Nicotine dependence among workers: Is it a time for smoke-free workplaces!

The adverse effects of smoking, a chronic relapsing disease, have been recognized at least since 1604.[1] Even after understanding the risks of smoking or smokeless tobacco, and also the benefits of smoking cessation, for both general and specialized physicians, smoking cessation is not on priority.

Smoking or chewing tobacco is viewed as a part of lifestyle and moreover a habit which continues despite its hazardous consequences. Almost all smokers begin smoking in very adolescence under influence of numerous social factors which include mimicking of family members and friends in circle, promotion through advertising and public images, as a status symbol in society, and some get the feel of macho man via smoking. Easy accessibility and low cost of raw tobacco products also contribute to overuse of nicotine and its products. In India, 20% of total tobacco consumption is through cigarette smoking as compared to bidi smoking which accounts for around 40% of total tobacco consumption.[2] Smokeless tobacco use in the form of gutkha is also highly prevalent in countries such as India.

Stressful life, workplace stress, and nature of work also influence smoking behavior of an individual. John et al.[3] studied a community sample of Northern German area and observed that higher work strain was associated with stronger relation with Fagerstrom Test for Nicotine Dependence (FTND). Migration in search of job from rural areas also influences the smoking behavior. Cui et al.[4] categorically demonstrated that rural-urban migrant workers manifested a high prevalence of stress in both life and work. Both forms of stress showed association with current smoking and life stress was found to outweigh the impact of work stress.

The sidestream smoke also called secondhand smoke is also harmful. Many studies till now have clearly demonstrated the association between exposure to secondhand smoke at home or at work and risk of chronic obstructive pulmonary disease which may also be a dose-dependent phenomenon. Therefore, smoking at workplaces not only harms the individual smoker but also puts his/her coworkers at risk of developing harmful hazards of smoking.

A study recently done in Delhi by Prashar et al.[5] and published in this issue titled, “Prevalence and correlates of nicotine dependence among construction site workers” raises at least three issues, namely, (i) is tobacco chewing safer than smoking, (ii) place of FTND in smokers, (iii) will smoke-free workplace help in this regard ?

The authors have found more numbers of tobacco chewers than smokers in their study. Both forms have nicotine as primary substrate responsible for addiction. Three to four times more nicotine is absorbed from chewing tobacco than smoking cigarette. It has higher risk of developing oral cancers apart from other known local effects in the oral cavity. However, the absence of sidestream smoke with this form prevents others from passive smoke exposure.

The authors have correlated various risk factors associated with a relatively high prevalence of smoking and tobacco use at workplaces. They have also been able to demonstrate that majority of their study population (78%) started smoking because of peer pressure, again supporting the role of workplace stress in commencement of tobacco use.

Tobacco users have varying degree of nicotine dependence. Nicotine being most important psychologically active drug in tobacco causes addiction similar to heroin and cocaine. Fagerstrom Tolerance Questionnaire (FTQ) is a simple and widely used paper and pencil test of nicotine dependence and correlates with other proposed measures of nicotine dependence (carbon monoxide, nicotine, and cotinine level). Recently revised version of FTQ, the FTND is as reliable as FTQ and has somewhat higher internal consistency.[6] The authors of the present study have used this test to assess nicotine dependence in their study population and reported 51% of them being moderate to severe dependent. Moreover, 60% of themselves found it difficult to refrain from smoking or chewing tobacco in public places; further supporting the fact that FTND may also predict the outcome with nicotine replacement as a function of dose.

Worksite tobacco control initiatives face a crucial challenge. Nicotine replacement therapy (NRT) is only one of options to quit smoking. Provisions of smoke-free workplaces are an area of debate from erstwhile and difficult to implement. However, does it work? A systematic review of smoke-free policies to reduce tobacco use by Hopkins et al.[7] has identified strong evidence of effectiveness of smoking bans and restriction in reducing environmental (secondhand) tobacco smoke, reduced tobacco use among workers with added economic benefits. Another study by Michael and Stanton compared the cost-effectiveness of NRT with state-wide smoke-free workplaces. They found that smoke-free workplace policies are about 9 times more cost effective than free NRT program and opined that it should be a public health funding policy even when the primary goal is to promote individual smoke cessation.[8]

David and Lois studied the motivational characteristics of smokers at workplace and revealed that <8% of the employed smokers were ready to quit smoking.[9]

Given the multiple risks of smoking and smokeless tobacco use, it is imperative that successful comprehensive programs are needed to be developed to protect and promote the health and quality life of workers.