The European Journal of Public Health Advance Access originally published online on May 27, 2005
The European Journal of Public Health 2005 15(3):270-275; doi:10.1093/eurpub/cki057
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Smoking |
Workplace smoking policies in Taiwan and their association with employees' smoking behaviours
Susan C. Hu1, Sunny Y. Huang2, Derchiang Li3, Chi P. Wen4 and Shan P. Tsai5
1 Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
2 Department of Health Education, National Taiwan Normal University, Taiwan
3 Department of Industrial Management, National Cheng Kung University, Tainan, Taiwan
4 Division of Health Policy Research, National Health Research Institutes, Taiwan
5 Corporate Health Department, Shell People Services—Americas, Houstohon USA
Correspondence: Susan C. Hu, PhD, Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan, tel. +886 6 2082523, fax +886 6 2359033, Email: shuhu{at}mail.ncku.edu.tw
Received May 14, 2004, accepted September 16, 2004
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Abstract |
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Background: The implementation of worksite smoking policies has shown significant effects on reducing employees' smoking consumption and protecting non-smoking workers. However, there are no data about workplace smoking policies in Taiwan. The purpose of this study was to document the status of worksite smoking policies in Taiwan and its potential impact on employees' smoking behaviours. Methods: A two-stage investigation was conducted. The first stage was to examine the current status of workplace smoking policies and the second was to evaluate the relationship between workplace smoking policies and employees' smoking behaviours. After two follow-ups in each stage, 264 companies and 1141 employees returned their questionnaires. Results: Workplace smoking policies were associated with types of businesses and size of workplaces. Only approximately half of manufacturing and service companies have implemented a prohibitive smoking policy. Large facilities (>750 employees) were more likely to implement a prohibitive policy (57%). Employees in workplaces with a prohibitive policy had lower prevalence of smoking and cigarette consumption, and less exposure to passive smoking. Although most smokers agreed with banning smoking in their work environment, no difference in interest in participating in cessation programs was found. Conclusions: Significant associations were found between workplace smoking policies and employees' smoking behaviours. Results of the study provide basic information for designing more refined smoking policies in the workplace in Taiwan.
Keywords: smoking behaviours, smoking policy, Taiwan, workplace
Cigarette smoking is well documented as a major cause of deaths and illnesses for several diseases1 and results in enormous medical costs and economic loss.2,3 Since the US Environmental Protection Agency categorized environmental tobacco smoke a group A human carcinogen,4 workplace smoking has become an important issue, because of not only the above costs, but also the exposure to secondhand smoke for non-smoking workers.5,6
Studies have shown that restricting smoking in the workplace can promote the sensitivity of employees to smoking hazards, change their attitudes toward smoking and increase the probability of quitting.7–9 It can also reduce the quantity of smoking or reduce the frequency of smoking during daytime working hours.10–12 Even though the purpose of implementing workplace smoking policy is because of workplace safety, it is also the most effective way to protect the health of employees who do not smoke.13,14 Thus, the workplace is an ideal place to implement smoking polices because it can protect a large number of non-smokers from exposure to environmental tobacco smoke; also, because there is management support it is easy to facilitate cessation programs in the workplace.15,16
As one of the four Asia tigers, the government of Taiwan passed a Tobacco Hazards Control Act in 1997. The act prohibits smoking in most public places such as libraries, auditoria, preschools, hospitals, banks, post offices, aircrafts and on mass transit.17 However, the Act does not apply to private workplaces, which compose 95% of workplaces in Taiwan. Although a small number of enterprises have initiated various smoking policies in the workplace, the impact of such policies has received little attention. The purposes of the study were to investigate the extent of workplace smoking policies in Taiwan and to compare the impact of various smoking policies on employees' smoking behaviours.
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Methods |
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A two-stage survey was designed to address the above questions. The first stage was to examine the current status of workplace smoking policies and the second was to evaluate the relationship between workplace smoking policies and employees' smoking behaviours.
First stage investigation
First, we selected the top 500 manufacturing industries, the top 250 service companies and the top 50 banking institutions, according to the list published by Commonwealth in Taiwan (1995), as the target population of the study. Then we mailed a questionnaire to the Presidents of the selected companies and asked them to forward the questionnaire to the responsible manager.
The questionnaire for the first stage included: (i) background information of the workplace, e.g. type of business, number of employees; and (ii) types of smoking policy in the workplace and reasons for implementing the policy. Telephone interviews were conducted with 30 manufacturing companies outside the target population, in the Tainan area, for the purpose of pre-testing the first stage survey.
After two follow-ups, 264 companies, including 149 manufacturing industries, 88 service companies and 27 banking institutions, returned questionnaires. The average response rate was 62% (excluding companies closed and missing address).
Three types of workplace smoking policies were identified: prohibitive, restrictive and unrestricted. Prohibitive policy means that smoking is prohibited everywhere in the workplace except for the designated smoking room. Restrictive means that smoking is prohibited only in some safety sensitive places, such as production areas or storage rooms. Unrestricted policy means smoking is not specifically prohibited in the workplace.
Second stage investigation
After finishing the data collection of the first stage, we randomly selected (by simple random sampling method) and contacted 12 manufacturing companies that had different types of smoking policies (four companies with each policy). Among the companies contacted, 11 agreed to participate in the second stage investigation. These included four companies with a prohibitive policy, four companies with a restrictive policy and three companies with an unrestricted policy. The reason for choosing only one type of industry in the second stage is because of the relative comparability of the workplaces facilities.
In the 11 companies, we randomly selected (also by simple random sampling method) 50% of employees among companies with <1000 employees. For companies with >1000 employees, only 500 were randomly selected. Finally, a total of 2150 employees was recruited in the second stage, including 950 employees from prohibitive policy workplaces, 600 from restrictive policy and 600 from unrestricted policy.
The questionnaire for the second stage included: (i) employee demographic information, e.g. gender, age, level of education and income; (ii) smoking habits, e.g. smoking status, quantity of smoking, time and situations of smoking, previous quit attempt and interest in participating in workplace smoking cessation programs; and (iii) exposure to passive smoking and attitude toward restricted smoking policies in their work area. To pre-test the second stage questionnaire, we selected two companies in Tainan area as mentioned above, and recruited 60 employees from each company to investigate their smoking behaviours. The results of the pre-test were used to correct the final draft of the questionnaires used for the study.
The questionnaire was then self-administrated to each selected employee. In order to increase the response rate, a small gift was given along with the questionnaire. Through the assistance of these companies, we successfully collected 1141 valid questionnaire. These included 605 employees from the companies with prohibitive policy, 274 from the companies with restrictive policy and 262 from the companies with no restrictive policy. The average response rate in this stage was 71% (excluding blank questionnaires).
Data analysis
All questionnaire data were coded and entered into a personal computer. Statistical analyses including descriptive statistics, t-tests and 
2-tests were conducted using SAS software. The study period was from 1 June 1995 to 31 July 1996.
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Results |
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In the first stage survey, no difference was found between companies returned and unreturned mails in the number of employees and ranking of the companies. Among the 264 companies returning their questionnaire, most of them were medium- to large-sized with >250 employees (91%, 78% and 64% for the manufacturing industries, the service companies and the banking institutions, respectively). More than 95% of the manufacturing and service companies were private, whereas 35% of the banking institutions were governmental. Most questionnaires (79%) were filled out by managers of Department of Management, and else by directors of Department of Occupational Safety and Health.
Table 1 presents the status of smoking policies in the workplace. Only approximately half of the manufacturing industries (49.7%) and the service companies (51.1%) have implemented prohibitive smoking policy. Less than 30% of the banking institutions implemented such policies, and 48% of banks had no restrictive smoking policy at all. Larger facilities had a higher percentage of prohibitive smoking policy, especially among those with >750 employees (57.4%). Smaller facilities with <100 employees were least likely to have implemented a restrictive smoking policy. In fact, 38.7% of these facilities did not have any restrictive policy.
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Table 2 describes the reasons for implementing smoking policy in the workplace. The most frequently cited reason across these three types of enterprises was ‘to maintain good air quality in the work environment’ (71–90%). Workplace safety (66%) was a significant reason for the manufacturing industries. Other reasons included promoting employees' health and protecting non-smoking co-workers. Supporting government's restrictive smoking policies was ranked very low as one of the reasons (14–21%) and was mostly cited by the banks (43%).
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In the second stage, the relationship between types of smoking policies and the employees' smoking behaviours in 11 manufacturing industries was further investigated. Comparing the characteristics of employees in these workplaces, only gender was significantly different. The workplaces with a prohibitive smoking policy had more female employees (39.2%) than those with a restrictive (28.1%) or unrestricted policy (31.0%). No significance was found in age distribution and level of education.
Table 3 presents the prevalence of smoking by types of policies. Significant differences were found in male employees. The smoking prevalence of male employees was significantly lower (29.5%) in workplaces with prohibitive smoking policy than in those with either restrictive (42.7%) or unrestricted policy (44.5%). No differences were found between types of policies and prevalence of smoking in women employees because of very low smoking rates.
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Nevertheless, less than one-third (28.8%) of employees from workplaces with prohibitive policy reported having exposure to secondhand smoke in the workplace, as compared with more than half of employees from workplaces with restrictive (51%) or unrestricted policies (56%). Most smokers had positive attitudes toward a smoking ban in their workplaces, especially in those with a prohibitive policy (85.4%). Certainly, nearly all non-smokers (99%) in workplaces with restrictive or unrestricted policies supported a ban on smoking in their work environment.
Table 4 shows the relationship between types of policies and employees’ smoking behaviours. A significant difference was found in the amount of cigarettes smoked by type of policies (P<0.001). A majority (53%) of smokers in workplaces with prohibitive policy smoked <10 cigarettes per day, whereas more than half (54%) of smokers in workplaces with restrictive and more than two-thirds (73%) of those with unrestricted policy smoked 10–29 cigarettes each day.
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Except for smoking in the morning, no differences were found between types of policies and situations of smoking, such as after meals, when drinking alcohol, when engaging in social activities or during stressful events. Smoking in the morning was the most significant behaviour between types of policies. More than twice the number of smokers in workplaces with a restrictive or unrestricted policy smoked cigarettes within 10 min after getting up in the morning compared with those who work in a prohibitive smoking policy environment (26–30% versus 12%).
During daytime work hours, more than two-thirds of the smokers (69%) in workplaces with a prohibitive policy smoked in the designated smoking room. Only about half (52%) of smokers did so in the workplaces with a restrictive or unrestricted policy. No differences were found in attempts to quit in the past year or interest in smoking cessation programs between types of policies. Less than one-third of smokers in this study have ever tried to quit smoking in the past year. However, >60% of them were interested in participating in smoking cessation programs.
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Discussion |
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Cigarette smoking is one of the most serious health problems in Taiwan. The prevalence of smoking is 47–50% in males and 3–5% in females aged
18 years.18
The workplace is particularly important for Taiwan's anti-smoking campaigns because of the 50% of adult males who are smokers, >75% smoke at work.19 This is the first study to investigate smoking policies in the workplace in Taiwan. Results show that workplace smoking policies were associated with type of businesses and size of workplaces. The manufacturing industry, presumably because of safety necessity, had the highest percentage of restrictive smoking policy. However, only half of the manufacturing and service industries in Taiwan have implemented prohibitive policy. There are ample opportunities for improvement, because manufacturing and service industries are the major workforce in Taiwan.
This study confirmed that large facilities were more likely to implement restricted smoking policy,20 especially for those with 750 or more employees. More than half of such workplaces have implemented a prohibitive policy. This probably is because large facilities have more strict rules and regulations. The estimation of prevalence of workplace smoking policies in Taiwan is, however, low, because most of the companies in this survey were medium- to large-sized with >100 employees, accounting for only 5% of all companies in Taiwan. In other words, 95% of the workplaces in Taiwan were small-sized and were the least likely to have implemented restricted smoking policies.
In addition, workplace smoking restrictions have been found to have a great impact on minimizing smoking prevalence, as well as reducing the number of cigarettes smoked. The effects of workplace smoking policies varied; a total ban has the greatest impact on workplace smoking rates.14,21 Unfortunately, no smoke-free policy was found in any of the workplaces we investigated in Taiwan.
In the second stage of our investigation, consistent with other studies,10,11 our survey found significantly lower smoking prevalence and less exposure to secondhand smoke for employees in workplaces with a prohibitive policy. However, there was no significant difference in smoking prevalence and smoking behaviours between restrictive and unrestricted policies. This is because workplaces with a restrictive policy have usually set this because of work safety considerations. When a ban is set by necessity and not by choice, a smoking restriction is effectively the same as having no restriction, and has no effects on employees' smoking behaviours and exposure to passive smoking.
As to attitude toward smoking ban in work areas, it is interesting to find that most smokers support a smoking ban at their workplace, especially in workplaces with prohibitive and unrestricted policies. However, less than half of smoking employees in workplaces with a restrictive policy supported such a ban. This may reflect some implication of implementing smoking policy in workplaces. When a workplace has no smoking policy, most employees in the workplace agreed to have one. Once smoking policy has to be implemented, a unanimous smoking policy, such as a prohibitive policy, would earn more support. Partially restricting smoking in some work areas makes employees feel inconvenienced and unfairly treated over smoking at work, and in turn there is lower support for such a policy.
In addition, this study found most smokers in workplaces with a restrictive or unrestricted policy not only smoked more, but also were more dependent on nicotine. Smoking amount and smoking in the morning are two of the significant indices for measuring nicotine dependence.22 This study found employees in workplaces with a prohibitive policy smoke less and smoke mostly 60 min after waking up in the morning, whereas employees in restrictive or unrestricted policies smoke at least twice the amount of cigarettes and mostly in the early morning. A higher degree of nicotine dependence would make smokers more reluctant to quit.23 Most importantly, no significant increase in compensatory smoking off the job was found in prohibitive policies, as the amount of smoking was rather low.
This study did not show that restrictive smoking policy would influence employees' decision to quit smoking.8,9 This might be because the number of quitting attempts was only recorded for the past year, and the effects on quitting attempts may not be so dramatic when restricted smoking policies have been implemented for years. According to Mendez and Warner's analysis,24 reduce smoking prevalence could not solely be achieved through a decrease in smoking initiation on youth; it could be achieved immediately if the cessation rate increased by three times.
Forbidding smoking may not be the best method by which to reduce smoking prevalence. It can be seen as a kind of besiegement by smokers. The study found >60% of all smokers were interested in smoking cessation programs. Unfortunately, only two out of 264 enterprises reported that they have provided such programs for their employees;25 by comparison, half of enterprises have provided smoking cessation programs in their plants in the USA.26 Taiwan's enterprises should make greater efforts to implement smoking cessation programs.
The limitation of the study is inherent in any cross-sectional survey: it cannot explain the causal relationship between workplace smoke policies and employees' smoking behaviours. There is no answer for whether the lower percentage of smoking behaviours in the prohibitive group existed before or after the policy. We have, in advance, examined the socioeconomic status of smokers by types of policies in order to estimate the potential impact of these confounders. However, no significant differences were found in age distribution, educational and income levels. This might increase the confidence of inferring long-term effects of workplace smoking policies on employees' smoking behaviours in Taiwan.
Although finished before the Tobacco Hazards Control Act, this study has been the only one to present the status of workplace smoking policies across three types of industries in Taiwan and could serve as a starting point for comparing effects of implementing the Act. As the Act requires banks to ban smoking, we expect restricted smoking policies would increase rapidly among banks but not in manufacturing and service industries, because 95% of them are privately owned.
To understand more on workplace smoking policies, this study suggests that future research should collecting more information in workplaces with a restrictive smoking policy, such as whether there is a written smoking policy available for inspection and audit, who in the company is responsible for enforcement, how violators will be treated and whether any cessation assistance is provided by the employer, etc. For workplaces without policies, questions about reasons for not implementing a policy, whether they would consider them and barriers to having a smoking policy are suggested
Key points
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Acknowledgments |
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We wish to thank the National Science Council of Taiwan for funding this project (NSC-84-2421-H003-010). We also wish to give our sincere thanks to those enterprises that have been helpful in participating in this project
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