Tobacco Control In Workplace With Ecological Model Of Health Promotion

Tobacco control is one of the most severe public health problems worldwide. As reported in WHO Report on The Global Tobacco Epidemic 2009, there were more than 500 millions of annually death caused by tobacco use, of which most happened in low to middle income countries over the world. As this trend goes further, the toll will reach to more than one billion by end of this century. China is the largest producer and consumer of tobacco in the world. Due to China National Smoking and Passive Smoking Survey 2002, there were 350 million of smokers with the age between 15 to 69 years old, with current smoking prevalence of 57.4% for men and 51.9% exposued to seond hand smoke. In comparison of smoking rate by age, the people with the age during 30 to 50 years were higher than the other age groups, which indictaes occupation groups the most severe.Although tobacco use is believed as the most preventable cause of premature and disability, there is no one nation-wide tobacco control regulation in China. Most of current tobacco control regulations are employed either by municipal governments or manufacture entities. In terms of its implementation and thereafter the effectiveness, it's far from satisfactory. One of the main causes is of less mobilization and education to the population. Additionally, smokers who are willing to quit are having rare access to the helps and consultation. This, in turn, makes the low qui(?)ing tendency even lower and the cessation rate is equally to the relapse rate.Most of tobacco control studies in China were focusing on community population and specific occupation groups such as medical and education groups. There were few studies to the majority part of our occupation group in China, production operators. Neither on their smoking characteristics such as smoking rate, perceptions on smoking, quitting tendency and influencual factors, nor the efficient tobacco control strategies and intervention models. In contrast, a significant achievement has been made on tobacco control in workplace in western countries such as US and UK.This is a tobaccon control study with comprehensive interventions to occupation groups in workplace. The target group was employees working in a multinational company production plants in Shanghai. First of all, an anonymous questionnaire was administered to all employees to investigate their smoking behaviours, quitting attitudes and other smoking characteristics. With the survey results, smoking behaviours and potential influential factors relating to their quitting attitudes and behaviours were analysed; the findings were used for intervention measures. Two production sites with comparable factors including manufacture patterns, organization structures and personnels were selected as intervention site or control site. For the intervention site, the stage theory of organizational change and other ecological models of health promotion were applied. Communication with the management was proceeded to get their strong and clear commitment. Afterwards, further action plan and detail steps were discussed with middle-class management, including different functional department management. The goal of this section is to get them work together smoothly and efficiently. The strategies for intervention measures included two parts, one is to create supporting atmosphere of quitting smoking which referring to regulation, administration, organization as well as the management's commitment; another is focusing on employees. Our target group is the whole employees rather than just smoking group. During the intervention process, health promotion ecological model was applied. Intervention measures were implemented at multiple levels as individually, working units, production units and at plant level. Detail interventions were employed to the management, plant environment, tobacco control policies, regulation systems, rearrangement of smoking booths indoor and outdoor were all applied at different levels in different ways. The core purpose of these interventions masures was to improve their knowledge, awareness, quitting tendency and finally cessation successfully. No intervention programs were employed to control group except their regular nealth promotion programs run by the corporation internally. This research consists of two parts as:1) study on smoking behaviours of occupation group; 2) study on intervention to occupation group in workplace. Below were the the brief findings.Smoking behaviours of occupation groupsBenchmark survey on employees'smoking behaviours and knowledge as well as quitting attitudes was performed through an anonymous questionnaire. The results showed their current smoking prevalence rate was 41.5%, with the male employees' smoking rate of 55.9% and female of 1.2%. The average cigarettes smoked amount by male employees were 12.3±6.9 cigarettes per day, and 13.5±10.5 cigarettes per day by female; (since the number of female employees who smoked was quite few, below the analysis were only for male workers). Smoking prevalence increased with age. Daily cigarette consumption among age groups was not significant different (p>0.05) except the 50-years group. Education background showed having significant association with smoking behavior. With education increased, smoking rate was declined (p<0.05), same trend for smoking amount per day (p<0.05). There was significant difference on smoking rate and daily cigarette consumption among the occupation groups. Production operators showed the highest smoking rate and smoking amount daily (67.1%,13.0±6.8 cigarettes per day), while sales/marketing people had similar condition. Office/management group showed the lowest smoking rate of 31.0%, lab/technicians reported smoked the least cigarettes daily (8.6±5.9 cigarettes per day). Night shift workers showed higher smoking rate and the amount smoked everyday compared to day-time workers (p<0.05). Sales/marketing employees also showed the highest tobacco dependence which was indicated by the time of the first cigarette smoked after waking up in the morning. It's even higher than that of the production operators (p>0.05). Education also showed the relationship with tobacco dependence, in it employees with the lowest education background reported with the highest dependence compared to the other higher education groups. Quitting tendency also showed different among occupation groups. Office/management group showed in the highest proportion of smokers in pre-contemplation stage (59.7%), while sales/marketing smokers were in the highest proportion in preparation stage (11.3%). Unfortunately, education was not indictaed with significant association with quitting tendency. In terms of number of quitting attempts in the past 12 months, office/management staffs reported the highest proportion with no quitting attempt (48.6%). In contrast, lab/technicians showed the most proportion of having at least two times of quitting attampts (52.9%). Nearly 80% of employees believed smoking control policies imposed in their workplaces had to some extent impact on their smoking behaviours. More than 70% of smokers expressed their willingness to accept quitting consultation. With regards to the knowledge of smoking's impact to health and benefits of quitting smoking, there were no significant difference among the occupation groups, neither education background nor age groups. Most smokers recoganized health impact of smoking to respiratory illnesses, but few to stroke, coronary heart dieases and hypertension. Considering the potential confounding factors to smoker's behaviours and quitting tendency, we used multiple liner analysis and multiple logistic analysis method, with daily cigarette consumption and quitting tendency as dependent varibles, and age, education, gender, occupations, nigh shift work, first cigarette after waking up, number of quitting attempts, confidence on successful quitting, willingness to accept quitting consulling as independent variables. The results indicated that smoking control policies imposed in their workplaces had a significant association with employees'daily cigarette consumption (p<0.05). The employees from the workplaces where smoke-free policy had been imposed for 3 years smoked 3.4 cigarettes per day less than the smokers from restricitive smoking workplaces (95%CI:-5.529,-1.240) with p<0.05. But this association was only found on the workplaces where the smoking control policies had been imposed for 3 years. No such association was found among the workplaces where relevant policies had been implemented for 10 years. No matter what kind of smoking policies imposed in the workplaces, nor how long it had been imposed, no significant association between employee's quitting tendency and smoking control policies was measured out (p>0.05).Cessation intervention programs in workplaceThis part of study was focusing on interventions to the occupation groups in the workplaces, exploring the potential efficient and feasible intervention models which could be applied in the workplace. We used the stage theory of organizational change, starting from communication with the site management, coordination with the departments, reoptimizing administration systems and EHS systems, and finally systemization of the smoking control regulations/procedures in the workplace to guarantee this intervention be maintained in a longer term. It's a systematic intervention at the organization platform which created an appropriate atmosphere for futher individual behaviour intervention. Interventions were employed at multiple-level. For individual, working unit, production unit, plant management, working environment, smoking control policies, administration system and the arrangement of smoking booths indoor and outdoor, all were focused during the intervention process. To make our intervention more sustainable and long-term efficiency, we integrated our training programs into company EHS management system. This, on one hand, reduced potential additional workload caused by our program. On the other hand, this helped the plant strengthen its own competence in this field. During the intervention program, "workmate buddy group" was initiated in a voluntary-based to promote employees help each other, encourage each other, and supervise each other during the working time. Each buddy group included one or two smoking employees and two or more non-smoking employees who worked with the smoking employees in the same shift.After six months of intervention, further investigation was given. For the intervention group, the smoking prevalence reduced from pre-intervention of 59.8% to 39.1% (p<0.05), with the production operators having the most decrease (55.8% to 34.1%). 20-years group and 40-years group showed significant declined in smoking rate compared to baseline data(p<0.05), while no significant change in 30-years group. The average daily cigarette consumption was decreased from 15.2 cigarettes per day to 12.9 cigarettes per day afterwards. The proportion of heavy smokers (>20 cigarettes per day) declined from 20.2% before the intervention to 3.9% afterwards (p<0.05). Among the occupation groups, production operators showed significant decline of heavy smokers, while the office/management only indicated of increase in the proportion of light smokers with no change in heavy smokers.20-years group and 30-years group showed significant decrease in heavey smokers after intervention, while no change in 40-years group. In terms of knowledge and perceptions on smoking impact to health, it's also improved significantly. For quitting tendency, the proportion in preparation stage of quitting has increased from 11.0% before the intervention to 41.5% afterwards (p<0.01), while the proportion of the employees in pre-contemplation stage was decreased by 30%. In terms of acceptance to external helps, less than 10% of smokers accepted quitting help before the intervention. After intervention this proportion increased to 27.3%(p<0.05). In opposite, there was no significant change in most of indicators in control group. But they did have some significant changes in the follow up. The number of smokers in the control group who liked to accept support from their families and working mates was also significantly increased (p<0.05). This effect was benefit to the control groups, although it's as a "spilling" effect. The reason for such effect was partially explained as both intervention plant and control plant were belonged to one company and there were always some contact among the employees between the sites. Therefore, the information one site employees got could be disseminated to the other plants which definitely inpact employees on the other site. After five months of intervention, we used both self-claim and urine cotinine test to clarify the suceesful cessation result. The successful cessation result in intervention group was 24.6%, while it's only 6.4% in control group (p<0.05).In conclusion, this study explored the characteristics of smoking behaviours and quitting attitudes of occupation groups; identified their potential influencial factors. By using the stage theory of organizational change and other health promotion ecological models, intervention programs were employed to the production plants of a multinational chemical company in Shanghai. The results indictaed this model was effective, efficient and practical to occupation group in workplaces, especially decreased smoking prevalence and smoked amount, increased quitting attitudes and thereafter the successful cessation results. More importantly, our interventions measures were integrated into the plant's EHS management system which was demonstrated making tobacco control program more sustainably and efficiently. This model is believed worthwhile for further studies on its application to occupation group for health promotion in workplace.