectives specifically include efforts to prohibit or severely restrict smoking at work by increasing the percentage of worksites with a formal smoking policy (Objective 3.11) and by enacting comprehensive state laws on clean indoor air (Objective 3.12).

In response to these objectives and employee interest, Merrill Lynch and Company, Inc. (hereafter called Merrill Lynch) launched the Wellness and You program for employees at headquarters locations in New York City and in the state of New Jersey. Merrill Lynch is a US-based, global financial management and advisory company, with a leadership position in businesses serving individuals as well as corporate and institutional clients. Merrill Lynch’s 42,000 employees in more than 30 countries provide services including securities underwriting, trading and brokering; investment banking; trading of foreign exchange, commodities and derivatives; banking and lending; and insurance sales and underwriting services. The employee population is diverse in terms of ethnicity, nationality, educational achievement and salary level. Nearly half of the employee population is headquartered in the New York City metropolitan area (includes part of New Jersey) and in two service centers in Florida and Colorado.

Merrill Lynch’s Wellness and You Program

The Wellness and You program is based in the Health Care Services Department and is managed by a doctorate-level health educator who reports to the medical director. The core wellness staff consists of the manager and a full-time assistant, and is supplemented by staff physicians, nurses and employee assistance counselors as well as outside consultants as needed.

In 1993, its initial year, over 9,000 employees representing approximately 25% of the workforce participated in a variety of Wellness and You activities, including the following:

• self-help and written information programmes, including the distribution of pamphlets on a diversity of health topics and a Merrill Lynch personal health guide designed to encourage employees to get the tests, immunizations, and guidance they need to stay healthy
• educational seminars and workshops on topics of broad interest such as smoking cessation, stress management, AIDS, and Lyme disease
• comprehensive screening programmes to identify employees at risk for cardiovascular disease, skin cancer, and breast cancer. These programmes were provided by outside contractors on company premises either in health services clinics or mobile van units
• ongoing programmes, including aerobic exercise in the company cafeteria and personal weight management classes in company conference rooms
• clinical care, including influenza immunizations, dermatology services, periodic health examinations and nutritional counselling in the employee health services clinics.

In 1994, the program expanded to include an onsite gynecology screening program comprising of Pap smears and pelvic and breast examinations; and a worldwide emergency medical assistance program to help American employees locate an English-speaking doctor anywhere in the world. In 1995, wellness programs will be extended to service offices in Florida and Colorado and will reach approximately half of the entire workforce. Most services are offered to employees free of charge or at nominal cost.

Smoking Control Programs at Merrill Lynch

Anti-smoking programs have gained a prominent place in the workplace wellness arena in recent years. In 1964, the US Surgeon General identified smoking as the single cause of the greater part of preventable disease and premature death (US Department of Health, Education, and Welfare 1964). Since then, research has demonstrated that the health risk from inhaling tobacco smoke is not limited to the smoker, but includes those who inhale second-hand smoke (US Department of Health and Human Services 1991). Consequently, many employers are taking steps to limit or curtail smoking by employees out of concern for employee health as well as their own “bottom lines”. At Merrill Lynch, Wellness and You includes three types of smoking cessation effort: (1) the distribution of written material, (2) smoking cessation programs, and (3) restrictive smoking policies.

Written materials

The wellness program maintains a wide selection of quality educational materials to provide information, assistance and encouragement to employees to improve their health. Self-help materials such as pamphlets and audiotapes designed to educate employees about the harmful effects of smoking and about the benefits of quitting are available in the health care clinic waiting rooms and through interoffice mail by request.

Written materials also are distributed at health fairs. Often these health fairs are sponsored in conjunction with national health initiatives so as to capitalize on existing media attention. For example, on the third Thursday of each November, the American Cancer Society sponsors the Great American Smokeout. This national campaign, designed to encourage smokers to give up cigarettes for 24 hours, is well publicized throughout the United States by television, radio and newspapers. The idea is that if smokers can prove to themselves that they can quit for the day, they might quit for good. In 1993’s Smokeout, 20.5% of smokers in the United States (9.4 million) stopped smoking or reduced the number of cigarettes they smoked for the day; 8 million of them reported continuing not to smoke or reducing their smoking one to ten days later.

Each year, members of Merrill Lynch’s medical department set up quit-smoking booths on the day of the Great American Smokeout at home office locations. Booths are stationed in high-traffic locations (lobbies and cafeterias) and provide literature, “survival kits” (containing chewing gum, cinnamon sticks, and self-help materials), and quit-smoking pledge cards to encourage smokers to quit smoking at least for the day.

Smoking cessation programs

Since no single smoking cessation program works for everyone, employees at Merrill Lynch are offered a variety of options. These include self-help written materials (“quit kits”), group programs, audiotapes, individual counseling and physician intervention. Interventions range from education and classic behavior modification to hypnosis, nicotine replacement therapy (e.g., “the patch” and nicotine chewing gum), or a combination. Most of these services are available to employees free of charge and some programs, such as group interventions, have been subsidized by the firm’s benefits department.

Non-smoking policies

In addition to smoking cessation efforts aimed at individuals, smoking restrictions are becoming increasingly common in the workplace. Many jurisdictions in the United States, including the states of New York and New Jersey, have enacted strict workplace smoking laws that, for the most part, limit smoking to private offices. Smoking in common work areas and conference rooms is permitted, but only if each and every person present agrees to allow it. The statutes typically mandate that non-smokers’ preferences receive priority even to the point of banning smoking entirely. Figure 1 summarizes the city and state regulations applicable in New York City.

Figure 1. Summary of city and state restrictions on smoking in New York.

In many offices, Merrill Lynch has implemented smoking policies which extend beyond the legal requirements. Most headquarters cafeterias in New York City and in New Jersey have gone smoke-free. In addition, total smoking bans have been implemented in some office buildings in New Jersey and Florida, and in certain work areas in New York City.

There seems to be little debate about the adverse health effects of tobacco exposure. However, other issues should be considered in developing a corporate smoking policy. Figure 2 outlines many of the reasons why a company may or may not elect to restrict smoking beyond the legal requirements.

Figure 2. Reasons for and against restricting smoking in the workplace.

Evaluation of Smoking Cessation Programs and Policies

Given the relative youth of the Wellness and You program, no formal evaluation has yet been conducted to determine the effect of these efforts on employee morale or smoking habits. However, some studies suggest that worksite smoking restrictions are favored by a majority of employees (Stave and Jackson 1991), result in decreased cigarette consumption (Brigham et al. 1994; Baile et al. 1991; Woodruff et al. 1993), and effectively increase smoking cessation rates (Sorensen et al. 1991).

Back

Within the next decade, it is predicted, cancer will become the leading cause of death in many developed countries. This reflects not so much an increase in the incidence of cancer but rather a decrease in mortality due to cardiovascular disease, currently topping the mortality tables. Equally with its high mortality rate, we are disturbed by the specter of cancer as a “dread” disease: one associated with a more or less rapid course of disability and a high degree of suffering. This somewhat fearsome picture is being made easier to contemplate by our growing knowledge of how to reduce risk, by techniques permitting early detection and by new and powerful achievements in the field of therapy. However, the latter may be associated with physical, emotional and economic costs for both the patients and those concerned about them. According to the US National Cancer Institute (NCI), a significant reduction in cancer morbidity and mortality rates is possible if current recommendations relating to use of tobacco, dietary changes, environmental controls, screening and state-of-the-art treatment are effectively applied.

To the employer, cancer presents significant problems entirely apart from the responsibility for possible occupational cancer. Workers with cancer may have impaired productivity and recurrent absenteeism due both to the cancer itself and the side effects of its treatment. Valuable employees will be lost through prolonged periods of disability and premature death, leading to the considerable cost of recruiting and training replacements.

There is a cost to the employer even when it is a spouse or other dependant rather than the healthy employee who develops the cancer. The caregiving burden may lead to distraction, fatigue and absenteeism which tax that employee’s productivity, and the often considerable medical expenses increase the cost of employer-sponsored health insurance. It is entirely appropriate, therefore, that cancer prevention should be a major focus of worksite wellness programs.

Primary Prevention

Primary prevention involves avoidance of smoking and modifying other host factors that may influence the development of cancer, and identifying potential carcinogens in the work environment and eliminating or at least limiting workers’ exposure to them.

Controlling exposures

Potential as well as proven carcinogens are identified through basic scientific research and by epidemiological studies of exposed populations. The latter involves industrial hygiene measurements of the frequency, magnitude and duration of the exposures, coupled with comprehensive medical surveillance of the exposed workers, including analysis of causes of disability and death. Controlling exposures involves the elimination of these potential carcinogens from the workplace or, when that is not possible, minimizing exposure to them. It also involves the proper labeling of such hazardous materials and continuing education of workers with respect to their handling, containment and disposal.

Smoking and cancer risk

Approximately one-third of all cancer deaths and 87% of all lung cancers in the US are attributable to smoking. Tobacco use is also the principal cause of cancers of the larynx, oral cavity and oesophagus and it contributes to the development of cancers of the bladder, pancreas, kidney, and uterine cervix. There is a clear dose-response relationship between lung cancer risk and daily cigarette consumption: those who smoke more than 25 cigarettes a day have a risk that is about 20 times greater than that of non-smokers.

Experts believe that the involuntary intake of the tobacco smoke emitted by smokers (“environmental tobacco smoke”) is a significant risk factor for lung cancer in non-smokers. In January 1993, the US Environmental Protection Agency (EPA) classified environmental tobacco smoke as a known human carcinogen which, it estimated, is responsible for approximately 3,000 lung cancer deaths annually among US non-smokers.

The 1990 US Surgeon General’s report on the health benefits of smoking cessation provides clear evidence that quitting smoking at any age is beneficial to one’s health. For example, five years after quitting, former smokers experience a diminished risk for lung cancer; their risk, however, remains higher than that of non-smokers for as long as 25 years.

The elimination of tobacco exposure by employer-sponsored/ labor union-sponsored smoking cessation programs and worksite policies enforcing a smoke-free working environment represent a major element in most worksite wellness programs.

Modifying host factors

Cancer is an aberration of normal cell division and growth in which certain cells divide at abnormal rates and grow abnormally, sometimes migrating to other parts of the body, affecting the form and function of involved organs, and ultimately causing death of the organism. Recent, continuing biomedical advances are providing increasing knowledge of the carcinogenesis process and are beginning to identify the genetic, humoral, hormonal, dietary and other factors that may accelerate or inhibit it—thus leading to research on interventions that have the potential to identify the early, precancerous process and so to help restore the normal cellular growth patterns.

Genetic factors

Epidemiologists continue to accumulate evidence of familial variations in the frequency of particular types of cancer. These data have been bolstered by molecular biologists who have already identified genes that appear to control steps in cellular division and growth. When these “tumor suppressor” genes are damaged by naturally-occurring mutations or the effects of an environmental carcinogen, the process may go out of control and a cancer is initiated.

Heritable genes have been found in patients with cancer and members of their immediate families. One gene has been associated with a high risk of colon cancer and endometrial or ovarian cancer in women; another with a high risk of breast and ovarian cancer; and a third with a form of malignant melanoma. These discoveries led to a debate about the ethical and sociological issues surrounding DNA testing to identify individuals carrying these genes with the implication that they then might be excluded from jobs involving possible exposure to potential or actual carcinogens. After studying this question, the National Advisory Council for Human Genome Research (1994), raising issues to do with the reliability of the testing, the present effectiveness of potential therapeutic interventions, and the likelihood of genetic discrimination against those found to be at high risk, concluded that “it is premature to offer DNA testing or screening for cancer predisposition outside a carefully monitored research environment”.

Humoral factors

The value of the prostate specific antigen (PSA) test as a routine screening test for prostatic cancer in older men has not been scientifically demonstrated in a clinical trial. However, in some instances, it is being offered to male workers, sometimes as a token of gender equity to balance the offering of mammography and cervical Pap smears to female workers. Clinics providing routine periodic examinations are offering the PSA test as a supplement to and, sometimes, even as a replacement for the traditional digital rectal examination as well as the recently introduced rectal ultrasound examination. Although its use appears to be valid in men with prostatic abnormalities or symptoms, a recent multinational review concludes that measurement of PSA should not be a routine procedure in screening healthy male populations (Adami, Baron and Rothman 1994).

Hormonal factors

Research has implicated hormones in the genesis of some cancers and they have been used in the treatment of others. Hormones, however, do not appear to be an appropriate item to emphasize in workplace health promotion programs. A possible exception would be warnings of their potential carcinogenic hazard in certain cases when recommending hormones for the treatment of menopausal symptoms and the prevention of osteoporosis.

Dietary factors

Researchers have estimated that approximately 35% of all cancer mortality in the US may be related to diet. In 1988, the US Surgeon General’s Report on Nutrition and Health indicated that cancers of the lung, colon-rectum, breast, prostate, stomach, ovary and bladder may be associated with diet. Research indicates that certain dietary factors—fat, fiber, and micronutrients such as beta-carotene, vitamin A, vitamin C, vitamin E and selenium—may influence cancer risk. Epidemiological and experimental evidence indicates that modulation of these factors in the diet can reduce the occurrence of some types of cancer.

Dietary fat

Associations between excess intake of dietary fat and the risk of various cancers, particularly cancers of the breast, colon and prostate, have been demonstrated in both epidemiological and laboratory studies. International correlational studies have shown a strong association between the incidence of cancers at these sites and total dietary fat intake, even after adjusting for total caloric intake.

In addition to the amount of fat, the type of fat consumed may be an important risk factor in cancer development. Different fatty acids may have various site-specific tumor-promoting or tumor-inhibiting properties. Intake of total fat and saturated fat has been strongly and positively associated with colon, prostate, and post-menopausal breast cancers; intake of polyunsaturated vegetable oil has been positively associated with post-menopausal breast and prostate cancers, but not with colon cancer. Conversely, consumption of highly polyunsaturated omega-3 fatty acids found in certain fish oils may not affect or may even decrease the risk of breast and colon cancers.

Dietary fiber

Epidemiological evidence suggests that the risk of certain cancers, particularly colon and breast cancers, may be lowered by increased intake of dietary fiber and other dietary constituents associated with high intakes of vegetables, fruits, and whole grains.

Micronutrients

Epidemiological studies generally show an inverse relationship between cancer incidence and intake of foods high in several nutrients having antioxidant properties, such as beta-carotene, vitamin C (ascorbic acid), and vitamin E (alpha-tocopherol). A number of studies have shown that low intakes of fruits and vegetables are associated with increased risk of lung cancer. Deficiencies of selenium and zinc have also been implicated in increased cancer risk.

In a number of studies in which the use of antioxidant supplements was shown to reduce the expected number of serious heart attacks and strokes, the data on cancer were less clear. However, results from the Alpha-Tocopherol, Beta-Carotene (ATBC) Lung Cancer Prevention clinical trial, conducted by the NCI in collaboration with the National Public Health Institute of Finland, indicated that vitamin E and beta-carotene supplements did not prevent lung cancer. Vitamin E supplementation also resulted in 34% fewer prostate cancers and 16% fewer colorectal cancers, but those subjects taking beta-carotene had 16% more lung cancers, which was statistically significant, and had slightly more cases of other cancers than those taking vitamin E or the placebo. There was no evidence that the combination of vitamin E and beta-carotene was better or worse than either supplement alone. The researchers have not yet determined why those taking beta-carotene in the study were observed to have more lung cancers. These results suggest the possibility that a different compound or compounds in foods which have high levels of beta-carotene or vitamin E may be responsible for the protective effect observed in epidemiological studies. The researchers also speculated that the length of time of supplementation may have been too short to inhibit the development of cancers in long-term smokers. Further analyses of the ATBC study, as well as results from other trials in progress, will help resolve some of the questions that have arisen in this trial, particularly the question of whether large doses of beta-carotene may be harmful to smokers.

Alcohol

Excessive use of alcoholic beverages has been associated with cancer of the rectum, pancreas, breast and liver. There is also strong evidence supporting a synergistic association of alcohol consumption and tobacco use with increased risk of cancer of the mouth, pharynx, oesophagus and larynx.

Dietary recommendations

Based on the compelling evidence that diet is related to cancer risk, the NCI has developed dietary guidelines that include the following recommendations:

• Reduce fat intake to 30% or less of calories.
• Increase fibre intake to 20 to 30 grams per day, with an upper limit of 35 grams.
• Include a variety of vegetables and fruits in the daily diet.
• Avoid obesity.
• Consume alcoholic beverages in moderation, if at all.
• Minimize consumption of salt-cured (packed in salt), salt-pickled (soaked in brine), or smoked foods (associated with increased incidence of stomach and oesophageal cancer).

These guidelines are intended to be incorporated into a general dietary regimen that can be recommended for the entire population.

Infectious diseases

There is increasing knowledge of the association of certain infectious agents with several types of cancer: for example, the hepatitis B virus with liver cancer, the human papillomavirus with cervical cancer, and the Epstein-Barr virus with Burkitt’s lymphoma. (The frequency of cancer among patients with AIDS is attributable to the patient’s immunodeficiency and is not a direct carcinogenic effect of the HIV agent.) A vaccine for hepatitis B is now available that, when given to children, ultimately will reduce their risk for liver cancer.

Worksite Cancer Prevention

To explore the potential of the workplace as an arena for the promotion of a broad set of cancer prevention and control behaviors, the NCI is sponsoring the Working Well Project. This project is designed to determine whether worksite-based interventions to reduce tobacco use, achieve cancer preventive dietary modifications, increase screening prevalence and reduce occupational exposure can be developed and implemented in a cost-effective way. It was initiated in September 1989 at the following four research centers in the United States.

• M.D. Anderson Cancer Center, Houston, Texas
• University of Florida, Gainesville, Florida
• Dana Farber Cancer Institute, Boston, Massachusetts
• Miriam Hospital/Brown University, Providence, Rhode Island

The project involves approximately 21,000 employees at 114 different worksites around the United States. Most of the selected worksites are involved predominantly in manufacturing; other types of worksites in the project included fire stations and newspaper printers. Tobacco reduction and dietary modification were areas of intervention included in all of the worksites; however, each site maximized or minimized particular intervention programs or included additional options to meet the climatic and socioeconomic conditions of the geographic area. The centers in Florida and Texas, for example, included and emphasized skin cancer screening and the use of sun screens because of increased exposure to the sun in those geographic regions. The centers in Boston and Texas offered programs that emphasized the relationship between cancer and tobacco use. The Florida centre enhanced the diet modification intervention with supplies of fresh citrus fruits, readily available from the state’s farming and fruit industry. Management-employee consumer boards also were established at the worksites of the Florida centre to work with the food service to ensure that the cafeterias offered fresh vegetable and fruit selections. Several of the worksites participating in the project offered small prizes—gift certificates or cafeteria lunches—for continued participation in the project or for achievement of a desired goal, such as smoking cessation. Reduction of exposure to occupational hazards was of special interest at those worksites where diesel exhaust, solvent use or radiation equipment were prevalent. The worksite-based programs included:

• group activities to generate interest, such as taste testing of various foods
• directed group activities, such as quit-smoking contests
• medical/scientific-based demonstrations, such as  testing, to verify the effect of smoking on the respiratory system
• seminars on business practices and policy development aimed at significantly reducing or eliminating occupational exposure to potentially or actually dangerous or toxic materials
• computer-based self-help and self-assessment programmes on cancer risk and prevention
• manuals and self-help classes to help reduce or eliminate tobacco use, achieve dietary modifications, and increase cancer screening.

Cancer education

Worksite health education programs should include information about signs and symptoms that are suggestive of early cancer—for example, lumps, bleeding from the rectum and other orifices, skin lesions that do not appear to heal—coupled with advice to seek evaluation by a physician promptly. These programs might also offer instruction, preferably with supervised practice, in self-examination of the breast.

Cancer screening

Screening for precancerous lesions or early cancer is carried out with a view to their earliest possible detection and removal. Educating individuals about the early signs and symptoms of cancer so that they may seek the attention of a physician is an important part of screening.

A search for early cancer should be included in every routine or periodic medical examination. In addition, mass screenings for particular types of cancer may be carried out in the workplace or in a community facility near the worksite. Any acceptable and justifiable screening of an asymptomatic population for cancer should meet the following criteria:

• The disease in question should represent a substantial burden at the public health level and should have a prevalent, asymptomatic, nonmetastatic phase.
• The asymptomatic, nonmetastatic phase should be recognizable.
• The screening procedure should have reasonable specificity, sensitivity and predictive values; it should be of low risk and low cost, and be acceptable to both the screener and the person being screened.
• Early detection followed by appropriate treatment should offer a substantially greater potential for cure than exists in cases in which discovery was delayed.
• Treatment of lesions detected by screening should offer improved outcomes as measured in cause-specific morbidity and mortality.

The following additional criteria are particularly relevant in the workplace:

• Employees (and their dependants, when involved in the programme) should be informed of the purpose, nature and potential results of the screening, and a formal “informed consent” should be obtained.
• The screening programme should be conducted with due consideration for the comfort, dignity and privacy of the individuals consenting to be screened and should involve minimal interference with working arrangements and production schedules.
• Screening results should be conveyed promptly and privately, with copies forwarded to personal physicians designated by the workers. Counselling by trained health professionals should be available to those seeking clarification of the screening report.
• The individuals screened should be informed of the possibility of false negatives and warned to seek medical evaluation of any signs or symptoms developing soon after the screening exercise.
• A prearranged referral network should be in place to which those with positive results who are not able or do not wish to consult their personal physicians may be referred.
• The costs of the necessary confirmatory examinations and the costs of treatment should be covered by health insurance or otherwise be affordable.
• A prearranged follow-up system should be in place to be sure that positive reports have been promptly confirmed and proper interventions arranged.

A further final criterion is of fundamental importance: the screening exercise should be conducted by properly skilled and accredited health professionals using state-of-the-art equipment and interpretation and analysis of the results should be of the highest possible quality and accuracy.

In 1989 the US Preventive Services Task Force, a panel of 20 experts from medicine and other related fields drawing upon hundreds of “advisors” and others from the United States, Canada and the United Kingdom, assessed the effectiveness of some 169 preventive interventions. Its recommendations with respect to screening for cancer are summarized in table 1. Reflecting the Task Force’s somewhat conservative attitude and rigorously applied criteria, these recommendations may differ from those advanced by other groups.

Table 1. Screening for neoplastic diseases.

Source: Preventive Services Task Force 1989.

Screening for breast cancer

There is a general consensus among experts that screening with mammography combined with clinical breast examination every one to two years will save lives among women aged 50 to 69, reducing breast cancer deaths in this age group by up to 30%. Experts have not reached agreement, however, on the value of breast cancer screening with mammography for asymptomatic women aged 40 to 49. The NCI recommends that women in this age group should be screened every one to two years and that women at increased risk for breast cancer should seek medical advice about whether to begin screening before age 40.

The female population in most organizations may be too small to warrant the installation of mammography equipment onsite. Accordingly, most programs sponsored by employers or labor unions (or both) rely on contracts with providers who bring mobile units to the workplace or on providers in the community to whom participating female employees are referred either during working hours or on their own time. In making such arrangements, it is essential to be sure that the equipment meets standards for x-ray exposure and safety such as those promulgated by the American College of Radiology, and that the quality of the films and their interpretation is satisfactory. Further, it is imperative that a referral resource be prearranged for those women who will require a small needle aspiration or other confirmatory diagnostic procedures.

Screening for cervical cancer

Scientific evidence strongly suggests that regular screening with Pap tests will significantly decrease mortality from cervical cancer among women who are sexually active or who have reached the age of 18. Survival appears to be directly related to the stage of the disease at diagnosis. Early detection, using cervical cytology, is currently the only practical means of detecting cervical cancer in localized or premalignant stages. The risk of developing invasive cervical cancer is three to ten times greater in women who have never been screened than in those who have had Pap tests every two or three years.

Of particular relevance to the cost of workplace screening programs is the fact that cervical cytology smears can be obtained quite efficiently by properly trained nurses and do not require the involvement of a physician. Perhaps of even greater importance is the quality of the laboratory to which they are sent for interpretation.

Screening for colorectal cancer

It is generally agreed that early detection of precancerous colorectal polyps and cancers by periodic tests for fecal blood, as well as digital rectal and sigmoidoscopic examinations, and their timely removal, will reduce mortality from colorectal cancer among individuals aged 50 and over. The examination has been made less uncomfortable and more reliable with the replacement of the rigid sigmoidoscope by the longer, flexible fibreoptic instrument. There remains, however, some disagreement as to which tests should be relied upon and how often they should be applied.

Pros and cons of screening

There is general agreement about the value of cancer screening in individuals at risk because of family history, prior occurrence of cancer, or known exposure to potential carcinogens. But there appear to be justifiable concerns about the mass screening of healthy populations.

Advocates of mass screening for the detection of cancer are guided by the premise that early detection will be followed by improvements in morbidity and mortality. This has been demonstrated in some instances, but is not always the case. For example, although it is possible to detect lung cancer earlier by use of chest x rays and sputum cytology, this has not led to any improvement in treatment outcomes. Similarly, concern has been expressed that increasing the lead time for treatment of early prostatic cancers may not only be without benefit but may, in fact, be counterproductive in view of the longer period of well-being enjoyed by patients whose treatment is delayed.

In planning mass screening programs, consideration must also be given to the impact on the well-being and pocketbooks of patients with false positives. For example, in several series of cases, 3 to 8% of women with positive breast screenings had unnecessary biopsies for benign tumors; and in one experience with the fecal blood test for colorectal cancer, nearly one-third of those screened were referred for diagnostic colonoscopy, and most of them showed negative results.

It is clear that additional research is needed. To assess the efficacy of screening, the NCI has launched a major study, the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trials (PLCO) to evaluate early detection techniques for these four cancer sites. Enrolment for the PLCO began in November 1993, and will involve 148,000 men and women, aged 60 to 74 years, randomized to either the intervention or the control group. In the intervention group, men will be screened for lung, colorectal and prostatic cancer while women will be screened for lung, colorectal and ovarian cancer; those assigned to the control group will receive their usual medical care. For lung cancer, the value of an annual single-view chest x ray will be studied; for colorectal cancer, annual fibreoptic sigmoidoscopy will be performed; for prostate cancer, digital rectal examination and a blood test for PSA will be done; and for ovarian cancer, yearly physical and transvaginal ultrasound examinations will be supplemented by an annual blood test for the tumor marker known as CA-125. At the end of 16 years and the expenditure of US$ 87.8 million, it is hoped that solid data will be obtained about how screening may be used to obtain early diagnoses that may extend lives and reduce mortality.

Treatment and Continuing Care

Treatment and continuing care comprise efforts to enhance the quality of life for those in whom a cancer has taken hold and for those involved with them. Occupational health services and employee assistance programs sponsored by employers and unions can provide useful counsel and support to workers being treated for cancer or who have a dependant receiving treatment. This support can include explanations of what is going on and what to expect, information that is sometimes not provided by oncologists and surgeons; guidance in referrals for second opinions; and consultations and assistance with regard to access to centers of highly specialized care. Leaves of absence and modified work arrangements may make it possible for workers to remain productive while in treatment and to return to work earlier when a remission is achieved. In some workplaces, peer support groups have been formed to provide an exchange of experiences and mutual support for workers facing similar problems.

Conclusion

Programs for the prevention and detection of cancer can make a meaningful contribution to the well-being of the workers involved and their dependants and yield a significant return to the employers and labor unions that sponsor them. As with other preventive interventions, it is necessary that these programs be properly designed and carefully implemented and, since their benefits will accrue over many years, they should be continued on a steady basis.

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