smoking intervention in the workplace using videotapes and nicotine chewing gum
TRANSCRIPT
PREVENTIVE MEDICINE 17, 48-59 (1988)
Smoking intervention in the Workplace Using Videotapes and Nicotine Chewing Gum’
STEPHEN SUITON,PH.D,~ANDROBERTHALLETT, PH.D
Institute of Psychiatry, Addiction Research Unit, University of London, 101 Denmark Hill, London SE5 8AF, England
This article reports a series of randomized controlled studies in four companies in the United Kingdom which were designed to evaluate minimal smoking intervention programs based on the use of motivational videotapes or nicotine chewing gum. In the videotape studies, groups of smokers (N = 603) were randomly assigned to watch one of several different videotapes. They were followed-up, along with nonparticipants (N = 1,015), at 3 months and again at 1 year, and a biochemical validation of abstinence was performed. There were significant differences between the videotape conditions with regard to attitudes assessed immediately after exposure (intention and fear) and the proportion of smokers who tried to stop, but there were no significant differences in cessation, even in the short term. Using a strict definition of abstinence, long-term abstinence rates were under 10% in all four studies. In one company, we also investigated the effect of offering brief individual treat- ment based on nicotine chewing gum to a randomly chosen 50% sample of the videotape group (N = 161) still smoking at the 3-month follow-up. The treatment course was adminis- tered by occupational health nurses and consisted of four short consultations over a 12- week period. The results were encouraging: 16% of those who took the offer stopped during treatment and were still abstinent 1 year after the start of treatment compared with only 2% of the randomized no-intervention control group and 0% of those who were invited but did not attend. 8 1988 Academic Press. Inc.
INTRODUCTION Recently, there has been increased interest in the workplace as a setting for
smoking cessation and other health promotion programs (1, 5, 6, 13, 23, 25). The workplace has a number of advantages in this respect. Workplace programs have the potential to reach large numbers of smokers who may be more representative of the smoking population than the small self-selected subgroups who attend smokers’ clinics and other formal treatment programs. Moreover, in most work settings smokers constitute a semicaptive audience which can be studied, treated, and followed-up over relatively long periods of time. Given such advantages, there have been surprisingly few controlled evaluations of workplace smoking cessation programs. Notable exceptions include a study of physician counseling on the smoking behavior of naval shipyard workers (12), the “Whitehall study” which also investigated the efficacy of antismoking advice (15, 16), and the World Health Organization Collaborative Heart Disease Prevention Project (24).
This article reports a series of randomized controlled studies conducted in four companies in the United Kingdom. The aim of the studies was to evaluate the
i Financial support for this study was provided by the Medical Research Council, London, En- gland.
2 To whom reprint requests should be addressed.
48 0091-7435/88 $3.00 Copyright 0 1988 by Academic Press, Inc. Au rights of reproduction in any form reserved.
SMOKING INTERVENTION IN THE WORKPLACE 49
efficacy of minimal smoking intervention programs based on either motivational videotapes or nicotine chewing gum (Nicorette). In the videotape studies, we used two television programs, “Dying for a Fag?” and “Smokers’ Luck,” that vividly portray the harmful health consequences of smoking. These were com- pared in an experimental design with control videotapes dealing with the politics of smoking or with a different health topic (seat belt use). Two edited versions of “Dying for a Fag?“, designed to investigate specific hypotheses about the effects of fear and confidence, were also tested. Previous studies of the effectiveness of “Dying for a Fag?” (3, 21) suggested that it had at least a short-term effect on behavior. A study of viewers’ reactions to “Smokers’ Luck” has been published by Dyer (2).
Many smokers are likely to require more than a single session of information about the dangers of smoking to induce them to stop. In one company we also investigated the effect of offering a brief treatment course based on the use of nicotine chewing gum that was administered by the occupational health staff. Nicotine gum has been used in both clinic and general practice settings with en- couraging results (8), but to our knowledge there have been no controlled studies in workplace settings.
VIDEOTAPE STUDIES
Method
Procedure. Four companies, all based in or near London, with well-staffed oc- cupational health departments were involved in the project. Similar studies in two other companies had to be abandoned because of poor response rates to the ini- tial survey and because of threatened industrial action in one of the firms.
The four studies used a similar design. A short questionnaire was sent to all employees at each site to determine the number of cigarette smokers, to obtain background information (sex, age, and cigarette consumption), and to recruit smokers into the program. Response rates to the survey ranged from 78 to 88%, and cigarette smoking prevalence among respondents ranged from 22 to 36% (see Table 1). (In three of the studies, subjects were also offered the chance to win one of several small cash prizes if they returned a completed questionnaire. There was no evidence, however, that this was effective in boosting the response rate.) In Study 1 the program was described as a “health information program” on smoking and seat belt use and was open to all employees. In the other studies the program was described as a “smoking education program” and was restricted to smokers only. As Table 1 indicates, of those cigarette smokers who returned the questionnaire, the proportion expressing interest in participating in the program ranged from 56 to 77% across all four studies. Of these, 51-76% (29-58% of those who returned the initial questionnaire) subsequently attended the videotape sessions.
The videotape sessions were given during working hours about 2 months after the survey was administered. Subjects were shown one of several different video- tapes in small groups. Sessions were randomly assigned to videotapes. The total number of sessions in each company varied from 18 to 23. The videotapes all
50 SUTTON AND HALLETT
TABLE 1 DESCRIETIVE DATA FOR THE FOUR VIDEOTAPE STUDIES
Study 1 Study 2 Study 3 Study 4
Number of employees on roll 587 1,784 1,835 2,983 Response rate to survey 78%a 83%= 81% 88%” Cigarette smoking prevalence 29% 36% 2% 22%
Cigarette smokers onlyb Base = 132 Base = 524 Base = 423 Base = 539 Men (%) 77% 43% 60% 62% Mean age 39 31 40 38 Mean daily cigarette consumption 17 19 15 17 Those in nonmanual occupations 51% -c 29% 76% Those who wanted to take part 77% 56% 69% 58%
(101) (299 cw (313) Those who attended videotape 58% 29% 47% 33%
sessions (77) (150) (197) (179) Those who provided complete data 97%d 96% 89% 96%
at 3-month follow-up (75l77) (503) (376) (517) Those who provided complete data 89%” 94% 85%” 99%”
at l-year follow-up (118/132) (494) (361) (532)
a Subjects were offered the chance of winning one of several cash prizes if they returned a com- pleted questionnaire.
6 A small number of cigarette smokers who stopped between the initial survey and the videotape intervention have been excluded from these bases.
c It was not possible in this study to include the question on occupation in the survey questionnaire. However, the great majority of employees in this firm were office workers.
d Nonparticipants were not followed-up at the 3-month stage in this study.
lasted about 25 min and were shown in color on a large video monitor. After watching a videotape, subjects completed a questionnaire designed to assess, among other things, their intention to try to stop smoking, their confidence in their ability to stop smoking, and the amount of fear aroused by the videotape. (Subjects in Study 1 also answered questions relating to seat belt use.) As they left, subjects who had watched a smoking videotape were given a booklet called “The Smoker’s Guide to Non-Smoking” produced by the Health Education Council, which gave advice on how to stop smoking. Subjects in the seat belt sessions were given a leaflet about seat belt use. Each session was completed in less than an hour.
Three months later participants were sent a short questionnaire through the company internal mail to find out whether they had tried to stop smoking and, if so, whether they had been successful in their attempt. The final follow-up took place 1 year after the videotape intervention. Subjects were sent another short questionnaire to ascertain their smoking status. (They were again offered the chance of winning a cash prize if they returned a completed questionnaire.) At each follow-up, those who did not return the questionnaire were contacted by the researchers (by telephone or in person) or, in some cases, by the occupational health nurses. Subjects who claimed to have stopped smoking were interviewed,
SMOKING INTERVENTION IN THE WORKPLACE 51
and a measure of carbon monoxide (CO) in end-expired air after breath-holding was obtained using an Ecolyzer 2000 with an ethanol filter (11); a cut-off of 10 ppm was used. Cigarette smokers who did not attend the videotape sessions (nonparticipants) were followed-up in the same way. As shown in Table 1, the follow-up response rates ranged from 85 to 99%. In the data analysis nonrespon- dents were classified as continuing smokers.
In order to assess the extent of response bias in the initial survey, retrospective surveys of the smoking habits of people who failed to respond to the initial survey were conducted in Studies 3 and 4. The surveys took place at the time of the l-year follow-up and asked about smoking status and smoking habits at the time the initial survey had been conducted. A lottery was again used in an attempt to boost the response rate. The final response rates (among those who failed to re- spond to the initial survey) were 39% in Study 3 and 45% in Study 4. Retrospec- tive cigarette smoking prevalence among these samples was significantly higher than that among the initial survey responders (45% vs 29% in Study 3, 34% vs 22% in Study 4), suggesting a small response bias in the original survey in favor of nonsmokers being more likely to return a questionnaire.
The Videotapes
Table 2 summarizes the design of the four studies and the videotapes used. An unedited version of “Dying for a Fag?“, made by Thames Television and first broadcast in 1975, was used in all four studies. The film consists of an extended interview with Peter, a former heavy smoker who is dying of lung cancer. Infor- mation about the health risks of smoking is intercut with the interview sequences. Two additional versions were created to investigate the effects of fear and confi- dence. In one version (used in Study 2), a specially prepared 5-min sequence designed to boost confidence was added to the end of the program. The message conveyed by this sequence, featuring the original program’s presenter, a psychia- trist working ,in the field of smoking cessation, and a number of successful ex- smokers, was that those who want to stop smoking can succeed if they make a serious attempt to do so. In the second version (used in Study 3), a memorable sequence involving bins full of cancerous lungs was edited out.
In Study 4, an edited version of a BBC television program called “Smokers’ Luck” was also used. This features a man who continues to smoke despite having had both legs amputated because of a smoking-related disease.
Three different control videotapes were used. These consisted of a videotape on a different health topic (seat belt use), which was used in Study 1, and two videotapes on the political and advertising aspects of smoking (“License to Kill” and “The Tobacco War”), neither of which emphasized the health consequences of smoking or contained any material that could be regarded as frightening or shocking. (To this end, a lung cancer operation sequence was edited out of “Li- cense to Kill”.) “License to Kill” was used in Study 2 and “The Tobacco War” in Studies 3 and 4.
Outcome Measures On the 3-month follow-up questionnaire, subjects were asked (“Since you saw
the film/Since the films were shown . . .) have you tried to stop smoking (or to cut
TABL
E 2
OU
TCO
ME
DAT
A FO
R T
HE
FOU
R V
IDEO
TAPE
ST
UD
IES
Stud
y 1
Stud
y 2
Stud
y 3
Stud
y 4
DFF
SB
N
P D
FF
DFF
+ C
LT
K N
P D
FF
DFF
-
G
TW
NP
DFF
SL
TW
N
P O
utco
me
crite
rion
(33)
W
I (5
%
(46)
(5
0)
(54)
(3
74)
(56)
(6
7)
(74)
(2
26)
(62)
(5
9)
(58)
(3
60)
Trie
d to
sto
p (3
-mon
th f
ollo
w-u
p)
42%
” 20
%
- 61
%
48%
56
%
25%
b 38
%
34%
22
%
ll%C
31
%
24%
31
%
17%
” C
laim
ed a
bstin
ence
at
3 m
onth
s 9%
9%
-
28%
20
%
17%
13
%’
14%
6%
4%
6%
10
%
2%
14%
7%
Va
lidat
ed a
bstin
ence
at
3 m
onth
s 6%
5%
-
17%
18
%
15%
9%
d 11
%
3%
4%
2%
5%
2%
10%
5%
2
Cla
imed
lon
g-te
rm
3 ab
stin
ence
3%
2%
5%
13
%
8%
11%
5%
’ 4%
3%
4%
2%
5%
2%
7%
3%
2
Valid
ated
lon
g-te
rm
abst
inen
ce
3%
0%
5%
11%
8%
9%
4%
f 4%
3%
4%
2%
3%
2%
5%
3%
iz
i
“Com
plet
e”
abst
inen
ce
3%
0%
5%
7%
3%
2%
z (1
) (0
) (3
) (3
) (:p
$7
(1
3)
(1)
(ip
$1”
$7
,:lo
(i:”
(:;
(i:”
g
Not
e.
Key
to g
roup
s: D
FF,
“Dyi
ng
for
a Fa
g?“;
DFF
+
C,
“Dyi
ng
for
a Fa
g?”
plus
con
fiden
ce-b
oost
ing
sequ
ence
; D
FF
- G
, “D
ying
fo
r a
Fag?
” G
min
us g
ory
sequ
ence
; S
L,
“Sm
oker
s’
Luck
”; SB
, se
at b
elts
(co
ntro
l);
LTK,
“L
icen
se
to.K
ill”
(con
trol);
TW
, “T
he
Toba
cco
War
” (c
ontro
l);
NP,
3
nonp
artic
ipan
ts.
Sign
ifica
nt d
iffer
ence
s (u
ncor
rect
ed
x2,
1 df
)
Betw
een
vide
otap
e co
nditi
ons
Betw
een
parti
cipa
nts
and
nonp
artic
ipan
ts
ax2
= 4.
3 P<
0.
05
b x2
= 4
1.0
P<
0.00
01
cx2
= 6.
4 Pc
O.0
2 dX
2 =
7.3
P<O
.Ol
ex2
= 4.
7 PC
O.0
5 f
x2 =
5.1
P<
0.
05
g x2
=
26.0
PC
0.
0001
h
x2 =
9.
2 PC
0.
005
SMOKING INTERVENTION IN THE WORKPLACE 53
down)?” (Yes, I’ve tried to stop smoking; Yes, I’ve tried to cut down; No, I haven’t tried to stop smoking or to cut down). Those who had tried to stop or to cut down were asked, “How have you got on so far in your attempt?” (I’ve stopped smoking; I’ve cut down to about - cigarettes a day; I still smoke about as many as I did before). In order to ascertain smoking status at the l-year follow-up, subjects were asked simply “Are you a cigarette smoker?”
The following dichotomous outcome criteria were constructed from subjects’ responses to these questions and their CO levels: (a) tried to stop during the 3-month follow-up period; (b) claimed abstinence at 3 months; (c) validated absti- nence at 3 months, i.e., as for (b), but also had a CO level of ~10 ppm; (d) claimed long-term abstinence, i.e., as for (c), but also claimed to be still not smoking at 1 year; (e) validated long-term abstinence, i.e., as for (d), but were also validated a second time at 1 year. These five outcome criteria represent a hierarchy of increasingly strict definitions of outcome. Even so, some people who were classified as validated long-term abstainers said at the validation interview that they had smoked some tobacco during the period in question. We therefore created the following additional criterion: (f) “complete” abstinence, i.e., as for (e), but excluding anyone who smoked more than one cigarette, cigar, or pipe in the period between the 3-month and l-year follow-ups.
Only 10 people refused to be tested for CO or failed to attend their appoint- ment. Of the 170 people who were tested and who claimed to have stopped smoking, only 5 had CO levels greater than 10 ppm, giving an overall “decep- tion” rate of 3% (8% if “refusals” are included).
Subjects
The final sample comprised the 1,618 cigarette smokers who returned the initial questionnaire. There were 603 participants and 1,015 nonparticipants. As Table 1 shows, men were in the majority except in Study 2. Subjects in Study 2 were also younger on average. Mean daily cigarette consumption was in the range U-20/ day.
Evidence from the restrospective surveys showed that in Study 3 cigarette smokers who responded to the original survey tended to be lighter smokers, were younger, and included more women and more people in nonmanual occupations. There was no evidence for such differences in Study 4.
Analysis
Since a nested design was employed (sessions nested within videotapes), lo- gistic regression analysis was used to check for possible session effects. There was little evidence for session differences, so the main results are reported in terms of comparisons between the videotape conditions and between participants and nonparticipants for each study separately using x2 tests and analysis of vari- ance. In additional analyses, the data from the four studies were combined to examine study differences and to improve statistical power for the comparisons
54 SUTTON AND HALLET-I
between the videotape conditions and between participants and nonparticipants. Logistic regression was again used for these analyses.
Results
Comparison of videotapes. Though not the main focus of this report, it is worth noting that there were a number of significant differences between videotape con- ditions with regard to the attitudinal variables measured on the postexposure questionnaire. In the first two studies, those who watched “Dying for a Fag?” had significantly stronger intentions to try to stop smoking than those who watched the control videotape. There were no significant effects on intentions in Studies 3 and 4. In three of the studies (2, 3, and 4) there was a significant difference between the videotapes in the amount of fear aroused. In all cases, the unedited version of “Dying for a Fag?” aroused the most fear and the control videotape (“License to Kill” or “The Tobacco War”) the least. The attempt to manipulate confidence in Study 2 was not successful. There was no significant difference in confidence between the unedited version of “Dying for a Fag?” and the version with the added confidence-boosting sequence.
The results for the behavioral criteria of outcome are shown in Table 2. There were no significant differences between the videotape conditions on any of the outcome measures, with the single exception of Study 1 where the proportion who tried to stop smoking was significantly higher in the group who watched “Dying for a Fag?“. Using the strictest definition of abstinence, long-term absti- nence rates among participants were below 5% in all studies except Study 2.
Combining the data from the four studies, the proportion of smokers who tried to stop was significantly (P < 0.05) higher among those who watched the unedited version of “Dying for a Fag?” than among those who watched one of the control videotapes. However, there were no significant differences between these two groups on any of the abstinence criteria. There was a significant study effect with regard to all the outcome measures except “complete” abstinence; the attempt and cessation rates among participants in Study 2 were higher than those in the other three studies. There were no significant differences between men and women on any of the outcome measures. Nor was there any evidence that the videotapes were differentially effective in these two groups.
Comparison of participants and nonparticipants. Table 2 also shows the results for nonparticipants. In Study 2 participants did significantly better than nonparti- cipants with regard to all the outcome criteria, though for the strictest criterion of abstinence the difference was only marginally significant (P < 0.06). In Studies 3 and 4 significantly more participants than nonparticipants reported having tried to stop smoking in the 3-month follow-up period, but there were no other differ- ences in outcome between these two groups.
In an analysis based on the combined data set, significantly more participants than nonparticipants tried to stop smoking and more of them did stop smoking, though the differences were not significant with regard to the two most stringent outcome criteria. Again, there was a significant study effect, the overall rates of trying to stop and of cessation being higher in Study 2.
SMOKING INTERVENTION IN THE WORKPLACE 55
NICOTINE GUM STUDY
Method
Procedure. The main study was conducted in the fourth company after pilot studies in the first two companies. Cigarette smokers (N = 161) who had watched a videotape but who were still smoking at the 3-month follow-up stage and had not left the company were randomly divided into two groups.3 Those in the first group (N = 79) were sent a personal invitation from the occupational physician to take part in a treatment course involving four brief individual consultations over a 3-month period. No invitation was sent to smokers in the second group (N = 82), who thus constituted a randomized no-intervention control group.
The consultations were given by occupational health nurses, one nurse being present at each consultation. Before the treatment course started, the nurses were given a typed sheet that contained recommendations on the schedule and content of the consultations. The recommended schedule was four consultations over a 1Zweek period, with intervals of 2, 4, and 4 weeks, respectively, between the consultations. Each consultation was to take a maximum of 15 min, so that the total time per patient for the full treatment course would be no more than 1 hr. The nurses adhered fairly closely to these recommendations. The number of con- sultations ranged from 1 to 5 with a mean of 3.5, and the longest period between the first and last consultation was about 4 months.
In the first consultation, the rationale for using the gum was explained and instructions on how it should be used were given. [see (17, 19)3. Subjects were given a private prescription for one box (105 pieces) of 2-mg Nicorette, which they were told would cost about &6, and a copy of the manufacturer’s booklet. Subsequent consultations were used to give encouragement and support, to check that subjects were using the gum correctly, to deal with any problems, and to give further prescriptions when necessary.
Thirty-two (40.5%) of the invited group attended at least one consultation. Five of the control group also asked for and were given treatment. All those who took part were contacted 1 year after the start of the treatment course and were inter- viewed about their smoking habits. If they claimed to have stopped smoking, their CO levels were also measured. In addition, those in the nonparticipant groups (i.e., those who did not take the offer of treatment and those in the control group) who were long-term abstainers over the period in question were con- tacted. (These people were identified from their responses to the questionnaire distributed 1 year after the videotape intervention.) The response rate was 100%. No one refused to be tested and all those who claimed to have stopped smoking had CO levels no higher than 10 ppm.
Measures. Three dichotomous outcome criteria were used: (a) claimed absti- nence at the end of treatment (no validation was done at this stage); (b) validated long-term abstinence, i.e., stopped during treatment, claimed to be still abstinent
3 In case there was any residual effect of attending the same videotape session, the randomization was done within each session. Half of those smokers who had attended a given videotape session were randomly assigned to the first group and the other half to the second group, and so on for each session. This resulted in unequal numbers in the two groups.
56 SUTI’ON AND HALLETI
at the l-year follow-up, and had a CO level of <lo ppm; and (c) “complete” abstinence, i.e., as for (b) but excluding anyone who smoked more than one ciga- rette, cigar, or pipe during the period in question.
Subjects. The 161 smokers had a mean cigarette consumption of 19 cigarettes/ day: 57% were men, 75% were in nonmanual occupations, and their mean age was 40. They were thus similar to the total sample of 539 cigarette smokers iden- tified at the initial survey (see Table 1, column 4).
Results
The results are given in Table 3. There were effectively three groups (A, B, and C). Group A comprises those who were invited and who attended at least one consultation, Group B those who were invited but who did not take up the invita- tion, and Group C those who were not sent an invitation (the control group).
The abstinence rates among nonparticipants were extremely low and did not differ significantly between those who were invited to take part but did not attend (Group B) and the control group (Group C). In contrast, 16% of those who at- tended for treatment (Group A) were abstinent throughout the follow-up period.
Table 3 gives the significance test results for the randomized comparison of the invited group as a whole (A + B) and the control group (Group C). The two groups differed significantly but only with respect to the less stringent outcome criterion. The comparison of the treated group (Group A) and the control group (Group C) was highly significant for both outcome criteria.
There was no evidence for a self-selection bias. Those who were invited and attended (Group A) did not differ significantly from those who were invited but did not attend (Group B) with regard to any of the pretreatment variables exam- ined, including age, sex, cigarette consumption, percentage in nonmanual occu- pations, and motivation and confidence measured on the initial survey question- naire .
Of the 32 participants, only 2 were not given a prescription for the gum; neither
TABLE 3 OUTCOMERESULTSFORTHENICOTINEGUM STUDY
Outcome criterion
Invited
Attended Did not attend Control Significance tests”
(N =A 32) (N =B 47) (N =c 82)
(x2)
(A + B) vs C A vs C
Abstinent at end 47% - - - - of treatment (15)
Validated long-term 22% (i$ ,:;”
P< 0.05 PC 0.001 abstinence (7)
“Complete” 16% (F
2w NS P < 0.01 abstinence (5) (2)
D Groups B and C did not ditfer significantly on either criterion of long-term abstinence. * Five of the 82 people in Group C asked for and were given treatment. One of these was a long-term
abstainer and is classified as a control group success.
SMOKING INTERVENTION IN THE WORKPLACE 57
of these was a long-term abstainer. Of the 30 who were prescribed gum, 23 actu- ally obtained and used it. The majority of these (14, or 61%) used one box or less in total. There was no significant association between amount of gum used and success rate.
DISCUSSION
With regard to the results of the videotape studies, although the evidence sug- gested that “Dying for a Fag?” influenced attitudes (intention and fear) assessed immediately after exposure and encouraged more smokers to try to stop, there were no significant differences in abstinence rates between the videotapes, even in the short term. A recent experimental evaluation of a six-part BBC television series called “So You Want To Stop Smoking?“, which stressed the positive ben- efits of quitting rather than the dangers of smoking, also found no significant effect on smoking cessation (or even on the proportion of smokers who tried to stop) when compared with the control videotape “License to Kill” (22). The re- sults of these studies are surprising since the videotapes we tested are in our opinion the most impressive programs about smoking that have been broadcast on British television in recent years. The results suggest that videotapes of televi- sion programs, whether they vividly portray the dangers of smoking or aim to give constructive advice and encouragement to smokers who want to stop, are of little practical use in workplace smoking cessation programs. Minimal interven- tion of this kind appears to have a minimal effect.
As might be expected, participants showed higher rates of attempt and cessa- tion than nonparticipants. However, the differences were not significant for the two most stringent outcome criteria, suggesting that the combined effect of self- selection and taking part in the program (irrespective of which videotape was seen) was not sufficient to produce a lasting difference in cessation between par- ticipants and nonparticipants.
The rates of attempt and cessation were substantially higher in Study 2 than in the other three studies. Although an examination of Table 1 reveals that smokers in Study 2 were on the average younger and smoked more heavily, and Study 2 included more women than the other three studies, the better results obtained in this study can be interpreted as a seasonal effect. In this study the videotapes were shown in late November-early December and the short-term follow-up commenced in March. Many smokers attempt to stop in the New Year and watching a videotape immediately before Christmas may have encouraged more to do so. It may also be relevant that the BBC television series “So You Want To Stop Smoking?” was screened at around this time.
Although the findings of our videotape studies were generally negative, they do show that a substantial proportion of a defined population of cigarette smokers can be recruited to take part in a worksite smoking program. The percentage of cigarette smokers in the four studies attending the videotape sessions ranged from 29 to 58%. The high rate of participation in Study 1 (58%) may have been due to the nature of the program which, unlike those conducted in the other firms, did not focus on smoking alone. Conducting the programs during work lours probably encouraged greater participation. Indeed, for many workers
58 SUTTON AND HALLETT
having an hour off from work may itself be a sufficient incentive to take part. This may partly account for the higher participation rates observed in Studies 1 and 3, where the percentage of manual workers among the employees was relatively high. Another feature of work-based smoking programs that may encourage greater participation is that participants do not have to spend much time and effort to attend the program, particularly if it involves only one session.
The results of the nicotine gum study were more encouraging. Our findings suggest that the offer of brief individual treatment based on the use of nicotine gum and administered by occupational health staff can have a useful effect on long-term abstinence. Furthermore, the pattern of results (a virtually zero absti- nence rate except among those who attended for treatment) and the lack of evi- dence for a self-selection bias suggest that the higher success rate among the treated group was due to the treatment itself rather than to self-selection of po- tential successes into that group. To our knowledge, this study is the first con- trolled evaluation of a workplace smoking intervention program using nicotine gum. Previous studies of the gum have been conducted either in specialized smokers’ clinics [e.g., (7, 10, 20)] or in general practice settings [e.g., (4, 9, 14, 18)]. As would be expected, the clinic-based studies, which used highly selected subjects and relatively intensive treatment, yielded higher long-term success rates (sustained l-year abstinence rates of around 30% in the studies cited). The suc- cess rate of 16% obtained in this study compares favorably with this figure and was achieved with 1 hr or less of therapist time per subject. It may be possible to reduce the cost of the treatment without impairing its efficacy by reducing the number of sessions and by treating people in groups rather than individually. In our view, the size of the smoking problem is such that we need to develop cost- effective minimal intervention approaches that can be applied to large numbers of smokers. The results of the present study suggest that the use of nicotine chewing gum in workplace settings is one such promising approach.
ACKNOWLEDGMENTS
The following firms were involved in the project: FBC Limited, Hauxton, Cambridge (Dr. J. L. Bonsall, Sister P. A. ‘Ibmer, Sister M. A. Clark, Miss N. J. Court); American Express International Banking Corporation, Amex House, Brighton, Sussex (Dr. M. A. Barker, Sister T. Cunliffe-Steele, Sister S. Hollands, Ms. E. Robertson); Beechams Pharmaceuticals, Worthing, West Sussex (Dr. C. G. Vokins, Dr. R. G. Orr, Sister M. Cottingham, Mrs. E. Reynolds); Shell U.K. Limited, Shell-Mex House, London (Dr. R. Houston, Dr. K. H. M. Young, Professor D. H. Elliott, Ms. K. Roll, Mrs. A. Allard; Sisters P. Nowland and N. Teakle administered the nicotine gum treatment). We thank the occupational health staff who collaborated with us in this research as well as the employees who participated in the studies. We also thank members of the Smoking Section of the Addiction Research Unit for their helpful comments on an earlier draft of this paper.
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