reinforce smoking abstinence (Morgan 1981). Many smokers, partic-
ularly women, are concerned about potential weight gain as a result
of smoking cessation, and such programs can address these concerns
(Ellis 1980).
  There are also potential disadvantages of multiple risk factor
reduction programs. They may be difficult to implement because
staff expertise is required in multiple areas and because some risk
factors, such as smoking, may not be relevant for all participants. In
addition, multiple risk factor reduction programs must present a
large amount of complex information, usually in a limited time, and
consequently the amount of attention devoted to a given risk factor
such as smoking must often be less than is the case in single
modality programs.
Two main types of multiple risk factor reduction programs have
involved smoking cessation. The first is large-scale clinical trials for
the prevention of coronary heart disease. The Belgian and British
WHO studies reported by Kornitzer and Dramaix and colleagues
, (1980) and by Rose and colleagues (1980) were conducted solely in
industrial settings and were discussed in detail in the 1983 Report of
the Surgeon General (US DHHS 1983). These studies are well
designed and have collected multiple dependent variables, including
indices of overall health risk or morbidity and mortality statistics.
  The other main type of multiple risk factor reduction program
that has been developed is worksite wellness programs conducted by
large companies for their employees. Examples include the STAY-
WELL program of the Control Data Corporation (Naditch 1984), the
Live for Life program of Johnson and Johnson (Nathan 1984), and
programs offered by IBM, the Campbell Soup Company, and the
Ford Motor Company (Parkinson et al. 1982; Ware and Block 1982).
Unfortunately, the outcomes of almost all industry-sponsored pro-
grams reported to date are difficult to interpret owing to varying
methods of reporting results, difficulties in following subjects, and
lack of objective measures of smoking status. Reports of company
wellness programs with more than anecdotal data on smoking
modification results (e.g., Grove et al. 1979; Sorman 1979) are
summarized in Table 1.
Cessation rates in multiple risk factor reduction programs in
worksites have ranged from 7 to 33 percent at followup. Many of
these rates are lower than those typically reported in other worksite
smoking studies and are not consistently better than comparison
conditions in controlled studies (Kornitzer, De Backer et al. 1980;
Meyer and Henderson 1974). Interpretation of these data is proble-
matic because of the lack of direct comparisons with smoking-
cessation-only interventions, because subjects with multiple risk
factors may be more recalcitrant than other subjects, and because


TABLE 4.-Organizational characteristics potentially
     affecting outcome of worksite smoking
       programs

Sue of works1te


Current worksite
smoking policies

Degree of management
support for program

History of health
promotion efforts
in the worksite

Sex ratio of employees

17)



(8)



(91





(10)

Union/management
relations


Percent of smokers
in the worksite

Growth oriented vs.
consolidating climate
of organization

Rank and sociometnc
standing of primary
contact person

t-5,   Job stability/turnover

(11)

Socioeconomic level
of employees

the risk factor reduction programs reported in this section tend to be
ongoing programs rather than one-shot smoking clinics.

Organizational Characteristics and Other Factors

Conducting outcome research in worksite settings involves a
number of unique factors that may mediate or interact with program
success. The organizational characteristics that may mediate pro-
gram success are outlined in Table 4. Although this list is certainly
not exhaustive, investigators should consider these factors when
conducting worksite smoking programs. An example of the potential
effects of organizational characteristics is the variability in outcome
reported by Glasgow and Klesges and their colleagues (Glasgow et al.
1984, in press; Klesges et al. 1985). The basic treatment programs
utilized in these studies were almost identical and were implemented
by many of the same therapists. Yet, the 6-month abstinence rates in *
the different organizations ranged from 14 to 33 percent.

Few of these variables have been addressed in worksite smoking
studies. Bishop and Fisher (1984) have conducted similar multilevel
smoking cessation programs in a number of different organizations,
ranging in size from 200 to 6,000 employees. They reported substan-
tially lower participation rates in large companies, a finding that is
consistent with results of studies of worksite weight loss programs
(Brownell et al., in press). Also, the studies outlined in Tables 1
through 3 suggest that the highest cessation rates are obtained in
smaller worksites. Taken together, these trends suggest that differ-
ent interventions and different ways to assure participation need to
be developed for large corporations. The problem may be one of


implementation, not design. Company policy regarding vesting
responsibility in division leadership may be a critical variable.
In terms of the second variable in Table 4, worksite smoking
policies, it is important to emphasize that smoking cessation groups
are but one way to influence rates of worksite cigarette smoking
(Bennett and Levy 1980). Although there have certainly been more
reports on cessation programs than on other approaches to occupa-
tional smoking control, evaluations of alternative procedures are
beginning to appear. In particular, Dawley and colleagues (Dawley
and Baldwin 1983; Dawley and Burton, in press; Dawley et al. 1980)
and Jason and colleagues (Jason and Liotta 1982; Jason and Clay
1978; Jason and Savio 1978) have studied the effects of no-smoking
signs and requests not to smoke. These studies indicate that the
posting of nonsmoking signs and the establishment of nonsmoking
areas temporarily reduce smoking rates, but that active enforcement
of such policies is necessary to produce substantial or lasting
decrements in smoking behavior (Dawley et al. 1980; Jason and
Liotta 1982; Jason and Savio 1978). One caveat to be kept in mind in
evaluating the effects of worksite smoking restrictions is that
workers may "compensate" by smoking more during breaks and
after work (Meade and Wald 1977). Evaluations of the effectiveness
of smoking restrictions should therefore assess smoking rates during
both work and nonwork hours and include objective measures of
smoking exposure.
Dawley and colleagues subdivided smoking modification efforts
into three categories: smoking control (limiting or restricting smok-
ing to designated areas); smoking discouragement (educational
efforts to encourage people to stop smoking); and smoking cessation
(more formal treatment programs). They also suggested that "work-
site smoking cessation programs operate most effectively when
offered in conjunction with worksite smoking control and discourage-
ment efforts" (Dawley et al. 1984, p. 3291, a highly testable
hypothesis that has yet to be experimentally investigated.
The potential to use modifications of the work environment to aid
in smoking cessation, including restricting smoking, removing
cigarette machines, and altering work rules or situations that
promote smoking, make the worksite more than simply a location for
cessation interventions. The elimination of environmental supports
for smoking, alteration of the smoker's self-image, changing the
perception of the smoker among peers, and revising the social norms
about smoking in the worksite may all provide a powerful motiva-
tion for the smoker to quit and support the successful maintenance
of cessation. These changes in the workplace environment and
attitudes may be more important than the components of the
behavioral intervention used to get workers to quit, and experimen-
tal verification of the impact of these changes would provide a useful


guide for the structuring of future comprehensive worksite interven-
tions. Because it would probably be unlikely that researchers would
gain access to experimental manipulation of some of the more
controversial aspects of guidelines (hiring policies and penalities for
smoking), opportunities that may arise to study such changes in
noncontrolled research would be worth pursuing.

Few data have been collected on the other variables listed in Table
4. Research on worksite smoking programs should at least provide
descriptive information to determine how these variables affect
program success. The fit between organizational and program
characteristics has been neglected in past occupational smoking
control research. It is hoped that future research will be able to
identify the types of programs that are most effective in each
different worksite setting.

Implementation of Worksite Smoking Programs
This section focuses on two major classes of implementation issues:
recruitment procedures and characteristics of intervention pro-
grams.

Promotion and Recruitment

The initial contact with a worksite can prove critical to the success
of a project. It is generally recommended that the initial meeting be
with the chief executive of the organization (Klesges and Glasgow
1985). Although this officer typically does not coordinate the
program, support from top-level management appears to be impor-
tant in program recruitment and implementation (Grove et al. 1979).
Another method of enhancing participation and organizational
involvement is the formation of a steering committee (Bishop and
Fisher 1984; Stachnik and Stoffelmayr 1981) composed of key
representatives from both labor and management. Employees should
perceive that the program is voluntary and that they have input into
its implementation. Steering committees of this kind may be
particularly important in large worksites with unionized employees.
Management support appears to be quite important to the success of
the committee (Bishop and Fisher 1984).

Upon securing permission to offer a program, it is helpful to
conduct a brief worksite needs assessment (e.g., Heckler 1980;
Kanzler et al. 1976; Klesges and Glasgow 1985). The survey can be
used to determine (1) the number and characteristics of smokers in
the worksite, (2) the number of smokers potentially interested in
participating, and (3) preferences concerning the types of programs
that might be offered (e.g., self-help versus group meetings; absti-
nence versus reduced smoking) and the most convenient times for
meetings to be scheduled.

504


During the recruitment phase, information about the program
should come from a variety of sources, such as posters, memos, and
brochures. Advertising experts recommend providing multiple expo-
sures to a "product" (in this case, a smoking program) to promote
attitude change and to convince participants to take action regard-
ing the product (Sawyer 1981). Promotional materials should include
information about the cost of a program, stress that participation is
voluntary and individual results are confidential, and counter
possible misconceptions (e.g., "I have to quit at the first session"; "1'11
lose my job if I don't participate"). It is helpful if at least one memo
or announcement comes from top management. At this stage,
human resources or personnel directors can be extremely useful in
suggesting the best ways to promote the program in their particular
setting. Involving the local media may also increase the credibility of
the program as well as provide no-cost advertising for both the
program and the worksite.

Prior to the actual implementation of a smoking program, some
programs prepare worksites for health-behavior change (Andrews
1983; Bennett and Levy 1980; Ellis 1979; Grove et al. 1979; Heckler
1980). These preparatory procedures have ranged from prescreening
health exams (Ellis 1979) to the initiation of smoking restrictions
(Andrews 1983; Bennett and Levy 1980). Warnings of the impending
restrictions with indications of the "target restriction date" allow
workers to prepare for changes, such as by joining available
programs. Although empirically untested, these recruitment proce-
dures may help to convince employees to join smoking programs.

Program Characteristics

The advantages of occupational smoking control programs dis-
cussed earlier do not automatically or necessarily occur. Programs
must be made convenient. Higher participation rates are usually
found in programs that offer time off work (e.g., Klesges et al. 1985;
Scott et al. 1983). Time off work for participation can be a double-
edged sword, however. It may increase the number of smokers who
participate primarily to be excused from their work stations, and it
may also create demands among nonsmoking employees for time off
work to attend other health-related classes. Generally, the benefits
of conducting programs during work hours outweigh the potential
costs, and if management is not willing to grant time off work, it may
at least be possible to negotiate time sharing between employee and
employer (e.g., l/2 hour of work time, l/2 hour during lunch hour or
after work). Investigators should also be aware of the difficulties
involved in scheduling group meetings in worksites where employees
work rotating shifts, such as hospitals.

In addition to being convenient, programs should be attractive to
participants. For example, allowing smokers to choose the type of


program (such as nicotine fading versus aversive smoking), the
modality of intervention (self-help manual versus group meetings),
the treatment goals (abstinence versus reduced smoking), and the
type of group leader (health professional versus peer facilitator) may
be helpful in attracting and retaining participants. Different compo-
nents of a comprehensive program, such as physician advice, no-
smoking policies, stop-smoking contests, or group meetings, may
mutually reinforce each other. While these suggestions await
empirical verification, providing smokers with a number of choices
should serve to increase participation rates.

Finally, feedback on progress may serve to increase the magnitude
of behavior change. For example, participants can be provided with
frequent feedback on carbon monoxide levels as they reduce their
smoking (e.g., Rand et al. 1984; Scott et al. 1983). Charts displaying
the weekly progress of different groups can be posted in employee
lunchrooms or lounges. Periodic progress reports to department
supervisors might also be helpful. To avoid stigmatizing particular
individuals, public feedback should be provided on progress by the
group rather than by individuals.

There are a number of problems in conducting worksite smoking
modification groups that should be avoided, or at least anticipated.
Group composition is one such sensitive issue. For example, mixing
high-ranking executives with production workers can almost elimi-
nate group discussion. However, this may depend on the company's
tradition of interaction among workers of different levels, on the
skills of the group leaders, and so on. Scheduling difficulties can
arise in settings were employees rotate shifts or travel frequently, or
where meeting rooms are scarce or distant from work stations. One
also needs to be sensitive to negativism or complaining, which can
become contagious; the group's focus must be kept positive. A
positive perspective is particularly important when conducting
competition or incentive interventions in which certain individuals
or groups must "lose." A more optimistic perspective that can be
used to encourage participants is that eveyone can win something by
changing their smoking, so there are no losers.

Finally, Marlatt and Gordon's (1985) concept of stopping smoking
as a `journey" can be quite helpful. On their journey, people may
experience temporary setbacks or detours (relapses), but this should
not prevent them from reaching their destination (abstinence). The
presence of an ongoing program that makes it easy to try different
options or to recycle a procedure can serve to reinforce this concept
and to improve long-term results.

506


Recommendations for Future Research

A number of suggestions for the implementation of worksite
smoking modification programs have been outlined. Given the
limited nature of the data available, few of these guidelines are
experimentally derived. Research is needed to empirically support or
refute these recommendations. This section discusses needs for
future research in the field of worksite smoking modification.
Recommendations are made on both research methodology and
substantive issues for further investigation.

Methodological Issues

Greater use should be made of creative experimental and quasi-
ex;erimental designs, as discussed by Cook and Campbell (1979). In
particular, it should be possible to sequentially introduce an
intervention or intervention components in different worksites using
time-series or multiple baseline designs or to investigate the
incremental effects of adding different strategies, such as physician
messages, incentives, and social support procedures, to a basic
treatment program.

Greater consistency across studies in the criteria used to define
smoking status would substantially aid in the interpretation of
results. Berglund and colleagues (1974) and Shipley and colleagues
(1982) have provided guidelines for reporting outcomes of smoking
cessation studies that should be more widely adopted. For calculat-
ing abstinence rates, a standard common denominator representing
the number of subjects entering a program should be used across all
points in time and any dropouts should be considered conservatively
as smokers. In studies in which it is deemed important to evaluate
reductions in smoking behavior (e.g., percent reduction in number of
cigarettes smoked or nicotine content) in addition to the proportion
of abstinent subjects, analyses should be conducted on nonabstinent
subjects only. This procedure avoids confounding the results due to
cessation with results due to changes in smoking rate or topography.
Worksite programs should report cessation success as the fraction of
the smokers in the workforce as well as the fraction who agreed to
participate in the program.

Objective verification of smoking status is particularly important
in programs involving financial incentives, competition between
rival organizations, social pressure and support to quit, or controlled
smoking instead of abstinence. Each of the biochemical measures of
smoking exposure has its own advantages and limitations (Benowitz
1983; Pechacek et al. 1984).

Another methodological problem faced by occupational smoking
modification programs concerns the consistency between units of
assignment and units of analysis (Biglan and Ary 1985). Typically,

507


whole companies are assigned to treatment or control conditions, but
results are analyzed using individual subjects as the unit. This
creates interpretive problems because of the potential dependency
among results of smokers within a given worksite (or treatment
group). Although there are no easy answers to this dilemma,
investigators should consider (1) conducting treatment in a suffi-
ciently large number of companies that the worksite can be used as
the unit of analysis; (2) utilizing hierarchical or nesting designs to
separate the effects of worksite from intervention condition (Myers
1972); or (3) when feasible, assigning individuals within worksites to
different treatment conditions.

Future research should pay greater attention to possible interac-
tions between worksite and treatment variables. For example,
interorganizational competition procedures may be highly effective
in worksites where employees feel highly committed to the company,
but ineffective in settings low in organizational commitment.
Organizational and social network factors may also interact with,
mediate, or enhance program impact.

More data also need to be collected on the "generalization" effects
of worksite smoking modification programs. Employers may be more
interested in program effects on employee morale, job satisfaction,
and absenteeism than on health outcomes such as smoking status.
Similarly, more information should be reported on the costs and
health benefits of occupational smoking reduction programs. Prog-
ress in this area would be facilitated by a systematic review of and
recommendation for procedures to be employed in determining the
cost effectiveness and cost benefit of worksite smoking programs.

Substantive Areas

Three primary objectives need to be achieved by future research in
worksite smoking modification. First, more research should be
conducted on ways to increase participation and followthrough rates
in worksite programs. For example, using various incentive proce-
dures (e.g., paycheck bonuses versus team competition versus
lotteries) might be expected to enhance participation. Further
investigations are needed on the impact on participation rates of
interventions such as quitting contests, self-help materials, *or
hotlines that do not require a large investment of time and effort by
participants. The majority of worksite smoking studies to date have
focused on group cessation programs, but surveys consistently
indicate that most smokers are not interested in participating in
such programs (US DHHS 1982; Schneider et al. 1984). For the
reasons discussed earlier, renewed emphasis on physician stop-
smoking messages is also indicated.

The second main content issue is how to enhance the outcome
rates of worksite smoking modification programs. One approach to

508


this problem is to evaluate the utility of comprehensive intervention
programs and environmental changes (no-smoking policies, cigarette
machine removal, prominent no-smoking posters) with cessation
groups. Other approaches are assessing the impact of multiple risk
factor programs versus single modality programs and of ongoing,
continuous intervention programs in place for a year or more versus
one-time-only program offerings.

The final category of recommendations for future research in-
volves investigating subject and therapist factors that affect treat-
ment outcome (Klesges and Glasgow 1985; Orleans and Shipley
1982). Additional study is needed of the enrollment patterns and
success rates of men versus women, white-collar workers versus blue-
collar workers, and heavy smokers versus light smokers. Also, little
is known about the characteristics of successful program leaders
(e.g., ex-smoker coworkers versus professional group leaders).

Summary and Conclusions

1. Smoking modification and maintenance of nonsmoking status
among initial quitters has the promise of being more successful
in worksite programs than in clinic-based programs. Higher
cessation rates in worksite programs are achieved with more
intensive programs.

2. Incentives for nonsmoking appear to be associated with higher
participation and better success rates. Further research is
needed to specify the optimal types of incentive procedures.
3. Success of a worksite smoking program depends upon three
primary factors: the characteristics of the intervention pro-
gram, the characteristics of the organization in which the
program is offered, and the interaction between these factors.
4. Research is needed on recruitment strategies and participation
rates in worksite smoking programs and on the impact of
interventions on the entire workforce of a company.
5. More investigations are needed on worksite characteristics
associated with the success of occupational programs and on
comprehensive programs including components such as quit-
smoking contests, no-smoking policies, physician messages, and
self-help materials in addition to smoking cessation clinics.
6. The implementation of broadly based health promotion efforts
in the workplace should be encouraged, with smoking interven-
tions representing a major component of the larger effort to
improve health through a worksite focus.

509


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