THE ROLE OF EMPLOYERS IN FACILITATING SMOKING CESSATION AMONG STAFF: PERSPECTIVE OF DRIVERS IN A NIGERIAN UNIVERSITY.

BACKGROUND: Several interventions have been instituted to encourage smoking cessation among smokers. Many adults are currently working and spend several hours a day at work. Employers thus have a role to play in encouraging staff who smoke to quit. This study investigated the perception of drivers employed in the University of Ibadan, Nigeria on the role of their employers in facilitating smoking cessation among staff who smoke.
METHOD: All 176 drivers employed by the University and who were available on the days of the interviews were interviewed. A semi-structured questionnaire was used to obtain information on drivers' opinion on the role of employers in facilitating smoking cessation among staff.
RESULTS: All the drivers were male and had a mean age of 51.2 ± 5.8 years. Five (2.8%) drivers were current smokers. One hundred and thirty-six (77.3%) drivers were of the opinion that their employers had a role to play in encouraging smoking cessation among staff who smoke. They felt this could be done by organizing workshops to sensitize staff on the dangers of smoking 73 (53.7%), educating staff about the health effects of smoking 26 (19.1%) and arresting staff caught smoking during official hours 20 (14.7%).
CONCLUSION: Many of the drivers felt that their employers had a role to play in encouraging smoking cessation among staff. The University authorities should build on this and take specific steps to institute a comprehensive workplace antitobacco policy which includes smoking cessation interventions to assist staff who smoke to quit.

INTRODUCTION

Tobacco use including cigarette smoking is an established public health problem[1] and various efforts have been put in place to curb the practice. Current data indicates that the global prevalence of smoking is declining. However, rates still remain unacceptably high and appear to be increasing in some regions of the world such as the World Health Organization (WHO) Eastern Mediterranean Region and the African Region.[2] Data from the World Health Organization (WHO) revealed that globally, over 1.1 billion people comprising about 36.1% males and 6.8% females smoked tobacco in 2015 [2]. The Global Adult Tobacco Survey (GATS) conducted in Nigeria in 2012 recorded that approximately 3.7% of individuals aged 15 years and older (comprising 7.2% of males and 0.3% of females) were current cigarette smokers.[3] The deleterious effects of smoking on smokers and non-smokers exposed to environmental tobacco smoke have been previously documented.[1] Some of these deleterious effects include an increased risk of developing diseases/conditions including cancers of the respiratory and gastrointestinal systems; chronic respiratory diseases (e.g., asthma, chronic obstructive pulmonary disease); cardiovascular diseases and metabolic diseases.[1, 4, 5]

A high proportion of current smokers in Nigeria are adult men in the working age group[3] and this has undesirable effects that extend beyond the individuals who smoke. This is because employees who smoke at work expose non-smoking co-workers to their tobacco smoke and the attendant consequences of second-hand smoke. Studies have shown that workplaces constitute important source of exposure to second-hand smoke for non-smoking adults.[6-8] Furthermore, the establishment often incur losses from workers who smoke as a result of decreased productivity, increased sickness absenteeism and loss of workdays due to smoking-related illnesses, increased unproductive time during work hours as a result of smoke breaks and higher insurance premiums.[9] Employers thus have an important role to play in instituting workplace smoking-control policies and interventions in order to safeguard the health of their smoking and nonsmoking staff, ensure optimal workplace productivity and reduce unnecessary economic losses.

Workplaces have been identified as an ideal setting within which anti-smoking interventions can be implemented [10] especially because many adults currently work and spend considerable time at their workplace. This makes the staff relatively amenable to workplace anti-smoking inter ventions. Researchers have documented that smoke-free workplace policies lead to reductions in the prevalence of smoking and the amount of cigarettes consumed by the staff.[11, 12] Beyond having polices that prohibit smoking in the workplace, it is equally important for employers to provide smoking-cessation interventions to their staff. Extant literature has documented that smoking cessation interventions which are implemented in the workplace are cost-effective.[10,13] Some work places already have no-smoking policies which include smoking cessation interventions in place. For example, WHO has a policy that prohibits smoking on its premises, and in addition to this, the organization has specific interventions aimed at supporting smoking cessation among its staff. These include provision of counselling and follow-up, and provision of prescriptions for pharmaceutical therapy (including nicotine replacement products).[14]

In Nigeria, some tobacco control efforts have been in place although universal implementation and monitoring of tobacco control efforts are sub-optimal. In 1990, the military government in Nigeria passed the Tobacco Smoking (Control) Decree No. 20[15], (and later the Tobacco Smoking (Control) Act No. 20). The decree prohibited smoking in 'public places' (including cinemas, stadia, offices, public transport, lifts, medical establishments, schools, and nursery institutions) and prohibited use of print and electronic media, including television, to advertise tobacco. Furthermore, the decree mandated that the tar and nicotine content of tobacco be displayed on each pack, along with a warning from the Federal Ministry of Health stating that tobacco smoking is dangerous to health. Nigeria signed the WHO Framework Convention on Tobacco Control (FCTC) in June, 2004 (ratified in 2005). In 2015, The Nigerian Tobacco Control Bill (NTCB) was signed and became an act i.e., The Nigerian Tobacco Control Act 2015 [16] and this represented a landmark achievement in tobacco control in Nigeria.

There is limited published data on the existence of a no-smoking policy in workplaces in Nigeria or the extent to which workplaces in the country provide smoking cessation interventions to their staff. There are anecdotal reports that some establishments, especially those in the hospitality industry such as hotels and guest houses have no-smoking notices within their premises. An important step towards instituting comprehensive workplace tobacco control policies which should incorporate smoking cessation interventions is to engage with various categories of the employees including smokers, non-smokers, union leaders and management. This allows employees' perspectives and suggestions to be obtained and taken into consideration and also enables employee support for these tobacco control programmes.[9,17] A few studies have reported on the perception of employees on the role of their employers in implementation of work-place tobacco control policies and promotion of smoking cessation among staff. For example, Eadie et al in their paper on bar workers responses to the smoke-free legislation in Scotland reported that prior to implementation of the legislation, bar workers who smoked were generally resistant to the legislation while non-smokers were largely ambivalent. Both categories of bar staff however became more favourably disposed to the legislation, after it was introduced and they experienced some benefits of the legislation.[18] Thiede et al in their paper on the feasibility of promoting smoking cessation in small worksites, found that most of the employees felt their employers should promote or provide "non-pushy" ways to encourage their employees to quit smoking while few stated that, 'their smoking was none of their employer's business'.[19] We did not find any published literature on workers' perception about the role(s) of their employers in providing smoking cessation interventions for staff in Nigeria thus highlighting a gap in this important aspect of interventions relating to part II of the FCTC, i.e. the reduction of demand for tobacco.[20] In this study, our objective was to assess the University of Ibadan drivers' perception of the role of their employers in encouraging smoking cessation among staff. This information was collected as part of a larger study to improve the drivers' capacity for road safety and provision of first aid for road crash victims.[21, 22]

MATERIALS AND METHODS

This aspect of the larger study (on improvement of the drivers' capacity for first aid and road safety), involved a cross-sectional survey of all full-time drivers employed by the University of Ibadan, Oyo state, Nigeria and who were available on the days of the interviews. The University was established in 1948 and it is the Premier University in Nigeria.[23] University of Ibadan is owned by the Federal Government of Nigeria and in addition to academic and other categories of non-academic staff, drivers are also employed to drive the official vehicles attached to the University principal officers, heads of department and other service units. At the time of the study, the University did not have a workplace policy on tobacco control, however, being a public establishment, the provisions within the extant laws on smoking in the country; i.e. the Tobacco Smoking (Control) Decree 1990 No. 20 which prohibited smoking in 'public places' (including offices)[15] was applicable to the institution.

An inter viewer-administered semi-structured questionnaire was used to obtain information on drivers': (i) socio-demographic characteristics, (ii) awareness of a law prohibiting smoking in public places, (iii) awareness of workplace regulations regarding smoking and (iv) perception of the role of their employers in facilitating smoking cessation among its staff. The purpose of the study was explained to the drivers and they were assured that they were free to decline to participate and would not suffer any consequences if they decided not to participate in the study. All the drivers provided written informed consent.

Factors associated with the drivers' perception of the role of the University in facilitating smoking cessation amongst its staff was assessed using the chi square test. The independent variables were: drivers' age, highest level of education, drivers' awareness of a law banning smoking in public places, smoking status and use of other psycho-active substances. Data were analyzed using SPSS version 20 and the level of significance was set at p < 0.05. Ethical approval for the study was obtained from the University of Ibadan/ University College Hospital, Ibadan Ethics Review Committee. Permission to conduct the study was also obtained from the University and written informed consent was obtained from all the drivers.

RESULTS

A total of 176 drivers were interviewed. They were all male, had a mean age of 51.2 ± 5.8 years and the highest level of education was primary education for 107 (60.8%) of the drivers (Table 1). Five (2.8%) drivers admitted to currently smoking cigarettes and only one said he sometimes smoked while driving.

Table 1:

Socio-demographic characteristics of the respondents

Socio-demographic characteristics of the drivers	Frequency	Percentage
Marital Status(n=175)
Married	174	99.4
Widowed	1	0.6
Highest level of education
Primary	120	68.2
Secondary	47	26.7
Post-secondary	4	2.3
Others	5	2.8
Religion
Christianity	129	73.3
Islam	47	26.7

Eighty-three drivers (47.2%) were aware of a law prohibiting smoking in public places (Table 2). Seventy-one drivers (40.6%) felt that the University had an existing policy against smoking. The drivers who indicated that the University had a no smoking policy were asked to state what this policy entailed. Forty-six (64.8%) felt that the policy prohibited smoking in open areas/ public spaces within the University premises, nine (12.7%) mentioned that it prohibited smoking during office hours and seven (9.9%) each felt the policy included a health educational component which informed staff about the negative health effects of smoking, while seven (9.9%) said the policy prohibited smoking while driving. Two drivers stated that the policy mandated displaying of no smoking notices within the premises.

Table 2:

University drivers' awareness of an anti-smoking law/ policy and their perception of the role of their employers in facilitating smoking cessation among staff

Variables	Frequency	Percentage
Is respondent aware of any law banning smoking in public places (n = 176)
Yes	83	47.2
No	82	46.6
Don't know	11	6.3
Is respondents aware if the University has a no-smoking policy?
Yes, the University has a policy	71	40.6
No, University has no policy	104	59.4
Perceived elements of the University policy (n = 71)
Prohibition of smoking in open places on the	46	64.8
university premises
Prohibition of smoking during office hours	9	12.7
Prohibition of smoking while driving	7	9.9
Provision of health education on dangers of smoking	7	9.9
Displaying of no smoking notices	2	2.8
Suggested interventions the university can implement to facilitate smoking cessation among staff (136)
Organizing trainings/workshops	73	53.7
Health education on problems associated with smoking	26	19.1
Arresting smokers	20	14.7
Displaying no-smoking notices	14	10.3
Prohibit smoking when driving	3	2.2

One hundred and thirty-six (77.3%) drivers opined that their employers had a role to play in encouraging smoking cessation among staff (Table 2). The drivers explained that the institution could achieve this by organizing workshops to sensitize staff about the dangers of smoking 73 (53.7%), educating staff about the negative health effects of smoking 26 (19.1%), arresting staff caught smoking during office hours 20 (14.7%), and by putting up 'no smoking' notices within the premises of the university 14 (10.3%). None of the drivers mentioned the use of nicotine replacement therapy or other forms of cessation medication, counselling or establishment of peer mentor support networks.

None of the factors; drivers' age, level of education, awareness of the existence of a law banning smoking in public places, current use of tobacco or current use of at least one psycho-active substance was significantly associated with the drivers' perception that employers had a role to play in encouraging staff to stop smoking (Table 3). Although, the proportion of drivers who reported that their employers had a role to play in encouraging smoking cessation among staff increased with increasing age, this was not statistically significant.

Table 3:

Factors associated with drivers' perception that employers have a role to play in encouraging smoking cessation among staff

	Employer has a role to play in facilitating smoking cessation among smoking staff		X2	p-value
	Yes	No
Age group
< 40 years	3(50.0)	3(50.0)
40 -49 years	39(73.6)	14(26.4)
50 years and above	92(81.4)	21(18.6)	4.098	0.098
Highest level of education
Primary and below	96(76.8)	29(23.2)
Secondary	37(78.7)	10(21.3)
Tertiary	3(75.0)	1(25.0)	0.312	0.933
Current smoking status
Smokes	3(60.0)	2(40.0)
Does not smoke	133(77.8)	38(22.2)	0.874	0.319
Use of at least one psychoactive substance
Yes	38(82.6)	8(17.4)
No	98(75.4)	32(24.6)	1.010	0.414
Awareness of a law banning smoking in public places
Yes	65(78.3)	18(21.7)	0.096	0.756
No	71(76.3)	22(23.7)

A higher proportion of non-smokers 133 (77.8%) compared with smokers 3 (60.0%) also stated that employers had a role to play in encouraging smoking cessation among staff (this was not statistically significant).

DISCUSSION

The prevalence of smoking among the university drivers was found to be 2.8%. This is slightly lower than the national prevalence of current smoking of cigarette of 3.7% reported in the Global Adult Tobacco Survey [3] and comparable with a prevalence of 2.9% obtained in the Southwestern part of the country in the same survey. This prevalence is indicative of the early phase (stage I) of the tobacco epidemic modelled by Lopez et al when smoking prevalence and health consequences are low.[24] Interventions are very important during this period to prevent the rapid increase in prevalence which occurs towards the end of this stage as the epidemic progresses to the next stage.

About half of the respondents were aware of a ban on smoking in public places which is included in the 1990 Tobacco Smoking (Control) Decree (Act) No. 20. A little less than two-thirds of the drivers incorrectly mentioned that the University had a workplace policy against smoking. This was probably because they assumed that the Tobacco Smoking Act was synonymous with a workplace policy. However at the time of data collection and to date, the University is yet to institute a policy against smoking. This is an area which requires urgent action. It is encouraging that more than three quarters of the drivers stated that their employer had a role to play in facilitating smoking cessation among the staff and they provided useful suggestions of specific interventions which could be implemented. Findings from the qualitative study by Tiede et al similarly revealed that many of the employees interviewed felt that their employers had a role to play in promotion of smoking cessation in their workplace.[19] The specific interventions mentioned by our drivers focused mainly on education of smokers about the dangers of smoking and these are also similar to interventions highlighted by employers in other studies.[19, 25] A notable difference however, was that our respondents did not mention provision of quit lines, peer support, nicotine replacement therapy or drugs. This might be a reflection of the general low knowledge about smoking cessation interventions in Nigeria.[26-28] The importance of having a range of interventions has been emphasized as being important to improve the effectiveness of the intervention [25]. Approximately 14% of our participants mentioned arresting offenders as a possible workplace smoking cessation intervention. This is quite unlike the findings reported by Tiede et al in which the employees emphasized that the methods to be instituted by their employers should not be 'pushy'.[19] There was no statistically significant association between drivers' age, level of education, awareness of a national law or use of at least one psycho-active substance and the drivers' perception that their employers had a role to play in smoking cessation. Carroll et al in their review found varied results with respect to smoking status and support for a workplace smoking reduction or cessation policy.[25] They also found that smokers and non-smokers were in favour of the laws while others reported that smokers were not in favour of these policies.[25]

CONCLUSION

Our study findings revealed a relatively low prevalence of current smoking and many of the drivers were of the opinion that their employer had a role to play in helping staff to quit smoking. In view of this, we recommend that the University should take urgent steps towards instituting a comprehensive no-smoking policy which should incorporate cessation interventions. There will be need to involve other categories of staff in this process in order to ensure buy-in for the interventions when they are implemented.

Limitations

The design was cross-sectional and this precludes assertions of causality. Drivers comprise just one category of staff in the University, it could be useful to conduct a similar study among other categories of staff as part of efforts to develop a comprehensive no smoking policy for the University.