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that 58 percent had made "some changes" in their smoking and 35 percent had made "substantial changes." At control sites, 15 percent of the employees had made "some changes" and 8 per- cent "substantial changes." A long-term evaluation of the program is in process. Some multiple risk factor projects use workers as subjects, but they are not really "worksite pro- grams: " Rather, they are long-term clinical research trials funded by public moneys. These projects were selective in who they included in their study (e.g., some limited services to men or persons who were at high risk of heart disase or respiratory illness). The results for some of these projects are shown in the comprehensive table (under Risk Factor Intervention 'Ii ials) and will not be examined here. 7iwo dozen worksite cessation programs already have been described in this volume according to the method used; their followup quit rates are shown in the comprehensive table. They also will be noted here to bring together worksite programs in this chapter. In this volume, cessation methods were reviewed under 10 categories. Methods used by worksite programs that were evaluated included all but three categories (medication, acupuncture, and mass media and community programs). Several programs that offered treatment options provided one result for all participants. The methods will be reviewed under six categories with the number of trials noted in parentheses: self-care (4); educa- tional methods, clinics, and groups (19); nicotine chewing gum (2); hypnosis (2); physician counsel- ing (4); and behavioral methods (26). Nine of the behavioral trials used cessation and reduction pro- grams. There was one miscellaneous program with five trials. Studies with more than one method were classified in just one category. The discussion will emphasize the programs with followup quit rates of at least 6 months, but programs with shorter followups also will be cited. In all, there were 35 worksite programs with followup results provided by 30 different investi- gator teams. Tiwo teams did two studies each, and one team did four studies. These 35 programs generated 62 trials. Six of the studies were reported between 1970 and 1977, 11 were reported between 1978 and 1982, and 18 were reported in 1983 or later. Four programs were conducted in several cities, and nine included more than one company. Five programs were carried out among the Armed Forces, and four were conducted at VA hospitals. Eleven of the 35 programs had at least 1-year followups, 2 had 9-month followups, 14 had 6-month followups, and 8 had less than 6-month followups. In terms of trials, 21 had at least a 1-year followup, and 26 had at least a 6-month followup. Four programs that used cessation and reduction methods validated their results by either CO or SCN testing. Only seven other programs validated their results by physiological measurements. Table 22 provides the quit rates for the 62 trials generated by the 35 programs, along with the methods used, number of subjects, length of follow- up, investigators, locations, and identity of the worksite (where this information was available). The programs that validated self-reports by physio- logical measures are indicated. The results reported for several studies were confusing and incomplete; I had to calculate their results or rely on secondary sources. In interpreting these followup results, the same cautions apply, as noted previously, regarding self-reports and followup procedures. Self-reported abstinence rates may be inflated although non- smoking during working hours might be diflicult for a worker who has claimed to quit. Still, the worker could smoke at home and refrain in the office. Table 22 FOLLOWUP QUIT RATES OF WORKSITE CESSATION PROGRAMS Reported 1974-1986 Nnmbez Quit of Rate Follownp Investigators Intervention Method Subjects (%) Period Location Year of Report Notes Lectums, discussion, buddies, 81 30 6 Months Bauer 1978159 Bell Laboratories. and videotapes (5 days) Murray Hill, NJ Lectures, films, and counsel- 33 55 1 Year ing (11 sessions and 4 followup sessions Educational groups and 15 47 6 Months lectures Self-help modules (nine), 36 14 smoke holding, nicotine fading, and self-control Miller 1981152 Cummins Engine Company. Columbus, Ohio CO validation. 1984150 VA Hospital. T1vo patients included Dawley, Fleischer, in group. Six subjects who did not and Dawley complete treatment were not New Orleans, LA followed up. 6 Months Nepps New Brunswick. NJ 1982116 CO validation. Quit rate for 19 subjects starting second module was 26 percent. Johnson & Johnson Corporation. 104 TIlVIN 293433

Tabie 22 (continued) lrnmber Quit of Rate FbIIowap I(nvestigators Year of Intervention Method Subjects (%) Period Location Report Notes Five-Day Plan and six 118 27 1 Year Mossman maintenance sessions Albuquerque. NM Five-Day Plan 35 23 3 Months Seventh-day Adventist Church. Seattle, WA SmokEnders 30 40 1 Year Kanzler, Jaffe, and Zeidenberg New York, NY Groups, peer support, and 101 taped telephone messages (6 weeks) Group counseling Self-help Control Group meetings and self-help manual 9 6 Months Grove, Reed, and Miller, Indianapolis, IN 218' 40 4 Months Flow 18 Corvallis, OR 5 54 15 3 Months Perrin, Tanant. Moreton, and East England Four options of group sup- 179 35 1 Year Brennan port: minimal intervention, New York. NY self-quit telephone calls. messages, or buddies ALA-FFS manual and trouble 18 33 1 Year Bishop and Fisher shooting for some and four Eastern Missouri meetings for some ALA-FFS manual and group 48 33 meetings ALA-FFS manual and group 46 -7 meetings Group meetings, iottery, no- smoking contest, contracts, and 20 meetings over 7 months Health risk appraisal, health education modules, and meetings Nicotine chewing gum, clinic, and workbook Clinic-3 treatments: Full-19 sessions Minimal contact-4 sessions Self-help Nicotine chewing gum nr 91 6 Months Stachnik and 80 Stoffelmayr 85 Michigan nr 53 5 Months Spilman, Goetz, Schultz. Bellingham, and Johnson Bedminster. NJ, and Kansas City, MO 243 20 1 Year Schlegel. Manske, and Shannon 29 28 Canadian 25-38 military bases 17-29 7-10 161 11 1 Year Soul At sea 1978158 Employee spouses in^luded. Sandra Labs. 1980746 Boeing Aircraft. Result based on 27 subjects followed up was 30 percent. 19761118 New York Psychiatric Institute, Columbia Presbyterian Medical Center. and family members. Tiventy subjects graduated. 1979175 American Health Foundation pro- gram for Blue Cross/Blue Shield. CO validation. 1980187 Doctoral dissertation. 1982768 Program conducted at two sites. Laboratory of scientists and engineers. Office of engineers and clerks. 1983181 Metropolitan Life Insurance Com- pany. All participants over 4-year period combined in evaluation. Success ranged from 29 to 40 percent. 1984170 EASE (Employer Assisted Smoking Elimination). 1983757 Program conducted at three sites: hospital service organization, manufacturing company, and bank. 1986767 AT&i' Communications. Par- ticipants came from 690 randomly selected employees from two sites. 1983249 Six-month program. Results based on those choosing abstinence as goal. 'li.venty-nine percent represents result for three treatments combined. 198425' British naval seamen serving on H.MS. Hermes. 105 TIMN 293434

Thb1e 22 (continned) Intervention Method Hypnosis and group sessions Wait-list control Hypnosis Group Antismoking message during physical examination Physician advice Individual counseling Behavioral modification Physician examination, advice, and warning to quit Physician warning during examination Behavioral counseling Rapid smoking, warm smoky air, and handling cigarette litter Rapid smoking and educa- tional seminars (4 weeks) Regular-paced aversive smoking and self-control Electric shock, rapid smoking. and education (4 weeks) Classes-behavioral method Nicotine fading (8 sessions) and Health education Stress management Social support Brand fading, abstinence training, feedbaek, and public posting of carbon monoxide levels Wait-list controls 106 Number of Subjects Quit Rate (%) Followup Period Investigators Location Year of Report 35 31 3 Months Jeffrey. Jeffrey, 1985771 30 0 Greuling. and 48 19 6 Months Gentry El Paso, TX Frank, Umlauf, 1986770 15 20 Wonderlich, and 1,493 13 1-2 Years Ashkanazi Columbia, MO Pincherle and 1970"3 14 15 3 Months Wright London. England Meyer and 1974772 10 10 Henderson 12 9 Palo Alta CA 543 19 2 Years Richmond 1976424 361 4 11 Months Columbus, OH Li. Coates, Kim, 1983415 215 8 and Ewart Baltimore, MD 12 17 9 Months Dawley and 1977564 172 28 6 Months Sardenga New Orleans. LA Parker and 198157 26 20 6 Months Younggren Tacoma. WA Danaher 1980745 31 39 6 Months Dearbom. MI Younggren and 197777' 36 25 6 Months Parker Tacoma. WA Pomerleau and 1980745 3 Months Pomerleau Camden. NJ Abrams. Pinto, 1985742 18 33 Monti. Jacobus, 18 27 Brown, and Elder 18 6 Providence, RI 18 33 9 Months Scott. Denier, and 1983636 10 0 Prue Jackson. MS Notes William Beaumont Army Medical Center. Military personnel and dependents. Group had four sessions. University of Missouri-Columbia. Business executives. Thirty-six screened as high risk of heart disease. Varian Corporation. Cummins Engine Company. Shipyard workers. CO validation. VA hospital employees. Clinic in military setting. Ft. Lewis. Danaher and Lichtenstein self- help book used. Ford Motor Company. Subjects were soldiers at Ft. Lewis. Campbell Soup Company. Pro- gram by Center for Behavioral Medicine. University of Pennsylvania. CO validation. Program con- ducted at two sites: medical manufacturing company and insurance carrier. VA hospital nurses. Twenty-six subjects but not all subjects car- ried out treatment. CO validation. Three-month treatment. TIMN 293435

Zhble 22 (continued) Intervention Method Number of Subjects Quit Rate (%) FoIIowup Period Investigators Location 28 14 3 Months Sutton and Eiser London, England 33 0 33 3 12-15 Months Sutton and Hallett nr 0 nr 11 nr 11 nr 8 3-5 Months nr 4 nr 3 nr 6 36 61 1 Year Powell 48 44 (Smokeless 46 43 Program) 51 45 Dearborn, MI 39 49 16 14 6 Months Kiesges, Vasey, 91 18 and Glasgow Fargo. ND 12 25 6 Months Malott. Glasgow; O'Neill, and Klesges 12 17 6 Months Fargo. ND Glasgow. Klesges, - Godding. Vasey. 12 33 and O'Neill 13 0 Farga ND 11 0 13 25 6 Months Glasgow Klesges, 16 23 and O'Nelll Fargo. ND Year of Report Notes Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Fear videotape and quit- smoking booklet Control videotape and quit- smoking booklet Lectures, stress management, negative smoking. relaxation, snap rubberband. mainte- nance meetings, positive rewards, and self-control Cessation/reduction program Cessation/reduction program. competition, and posted feedback charts Cessation/reduction (brand fading and reduce number of cigarettes per day) Cessation/reduction and partner support Cessation/reduction (7 meetings): - Gradual reduction Abrupt reduction Gradual reduction and feedback Cessation/reduction program Cessation/reduction program and social support Self-Care The preference for self-care methods was discussed earlier.47 'Ib accommodate this pref- erence, companies have offered self-help guides, particularly materials produced by ALA, ACS, and NCL The ALA manuals and video program can be adapted to the workplace. The American Heart 1984'80 Hard-hitting film from British TV- Dying for a fag? Control videotape was on alcohol, seat belts, or political and commercial aspects of smoking. Programs conducted at five firms. 1984778 N,for last 4 firms for fear videotape was 183; control videotape was 224. All results were validated by expired air CO. 1985204 Ford Motor Company. Results based on subjects attending at least two treatment sessions and subjects who answered followups. 1986742- Savings and loan. Four banks. CO 758 and SCN validation. 1984775 'Iblephone company and medical clinic. Subjects chose buddies. CO validation. 1984774 Choice of abstinence or controlled smoking. CO validation. '181ephone company. 1985776 CO and SCN validation. Zi.vo meetings. VA hospital, health care service company, and savings and loan bank. Association (AHA) offers a multiple risk factor inter- vention program designed for the workplace that includes a module on smoking cessation. The NCI self-help smoking cessation kit (Calling It Quits) is contained in the AHA module. In 1983, 57 percent of American insurance companies with smoking cessation programs made self-help literature 107 TIMN 293436

available.702 Unfortunately, only a few worksite self- help programs have been evaluated. As part of a doctoral dissertation, Nepps evaluated the Johnson and Johnson cessation pro- gram consisting of nine self-help modules.l'e Thirty-six white-collar workers were recruited for the voluntary cost-free program. After an orienta- tion, participants were given a manual of nine modules that combined behavioral techniques (e.g., smoke holding, nicotine fading, and self-control). The techniques were dispensed sequentially to par- ticipants contingent upon completion of progress reports. Only 19 of the 36 subjects returned for module 2, and only 6 participants completed a119 modules. Based on all 36 participants, the quit rate was 14 percent; for the 19 subjects who returned for module 2, the quit rate was 26 percent. Par- ticipants were given weekly carbon monoxide assessments to corroborate self-reports and provide feedback on progress. Flow also did doctoral dissertation research on a worksite self-help program comparing it to a group method 187 Subjects (N=218) were random- ized to the two treatments and a control. At a 4-month followup, group subjects showed 40- percent success compared to 18-percent success for self-help subjects. Several worksite programs provide increasing levels of support consisting of self-help, minimal contact, and groups. Bishop and Fisher offer employees at companies in Eastern Missouri three procedures: self-help, self-help plus trouble shooting, and a comprehensive group clinic"° The ALA manuals are provided, and in the trouble shooting condition, subjects are expected to attend four meetings over a 6-week period. The com- prehensive group format (nine meetings over 7 weeks) is based on the ALA clinic but modified for the workplace. Unfortunately, the evaluations available do not provide separate results for the three procedures. At 1 company with 190 employ- ees, 18 of 63 smokers entered the program; one- third were abstinent at a 12-month followup. Two trials of the comprehensive groups resulted in 33- percent and 7-percent quit rates at 1 year. Bishop and Fisher call their program EASE (Employer Assisted Smoking Elimination). They train employees to run the clinics. One feature of the program is the formation of a steering commit- tee at each site to promote the program. EASE was begun at nine worksites during 1983-1984. A number of other evaluations of this program are under way. Orleans and Pinney recommend three self-help programs for the worksite provided by ALA, Con- trol Data Corporation, and Orlean's self-help book.702 The ALA self-help home video program (In Control) and the manuals were described in the 108 self-care section. ALA assists in designing worksite programs, including training, promotions, followups, and evaluations. The STAYWELL course of the Control Data Cor- poration consists of two self-administered pro- grams. The How to Quit Smoking Self-Study Course provides a 6- to 8-week plan for quitting smoking halfway through the course and then covers skills helpful for maintenance. Three telephone contacts with a STAYWELL consultant are scheduled for each participant. The cost of the course is $30. The second course, PLATO, is computer-based. It also is 6 to 8 weeks of self- instruction and includes aversive smoking instruc- tions. The computer course, updated continually based on a national analysis, costs $170. Control Data Corporation offers consultation to companies implementing smoking policies, promotions, or programs. Orleans and Pinney reported that an evaluation of the self-study course among 40 par- ticipants returning a questionnaire indicated that 35 percent had quit smoking at the end of the pro- gram. A long-term followup is under way.702 Orleans produced a self-help book through her consulting firm.766 The workbook presents an 8-week quitting program that includes 4 weeks of nicotine fading through brand switching. Users complete a series of exercises and are helped to develop skills needed for maintenance. Guidelines are provided for family members on how to be sup- portive. The price of the workbook varies from $15 to $25 depending on the volume of purchases and whether telephone calls are included. Consultation and training are offered to companies that intend to implement programs or policies. An evaluation of the guide is now under way. Orleans and Pinney caution that self-help materials should equip employees with quitting skills and knowledge of the characteristics that distinguish successful quitters.702 These attributes include positive quitting motivations, effective quit- ting skills, and meaningful social supports for quit- ting and remaining off cigarettes. Educational Methods, Clinics, and Groups As already noted, many companies offer educa- tional or group programs on smoking, but only a few have followup evaluation results. Three worksite cessation programs with followup results were made up of lectures, discussions, and answering questions. At Bell Laboratories, the program lasted 5 days and included videotapes and pairing par- ticipants as buddies lg3 The quit rate after 6 months for 81 employees was 30 percent. The Cummins Engine Company course ran 11 sessions with 4 followup sessions; films and counseling were TIMN 293437