Workplace Tobacco Management Project Research … · Workplace Tobacco Management Project Research Findings (Evaluation) Report For submission to the Health Promotion Unit, ACT Government

Workplace Tobacco Management Project

Research Findings

(Evaluation) Report

For submission to the Health Promotion Unit, ACT Government Health Directorate as part of the contractual reporting requirements

10 December 2011

www.atoda.org.au

Context of this report within the entire Workplace Tobacco Management Project The Workplace Tobacco Management Project was funded in part by the Health Promotions Unit, ACT Government Health Directorate and by the AOD Policy Unit, ACT Government Health Directorate. The aspect of the project funded by the Health Promotions Unit has ended (10 December 2011), however the aspect of the project funded by the AOD Policy Unit will continue into 2012. This research evaluation report is provided to the Health Promotions Unit as part of the contractual requirements of the project. The additional funding through the AOD Policy Unit allows time for another, larger publicly available report to be produced and a broader evaluation process to be conducted with stakeholders. These research evaluation findings will be incorporated into the broader project and evaluation report, which will be completed in early 2012. It is therefore suggested that this report be regarded as indicative of the overall project processes, successes/challenges and findings, with further details to be provided within the secondary report. This report was prepared by Ray Lovett, external research evaluator to the Project, with input from the Project Team including Kathryn Sequoia, Amanda Bode and Carrie Fowlie. For further information please contact: Carrie Fowlie Executive Officer Alcohol Tobacco and Other Drug Association ACT (ATODA)

Workplace Tobacco Management Project Research Findings (Evaluation) Report (December 2011) 2


1. Executive Summary This report presents the research findings (evaluation) of the Workplace Tobacco Management Project (WTMP). The WPTMP aimed to:

• Support the development and implementation of Workplace Tobacco Management Policies (focused on staff) in nine sites (three from the alcohol and drug sector, three from the mental health sector and three youth organisations)

• Increase awareness of workplace tobacco management policies amongst staff • Reduce harms associated with smoking behaviours for the staff in the pilot sites

To achieve these aims the WPTMP utilised a structured program approach that consisted of a number of key elements including: Governance The governance elements were:

• Memorandums of understanding (MOUs) between the three peak organisations involved (ATODA, Mental Health Community Coalition ACT and the Youth Coalition of the ACT), to ensure sector leadership was at the forefront in delivering the project.

• MOUs between ATODA and each of the participating sites to describe the two-way responsibilities of the project.

• The WPTMP Advisory Committee aimed to shared experiences between sites and act as a way to distribute information.

Project management Project management elements were:

• Employment of a project officer to assist sites with the development and implementation of their Tobacco Management Policy through the development and updating of the site workplan.

• Development of project template documents (policy, work-plans and site resources) • Site meetings which occurred regularly between the project officer and staff and

management at each site. • An email distribution list which was developed and heavily utilised during the project to

inform project updates and to communicate data collection periods. Monitoring and evaluation

• Baseline and three follow up surveys were conducted among staff and at the

organisational level. • Changes in key variables were monitored over the life of the project, with this

information feeding into the WPTMP steering group. • A number of abstracts and presentations were prepared and delivered discussing

project outcomes and processes. This evaluation comprised a baseline electronic survey of staff and the organisations in which staff were employed. In addition to the baseline survey three follow-up surveys were conducted with staff and organisations from the nine sites. All staff


employed in the nine sites were eligible to participate if they were aged 18 years and over. The baseline surveys were conducted mid September 2010 to early October 2010. The follow-up surveys were conducted between March and April 2011 (Follow-up 1), August 2011 (Follow-up 2) and November 2011 (Final). The results from the follow-up surveys were then compared to baseline and between follow-up survey periods. The surveys measured:

• Tobacco policy elements currently in place • Prevalence of smoking amongst staff • Levels of nicotine dependence amongst smokers • Intention of staff to quit or reduce • Previous quit attempts (smokers and ex-smokers) including stories about the Quit

experience (QUAL) • Staff knowledge of workplace tobacco policy • Staff observations concerning smoking culture (or no culture of smoking) at work • Circumstances impacting on decisions to quit smoking for smokers and ex-smokers • Barriers and enablers to policy development and implementation in the workplace

(QUAL) • Attitudes to tobacco in specified workplace settings • Organisation approach to policy development • Staff involvement in policy development processes

Policy development and implementation Despite numerous barriers to development and implementation of tobacco management policies in workplaces: All sites implemented tobacco management policies This achievement was as a result of the information provided by baseline and follow-up surveys which monitored the policy development and implementation process. The employment of the projects-project officer usually worked with site champions and leaders who were able to work together on the work-plan actions. The work-plan was valuable in ensuring areas identified for action were acted on. Most sites were able to involve stakeholders in the policy development process Most sites had included staff tobacco management as a standing agenda item in their regular staff meetings and it appears debate occurred around elements of the policy such as designated smoking areas and whether smoke breaks were paid or unpaid. Using a less threatening framing of the policy (Workplace tobacco management vs Smoke-free) also contributed to involvement. Levels of support for the policy implementation across all sites was good While initial support for the policy was low, by the final survey over half of all staff were highly supportive of the policy implementation, 80 percent of boards were supportive and 100 percent of all managers were supportive. While clients were not directly involved in completing surveys, staff were asked to indicate how supportive they thought clients would be. From baseline, staff thought that no clients would be


supportive. In the final survey staff indicated that almost 40 percent of clients were now supportive of the policy. Framing policy development and implementation in a positive and empowering way achieves results, a focus on harm reduction makes tobacco policy congruent with sector philosophies When staff were asked to describe the way policy development and implementation was occurring at their site, overwhelmingly the most described approach was ʻempowermentʼ and ʻpositiveʼ. At the commencement of the project efforts were made to inform staff that the approach used was not about banning or making staff quit smoking, it was about helping all staff reduce exposure to tobacco smoke (health framing) and to support staff who wanted to reduce and or quit. When tobacco policy was framed as consistent with the service delivery philosophy of the ATOD, mental health and youth sectors, people were more accepting. Attitudes and behaviours Changes to tobacco assessment and treatment, particularly for clients was observed late in the project Across two particular variables staff reported changes in their thinking. They related to client tobacco use. A notable reduction in the number of staff thinking clients did not want to reduce or quit smoking was observed from 70 percent to 45 percent, although this is still higher than other studies have reported. In the baseline survey about 30 percent of staff believed that if clients were not able to smoke this would lead to impaired treatment outcomes. This reduced to fewer than 18 percent in the final survey. In the final months of the project a staff training program was conducted which may be the factor contributing to the increased awareness of clients wanting to quit by staff. Smoking rates

No statistically significant reductions in smoking rates were observed If the rates of current smoking were declining related to the project initiatives alone we should see no change in the category of never smoked. This tells us that current smokers were leaving the workforce or not participating in surveys and the number of people who have never smoked is increasing in the pilot sites. The question then arises: Is it because sites are undertaking this work which is forcing current smokers from the workplace?

The project facilitated a doubling in the number of quit attempts among smokers Of the smokers participating in the pilot project, half reported a doubling of the quit attempts during the project period. This is most likely due to the NRT provided as part of the project.

Nearly all smokers want to quit


Similar to other studies, smokers participating in the Project overwhelmingly want to quit (over 90% at each survey period) and most are organising how they are going to quit (60-70 percent). When compared to baseline, most smokers in the pilot sites are now categorized as having a low to moderate nicotine dependence.

There has been a small increase in staff confidence to quit and a small decrease in staff self assessed levels of nicotine addiction At the commencement of the project 55 percent of staff were considered to have a moderate to high nicotine dependence. At the conclusion of the project the proportion of staff with a moderate to high nicotine dependence has declined to 38 percent. Debriefing, meal breaks and building workplace relationships are facilitators of smoking in the project sites.

Almost all staff reported that smoking was used to debrief after a stressful work situation, meeting or client interaction. Smoking was also reported as a standard part of breaks and meals. Relationships between staff and clients were also reported as being enhanced through smoking. Strengths and weakness of the chosen evaluation design There are a number of factors that have contributed to the success of this evaluation and a number that have had a negative impact. Both are discussed below. Staff turnover Evaluation limitations: One of the limitations of the evaluation was the ability to draw too many inferences from the repeated measured design. This was in part due to the high turnover of staff across a number of participating sites. Upon inspection of the four data periods it was identified that only 13 participants had completed the baseline and all follow-up surveys. Fifteen had complete baseline and follow-up 2. Follow-up 2 and final survey saw a much higher number of staff completing surveys (41). Staff participation in electronic surveys One of the successes was the participation rate of staff in the completion of the electronic surveys. Across the four time points, staff participation was 77, 52, 54 and 62 percent. It is usual for internet based surveys to have participation rates of 20-30 percent. Survey results informing workplans Part of the original design was to ensure that organisational and staff surveys were used to inform decision-making and this was largely successful. When an organisation completed their baseline survey, the results informed the content of the sites work plan. One area where staff survey results could have been better utilised was to feed back some of the staff attitudes and beliefs data to sites for myth busting


exercises or additional training as there were minimal shifts related to staff attitudes concerning their own smoking related behaviours in the workplace. Conclusions and implications Overall, the results of this evaluation point to a successful project. There are areas where results could be enhanced with additional focus in the future. The task of developing and implementing tobacco policies in sites was very successful using the methods identified by sites and by using the work plan structure. Staff were heavily involved or were very aware and supportive of the process (project aims 1 and 2). A relative success was reducing the harms associated with tobacco smoke exposure. While there was a decrease in smoking rates amongst staff and reductions in consumption of tobacco, these were not significant changes. Passive smoke exposure should also be significantly reduced due to designated smoking areas and a change in cultures associated with smoking. The least impact observed was in attitudes and some behaviours related to smoking by staff. Many staff are fearful of clients not being able to smoke and feel that smoking is a useful tool to manage other symptoms. There is also a disconnect about staff thinking clients are not willing or ready to change smoking behaviours or quit. This could be addressed with additional staff training or research being conducted within the three sectors to examine the issue. Policy development and implementation were facilitated by a feedback loop from each survey period into site work plans. This process occurred primarily through the WTMP Project Manager. This process proved vital in the progression of the project. This became evident when, for a short time the project officer position was vacant and some momentum was lost. Staff engagement is vital in changing support for these policies in the workplace as demonstrated by this evaluation. The key to this approach was identifying an individual or a group of individuals within each organisation that became the champion/s for the project. With an ability to re-identify data a more concerted effort to follow up participants could have been achieved. For those who had left services, a natural experiment process could also be created if staff consented to follow up interviews. Comparisons of smoking reduction could then be made between samples of WPTMP participants and non-participants. Broadening the project to a larger group in the future will allow greater participation and ability to conduct inferential analysis. Subsidised NRT was offered as part of the project at a later stage and follow up of this group of staff. A focus on following up these staff has begun, but is yet to be completed. Any expansion of this project in the future will need to consider the follow up and analysis of data from this group of staff. Note: further conclusions, implications and recommendations will be drawn out from the secondary evaluation process which will be undertaken outside of the Health Promotions Unit funded component of the Workplace Tobacco Management Project. These will be available in early 2012.


2. Project description The alcohol, tobacco and other drug and mental health sector components of the Workplace Tobacco Management Project (WTMP) (the Project) were funded by the Health Promotions Unit, ACT Government Health Directorate under a Healthy Future – Preventative Health Program. The Project was undertaken from 31 May 2010 until 8 December 2011.

• The Project is guided by the broad goals of the: • Healthy Future – Preventative Health Program, and • ACT Government Health Directorate Smokefree Workplace Policy.

The Project was lead by the Alcohol Tobacco And Other Drug Association ACT (ATODA) in partnership with the Mental Health Community Coalition ACT (MHCC) and the Youth Coalition of the ACT and is implemented in collaboration with pilot sites in the mental health, youth and alcohol, tobacco and other drug sectors. Project aims The aims of the Project were to:

• Support the development and implementation of Workplace Tobacco Management Policies

• Increase awareness of workplace tobacco management policies amongst staff • Reduction harms associated with smoking behaviours for the staff in the pilot sites.

Pilot sites The participating sites in the pilot project are:

• Alcohol Tobacco and Other Drug Association ACT (ATODA) • Karralika Therapeutic Community, Karralika Programs Inc. (Formerly Alcohol and Drug

Foundation ACT) • Mental Health Community Coalition ACT (MHCC ACT) • Personal Helpers and Mentors Program (PHaM), Mental Health Foundation ACT • STEPS, CatholicCare Canberra and Goulburn • Ted Noffs Foundation ACT • The Rainbow, Mental Health Foundation ACT • Womenʼs Information, Resources and Education on Drugs and Dependency (WIREDD),

Toora Women Inc. • Youth Coalition of the ACT

Project elements A number of project elements were determined at the commencement of the project to guide the projectʼs progress. These included:

• Delineating the roles of the ATODA; MHCC ACT; and the Youth Coalition as Project partners.

• Establishing, developing and implementing governance structures for the Project. • Communicating and providing information and resources to the pilot sites and

stakeholders, about smoking attributes within the pilot sites and about elements of the


ACT Government Health Directorate Smoke-Free Policy that sites needed to consider when developing and implementing their own policies.

• Assisting in the development of tailored work-plans for participating programs to support the development of workplace policies.

• Support participating programs and staff to implement their work-plans, including the implementation of tobacco management policies.

• Providing pilot sites with template policies for modification to the local context. • Conducting monitoring and evaluation activities to measure critical factors and contribute

to the evidence base. • Providing regular reporting against agreed performance of the Project

Figure 1 highlights the project structure including project elements, data collections, policy development process including the site work plan. Diagram 1: WTMP structure


Project target groups and stakeholders While the pilot sites (primary target groups) were the focus of the Project, it was recognised from the outset that there were also other stakeholders with an interest in the Projectʼs progress. Pending the results; application of the Project methods and tools may have applicability across the broader sector (Secondary target groups). Stakeholders were also heavily involved to ensure two-way communication and dissemination. Primary target groups

• Participating ATOD programs (pilot sites) and workers in these programs, as identified with ATODA.

• Participating mental health programs (pilot sites) and workers in these programs, as identified with the MHCC ACT.

• Participating youth programs (pilot sites) and workers in these programs, as identified with the Youth Coalition of the ACT.

Secondary target groups The organisations that deliver participating programs more broadly the ACT:

• ATOD sector • Youth sector • Mental health community sector

Other key stakeholders

• ACT Division of General Practice • Alcohol and Drug Policy Unit, ACT Government Health Directorate • Cancer Council ACT • Health Promotions Unit, ACT Government Health Directorate • Mental Health Policy Unit, ACT Government Health Directorate • Pharmacy Guild of Australia (ACT)

Governance The Project was guided by an Advisory Committee with Terms of Reference. Committee meeting dates:

• 16th July 2010 • 30th September 2010 • 24th March 2011 • 25th July 2011 • 24th October 2011

Ethics The research evaluation of the Project, including surveys, received ethics approval from the ACT Government Health Directorate Human Research Ethics Committee – ETHLR.10.313.


3. Research evaluation Purpose of the research evaluation The purpose of this research evaluation was to determine if the aims of the Project were met. Therefore the evaluation is concerned with:

• Monitoring pilot site tobacco management policy development and implementation (including the processes involved).

• Monitoring staff awareness of and attitudes to workplace tobacco management policies • Measuring staff, management and governance structure involvement on tobacco

management policy development and implementation processes. • Monitoring staff, management and governance structure support for the development

and implementation of tobacco management policies within organisations. • Monitoring (including measuring changes in) smoking behaviours and attitudes within

the pilot sites pilot sites. • Evaluating what processes and factors contributed to changes in the above.

Methodology This research evaluation used a mixed methods approach. Research design and data elements Design The evaluation used two methods to monitor and evaluate the Project:

• Repeated measures tests measured changes in participantsʼ smoking behaviours, attitudes to, and knowledge of organisational policies.

• Qualitative survey data, observation and interviews at each organisation were used to answer the how and why of decisions taken within the pilot organisations regarding policy development and implementation processes.

Data collection matrix Three methods of data collection were used to inform the monitoring and evaluation. Baseline organisation and staff surveys Surveys of organisations and staff were undertaken within pilot organisations to elicit information about:

• Tobacco policy elements currently in place • Prevalence of smoking amongst staff • Levels of nicotine dependence amongst smokers • Intention of staff to quit or reduce • Previous quit attempts (smokers and ex-smokers) including stories about the Quit

experience (QUAL) • Staff knowledge of workplace tobacco policy • Staff observations concerning smoking culture (or no culture of smoking) at work • Circumstances impacting on decisions to quit smoking for smokers and ex-smokers


• Barriers and enablers to policy development and implementation in the workplace (QUAL)

• Attitudes to tobacco in specified workplace settings Follow-up survey of organisations and staff The follow up surveys were used to monitor changes in from the baseline survey. Field notes (observations) and field interviews The initial Project Manager made a number of field notes from observing processes around tobacco policy developments within the pilot sites. These observations were concerned with how the policy process was being undertaken in each pilot site. The results from these observations are mixed with the quantitative data where appropriate and offer insights into the how and why of the policy development and implementation processes within sites. In addition to these field observations, additional field interviews were conducted from June to September 2011. These interviews were with management and staff in each of the pilot sites. The interviews aimed to assess how the process of tobacco policy development and implementation was seen by staff, management and by their governing structures. Sampling All staff in the nine pilot sites were eligible to complete the baseline and follow –up internet based surveys. The surveys were conducted as a census. Data Analysis The baseline and follow-up surveys were analysed using SPSS version 19. Descriptive analysis Descriptive analysis is provided for:

• Staff participation • Sector of work • Gender • Age groups • Education • Income groups

Inferential analysis Where indicated, testing for statistically significant differences between independent and dependent variables was conducted. For each of the categorical repeated measures included in this report Cochranʼs Q Test has been utilised to examine statistical significance of changes in variables over time. For continuous data one-way repeated measures ANOVA has been conducted to test for statistical significance.


Qualitative analysis A cross case analysis was conducted to determine any common themes across sites. Thematic analysis was performed by examining the content (content analysis) of the qualitative data gathered from the field reports, interviews and surveys. Themes are organized and presented in categories.


3. Research evaluation findings This section reports results from the four staff and organisational surveys, and qualitative data from the survey, field notes and interviews. The findings first present the organisational staffing details and participation in the staff surveys, then the demographic characteristics of site staff. The second section presents the findings related to the three aims including how organisations undertook their policy development process, the levels of support for policy development and implementation and how engaged staff, management and organisation governance structures were in these processes. The final findings section presents findings in measures of reductions harms associated with smoking behaviours in the workplace for staff. Main characteristics of the pilot services At the first survey organisations were asked to report the number of staff employed in the pilot site. Table 1 contains the results from the employment data and Table 2 reports the participation rates for each of the surveys. Staff numbers

• Over half of staff were located in two services (Ted Noffs and Karralika) • The range of employment was 5–32 (headcount). • All pilot organisations completed the baseline and follow-up surveys (100%).

To establish a baseline of eligible participants pilot sites provided information about full-time equivalent (FTE) employment and staff headcount. The results are presented in Table 1. Table 1: Staff employed by pilot site (FTE & headcount) Organisation name FTE Headcount

Alcohol Tobacco and Other Drug Association ACT (ATODA)

4 5

Karralika, Alcohol and Drug Foundation ACT (ADFACT) 16 13 Mental Health Community Coalition ACT (MHCC ACT) 6.2 8 Personal Helpers and Mentors Program (PHaMS) &The Rainbow, Mental Health Foundation

7.95 9

STEPS, CatholicCare Canberra and Goulburn 7 17 Ted Noffs Foundation ACT 32 Womenʼs Information, Resources and Education on Drugs and Dependency (WIREDD), Toora Women Inc.

3.2 5

Youth Coalition of the ACT 4.2 6

Total 83


Staff participation in online surveys Participation by sector, as presented in Table 2 shows:

• A high initial participation in the baseline survey amongst staff of 77 percent (n=64). • Over the subsequent surveys participation declined to 56 and 55 percent for the 2 follow

up periods. • The final survey had a staff participation of 65 percent.

Table 2: WPTMP staff survey participation by sector and by survey period Baseline Follow-up 1 Follow-up 2 Final Sector n % n % N % N % ATOD 34 53 23 49 27 57 30 56 Mental Health 19 30 14 28 11 23 14 26 Youth 11 17 11 23 9 20 10 18 Subtotal 64 100 48 100 47 100 54 100 All eligible n=83

64 77 48 62 46 55 54 65

Participation by each of the pilot sites in the baseline survey was proportionate to their staffing numbers as demonstrated in figure 1. Figure 1: Pilot site representation in baseline survey (percent by organisation)


Age structure Figure 2 shows that:

• Over 50 percent of the female workforce in pilot sites are under the age of 34. • A higher proportion of males are in the older age groups. • The highest proportion of males and females are in the 25-34 years age group.

Figure 2: Pilot site age structure

Income Almost 70 percent of participants in the baseline survey had an annual income of $40,000 - $60,000, as seen in Figure 3.


Figure 3: Annual income categories of participants

Gender Figure 4 show that almost 75 percent of staff across the nine pilot sites were female. Figure 4: Gender of participants


Education level As shown in Table 3, participants in the project are well educated with more than 90 percent having an education above high school level. Table 3: Participant education level Type of education N % High school 5 7.8 Trade/Technical school (TAFE/CIT) 19 29.7 Some University 12 18.8 Undergraduate 19 29.7 Total 64 100 Findings concerning project aims At the commencement of the project all pilot sites were asked how they would go about developing and implementing a workplace tobacco management policy. A range of methods were discussed including potential barriers and enablers. Approaches to implementing a workplace tobacco management policy Before the commencement of the baseline survey feedback from staff was received concerning the terminology in use with the project. Staff in particular provided feedback that the terminology being used may be inappropriate and was in fact contributing to the anxiety around smoke-free policies being introduced. This led to inclusion of a question in the first site survey about what staff and organisations would prefer to call their policy. Across the nine pilot sites there were a variety of responses when the staff members were initially introduced to the Project. While there were different individual responses, there appeared to be little variation within each workplace. This is in part due the dynamics of the groups interactions as people discussed the issues and come to a point of agreement through social interaction. The reaction of each workplace did not directly correlate to the amount of smokers in each workplace. For example, the only workplace where there was a 100% smoking rate was the workplace that was most keen to participate in the Project and excited, if somewhat trepidatious, about managing their tobacco consumption. Two other worksites with very high smoking rates, both self-reported as approximately 75%, had divergent initial responses. One site had mixed responses but could see why they needed to take part, whilst the other site was resentful and angst ridden. Despite the variation in initial responses to the project the prevailing responses were emotional, in particular the reactions from current smokers. The emotional responses were far from simple. Rather, most individuals had a mixture of emotions. For example, several individuals were happy at being supported to manage their smoking but felt sad and often fearful at both ʻquittingʼ and the prospect of living without smoking. Other peopleʼs reactions were characterised as emblematic of cognitive


dissonance as their internal conflict manifest itself in rationalisations and justifications for their smoking in an obviously agitated manner (see above). While the initial introduction of staff to the WPTMP elicited a range of responses, both positive and negative, with passing of time all of the workplaces, including the individuals with the strongest appearances of resentment and anger, eventually came to embrace the WPTMP to varying degrees. As shown below, there was a distinct shift in support for the policy development and implementation process across the period of the project. Barriers and enablers to policy development and implementation This section provides the results of staff feedback into what enablers and barriers were present within the sites and what impacts these had amongst staff and service users. Health focus Staff identified improvements in health and having a healthier workplace as a mostly enabling issue in the policy process, even recognizing the impact that it might have in not being able to smoke with clients: Enablers

“Healthier although miss smoking with the clients” “Setting good environment, improving staff's health” “The staff won't die of lung cancer” “Decrease in tobacco consumption and therefore an increase in overall health”

Smoking as paid or unpaid work time, insurance issues and staff productivity Staff said that as a result of the policy development and implementation process, smoking becomes an unpaid break, which had both a negative and positive effect. There also continued to be some uncertainty about whether smoking was paid or unpaid: Enablers

“Makes people more aware of their smoking, regulates smoking in the work place” “Regulates breaks and productivity in the workplaceʼ”

Barriers ʻThe major issue I believe is time management, is a smoke break paid for? Is this remuneration across the board for all staff, does work cover apply if I'm off the floor to have a smokeʼ


“Difficult to implement when staff work on shift alone especially unpaid lunch breaks” “Unpaid breaks and need to extend/make up hours, offsite or approved smoking areas challenging”

Professionalism Some staff saw the reduction of smoking behaviour and limits of smoking with clients in particular as improving staff professionalism. Enabler

“Increase professionalism as staff not able to smoke with consumers”

Stress reduction and loss of informal networks There was some lamenting by some about losing what was considered a valuable part of the workplace where staff could come together and debrief or relive stress. Barriers

“Less time spent with staff debriefing whilst smoking and non-smoking staff missing the conversation” “People seem to enjoy the stress break they get from smoking” “Loss of informal networking/discussions with clients & staff from our service and others”

Choice Overwhelmingly staff saw the policy implementation as limiting of their choice to smoke. Enabler

ʻStaff feel supported to manage their use of tobaccoʼ

Barriers

“Believe there should be freedom of choice, believe that choice is being taken away” “Just the limits on adults being given the ability to make informed decisions” “Staff feel like this is a punitive measure” “Restrictions placed on work time; restrictions on personal choice”


“Too many people smoke too much. However, there's only so far you can and should interfere with free will”

Impacts for clients What could also be considered unintended consequences is that most staff saw the policy introduction as a positive. Particularly when clients were seeking support to quit and when staff were modeling positive behaviour towards clients. Enablers

“More clients asking for support for smoking cessation due to staff not smoking with them” “Staff not smoking or at least attempting to quit is great role modeling for client to think differently about quit programs” “Women smoking a bit less” “More conversations re clients outcomes, NRT, and reducing”

Barrier “Not being able to smoke with the service users”

Designated smoking areas Designated areas were contentious and were identified as barriers by staff to the policy development process. Barriers

“Deciding on designated smoking areas has been difficult because of working in a high rise environment with food outlets all around” “Different opinion on where is appropriate area”

Support and awareness for policy development and implementation amongst staff Staff and management were asked a series of questions about their knowledge of tobacco management policy development in their organisations. Staff awareness of policy The results in figure 5 show that:

• Over the life of the project there were significant changes in staff knowledge of their

organisation having a tobacco management policy in place. • At baseline more staff (40 percent) believed a tobacco management policy existed

compared to 25 percent of sites having a policy in place.


• As the project progressed all organisations had implemented a policy and almost all staff (90 percent) were aware that a workplace tobacco management policy was in place at their work site.

Figure 5: Staff knowledge and organisational policy implementation

Staff and organisational support for policy Much of the concern about the introduction of the smoke-free policy at ACT Government Health Directorate and in particular the Alcohol and Drug Service Withdrawal Unit focused of the processes involved in the policies introduction. The main concern centered on the lack of consultation with staff and managers at the site. In this evaluation, in addition to measuring the number of policies in place, a number of other measures were taken. These included:

• The level of support for tobacco management policies amongst the range of stakeholders involved at the workplace.

• The level of staff involvement in the policy development and implementation process; and

• Knowledge around the processes of the workplace work-plans used to enhance the policy development and implementation process.

Figure 6 shows that over the period of the project:

• The proportion of staff, management, clients and governance bodies improved their level of support for the implementation of a tobacco management policy.

• The sharpest rises in high levels of support were observed amongst boards and management between follow-up 1 and follow-up 2. This period corresponded with the majority of organisations working through their policy development processes and boards approving policies for implementation (as seen in figure 5).


Figure 6: Proportion of stakeholders highly supportive of staff tobacco management policy implementation

Staff involvement in policy development, knowledge of work-plan and staff perceptions of how the policy process was being handled. Staff were asked to identify their involvement in the policy development process including their involvement in assisting with work-plans. In addition, staff were also asked to indicate the level of discussion about smoking occurring around their workplaces concerning the policy. Quantitative and qualitative responses were requested to first determine if there was more talk among staff about the policy process and then to identify what the conversations were about. As figure 7 shows there were:

• Notable increases occurred across the survey periods in the proportion of staff with knowledge of the site specific work-plans. This is most likely due to the period between follow-up 1 and follow-up 2 being the time of most significant activity concerning policy development, implementation and finalization as identified in figure 5.


Figure 7: Proportion of pilot site staff involved in policy development, knowledge of work-plan, level of conversations being conducted in the workplace about smoking and staff perception of the way in which policy was being implemented by survey period.

The use of a positive and empowering approach Staff were asked to identify the positive elements concerning the policy development and implementation. From the qualitative data a number of themes emerged. By far the largest theme was the use of a positive and empowering approach.

“I believe the group are trying to introduce this policy as sensitively as possible. Having a goal to 'reduce' can be less confronting than a goal to 'quit'. Having an acceptance that we may stop many times for a while before we stop for good shows an understanding of how hard this is for a lot of people. Offering support to workers has been greatly appreciated.” “Positive and inclusive, places power with the agency - I see this as a health promoting activity.” “It's just there - no one is harassing me to quit, simply providing me the information and the opportunity. That's empowering and motivating.” “It's not seen as a negative or imposing action. It's inclusive and considerate of everyone.” “It encourages women to look at a different way of dealing with things”

Staff are involved and engaged It was felt that staff were involved, but additional consideration were yet to be sorted.

“Involvement of all staff. However, not yet consistent approach in promoting the policy to visitors”


Becoming the norm Some staff saw the policy implementation as part of normal organisational processes.

“The policy is now just part of how the organisation runs and is a non-issueʼ”

Places the process in the context of workers philosophy Some staff were able to put the context of the tobacco policy introduction in the harm reduction approach.

“It shows support to addiction” “I think it reduces exposure of secondary smoke to both other workers and clients and also removes the role modelling of smoking in front of clients”

Changes in smoking attitudes and behaviors The main focus of Table 4 is to show changes in responses to a range of attitudes and behaviors related to smoking situations. The results with the largest observed change are:

• Fewer staff believe that if clients are not allowed to smoke, this will impair treatment outcomes.

• Fewer staff believe clients will become aggressive if not allowed to smoke, although the change was observed in the final survey only.

• At baseline and through to follow up survey 2, most staff (approximately 70-75 percent) believed that clients were not ready or willing to quit. The final survey showed that less than half (45 percent) now believed clients were not ready or willing to quit.

• A similar result was seen when staff were asked if clients wanted to quit. The proportion of staff believing this is about half (17 percent), compared to the baseline survey result of 36 percent.

Table 4: Pilot site staff attitudes to tobacco assessment and treatment

Baseline Follow up 1 Follow up 2 Final Attitude/belief n % agree N %

agree n %

agree n % agree

Clients should be encouraged to quit smoking

39 62.9% 30 71.4% 24 58.5% 32 62.7%

Staff should be encouraged to quit

39 62.9% 31 73.8% 26 63.4% 31 60.8%

I think smoking is not as serious as the substance/mental health or other issue that they accessed our services for

18 29.0% 6 14.3% 11 26.8% 10 19.6%

Staff should be allowed to smoke with clients

9 14.5% 2 4.8% 4 9.8% 6 11.8%


*significant at p<.05

Smoking with clients helps build a better therapeutic relationship

11 17.7% 3 7.1% 4 9.8% 7 13.7%

Clients not allowed to smoke leads to impaired treatment outcomes

19 30.6% 9 21.4% 6 14.6% 9 17.6%*

I think you can only treat one issue at a time

9 14.5% 9 21.4% 8 19.5% 5 9.8%

I think many clients are not ready or willing to quit

44 71.0% 32 76.2% 29 70.7% 23 45.1%*

I think that clients will become more aggressive if they couldn't smoke

25 40.3% 17 40.5% 19 46.3% 18 35.3%

Smoking helps the client manage their symptoms

26 41.9% 18 42.9% 15 36.6% 16 31.4%

Smoking is one of the pleasures for people with AOD/Mental health and other issues

34 54.8% 15 35.7% 20 48.8% 22 43.1%

It would be impossible for a client to give up 2 addictions at once

6 9.7% 1 2.4% 5 12.2% 5 9.8%

Smoking has a therapeutic effect for the client

24 38.7% 13 31.0% 14 34.1% 18 35.3%

Clients don't want to stop smoking

22 35.5% 12 28.6% 15 36.6% 9 17.6%*

Smoking isn't a serious addiction

2 3.2% 2 4.8% 2 4.9% 3 5.9%

All clients should be asked about their smoking status

46 74.2% 34 81.0% 34 82.9% 33 64.7%


Changes in nicotine dependence levels (mean Fagerstrom score and by category of dependence) This section of the findings examines and reports changes in smoking behavior among pilot sites. Measures included the use of the Fagerstrӧm Test for Nicotine Dependence (FTND), self reported addiction and ability to quit (smokers). The FTND is a six-item questionnaire designed to measure the severity of nicotine dependence. The FTND has both high internal validity and test-retest reliability. The initial version, the Fagerstrom Tolerance Questionnaire (FTQ) was developed in the late 70ʼs (Fagerstrom 1978), with a revised version now more commonly used (Heatherton, Lynn et al. 1991). Since its development the FTND has been used to assess nicotine dependence across a number of intervention studies (Marques-Vidal, Kutalik et al. 2011), and has been used to assess probability of smoking cessation (Kozlowski, Porter et al. 1994). Two methods of examining dependence are presented. Figure 8 presents the mean Fagerstrom score. The second presents the different categories of dependence (Figure 9). A reliability and factor analysis of the Fagerstrom Test for nicotine dependence is also included in Appendix 4. The reliability analysis shows that the FTND is an acceptable instrument for use amongst this population. The cronbach alpha coefficient of the FTND amongst this population was .705. Figure 8: WPTMP Smoker mean FTND scores

Nicotine dependence categories In addition to mean FTND scores, FTND categories are used by practitioners to determine the most appropriate level of NRT (patches) to use. Figure 9 shows:

• Rates of high nicotine dependence amongst pilot site smokers is low. • The dependence profile in the baseline survey was vastly different to the subsequent

surveys.


Figure 9: Levels of nicotine dependence by survey period

Changes in levels of dependence categories Also reported (Figure 10), are changes between low, low-moderate and Moderate to high nicotine dependence. Figure 10 shows that:

• At Follow up survey 2 and Final, the proportion of smokers in pilot sites were much more likely to have Low – Low to moderate levels of nicotine dependence when compared with Baseline and Follow up survey 1.

Figure 10: Changes in combined (low-low to moderate and moderate to high) categories of nicotine dependence by survey period


Self reported level of addiction and ability to quit After the baseline survey, some staff wanted to be able to self identify their level of nicotine addiction (independently of Fagerstrom) and ability to quit. Two additional questions were developed to assess this, the questions were:

1. If you think about how addicted you are to smoking, and 1=not addicted and 7=totally addicted, rate your addiction level.

2. If you think about how hard you think it would be to quit smoking, and 1=not hard at all and 7=impossible, rate how hard it would be for you to quit smoking.

Figure 11 shows that: • Smokers level of addiction to nicotine has reduced, as has their self assessed ability to

quit smoking. • There appears to be some inconsistency with the level of addiction and ability to quit

when compared to mean FTND scores at the same intervals. Figure 11: Perceived level of addiction and ability to quit amongst smokers

Smokers quit profiles Smokers were asked about wanting to quit, whether they were organising a quit attempt, how many quit attempts they had made in their lifetime and if they had made any quit attempts in the 12 weeks preceding the survey. Figure 12 shows that:

• Consistently, most smokers working in the pilot sites wanted to quit smoking (almost 90 percent at each survey).

• Between 60-70 percent of current smokers in the pilot sites were organising a quit attempt.

• About half of smoker quit attempts (lifetime) occurred during the project. • On average, just over half of smokers reported reducing their tobacco consumption

during the project.


Figure 12: WPTMP smokers quit profile and quit attempts by survey period

Changes in smoking rates amongst smokers Figure 13 shows that;

• There is a reduction from baseline in the proportion of current smokers from just over 50 percent to 38 percent at follow up survey 2, this however increased again in the final survey to 45 percent.

Cochranʼs Q test showed that the reduction was not however statistically significant p=.519. Figure 13: Pilot site staff smoker profile by survey period


Exposure to tobacco smoke in the workplace (cultural factors) Staff were asked to describe the smoking cultures within the workplaces. Smoking cultures within workplaces are a significant contributor to exposure tobacco smoke among smokers, ex-smokers and staff that have never smoked. Common themes emerged and presented below. Debriefing A debriefing theme emerged that appeared related to working in a sometimes stressful environment and staff felt the need to speak with other staff about problems or situations related to their work:

“I will smoke with colleagues either socially or debriefing re: work matters”

Breaks and meals This theme was the most common theme and was described by almost all staff. Most indicated that smoking on a break or after meals was the done thing:

“With co-workers and when in need of a break” “I usually smoke with colleagues outside on breaks and handover” “Usually have a 'smoking buddy' at work. Make sure I have a morning tea break and a late lunch break”

After client interaction The second most identified theme. About half of smokers identified smoking with clients to build therapeutic relationships. This theme also appeared related to the debriefing theme as it primarily concerned de-stressing and debriefing with other staff: ʻI usually smoke after seeing a client or after a groupʼ During staff meetings This theme was closely related to smoking during breaks and with meals and coffee, although contained elements of coming together of the marginalized and as a way to come together with other workers:

“Oddly, it is a bonding experience for those stigmatized due to the fact they smoke” “Smoking with the boss and colleagues allowed me to form relationships not available to non smokers”

Case study (anonymous site)


One pilot site experienced a significant shift in workplace smoking culture between commencement and completion of the Project. One individual that left, then returned provided a small case study into the changes observed:

“I was one of the few non-smokers employed with the organisation last year when the pilot Work Place Tobacco Management Project was initiated. At this time there was a very strong smoking culture. Employees socialised and de-stressed during the shift by having a cigarette. Non-smokers often felt left out and felt resentment towards the smokers as they sometimes left the non-smokers alone with the clients so that they could have a cigarette. When the WTMP was implemented in our centre there was a great deal of outrage from the smokers who believed this project to be forcing them to stop smoking. It created a lot of negativity and was an issue that was raised frequently at staff meetings. I left the organisation for a period and returned some time later. During the time that I was away I have noticed a substantial change in the attitudes held by staff towards smoking and also the number of staff who smoke. The majority of our staff now identify as non-smokers or do not smoke when they are at work. People are supportive and encouraging of other staff members who want to stop smoking, and very little socialising occurs at our designated smoking area. There has been a high staff turnover in the past six months which raises many questions of how the project may have affected attitudes/ rates of smoking. However it is very clear to me that the project started a positive cultural shift within our organisation, particularly within the attitudes and behaviours of the shift workers.”

Changes in smoking culture and workplace tobacco smoke exposure At each survey period staff were asked to describe any changes in smoking culture within their workplace. In the final survey, staff indicated:

• That in about half of the sites, there were no perceived changes in smoking culture within their workplace.

• There was an increase in the number of staff who did not smoke at work, or reduced their frequency of smoking when at work.

• There were designated smoking areas or banning of smoking on the grounds of most organisations.

• Staff were having to make up work time taken for smoking during the day, as this was now not considered ʻpaid timeʼ at work.

• An awareness of a formal staff tobacco use policy operating at their workplace.


4. References Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD, (2007) The burden of disease and injury in Australia 2003. PHE 82. Canberra AIHW. http://www.aihw.gov.au/publications/index.cfm/title/10317 Bowman & Walsh (2003) Smoking intervention within alcohol and other drug treatment services: a selective review with suggestions for practical management, in Drug and Alcohol Review, Vol. 22 issue. 1, pp. 73-82 Cahill, K., Moher, & Lancaster, T. (2008) Workplace interventions for smoking cessation. Cochrane Database of Systematic Reviews, issue 4 Campbell, G., and Degendardt, L. 2008, ACT Drug Trends 2007: Findings from the Illicit Drug Reporting System, Australian Drug Trends Series No. 3, NDARC, Sydney Doll R., Peto, R., Boreham J, & Sutherland I (2004) Mortality in relation to smoking: 50 years observation on male British doctors. British Medical Journal. June 2004, 328:1519. http://www.bmj.com/cgi/content/full/328/7455/1519 Fichtenberg, C & Glantz, S. (2002) Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ, 325, 27 July, pp. 188-94 Gruman, J., Lynn W., Worksite and Community Intervention for Tobacco, In: (eds) Orleans C.T., Slade J. Nicotine Addiction: Principles and Management. New York: Oxford University Press, 1993: 396-411 Kerle, C, & Jago, A (2005) “A Non Smoking Policy in a 15 Bed Detoxification Unit” in: Australian Resource Centre for Healthcare Innovation. Leishman, S. (2008) Review of the Impact of the Smoke Free Policy Introduction at the ACT Government Health Directorate Withdrawl Unit: Evaluation of the Impact, in relation to service Utilisation and Client Behaviour, of the Smoke-free Policy on Clients, Staff of the ACT Government Health Directorate ADP Withdrawl Unit and the Broader AOD Sector in the ACT. ACT Government Health Directorate Mackay J. and Erikson M. 2002. The Tobacco Atlas. World Health Organisation. Geneva. Switzerland. Moeller-Saxone, K. 2008, Cigarette smoking and interest in quitting among consumers at a Psychiatric Disability Rehabilitation and Support Service in Victoria, Australian and New Zealand Journal of Public Health, vol. 32(5), pp. 479481 Lawn, S. (2005) “Cigarette Smoking in Psychiatric Settings: Occupational Health, Safety, Welfare and Legal Concerns” in: Australian an New Zealand Journal of Psychiatry, vol. 39,pp. 886-891 Ragg M., Ahmed T. (2008) Smoke and mirrors: a review of the literature on smoking and mental illness. Tackling Tobacco Program Research Series No. 1. Sydney: Cancer Council NSW


Richter, K (2006) “Good and Bad Times for Treating Cigarette Smoking in Drug Treatment” in: Journal of Psychoactive Drugs, vol. 38, no. 3 pp. 311-316 Reily, P., Murphy, L., & Alderton, D. (2006) “Challenging Smoking Culture Within a Mental Health Service Supportively” in: International Journal of Mental Health Nursing, vol. 15, pp. 272-278 U.S. Department of Health and Human Services. 2006. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. [Atlanta, Ga.]. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Washington, D.C.

Documents

Workplace Tobacco Management Project Research … · Workplace Tobacco Management Project Research Findings (Evaluation) Report For submission to the Health Promotion Unit, ACT Government