Upload
others
View
5
Download
0
Embed Size (px)
Citation preview
UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)
UvA-DARE (Digital Academic Repository)
Smoking cessation in the NetherlandsOccupational settings and nationwide policiesTroelstra, S.A.
Publication date2019Document VersionOther versionLicenseOther
Link to publication
Citation for published version (APA):Troelstra, S. A. (2019). Smoking cessation in the Netherlands: Occupational settings andnationwide policies.
General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).
Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.
Download date:21 Jul 2021
CHAPTER 8 General discussion
General discussion
183
08
GENERAL DISCUSSION
This thesis aimed to evaluate the potential effects of smoking cessation policies and
interventions at national and local levels, including occupational settings. Based on this work,
we aimed to contribute to the development of smoking cessation services in national, local and
occupational settings. In this chapter, the main findings of this thesis are summarised and the
methodological considerations are discussed. Furthermore, the contribution of this thesis to
the overarching goal of encouraging smoking cessation is considered. Finally, leading from the
findings, reflections and conclusions of this thesis, implications for policy and recommendations
for future research are discussed.
Chapter 8
184
MAIN FINDINGS
Smoking and work performance
The aim of the first part of this thesis was to provide insight in the relation between sustained
smoking, smoking cessation, and work-related outcomes. In chapter 2, we studied the relation
between smoking and sickness absence by conducting a systematic literature review and meta-
analysis of scientific literature on this topic. We found robust evidence that smoking increases
both the risk and number of sickness absence days in the working population, regardless of
study location, gender, age, and occupational class. Furthermore, we did not find any differences
in risk of sickness absence between studies differing in correction for confounders, research
design, assessment of sickness absence, and duration of sickness absence. This suggests
that encouraging smoking cessation at the workplace could be beneficial for employers and
employees in multiple occupational settings.
In chapter 3, we analysed the association of sustained smoking and quitting with sickness
absence, work productivity and work ability among older workers. We found that sustained
smokers had higher, but not statistically significant sickness absence compared to non-smokers.
We did not find differences in productivity loss and work ability for sustained smokers compared
to non-smokers. Comparing quitters to sustained smokers, we found less favourable results for
quitters compared to sustained smokers in three out of the six associations. Among individuals
with a relatively poor physical health at baseline, work ability was significantly lower for quitters.
However we found no significant differences in sickness absence and productivity loss. This
surprising finding might indicate that the benefits of smoking cessation for employers could
take a longer time to manifest.
Impact of tobacco control policies on population level
The second part of this thesis entails the population impact of several Dutch tobacco control
policies implemented in previous years. We aimed to evaluate the association between
tobacco control policy measures and behaviour related to smoking cessation. Hereby, Google
Trends search query data on search terms related to smoking cessation were used as proxies
of population interest in smoking cessation. In chapter 4, Google Trends analyses were used
to determine whether the introduction of smoking bans in restaurants and bars and the
reimbursement of smoking cessation encouraged people to consider to quit smoking. We found
that the introduction of a smoking ban in the Dutch hospitality industry in 2008 was associated
with an increase in Google searches for information on smoking cessation for several weeks
around the implementation of the campaign. Furthermore, we found that the reimbursement
of smoking cessation support by Dutch healthcare insurance companies in 2011, and its
reintroduction in 2013, were associated with an increase in Google searches for information
on smoking cessation for several months.
General discussion
185
08
Chapter 5 describes the impact of the yearly Stoptober campaign on the contemplation of
smoking cessation on a population level by using Google Trends analyses. We found that in
the period of 2014 to 2016, the Dutch Stoptober campaign was associated with a 11 to 22%
increase in Google searches for information on smoking cessation for several weeks, starting
from the week Stoptober commenced up to several weeks after. From these results, it would
seem that Stoptober may affect smoking-related outcomes in the national population at large.
Stoptober campaign and smoking cessation on individual level
The third part of this thesis focused on the evaluation of the Stoptober campaign on a participant
level instead of a population level. In chapter 6, we took a quantitative approach in evaluating
the effect of the Stoptober campaign on smoking cessation and socio-cognitive determinants
of smoking. We estimated that after three months, about 50% of the Stoptober participants
would have quit smoking. Furthermore, we found that those who continued to smoke consumed
significantly fewer cigarettes. This suggests that Stoptober is effective in increasing quit success
among those willing to quit, and in reducing tobacco consumption among those yet unable to
quit. Furthermore, among participants who had quit smoking we observed mainly favourable
changes in determinants of smoking cessation. Among sustained smokers, we also found
favourable changes in several determinants of smoking cessation. This suggests that given their
large reach and relatively low costs, temporary abstinence campaigns such as Stoptober can
contribute to tackling smoking at the population level.
In chapter 7, we qualitatively evaluated the working mechanisms of the Stoptober campaign and
explored the experiences of its participants. We found that Stoptober supported participants
in their cessation attempt according to its theoretical principles: social contagion, SMART
goals, and PRIME. Furthermore, we found that ongoing support would be needed to increase
long-term abstinence. These findings support the continuation and wider implementation of
Stoptober. Connecting Stoptober to support tools and regular smoking cessation services may
improve the long-term abstinence rates of smokers after the campaign.
Chapter 8
186
REFLECTIONS ON METHODS
In this section, the methods that were used in this thesis are reflected upon. First, the advantages
and disadvantages of the various research designs and their contribution to the conclusions of
this thesis are discussed. Furthermore, the way smoking status was measured and how this could
have influenced our results is considered. Finally, the generalizability of the results is deliberated.
Research design
One of the main strengths of this thesis is the diversity of research designs we were able to use
to investigate diverse aspects of smoking cessation. In doing so, we took a pragmatic approach,
by making use of secondary data and by evaluating the impact of already implemented smoking
cessation policies and interventions. Four chapters, chapters 2, 3, 4, and 5, were based on
secondary data analysis. For two chapters, chapters 6 and 7, we chose to collect new data. In
total, four different research designs were used: a systematic review and meta-analysis (chapter
2), a longitudinal observational design (chapters 3 and 6), a quasi-experimental design using
time-series analysis (chapters 4 and 5), and a qualitative study (chapter 7).
Systematic review
The main advantage of systematic reviews, and more specifically, meta-regression analyses, is
the ability to aggregate information from multiple studies, leading to a higher statistical power
and a more robust estimate of an association (1). In this way, we were able to provide a precise
estimation of the association between smoking and sickness absence in chapter 2. Furthermore,
we were able to investigate the influence of several sources of variation in sample characteristics
and study design. However, the main disadvantage of systematic reviews is the dependence on
information provided in already published individual studies.
Longitudinal observational design
Chapters 3 and 6 both used a longitudinal observational design (i.e. cohort study). By using a
longitudinal design were able to observe the temporal order between smoking status and subsequent
work productivity (chapter 3), and participation in a smoking cessation campaign and subsequent
changes in smoking status (chapter 6). In this way, we could distinguish cause from effect, which
would not be possible in a cross-sectional study (2). However, a main drawback of this design is
the loss of subjects to follow-up (2). In chapter 6, the drop-out rate was very high. Therefore, we
conducted a non-response analysis and adjusted our estimate of the three-month quit rate.
Quasi-experimental design
In chapters 4 and 5, we used a quasi-experimental design to research the influence of two
national tobacco control policies and a smoking cessation campaign. A quasi-experimental
study is an intervention study that compares an intervention and a control group without
General discussion
187
08
randomization, since randomization is often not feasible when researching the impact of national
policies and mass media interventions (3, 4). In these studies, we compared smoking cessation
related Google Search queries in the Netherlands around the implementation of these policies
to those in Belgium around the same time period. Quasi-experimental designs can circumvent
many of the drawbacks of randomised controlled trials, such as ethical, political, financial, and
time constraints (5). However, even though quasi-experimental studies can be used to estimate
causation, on their own they cannot be used to make definitive causal inferences, since there
could be alternative explanations for the observed effect. Therefore, the results should be
interpreted in the context of findings from other research and alternative explanations for
research findings should be considered carefully.
Qualitative design
In chapter 7, we used a qualitative research design by conducting and reporting on semi-
structured interview with Stoptober participants. In contrast to quantitative research,
qualitative research is able to capture opinions, experiences, attitudes, and interactions (6).
Using a qualitative design, we were able to understand how the campaign supported smokers in
their attempt to quit smoking. Furthermore, based on participants’ experiences and suggestions,
we were able to formulate several recommendations for improvement of the Stoptober
campaign. Qualitative research also has several drawbacks, such as being subject to researcher
bias, lacking reproducibility, and lacking generalizability (7). However, several methods can be
used to improve the quality, such as triangulation, respondent validation, and reflexivity (8).
Combining research designs
As demonstrated in the previous paragraphs, each research design has specific strengths and
limitations. In this thesis, we used different research designs to investigate the role of smoking
status on work productivity. Chapters 2 and 3 both focus on the relation between smoking
status and work-related outcomes, and strengthen each other in several ways. First, whereas
chapter 2 provides a robust estimation of the general effect of smoking on sickness absence,
chapter 3 provides information on the influence of smoking in a specific population: Dutch older
employees. Second, researching the influence of various sources of variation on study outcomes
in chapter 2 enabled us to identify potential biases in chapter 3, which helped us to interpret the
unexpected outcomes of this study. Furthermore, in our observational study we could influence
the quality of reporting. In fact, we applied the quality assessment of chapter 2 to chapter 3 and
scored 9 out of 10. Finally, in our observational study we also investigated the impact of smoking
cessation and compared sickness absence with other work-related outcomes.
Chapters 5, 6, and 7 of this thesis assessed the impact of the Stoptober campaign by using
different research designs, a quasi-experimental design (chapter 5), a longitudinal observational
design (chapter 6), and a qualitative research design (chapter 7). A strength of this thesis is that
Chapter 8
188
each of these three chapters provides a different perspective on the impact of the Stoptober
campaign. In chapter 5, we found an increase in Google searches for smoking cessation on
national population level, in chapter 6 we found that, after participation, about half of the
participants had quit smoking, and in chapter 7 we found that Stoptober functions according to
its theoretical working mechanisms. In this way, we were able to shed light on the way in which
Stoptober contributes towards reducing smoking prevalence in the Netherlands in terms of
percentage of quitters, change in behavioural determinants, change in precursors of smoking
cessation, theoretical working mechanisms, and experiences of participants.
Our evaluation of the Stoptober campaign and our research on the association between
smoking status and work productivity both illustrate how the (potential) effectiveness of real
world interventions can be assessed in a pragmatic manner. By deliberately combining research
designs to study different aspects of sustained smoking and smoking cessation, it is possible to
assess and quantify potential impact, and to understand how this was achieved, which would
not have been possible if a single type of research design was used.
Measuring smoking status
In chapters 3 and 6, we used self-reported measures of smoking status. Smoking status
measured by self-report has been shown to be reliable (10, 11) or somewhat underestimated
(12), when validated by biomarkers, such as saliva or urine cotinine levels. We measured smoking
cessation by looking at temporal changes in participants’ self-reported smoking status. By
measuring smoking status at different time points, such as over a period of six years (chapter 3)
or before and after the start of an intervention (chapter 6), we were able to associate (changes
in) smoking status with interventions and outcomes with more certainty. For non-smoking and
sustained smoking, this enables us to assess whether participants’ smoking status is stable over
time. However, for participants who quit smoking, we have only captured single moments of
the process of quitting, and are unable to reflect on the intricacies of the process of smoking
cessation.
In chapters 4 and 5, we used online searching for information on smoking cessation as a proxy
to measure smoking cessation. According to the Transtheoretical Model of Health Behaviour
Change (13), in the contemplation phase people recognise that their smoking behaviour might
be problematic and consider the advantages and disadvantages of smoking cessation, which
could be followed by the preparation and action phase. Searching online for information on
smoking cessation could be considered a way to deliberate on the advantages and disadvantages
of smoking cessation, thereby functioning as a proxy for the contemplation phase, and
potentially the preparation phase of smoking cessation, which is an important step in the process
of actual smoking cessation (13). The main advantage of this type of data is that it provides
outcomes on a weekly basis on a national level. In this way, it is possible to relate increases in
General discussion
189
08
online searching for information with the introduction of national policies and interventions
with considerable precision. However, it remains uncertain to what extent an increase in online
searching for information on smoking cessation reflects an increase in actual smoking cessation.
Therefore, a next step would be to ask a representative national sample of smokers to report
their smoking status on a weekly basis and to compare this information to online searches for
smoking cessation. In this way, online searching for information on smoking cessation could be
validated as a proxy for actual smoking cessation.
Generalizability
In this section, the generalizability of the findings presented in this thesis is deliberated. Both
the generalizability of the findings for different countries and different occupational groups
are considered.
In chapter 2, we included a combination of studies with populations from various countries. In
our meta-regression analysis, we did not find any difference in the association between smoking
and sickness absence for study populations from western and non-western countries. However,
the number of studies from non-western countries was quite small, which limits the statistical
power. Worldwide, there are large differences in terms of smoking prevalence, smoking culture,
and tobacco control policies. The global prevalence of tobacco smoking is 19.9% (14). However,
the smoking prevalence in Europe is 29.4%, whereas the smoking prevalence in Africa is 9.8%
(14). Furthermore, although gender differences in tobacco use are relatively small in Europe and
the Americas, they are much larger in other regions. Countries also differ largely in terms of their
tobacco control policy. The Tobacco Control Scale (TCS) compares tobacco control activities in
35 European countries and scores them on a scale from 0 to 100 (15). Together with Hungary,
Turkey, and Sweden, the Netherlands takes a ninth place, with a score of 53. In chapters 4 and
5 of this thesis, we compared Dutch online searching behaviour after the implementation of a
smoking cessation intervention to similar data from Belgium. In the TCS, Belgium is placed 17th,
with a score of 49, which is reasonably similar to the Dutch score. The United Kingdom has the
most comprehensive tobacco control policy, with a score of 81. The countries with the lowest
scores are Germany, Austria, and Luxembourg.
Even though we think that all measures included in this thesis have the potential to encourage
smoking cessation in all countries, these considerable differences might hamper the generalizability
of the findings of this thesis. For example, a much higher or lower smoking prevalence might
negatively influence participation rates in a smoking cessation campaign such as Stoptober.
Furthermore, in countries where there are few tobacco control activities the compliance with
a smoking ban might at first be lower, which could limit its influence on (the contemplation of)
smoking cessation. Therefore, the generalizability of the results from this thesis might be limited
to countries with similar smoking prevalence and tobacco control activities.
Chapter 8
190
In chapters 2 and 3, we included employees from all types of occupational settings. However,
working conditions have been shown to influence work productivity-related outcomes (16).
Furthermore, in most Western countries there are large differences in smoking prevalence
among occupational classes (17). This could be caused by differences in workplace culture
and work environment. One could imagine that for construction workers, who mainly work
outdoors, it might be relatively easy to smoke during their work, whereas office workers might
need to walk to go to a designated smoking area. In chapter 2, we did not find any difference
in the association between smoking and sickness absence for different occupational classes.
However, several studies did not provide information on occupational class and the majority of
studies used a general working population sample. Since most of the studies included in chapter
2, and our study in chapter 3, were general population studies, we think that our results could
be generalised to all occupational settings.
General discussion
191
08
REFLECTIONS ON ENCOURAGING SMOKING CESSATION
Measures to encourage smoking cessation
Traditionally, tobacco control measures are grouped in demand side and supply side measures
(18). Demand side interventions, for example tax increases, advertising and promotion bans,
public campaigns, and smoking bans aim to reduce the demand for cigarettes. Supply side
interventions, such as age limits, trade restrictions, and actions against smuggling, aim to
reduce the supply of cigarettes (19). In this thesis, a different approach was taken, namely by
categorizing tobacco control measures according to their level of implementation. Hereby,
measures implemented at a national level are considered macro-level, measures implemented
within communities or organisations are considered meso-level, and measures that can be
implemented within primary care settings or households are part of the micro-level.
Macro-level
On a macro-level, smoking cessation can be encouraged by implementing national policies, such
as mass media interventions, smoke-free legislation, taxation, marketing and advertising bans,
and reimbursement of smoking cessation support. This thesis focused on smoke-free legislation,
reimbursement of smoking cessation support, and mass media interventions. However, since
advertising bans and price increases are effective tobacco control measures, they are discussed
briefly.
Comprehensive tobacco advertising bans are effective measures to reduce tobacco consumption
(20, 21). In most developed countries a marketing and advertising ban is in place. However, in the
Netherlands tobacco specialty shops are still allowed to promote their products on a small scale.
From 2020, a point of sale display ban in supermarkets will be introduced, which could reduce
smoking prevalence significantly (22). Furthermore, as of 2020 plain packaging of tobacco products
will be mandatory in the Netherlands (23). Raising the price of cigarettes to consumers by taxation
can also reduce smoking rates (24). Reductions in smoking rates after tax increases are stronger for
developing countries and among adolescents, young adults, and lower SEP individuals. However,
the financial burden of cigarette taxes is greater for low SEP individuals, especially since many of
them will remain smokers after a tax increase (24). In order to not further increase socioeconomic
inequalities, the implementation of further tax increases for tobacco products should be paired
with smoking cessation support that is specifically targeted to lower SEP individuals.
An increasing number of countries has introduced national policies banning smoking in indoor
public places and workplaces. In the Netherlands, smoking bans are placed in a multitude of
settings. By Dutch law, smoking is prohibited in public places, workplaces, and the hospitality
industry (25). Smoke-free legislation is associated with improved health outcomes on a national
Chapter 8
192
level, but the impact of smoke-free legislation on smoking prevalence and cigarette consumption
is unclear (26). Smoke-free policies can create environments that help smokers to quit (27, 28), by
changing attitudes towards smoking (29) and by increasing the challenges of finding alternative
places to smoke (30). A study on the effects of Dutch smoke-free legislation found that the
workplace smoking ban of 2004 (exempting hospitality industry workers) was associated with
a decrease in smoking prevalence, but not the partial smoking ban in the hospitality industry in
2008 (31). In chapter 4, we found that the smoking ban in the hospitality industry was associated
with a temporary increase in online searching about smoking cessation (32). However, smoke-
free legislation can also increase stigmatization among smokers (33), which could make quitting
more difficult (34). Therefore, smoke-free legislation should be positively framed, for example as
a way to establish positive role models for youth and to avoid exposure to second-hand smoking
(34, 35).
Another way to encourage smoking cessation is to reimburse the cost of smoking cessation
therapy and treatment. In 2011, the Netherlands implemented a national policy for all healthcare
insurers to reimburse behavioural counselling or behavioural counselling with pharmacological
therapy. The implementation of this policy and the accompanying media attention was associated
with a significant increase in online searching about smoking cessation lasting for several weeks
(chapter 4), and significant increases in quit attempts and quit success (36). However, to ensure
that all smokers willing to quit smoking are aware of this opportunity, it is important to continue
informing the public about reimbursement policy and ensuring that adequate implementation
remains on the agenda of policy makers.
Mass media interventions disseminate cessation-related messages informing smokers and
motivating them to quit through television, radio, and printed media. Traditionally, mass media
interventions, focused on increasing knowledge on the risks of smoking, thereby assuming that
by increasing awareness of the health risks of smoking, people would change their behaviour
(37). Later on, mass media interventions changed their approach towards developing skills to
cope with pressure to smoke, increasing self-efficacy, and de-normalizing smoking. It is suggested
that mass media interventions can be effective as a part of comprehensive tobacco control
programs, by influence individuals’ knowledge, attitudes, and behaviour, but the evidence for this
effectiveness is heterogeneous and of limited quality (37). In chapter 5, we looked at influence
of the Stoptober campaign on a national level and found that the introduction of the campaign
was associated with an increase in online searching for smoking cessation, which can be seen
as a change in smoking cessation related behaviour. Therefore, campaigns such as Stoptober,
which use a combination of traditional and social media, are based on supportive and positive
messaging, and are aimed at increasing self-efficacy among smokers, might be effective at the
macro-level.
General discussion
193
08
Meso-level
At the meso-level, smoking cessation can be encouraged through the implementation of policies
by organisations and communities. Smoking is strongly influenced by social context and distal
cues (38), and many social interactions take place within organisations and communities.
A Cochrane review has been published on the effect of comprehensive community-based
interventions, including, among others, mass media, self-help materials, cessation groups,
support groups and smoking policies. This review concluded that the quality of the evidence
is low, and that the effects of these interventions on smoking prevalence is very limited (39).
The workplace is a promising setting to encourage smoking cessation. Multiple effective
workplace interventions for smoking cessation are available, such as group therapy, individual
counselling, provision of pharmacotherapy, and multiple intervention programs (mainly)
targeting smoking cessation (40). Furthermore, next to a legislative smoking ban for the
workplace, several organisations have introduced institutional smoking bans, for example by
banning smoking from the organisations’ premises. At the workplace, comprehensive smoking
bans can decrease tobacco consumption rates, however the evidence is mixed, with some studies
concluding that workplace smoking bans are mainly leading to a displacement of smoking (28,
38, 41-43). Employers can be encouraged to implement these policies and interventions by
informing them about the costs of smoking and the potential benefits of smoking cessation.
The Stoptober campaign was mentioned earlier as an example of a macro-level intervention
because of its mass media campaign approach. However, due to its strong social component,
Stoptober can also be seen as a meso-level measure. Stoptober encourages smokers to
participate in a collective quit attempt, and asks non-smokers to support their smoking friends
and family members in this endeavour (44). Furthermore, Stoptober aims to create a community
of quitters by emphasizing the message that “we are doing this together”, and by encouraging
participants to interact on social media. Participants have the possibility to share experiences,
learn from each other, and to provide and receive peer support (44). In this way, Stoptober aims
to create a social movement that functions at the meso-level.
According to our findings from chapter 6, about half of the Stoptober participants had quit
smoking after three months and participation in the Stoptober campaign was associated with
favourable changes in attitude, self-efficacy, social norms, and habit strength (45). However, in
chapter 7 we found that ongoing support is needed to increase long-term abstinence. At the
meso-level, participants reported a need for more face-to-face contact, by using their current
social networks, for example colleagues, to stop smoking collectively or by facilitating local
Stoptober networks (46). In line with our respondents, studies on online smoking cessation
support suggest that face-to-face contacts may have added value for remaining abstinent (47,
48), especially for smokers who lack support in their own social circle (49). To establish such
Chapter 8
194
contacts, Stoptober could encourage participants to use their current social networks to stop
smoking collectively (e.g. together with work colleagues) or facilitate participants building an
additional social network (e.g. through local Stoptober meetings).
Micro-level
At the micro-level, smoking cessation can be encouraged through interventions on a household
and individual level. This thesis mainly focused on macro- and meso-level measures. However,
from chapter 7, we concluded that Stoptober could be improved by intensifying activities
at the micro-level. Connecting Stoptober participants to local smoking cessation services
may improve the long-term abstinence rates after the campaign. This could help smokers to
overcome barriers to using these services (50) and increase the likelihood of taking advantage
of professional support. Furthermore, by referring participants to primary caregivers, they can
receive pharmacological interventions, such as nicotine replacement therapy (NRT), bupropion,
varenicline, and cytisine. This would improve their chance of quitting, with low risk of adverse
effects (51).
Encouraging smoking cessation in the occupational setting
In this thesis, smoking cessation was approached from both a public health perspective (chapters
4 to 7) and from an occupational health perspective (chapters 2 and 3). However, public health
and occupational health are strongly interrelated. Work-related factors such as income, benefit
packages, physical demands, work stress, job insecurity, and exposure to occupational hazards
can lead to an increase in adverse health behaviours and health outcomes (52, 53). Furthermore,
through income, power, occupational prestige, and social connectedness, work largely influences
socioeconomic position, an important determinant of health behaviour (54). Worksite health
promotion and public health prevention have developed as rather separate domains (55, 56).
However, integrating these fields has major advantages, such as the possibility to reach specific
populations, provide new venues for health interventions, and promote the wellbeing of working
populations in a more holistic way (54, 57). Therefore, in this section the role of occupational
health in strengthening public health by encouraging smoking cessation will be discussed.
First, the benefits of using the workplace as a setting for smoking cessation and the factors
that influence successful implementation of smoking cessation interventions in the workplace
are discussed. Seconds, the benefits and drawbacks of implementing smoker-free workplace
policies, policies that do not focus on restricting or banning the act of smoking, but instead aim
to ban smoking employees from the workplace, are considered.
Benefits and implementation factors of encouraging smoking cessation at the workplace
Approaching smokers at the workplace has the potential to reach large groups of people and
specifically target vulnerable populations (58). In developed countries, smoking prevalence
and tobacco consumption levels are much higher among individuals with a low SEP. Therefore,
General discussion
195
08
they form an important target group for smoking cessation interventions. However, low SEP
smokers are hard to reach, less willing to participate in smoking cessation interventions,
and less likely to be successful in quitting smoking. For example, while smoking occurs more
frequently among lower educated adults, relatively more smokers with a higher education level
participated in Stoptober. Since people with similar cultural, social, and economic backgrounds
are often concentrated in occupational groups, the workplace can be used to specifically target
employee groups with a high smoking prevalence, such as blue-collar workers (59, 60). However,
individuals with a low SEP are more likely to be unemployed. In order to access this group of
vulnerable smokers, alternative strategies at the meso and micro-level should be used, such as
referral by primary care workers and active recruitment by local smoking cessation support
services (61).
Next to the potential to reach large groups and target specific groups of smokers, utilizing the
workplace as a setting for smoking cessation has several other advantages. First, the available
organisational structures, and communication channels can be used. For example, key persons can
be identified easily to help with development and implementation of the intervention, and email
messages, notification boards, or team meetings can be used to disseminate the intervention
(59, 62). Second, since most people spend a large part of the week at their work, workplace
interventions have the potential for high exposure rates. Furthermore, the already existing
social networks can be used to promote the intervention, provide peer support and influence
social norms (40, 63). Co-workers can either positively influence their colleagues, by quitting
together or providing support and shared experiences (63). Social norms at the workplace,
either descriptive of subjective, can facilitate behaviour change (64). Fourth, occupational
health professionals can also play an important role in the design and implementation of
smoking cessation interventions (58), since they have expertise in worksite health promotion,
are familiar with the working conditions, and have knowledge of the organisational structures.
Finally, employers can support participants by providing opportunities and incentives to their
employees (63). The evidence on using financial incentives to increase participation rates is
mixed. One recent RCT on the use of financial incentives found significant increases in long-
term abstinence rates (65).
Smoker-free workplace policies
More recently, some organisations have increased their efforts to decrease smoking prevalence
among their employees by implementing a smoker-free workplace policy. These policies do not
focus on restricting or banning the act of smoking, but aim to ban smoking employees from the
workplace instead. In practice, this often means that companies refrain from hiring smokers
and ask smoking employees to quit within a designated time period. Officially, employers are
not allowed to select potential employees based on their lifestyle, unless there are specific
demands placed on the job. Work settings that could entail specific demands concerned with
Chapter 8
196
smoking are for example submarines (66), and the offshore petroleum industry. In the past, some
organisations were allowed to implement a smoker-free workplace policy, since hiring smokers
would be against their organisational philosophy and exemplar role (67). For example, in 2005,
the World Health Organisation stopped hiring smokers (68).
Employers might also be motivated to implement smoker-free policies because of the potential
cost savings from the reduced productivity of smokers, as shown in chapter 2. The wider
implementation of smoker-free policies has far-reaching consequences. Several of these
consequences are positive. For non-smokers, their exposure to second hand tobacco smoke
will decrease. For smokers who quit after the implementation, the policy might also have positive
consequences, since their health status will most likely improve, which might cause an increase in
their productivity level (chapter 2). Furthermore, they would be less likely to relapse because the
lack of cues to smoke at the workplace and the potentially severe consequences of continuing
to smoke.
However, from an ethical and public health perspective, smoker-free policies are a controversial
method to encourage smoking cessation (69), even when the implementation of such a policy
would be paired with extensive smoking cessation support. Employees unable or unwilling to
stop smoking might find themselves being let go and unemployed. Unemployment can lead to
an increase in adverse health behaviours and health disparities (52, 68). Furthermore, smoking
rates are significantly higher among individuals with a lower SEP. Therefore, discrimination
based on smoking status might lead to increases in social inequalities and further stigmatization
of an already marginalised and often vulnerable group (70). Finally, by allowing employers to
discriminate based on smoking, a gliding scale might be introduced, where employees might also
want to control other off-duty lifestyle aspects, such as nutrition, physical activity and alcohol
intake (71).
Therefore, we do not support smoker-free policies, unless hiring smoking employees would be
seen as hypocritical, for example a smoking tobacco control advocate, or when smoking would
be hazardous, for example at the offshore petrochemical industry (72). Instead, if employers
want to reduce smoking prevalence among their employees, they should offer smoking cessation
interventions at the workplace. To increase participation rates they could offer the intervention
free of charge and during working hours.
Considerations for the future
Multiple effective and cost-effective measures are available to encourage smoking cessation,
and for most Western countries smoking prevalence rates are projected to decline in the
coming decades. However, according to a Dutch report, without the implementation of new
smoking cessation measures, the decline in smoking prevalence would stagnate in the next
General discussion
197
08
decade (Figure 1) (74). Smokers might become less sensitive towards already existing measures.
Therefore, more extensive measures and more comprehensive measures are necessary to
decrease smoking prevalence.
The most effective way to decrease smoking prevalence is the implementation of the World
Health Organisation MPOWER measures, including monitoring of tobacco use, a complete ban
on smoking in public places, free and easily accessible cessation advice and help from healthcare
workers, graphic pictorial health warnings on tobacco products, mass media campaigns, a
complete ban on tobacco marketing, and a tax increase on tobacco products. This could decrease
smoking prevalence in the Netherlands up to 5% in 2050 (Figure 1). The findings from this thesis
contributed to the body of evidence on the effectiveness of smoking bans in public places, or
more specifically the hospitality industry, the reimbursement of smoking cessation advice or
support, and smoking abstinence mass media campaigns.
In 2018, the Dutch Government, together with multiple stakeholders, presented the National
Prevention Agreement (“Nationaal Preventieakkoord”). The National Prevention Agreement
aims to lower smoking prevalence up to 5% by 2040, with taxation, point of sale display bans,
plain packaging, reducing points of sale, legislative smoking bans for schools, playgrounds,
kindergartens, petting zoos, sports clubs, and healthcare organisations. Furthermore, the
agreement aims to lower financial barriers to smoking cessation support, to encourage
companies to become smoke-free, and to encourage the development of smoking cessation
tools for occupational health professionals and to share best practices (23).
According to projections of the Dutch National Institute of Public Health and the Environment,
implementation of all measures proposed in the National Prevention Agreement might indeed
lower smoking prevalence to 5% by 2040. However, in order to eliminate smoking among
adolescents and pregnant women, two secondary aims of the National Prevention Agreement,
more extensive strategies are necessary, such as further tax increases, smoking bans, and point
of sale reductions (75).
Chapter 8
198
0
5
10
15
20
25
2015 2017 2020 2030 2040 2050
Smok
ing
prev
alen
ce %
Year
Reference (continued implementation of current policies)
Tax increase 5%
Tax increase 10%
Annual mass media campaign
WHO MPOWER measures + 5% tax increase
WHO MPOWER measures + 10% tax increase
No one starts smoking
Figure 1. Projected effects of tobacco control policies on smoking prevalence in the Netherlands (74).
General discussion
199
08
IMPLICATIONS FOR POLICY AND PRACTICE
As mentioned above, the National Prevention Agreement aims to lower smoking prevalence up
to 5% by 2040. The full implementation of all measures proposed in the agreement might lead to
this reduction. Each smoker that quits today brings us one step closer to a healthier, more equal,
and more productive society. Therefore, it is important to critically evaluate the potential of
settings and interventions to encourage smoking cessation and to identify ways to increase their
effectiveness. From this thesis, several recommendations can be derived for policy and practice.
Continued implementation of Stoptober
The results from this thesis suggest that the Stoptober campaign, given its large reach and
relatively low costs, might be effective in encouraging smoking cessation at the macro-level.
Therefore, it is recommended to continue the implementation of Stoptober with similar or
increased efforts and resources. The reach and effectiveness of the campaign could be increased
by integrating the campaign with other smoking cessation measures. The time period of the
Stoptober campaign could be used as a window of opportunity for interventions targeted at
smokers who contemplate smoking cessation. For example, at the macro-level the government
could inform the public about the reimbursement policy for smoking cessation support or use
October 1st as the first day to implement a tobacco taxation increase in order to encourage
smokers to participate in Stoptober and quit smoking.
On a meso-level, Stoptober could be implemented in the occupational setting by employers.
During the first phase of Stoptober, employees can be encouraged to participate in Stoptober.
Promotional material could be supplied to employers by Stoptober and could be disseminated
by occupational health professionals through the already available communication channels.
Furthermore, employers could appoint Stoptober ambassadors. These ambassadors are
employees who quit smoking themselves and are willing to encourage their co-workers to quit
smoking too. In collaboration with occupational health professionals, these ambassadors could
set up a support group of employees that want to participate in Stoptober. The members of
this social support group could supply social support to each other during Stoptober and in
the following months. Employers could provide incentives to their employees to encourage
participation and successful smoking cessation, for example by allowing the group to meet
during working hours and providing rewards for each week or month that participants remain
abstinent.
On a micro-level, Stoptober participants could be connected to local smoking cessation services.
This could help smokers to overcome barriers to access support and may improve the long-term
abstinence rates after the campaign. Primary care workers could actively advice their smoking
patients to quit and refer them to local smoking cessation support service. Furthermore, if
Chapter 8
200
Stoptober participants are encouraged to visit their primary caregiver for quit advice, they
could receive pharmacological interventions, which would improve their chance of quit success.
Furthermore, at the meso-level, Stoptober could facilitate the formation of local Stoptober
meetings in order to increase social support.
The outcomes of this thesis suggest that temporary abstinence campaigns such as Stoptober
can contribute to tackling smoking at the population level. These results support the wider
implementation of the campaign in other countries. Currently, Stoptober has been implemented
in the United Kingdom, France, New Zealand, and the Netherlands. However, other countries
with high access to traditional and social media channels, where a significant part of the smoking
population reports wanting to quit smoking, might also benefit from the implementation of
Stoptober. To increase implementation success in other countries, an international advisory
board for Stoptober could be installed to coordinate communications and activities, and to share
best practices.
Opportunities for the occupational setting
Even though the findings of this thesis on the relation between smoking and work productivity
are inconclusive, generally, smokers have a lower work productivity compared to non-smokers.
If employers want to reduce smoking prevalence among their employees, they should offer
smoking cessation interventions at the workplace. As argued in this thesis, implementing
smoking cessation interventions in the occupational setting has the potential to be highly
effective. To increase participation rates they could offer the intervention free of charge and
during working hours.
Legislative measures
According to the National Institute for Public Health and the Environment, to eliminate smoking
among vulnerable groups such as adolescents and pregnant women, more extensive strategies
are necessary, such as further tax increases, smoking bans, and point of sale reductions (74).
However, these strategies have the potential to further increase social inequalities. Further
smoke-free legislation, such as the smoking ban on premises of schools, petting zoos, and child
day-care centres that are included in the National Prevention Agreement, could be an effective
measure to reduce tobacco prevalence. In order to avoid marginalization and stigmatization of
already vulnerable groups, smoke-free legislation should be framed positively. A similar case can
be made for the implementation of further tax increases for tobacco products, which are also
part of the National Prevention Agreement. Tax increases place a heavier financial burden on
lower SEP individuals. In order to not further increase socioeconomic inequalities, they should
be paired with improved access to smoking cessation support that is specifically targeted to
lower SEP individuals and free of charge.
General discussion
201
08
RECOMMENDATIONS FOR FUTURE RESEARCH
Based on this thesis, several recommendations for future research can be formulated. First,
the diverging results from chapters 2 and 3 indicate that the relation between smoking status
and work productivity is complex. Therefore, more research is needed on the short- and long-
term effects of smoking cessation on work-related outcomes, in populations from different age
groups and different occupational settings, is necessary to formulate conclusions on the relation
between smoking cessation and work productivity.
In this thesis, two chapters researched the impact of smoking cessation policies and interventions
using Google Trends data. These chapters serve as examples of the potential of big data and
natural experiments in evaluating smoking cessation policies and interventions. This type of data
and methodology could be used to assess the impact of various measures at the national level,
including aspects from the National Prevention Agreement. However, as mentioned before, it
remains uncertain to what extent an increase in online searching for information on smoking
cessation reflects an increase in actual smoking cessation. Therefore, a nationally representative
panel of smokers who report their smoking status on a weekly basis should be composed. The
information derived from this panel should be compared to the weekly volume of online searches
for smoking cessation. In this way, online searching for information on smoking cessation could
be validated as a proxy for actual smoking cessation.
Three chapters in this thesis were based on the Stoptober campaign. In chapter 6, we evaluated
the effects of Stoptober after three months. Due to high drop-out rates we were not able to
evaluate the long-term effectiveness of Stoptober. Therefore we had to estimate the abstinence
rate after one year. Another drawback of this study was that smoking status was only reported
at a very limited number of moments, which makes it difficult to draw conclusions on the process
of smoking cessation during temporary smoking abstinence campaigns such as Stoptober.
Therefore, a new longitudinal study should be conducted to accurately map smoking cessation
trajectories until one years after the campaign. To avoid high drop-out rates, a smaller, more
selective sample of smokers should be recruited and actively approached, by telephoning or text
messaging, to complete all questionnaires. By using very brief surveys, that only include a few
simple questions participants can answer on their phone, we might be able to obtain daily data on
smoking status during Stoptober and weekly data for up to one year after. Additionally, qualitative
research among Stoptober participants, especially among participants who relapsed during or
after Stoptober, could increase insight in the timing and triggers of relapse. This information
could be used to improve the campaign and increase the effectiveness of Stoptober and other
smoking cessation interventions. A final recommendation to encourage smoking cessation is to
conduct research on the reach and effectiveness of Stoptober in different national, local, and
occupational settings.
Chapter 8
202
CONCLUSION
During the past decades, smoking has been increasingly recognised as an unprecedented
population health problem, due to its negative influence on health status, work productivity,
and societal costs. This thesis aimed to contribute to the development of smoking cessation
services in national, local and occupational settings, by evaluating the potential effects of
smoking cessation policies and interventions at national and local levels, including occupational
settings. We found evidence that smoking increases both the risk and number of sickness
absence days in the working population, but did not find evidence that smoking cessation
improves work-related outcomes. Therefore, more research is needed on the relation between
smoking cessation and work-related outcome in different populations. The smoking ban in the
hospitality industry, the reimbursement of smoking cessation support, and the yearly Stoptober
campaign were associated with increases in searching for information on smoking cessation in
the Dutch population. We found that about half of the Stoptober participants had quit smoking
after three months and that the campaign supported its participants according to its theoretical
principles. In order to further reduce smoking prevalence, employers should offer smoking
cessation interventions at the workplace, further smoke-free legislation should be implemented,
and the costs of smoking cessation services should be reimbursed. Furthermore, the reach and
effectiveness of the Stoptober campaign could be increased by cooperating with employers,
local smoking cessation services, and primary care givers.
.
General discussion
203
08
REFERENCES
1. Mulrow CD. Systematic Reviews: Rationale for systematic reviews. BMJ. 1994;309(6954):597.
2. Mann CJ. Observational research methods. Research design II: cohort, cross sectional, and case-
control studies. Emerg Med J. 2003;20(1):54.
3. Craig P, Katikireddi SV, Leyland A, Popham F. Natural Experiments: An Overview of Methods,
Approaches, and Contributions to Public Health Intervention Research. Annu Rev Public Health.
2017;38(1):39-56.
4. Kontopantelis E, Doran T, Springate DA, Buchan I, Reeves D. Regression based quasi-experimental
approach when randomisation is not an option: interrupted time series analysis. BMJ. 2015;350:h2750.
5. Bärnighausen T, Tugwell P, Røttingen J-A, Shemilt I, Rockers P, Geldsetzer P, et al. Quasi-experimental
study designs series—paper 4: uses and value. J Clin Epidemiol. 2017;89:21-9.
6. Sackett DL, Wennberg JE. Choosing the best research design for each question. BMJ.
1997;315(7123):1636.
7. Mays N, Pope C. Qualitative Research: Rigour and qualitative research. BMJ. 1995;311(6997):109.
8. Mays N, Pope C. Assessing quality in qualitative research. BMJ. 2000;320(7226):50.
9. Johnson RB, Onwuegbuzie AJ. Mixed Methods Research: A Research Paradigm Whose Time Has
Come. Educ Res. 2004;33(7):14-26.
10. Morabia A, Bernstein MS, Curtin F, Berode M. Validation of Self-Reported Smoking Status by Simultaneous
Measurement of Carbon Monoxide and Salivary Thiocyanate. Prev Med. 2001;32(1):82-8.
11. Wong SL, Shields M, Leatherdale S, Malaison E, Hammond D. Assessment of validity of self-reported
smoking status. Health reports. 2012;23(1):47-53.
12. Connor Gorber S, Schofield-Hurwitz S, Hardt J, Levasseur G, Tremblay M. The accuracy of self-reported
smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking
status. Nicotine Tob Res. 2009;11(1):12-24.
13. Prochaska JO, Velicer WF. The Transtheoretical Model of Health Behavior Change. Am J Health
Promot. 1997;12(1):38-48.
14. World Health Organization. Prevalence of current tobacco smoking among persons aged 15 years
and older Geneva, Switzerland. 2018 (Available from: http://apps.who.int/gho/data/view.sdg.3-a-data-
reg?lang=en).
15. Joossens L, Raw M. The Tobacco Control Scale 2016 in Europe. Brussels, Belgium: Association of
European Cancer Leagues,; 2017.
16. Melchior M, Krieger N, Kawachi I, Berkman LF, Niedhammer I, Goldberg M. Work Factors and
Occupational Class Disparities in Sickness Absence: Findings From the GAZEL Cohort Study. Am J
Public Health. 2005;95(7):1206-12.
17. Ham DC, Przybeck T, Strickland JR, Luke DA, Bierut LJ, Evanoff BA. Occupation and workplace policies
predict smoking behaviors: analysis of national data from the current population survey. J Occup
Environ Med. 2011;53(11):1337-45.
18. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva, Switzerland;
2003.
19. Jha P, Chaloupka FJ. The economics of global tobacco control. BMJ. 2000;321(7257):358-61.
20. Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. J Health Econ.
2000;19(6):1117-37.
21. Capella ML, Webster C, Kinard BR. A review of the effect of cigarette advertising. Int J Res Mark.
2011;28(3):269-79.
Chapter 8
204
22. He Y, Shang C, Huang J, Cheng K-W, Chaloupka FJ. Global evidence on the effect of point-of-sale display
bans on smoking prevalence. Tob Control. 2018;27(e2):e98.
23. Dutch Government. Maatregelen in het Nationaal Preventieakkoord 2018 (Available from: https://
www.rijksoverheid.nl/onderwerpen/gezondheid-en-preventie/nationaal-preventieakkoord.
24. Warner KE, Mendez D. Tobacco control policy in developed countries: Yesterday, today, and tomorrow.
Nicotine Tob Res. 2010;12(9):876-87.
25. Willemsen MC. Tobacco Control Policy in the Netherlands: Between Economy, Public Health, and
Ideology. 1st ed: Springer International Publishing 2018.
26. Frazer K, Callinan JE, McHugh J, van Baarsel S, Clarke A, Doherty K, et al. Legislative smoking bans
for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption.
Cochrane Database Syst Rev. 2016(2).
27. Hackshaw L, McEwen A, West R, Bauld L. Quit attempts in response to smoke-free legislation in
England. Tobacco Control. 2010;19(2):160.
28. Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms
and secondhand smoke exposure. Cochrane Database Syst Rev. 2016(5).
29. Nagelhout GE, de Vries H, Fong GT, Candel MJJM, Thrasher JF, van den Putte B, et al. Pathways of change
explaining the effect of smoke-free legislation on smoking cessation in The Netherlands. An application
of the international tobacco control conceptual model. Nicotine Tob Res. 2012;14(12):1474-82.
30. Eadie DR, MacAskill SG, Heim D, Hastings GB. Responding to change: how did bar workers adapt to
the smoke-free legislation in Scotland? Int J Environ Health Res. 2010;20(1):13-26.
31. Nagelhout GE, Willemsen MC, de Vries H. The population impact of smoke-free workplace and
hospitality industry legislation on smoking behaviour. Findings from a national population survey.
Addiction. 2010;106(4):816-23.
32. Troelstra SA, Bosdriesz JR, de Boer MR, Kunst AE. Effect of Tobacco Control Policies on
Information Seeking for Smoking Cessation in the Netherlands: A Google Trends Study. PLoS One.
2016;11(2):e0148489.
33. Ritchie D, Amos A, Martin C. “But it just has that sort of feel about it, a leper”—Stigma, smoke-free
legislation and public health. Nicotine Tob Res. 2010;12(6):622-9.
34. Evans-Polce RJ, Castaldelli-Maia JM, Schomerus G, Evans-Lacko SE. The downside of tobacco control?
Smoking and self-stigma: A systematic review. Soc Sci Med (1982). 2015;145:26-34.
35. Thomson G, Wilson N, Edwards R. At the frontier of tobacco control: a brief review of public attitudes
toward smoke-free outdoor places. Nicotine Tob Res. 2009;11(6):584-90.
36. Nagelhout GE, Willemsen MC, van den Putte B, de Vries H, Willems RA, Segaar D. Effectiveness of a
national reimbursement policy and accompanying media attention on use of cessation treatment and
on smoking cessation: a real-world study in the Netherlands. Tob Control. 2015;24(5):455.
37. Bala MM, Strzeszynski L, Topor-Madry R. Mass media interventions for smoking cessation in adults.
Cochrane Database Syst Rev. 2017(11).
38. Calo WA, Krasny SE. Environmental determinants of smoking behaviors: The role of policy and
environmental interventions in preventing smoking initiation and supporting cessation. Curr
Cardiovasc Risk Re. 2013;7(6):446-52.
39. Secker-Walker R, Gnich W, Platt S, Lancaster T. Community interventions for reducing smoking among
adults. Cochrane Database Syst Rev. 2002(2).
40. Cahill K, Lancaster T. Workplace interventions for smoking cessation. Cochrane Database Syst Rev.
2014(2).
41. Dunbar MS, Shiffman S, Chandra S. Exposure to workplace smoking bans and continuity of daily
smoking patterns on workdays and weekends. Addict Behav. 2018;80:53-8.
General discussion
205
08
42. Azagba S, Asbridge M. The association between smoking bans and nicotine dependence: A longitudinal
analysis of current smokers in Canada. 2013. 2817-20 p.
43. Borland RON, Cappiello M, Owen N. Leaving work to smoke. Addiction. 2006;92(10):1361-8.
44. Brown J, Kotz D, Michie S, Stapleton J, Walmsley M, West R. How effective and cost-effective
was the national mass media smoking cessation campaign ‘Stoptober’? Drug Alcohol Depend.
2014;135(100):52-8.
45. Troelstra SA, Harting J, Kunst AE. Effectiveness of a Large, Nation-Wide Smoking Abstinence Campaign
in the Netherlands: A Longitudinal Study. Int J Environ Res Public Health. 2019;16(3):378.
46. Troelstra SA, Kunst AE, Harting J. “Like you are fooling yourself”: how the “Stoptober” temporary
abstinence campaign supports Dutch smokers attempting to quit. BMC Public Health. 2019;19(1):522.
47. Cole-Lewis H, Perotte A, Galica K, Dreyer L, Griffith C, Schwarz M, et al. Social Network Behavior and
Engagement Within a Smoking Cessation Facebook Page. J Med Internet Res. 2016;18(8):11.
48. Graham AL, Zhao K, Papandonatos GD, Erar B, Wang X, Amato MS, et al. A prospective examination
of online social network dynamics and smoking cessation. PLoS One. 2017;12(8):18.
49. Bhattacharya A, Vilardaga R, Kientz JA, Munson SA. Lessons from Practice: Designing Tools to Facilitate
Individualized Support for Quitting Smoking. ACM Trans Comput Hum Interact. 2017;2017:3057-70.
50. Vidrine JI, Shete S, Cao Y, Greisinger A, Harmonson P, Sharp B, et al. Ask Advise Connect: A New Approach
to Smoking Treatment Delivery in Healthcare Settings. JAMA Intern Med. 2013;173(6):10.1001/
jamainternmed.2013.3751.
51. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an
overview and network meta-analysis. Cochrane Database Syst Rev. 2013(5).
52. Papadopoulos G, Georgiadou P, Papazoglou C, Michaliou K. Occupational and public health and safety
in a changing work environment: An integrated approach for risk assessment and prevention. Safety
Science. 2010;48(8):943-9.
53. Baron SL, Beard S, Davis LK, Delp L, Forst L, Kidd-Taylor A, et al. Promoting integrated approaches to
reducing health inequities among low-income workers: Applying a social ecological framework. Am J
Ind Med. 2013;57(5):539-56.
54. Ahonen EQ, Fujishiro K, Cunningham T, Flynn M. Work as an Inclusive Part of Population Health
Inequities Research and Prevention. Am J Public Health. 2018;108(3):306-11.
55. Quinn MM. Occupational health, public health, worker health. Am J Public Health. 2003;93(4):526-.
56. Davis L, Souza K. Integrating occupational health with mainstream public health in Massachusetts: an
approach to intervention. Public Health Rep. 2009;124 Suppl 1(Suppl 1):5-14.
57. Sepulveda M-J. From worker health to citizen health: moving upstream. J Occup Environ Med.
2013;55(12 Suppl):S52-S7.
58. Fishwick D, Carroll C, McGregor M, Drury M, Webster J, Bradshaw L, et al. Smoking cessation in the
workplace. Occup Med. 2013;63(8):526-36.
59. Hymel PA, Loeppke RR, Baase CM, Burton WN, Hartenbaum NP, Hudson TW, et al. Workplace Health
Protection and Promotion: A New Pathway for a Healthier—and Safer—Workforce. J Occup Environ
Med. 2011;53(6):695-702.
60. Sorensen G. Worksite tobacco control programs: the role of occupational health. Respir Physiol.
2001;128(1):89-102.
61. van Wijk EC, Landais LL, Harting J. Understanding the multitude of barriers that prevent smokers in
lower socioeconomic groups from accessing smoking cessation support: A literature review. Prev Med.
2019;123:143-51.
62. Robroek SJW, van Lenthe FJ, van Empelen P, Burdorf A. Determinants of participation in worksite
health promotion programmes: a systematic review. Int J Behav Nutr Phys Act. 2009;6(1):26.
Chapter 8
206
63. Carroll C, Rick J, Leaviss J, Fishwick D, Booth A. A qualitative evidence synthesis of employees’ views
of workplace smoking reduction or cessation interventions. BMC Public Health. 2013;13:1095-.
64. Dohnke B, Weiss-Gerlach E, Spies CD. Social influences on the motivation to quit smoking: Main and
moderating effects of social norms. Addict Behav. 2011;36(4):286-93.
65. van den Brand FA, Nagelhout GE, Winkens B, Chavannes NH, van Schayck OCP. Effect of a workplace-
based group training programme combined with financial incentives on smoking cessation: a cluster-
randomised controlled trial. Lancet Public Health. 2018;3(11):e536-e44.
66. Lando HA, Michaud ME, Poston WSC, Jahnke SA, Williams L, Haddock CK. Banning cigarette smoking
on US Navy submarines: a case study. Tob Control. 2015;24(e3):e188-e92.
67. Gray NJ. The case for smoker-free workplaces. Tob Control. 2005;14(2):143.
68. Houle B, Siegel M. Smoker-free workplace policies: developing a model of public health consequences
of workplace policies barring employment to smokers. Tob Control. 2009;18(1):64-9.
69. Voigt K. Ethical concerns in tobacco control nonsmoker and “nonnicotine” hiring policies: the implications
of employment restrictions for tobacco control. Am J Public Health. 2012;102(11):2013-8.
70. Brody H, McKinney EB. The ethics of requiring employees to quit smoking. AMA J Ethics. 2007;9(1):52-5.
71. Lecker MJ. The Smoking Penalty: Distributive Justice or Smokism? J Bus Ethics. 2009;84(1):47-64.
72. Chapman S. The smoker-free workplace: the case against. Tob Control. 2005;14(2):144.
73. Maastricht University, RIVM, Trimbos-Institute. Social cost-benefit analysis of tobacco control policies
in the Netherlands. Maastricht, The Netherlands: Maastricht University; 2016.
74. National Institute for Public Health and the Environment (RIVM). Quickscan potential impact National
Prevention Agreement. Bilthoven: RIVM; 2018.