Description of Problem

Project Description

Problem

The health consequences of cigarette smoking are well known to the medical and public health communities and almost universally acknowledged by the public, although the latter tend to underestimate the toll considerably.1 Efforts to prevent the onset of smoking and to encourage its cessation have achieved notable success,2 but the burden of tobacco remains extraordinary: approximately 50 million Americans continue to smoke and smoking annually accounts for almost a fifth of all deaths in the United States.3

Smoking, and its health toll, are increasingly concentrated in the lower socioeconomic strata of society, among minorities, the blue collar population, and those with the least education. Illustrative of the shift in smoking patterns over the past quarter century is the more than halving of smoking prevalence among college graduates, compared with the complete absence of change among individuals lacking a high school diploma.1 As such, future efforts to reduce the toll of smoking will have to concentrate on these more difficult to reach groups.

The population of blue collar workers represents a particularly attractive target for smoking control, primarily because such workers exhibit high rates of smoking and large numbers are concentrated in work settings amenable tointerventions. It is widely believed that the workplace can be an effective setting for promoting positive health behaviors. Employees represent a "captive audience" in an environment in which group pressure, and support, can facilitate behavior change. "Environmental" conditions of work can be structured to reinforce behavior change (e.g., restricting smoking to limited areas during breaks).4

For worksite smoking cessation programs to work, they must exist in the first place, be well designed and implemented, and receive support and encouragement from management. The latter is predicated on management's belief in their effectiveness and desirability. According to both survey findings and anecdotal evidence, increasing numbers of employers appear to be defining "desirability" in terms of the financial implications of investments in smoking cessation programs and other health promotion activities.5,6

From a social point of view, insisting on positive financial returns from health promotion is short-sighted; cost-effectiveness is the appropriate social criterion.4,7 But to date, we possess little good evidence on either the financial profitability or cost-effectiveness of workplace investments in smoking cessation, as well as the other categories of health promotion.8 Furthermore, we have virtually no insight into the social implications of private sector interventions. Developing the requisite information to inform decision makers -- corporate and social -- is an essential step toward determining how andwhere smoking cessation programs should be implemented, and under what fiscal arrangements.

Suppose, for example, that smoking cessation programs do not prove to save employers money; yet the programs produce better public health at a very reasonable price from a social perspective. Under such circumstances, it might behoove public policy makers, or private decision makers such as health insurance firms, to enable businesses to mount worksite programs in a manner that serves the social good and does not adversely affect the private bottom line.

To date, we lack the basic information needed to ascertain who benefits, how, and by how much.

Objective of Research

The objective of the proposed research is to evaluate the health, economic, and workforce demographic implications of smoking cessation programs administered in the worksite setting. Implications are to be considered from two perspectives: (1) the perspective of the business firm (Does worksite smoking cessation "pay"? Does it produce positive net economic returns to the firm, and does it promote employee health in a cost-effective manner?) and (2) a broader social perspective (What is the contribution of a firm's smoking cessation program to the health of the community in which the firm resides? Regardless of the financial returns to the business, does the program represent a cost-effective means of improving public health? If widelyimplemented, would successful worksite smoking cessation significantly influence the demographics of the workforce anticipated during the early years of the next century?)

To date, research on the effects of worksite smoking cessation programs has focused exclusively on the first perspective, that of the firm; the social implications of these interventions have been completely ignored. Furthermore, the dominant research strategy, evaluation of "natural" and quasi-experiments, has innate deficiencies (discussed below) that preclude useful evaluation of the impacts of smoking cessation programs beyond a few years; yet realization of the full health and economic effects of cessation requires the passage of multiple years. For this and other reasons discussed below, the proposed computer simulation holds the promise of developing unique insights into the consequences of this rapidly growing worksite health promotion activity, both for the firm that implements it and for the broader society that derives its full benefits.

A longer term objective of this research is to develop a model that can be adapted to other employment-based interventions, specifically including other health promotion activities and worksite treatment programs. As with the case of smoking cessation, the intent would be to evaluate the health, economic, and demographic implications from the divergent perspectives of the firm and the broader community in which it resides. Other forms of substance abuse would be of particularinterest, both innately and for the contrasts that might emerge when compared with the case of smoking cessation. Alcohol abuse, for example, kills many fewer people than does smoking; yet the immediate costs of abuse may be far greater, including adverse effects on workers' productivity and on that of their co-workers. Thus, it is not inconceivable that analysis of alcohol abuse programs, such as Employee Assistance Programs, would find greater economic rationale for firm involvement than would smoking cessation, but less of a differential between the firm's costs and benefits and those of the broader community.