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Smoking cessation in the NetherlandsOccupational settings and nationwide policiesTroelstra, S.A.

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CHAPTER 8 General discussion

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GENERAL DISCUSSION

This thesis aimed to evaluate the potential effects of smoking cessation policies and

interventions at national and local levels, including occupational settings. Based on this work,

we aimed to contribute to the development of smoking cessation services in national, local and

occupational settings. In this chapter, the main findings of this thesis are summarised and the

methodological considerations are discussed. Furthermore, the contribution of this thesis to

the overarching goal of encouraging smoking cessation is considered. Finally, leading from the

findings, reflections and conclusions of this thesis, implications for policy and recommendations

for future research are discussed.

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MAIN FINDINGS

Smoking and work performance

The aim of the first part of this thesis was to provide insight in the relation between sustained

smoking, smoking cessation, and work-related outcomes. In chapter 2, we studied the relation

between smoking and sickness absence by conducting a systematic literature review and meta-

analysis of scientific literature on this topic. We found robust evidence that smoking increases

both the risk and number of sickness absence days in the working population, regardless of

study location, gender, age, and occupational class. Furthermore, we did not find any differences

in risk of sickness absence between studies differing in correction for confounders, research

design, assessment of sickness absence, and duration of sickness absence. This suggests

that encouraging smoking cessation at the workplace could be beneficial for employers and

employees in multiple occupational settings.

In chapter 3, we analysed the association of sustained smoking and quitting with sickness

absence, work productivity and work ability among older workers. We found that sustained

smokers had higher, but not statistically significant sickness absence compared to non-smokers.

We did not find differences in productivity loss and work ability for sustained smokers compared

to non-smokers. Comparing quitters to sustained smokers, we found less favourable results for

quitters compared to sustained smokers in three out of the six associations. Among individuals

with a relatively poor physical health at baseline, work ability was significantly lower for quitters.

However we found no significant differences in sickness absence and productivity loss. This

surprising finding might indicate that the benefits of smoking cessation for employers could

take a longer time to manifest.

Impact of tobacco control policies on population level

The second part of this thesis entails the population impact of several Dutch tobacco control

policies implemented in previous years. We aimed to evaluate the association between

tobacco control policy measures and behaviour related to smoking cessation. Hereby, Google

Trends search query data on search terms related to smoking cessation were used as proxies

of population interest in smoking cessation. In chapter 4, Google Trends analyses were used

to determine whether the introduction of smoking bans in restaurants and bars and the

reimbursement of smoking cessation encouraged people to consider to quit smoking. We found

that the introduction of a smoking ban in the Dutch hospitality industry in 2008 was associated

with an increase in Google searches for information on smoking cessation for several weeks

around the implementation of the campaign. Furthermore, we found that the reimbursement

of smoking cessation support by Dutch healthcare insurance companies in 2011, and its

reintroduction in 2013, were associated with an increase in Google searches for information

on smoking cessation for several months.

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Chapter 5 describes the impact of the yearly Stoptober campaign on the contemplation of

smoking cessation on a population level by using Google Trends analyses. We found that in

the period of 2014 to 2016, the Dutch Stoptober campaign was associated with a 11 to 22%

increase in Google searches for information on smoking cessation for several weeks, starting

from the week Stoptober commenced up to several weeks after. From these results, it would

seem that Stoptober may affect smoking-related outcomes in the national population at large.

Stoptober campaign and smoking cessation on individual level

The third part of this thesis focused on the evaluation of the Stoptober campaign on a participant

level instead of a population level. In chapter 6, we took a quantitative approach in evaluating

the effect of the Stoptober campaign on smoking cessation and socio-cognitive determinants

of smoking. We estimated that after three months, about 50% of the Stoptober participants

would have quit smoking. Furthermore, we found that those who continued to smoke consumed

significantly fewer cigarettes. This suggests that Stoptober is effective in increasing quit success

among those willing to quit, and in reducing tobacco consumption among those yet unable to

quit. Furthermore, among participants who had quit smoking we observed mainly favourable

changes in determinants of smoking cessation. Among sustained smokers, we also found

favourable changes in several determinants of smoking cessation. This suggests that given their

large reach and relatively low costs, temporary abstinence campaigns such as Stoptober can

contribute to tackling smoking at the population level.

In chapter 7, we qualitatively evaluated the working mechanisms of the Stoptober campaign and

explored the experiences of its participants. We found that Stoptober supported participants

in their cessation attempt according to its theoretical principles: social contagion, SMART

goals, and PRIME. Furthermore, we found that ongoing support would be needed to increase

long-term abstinence. These findings support the continuation and wider implementation of

Stoptober. Connecting Stoptober to support tools and regular smoking cessation services may

improve the long-term abstinence rates of smokers after the campaign.

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REFLECTIONS ON METHODS

In this section, the methods that were used in this thesis are reflected upon. First, the advantages

and disadvantages of the various research designs and their contribution to the conclusions of

this thesis are discussed. Furthermore, the way smoking status was measured and how this could

have influenced our results is considered. Finally, the generalizability of the results is deliberated.

Research design

One of the main strengths of this thesis is the diversity of research designs we were able to use

to investigate diverse aspects of smoking cessation. In doing so, we took a pragmatic approach,

by making use of secondary data and by evaluating the impact of already implemented smoking

cessation policies and interventions. Four chapters, chapters 2, 3, 4, and 5, were based on

secondary data analysis. For two chapters, chapters 6 and 7, we chose to collect new data. In

total, four different research designs were used: a systematic review and meta-analysis (chapter

2), a longitudinal observational design (chapters 3 and 6), a quasi-experimental design using

time-series analysis (chapters 4 and 5), and a qualitative study (chapter 7).

Systematic review

The main advantage of systematic reviews, and more specifically, meta-regression analyses, is

the ability to aggregate information from multiple studies, leading to a higher statistical power

and a more robust estimate of an association (1). In this way, we were able to provide a precise

estimation of the association between smoking and sickness absence in chapter 2. Furthermore,

we were able to investigate the influence of several sources of variation in sample characteristics

and study design. However, the main disadvantage of systematic reviews is the dependence on

information provided in already published individual studies.

Longitudinal observational design

Chapters 3 and 6 both used a longitudinal observational design (i.e. cohort study). By using a

longitudinal design were able to observe the temporal order between smoking status and subsequent

work productivity (chapter 3), and participation in a smoking cessation campaign and subsequent

changes in smoking status (chapter 6). In this way, we could distinguish cause from effect, which

would not be possible in a cross-sectional study (2). However, a main drawback of this design is

the loss of subjects to follow-up (2). In chapter 6, the drop-out rate was very high. Therefore, we

conducted a non-response analysis and adjusted our estimate of the three-month quit rate.

Quasi-experimental design

In chapters 4 and 5, we used a quasi-experimental design to research the influence of two

national tobacco control policies and a smoking cessation campaign. A quasi-experimental

study is an intervention study that compares an intervention and a control group without

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randomization, since randomization is often not feasible when researching the impact of national

policies and mass media interventions (3, 4). In these studies, we compared smoking cessation

related Google Search queries in the Netherlands around the implementation of these policies

to those in Belgium around the same time period. Quasi-experimental designs can circumvent

many of the drawbacks of randomised controlled trials, such as ethical, political, financial, and

time constraints (5). However, even though quasi-experimental studies can be used to estimate

causation, on their own they cannot be used to make definitive causal inferences, since there

could be alternative explanations for the observed effect. Therefore, the results should be

interpreted in the context of findings from other research and alternative explanations for

research findings should be considered carefully.

Qualitative design

In chapter 7, we used a qualitative research design by conducting and reporting on semi-

structured interview with Stoptober participants. In contrast to quantitative research,

qualitative research is able to capture opinions, experiences, attitudes, and interactions (6).

Using a qualitative design, we were able to understand how the campaign supported smokers in

their attempt to quit smoking. Furthermore, based on participants’ experiences and suggestions,

we were able to formulate several recommendations for improvement of the Stoptober

campaign. Qualitative research also has several drawbacks, such as being subject to researcher

bias, lacking reproducibility, and lacking generalizability (7). However, several methods can be

used to improve the quality, such as triangulation, respondent validation, and reflexivity (8).

Combining research designs

As demonstrated in the previous paragraphs, each research design has specific strengths and

limitations. In this thesis, we used different research designs to investigate the role of smoking

status on work productivity. Chapters 2 and 3 both focus on the relation between smoking

status and work-related outcomes, and strengthen each other in several ways. First, whereas

chapter 2 provides a robust estimation of the general effect of smoking on sickness absence,

chapter 3 provides information on the influence of smoking in a specific population: Dutch older

employees. Second, researching the influence of various sources of variation on study outcomes

in chapter 2 enabled us to identify potential biases in chapter 3, which helped us to interpret the

unexpected outcomes of this study. Furthermore, in our observational study we could influence

the quality of reporting. In fact, we applied the quality assessment of chapter 2 to chapter 3 and

scored 9 out of 10. Finally, in our observational study we also investigated the impact of smoking

cessation and compared sickness absence with other work-related outcomes.

Chapters 5, 6, and 7 of this thesis assessed the impact of the Stoptober campaign by using

different research designs, a quasi-experimental design (chapter 5), a longitudinal observational

design (chapter 6), and a qualitative research design (chapter 7). A strength of this thesis is that

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each of these three chapters provides a different perspective on the impact of the Stoptober

campaign. In chapter 5, we found an increase in Google searches for smoking cessation on

national population level, in chapter 6 we found that, after participation, about half of the

participants had quit smoking, and in chapter 7 we found that Stoptober functions according to

its theoretical working mechanisms. In this way, we were able to shed light on the way in which

Stoptober contributes towards reducing smoking prevalence in the Netherlands in terms of

percentage of quitters, change in behavioural determinants, change in precursors of smoking

cessation, theoretical working mechanisms, and experiences of participants.

Our evaluation of the Stoptober campaign and our research on the association between

smoking status and work productivity both illustrate how the (potential) effectiveness of real

world interventions can be assessed in a pragmatic manner. By deliberately combining research

designs to study different aspects of sustained smoking and smoking cessation, it is possible to

assess and quantify potential impact, and to understand how this was achieved, which would

not have been possible if a single type of research design was used.

Measuring smoking status

In chapters 3 and 6, we used self-reported measures of smoking status. Smoking status

measured by self-report has been shown to be reliable (10, 11) or somewhat underestimated

(12), when validated by biomarkers, such as saliva or urine cotinine levels. We measured smoking

cessation by looking at temporal changes in participants’ self-reported smoking status. By

measuring smoking status at different time points, such as over a period of six years (chapter 3)

or before and after the start of an intervention (chapter 6), we were able to associate (changes

in) smoking status with interventions and outcomes with more certainty. For non-smoking and

sustained smoking, this enables us to assess whether participants’ smoking status is stable over

time. However, for participants who quit smoking, we have only captured single moments of

the process of quitting, and are unable to reflect on the intricacies of the process of smoking

cessation.

In chapters 4 and 5, we used online searching for information on smoking cessation as a proxy

to measure smoking cessation. According to the Transtheoretical Model of Health Behaviour

Change (13), in the contemplation phase people recognise that their smoking behaviour might

be problematic and consider the advantages and disadvantages of smoking cessation, which

could be followed by the preparation and action phase. Searching online for information on

smoking cessation could be considered a way to deliberate on the advantages and disadvantages

of smoking cessation, thereby functioning as a proxy for the contemplation phase, and

potentially the preparation phase of smoking cessation, which is an important step in the process

of actual smoking cessation (13). The main advantage of this type of data is that it provides

outcomes on a weekly basis on a national level. In this way, it is possible to relate increases in

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online searching for information with the introduction of national policies and interventions

with considerable precision. However, it remains uncertain to what extent an increase in online

searching for information on smoking cessation reflects an increase in actual smoking cessation.

Therefore, a next step would be to ask a representative national sample of smokers to report

their smoking status on a weekly basis and to compare this information to online searches for

smoking cessation. In this way, online searching for information on smoking cessation could be

validated as a proxy for actual smoking cessation.

Generalizability

In this section, the generalizability of the findings presented in this thesis is deliberated. Both

the generalizability of the findings for different countries and different occupational groups

are considered.

In chapter 2, we included a combination of studies with populations from various countries. In

our meta-regression analysis, we did not find any difference in the association between smoking

and sickness absence for study populations from western and non-western countries. However,

the number of studies from non-western countries was quite small, which limits the statistical

power. Worldwide, there are large differences in terms of smoking prevalence, smoking culture,

and tobacco control policies. The global prevalence of tobacco smoking is 19.9% (14). However,

the smoking prevalence in Europe is 29.4%, whereas the smoking prevalence in Africa is 9.8%

(14). Furthermore, although gender differences in tobacco use are relatively small in Europe and

the Americas, they are much larger in other regions. Countries also differ largely in terms of their

tobacco control policy. The Tobacco Control Scale (TCS) compares tobacco control activities in

35 European countries and scores them on a scale from 0 to 100 (15). Together with Hungary,

Turkey, and Sweden, the Netherlands takes a ninth place, with a score of 53. In chapters 4 and

5 of this thesis, we compared Dutch online searching behaviour after the implementation of a

smoking cessation intervention to similar data from Belgium. In the TCS, Belgium is placed 17th,

with a score of 49, which is reasonably similar to the Dutch score. The United Kingdom has the

most comprehensive tobacco control policy, with a score of 81. The countries with the lowest

scores are Germany, Austria, and Luxembourg.

Even though we think that all measures included in this thesis have the potential to encourage

smoking cessation in all countries, these considerable differences might hamper the generalizability

of the findings of this thesis. For example, a much higher or lower smoking prevalence might

negatively influence participation rates in a smoking cessation campaign such as Stoptober.

Furthermore, in countries where there are few tobacco control activities the compliance with

a smoking ban might at first be lower, which could limit its influence on (the contemplation of)

smoking cessation. Therefore, the generalizability of the results from this thesis might be limited

to countries with similar smoking prevalence and tobacco control activities.

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In chapters 2 and 3, we included employees from all types of occupational settings. However,

working conditions have been shown to influence work productivity-related outcomes (16).

Furthermore, in most Western countries there are large differences in smoking prevalence

among occupational classes (17). This could be caused by differences in workplace culture

and work environment. One could imagine that for construction workers, who mainly work

outdoors, it might be relatively easy to smoke during their work, whereas office workers might

need to walk to go to a designated smoking area. In chapter 2, we did not find any difference

in the association between smoking and sickness absence for different occupational classes.

However, several studies did not provide information on occupational class and the majority of

studies used a general working population sample. Since most of the studies included in chapter

2, and our study in chapter 3, were general population studies, we think that our results could

be generalised to all occupational settings.

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REFLECTIONS ON ENCOURAGING SMOKING CESSATION

Measures to encourage smoking cessation

Traditionally, tobacco control measures are grouped in demand side and supply side measures

(18). Demand side interventions, for example tax increases, advertising and promotion bans,

public campaigns, and smoking bans aim to reduce the demand for cigarettes. Supply side

interventions, such as age limits, trade restrictions, and actions against smuggling, aim to

reduce the supply of cigarettes (19). In this thesis, a different approach was taken, namely by

categorizing tobacco control measures according to their level of implementation. Hereby,

measures implemented at a national level are considered macro-level, measures implemented

within communities or organisations are considered meso-level, and measures that can be

implemented within primary care settings or households are part of the micro-level.

Macro-level

On a macro-level, smoking cessation can be encouraged by implementing national policies, such

as mass media interventions, smoke-free legislation, taxation, marketing and advertising bans,

and reimbursement of smoking cessation support. This thesis focused on smoke-free legislation,

reimbursement of smoking cessation support, and mass media interventions. However, since

advertising bans and price increases are effective tobacco control measures, they are discussed

briefly.

Comprehensive tobacco advertising bans are effective measures to reduce tobacco consumption

(20, 21). In most developed countries a marketing and advertising ban is in place. However, in the

Netherlands tobacco specialty shops are still allowed to promote their products on a small scale.

From 2020, a point of sale display ban in supermarkets will be introduced, which could reduce

smoking prevalence significantly (22). Furthermore, as of 2020 plain packaging of tobacco products

will be mandatory in the Netherlands (23). Raising the price of cigarettes to consumers by taxation

can also reduce smoking rates (24). Reductions in smoking rates after tax increases are stronger for

developing countries and among adolescents, young adults, and lower SEP individuals. However,

the financial burden of cigarette taxes is greater for low SEP individuals, especially since many of

them will remain smokers after a tax increase (24). In order to not further increase socioeconomic

inequalities, the implementation of further tax increases for tobacco products should be paired

with smoking cessation support that is specifically targeted to lower SEP individuals.

An increasing number of countries has introduced national policies banning smoking in indoor

public places and workplaces. In the Netherlands, smoking bans are placed in a multitude of

settings. By Dutch law, smoking is prohibited in public places, workplaces, and the hospitality

industry (25). Smoke-free legislation is associated with improved health outcomes on a national

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level, but the impact of smoke-free legislation on smoking prevalence and cigarette consumption

is unclear (26). Smoke-free policies can create environments that help smokers to quit (27, 28), by

changing attitudes towards smoking (29) and by increasing the challenges of finding alternative

places to smoke (30). A study on the effects of Dutch smoke-free legislation found that the

workplace smoking ban of 2004 (exempting hospitality industry workers) was associated with

a decrease in smoking prevalence, but not the partial smoking ban in the hospitality industry in

2008 (31). In chapter 4, we found that the smoking ban in the hospitality industry was associated

with a temporary increase in online searching about smoking cessation (32). However, smoke-

free legislation can also increase stigmatization among smokers (33), which could make quitting

more difficult (34). Therefore, smoke-free legislation should be positively framed, for example as

a way to establish positive role models for youth and to avoid exposure to second-hand smoking

(34, 35).

Another way to encourage smoking cessation is to reimburse the cost of smoking cessation

therapy and treatment. In 2011, the Netherlands implemented a national policy for all healthcare

insurers to reimburse behavioural counselling or behavioural counselling with pharmacological

therapy. The implementation of this policy and the accompanying media attention was associated

with a significant increase in online searching about smoking cessation lasting for several weeks

(chapter 4), and significant increases in quit attempts and quit success (36). However, to ensure

that all smokers willing to quit smoking are aware of this opportunity, it is important to continue

informing the public about reimbursement policy and ensuring that adequate implementation

remains on the agenda of policy makers.

Mass media interventions disseminate cessation-related messages informing smokers and

motivating them to quit through television, radio, and printed media. Traditionally, mass media

interventions, focused on increasing knowledge on the risks of smoking, thereby assuming that

by increasing awareness of the health risks of smoking, people would change their behaviour

(37). Later on, mass media interventions changed their approach towards developing skills to

cope with pressure to smoke, increasing self-efficacy, and de-normalizing smoking. It is suggested

that mass media interventions can be effective as a part of comprehensive tobacco control

programs, by influence individuals’ knowledge, attitudes, and behaviour, but the evidence for this

effectiveness is heterogeneous and of limited quality (37). In chapter 5, we looked at influence

of the Stoptober campaign on a national level and found that the introduction of the campaign

was associated with an increase in online searching for smoking cessation, which can be seen

as a change in smoking cessation related behaviour. Therefore, campaigns such as Stoptober,

which use a combination of traditional and social media, are based on supportive and positive

messaging, and are aimed at increasing self-efficacy among smokers, might be effective at the

macro-level.

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Meso-level

At the meso-level, smoking cessation can be encouraged through the implementation of policies

by organisations and communities. Smoking is strongly influenced by social context and distal

cues (38), and many social interactions take place within organisations and communities.

A Cochrane review has been published on the effect of comprehensive community-based

interventions, including, among others, mass media, self-help materials, cessation groups,

support groups and smoking policies. This review concluded that the quality of the evidence

is low, and that the effects of these interventions on smoking prevalence is very limited (39).

The workplace is a promising setting to encourage smoking cessation. Multiple effective

workplace interventions for smoking cessation are available, such as group therapy, individual

counselling, provision of pharmacotherapy, and multiple intervention programs (mainly)

targeting smoking cessation (40). Furthermore, next to a legislative smoking ban for the

workplace, several organisations have introduced institutional smoking bans, for example by

banning smoking from the organisations’ premises. At the workplace, comprehensive smoking

bans can decrease tobacco consumption rates, however the evidence is mixed, with some studies

concluding that workplace smoking bans are mainly leading to a displacement of smoking (28,

38, 41-43). Employers can be encouraged to implement these policies and interventions by

informing them about the costs of smoking and the potential benefits of smoking cessation.

The Stoptober campaign was mentioned earlier as an example of a macro-level intervention

because of its mass media campaign approach. However, due to its strong social component,

Stoptober can also be seen as a meso-level measure. Stoptober encourages smokers to

participate in a collective quit attempt, and asks non-smokers to support their smoking friends

and family members in this endeavour (44). Furthermore, Stoptober aims to create a community

of quitters by emphasizing the message that “we are doing this together”, and by encouraging

participants to interact on social media. Participants have the possibility to share experiences,

learn from each other, and to provide and receive peer support (44). In this way, Stoptober aims

to create a social movement that functions at the meso-level.

According to our findings from chapter 6, about half of the Stoptober participants had quit

smoking after three months and participation in the Stoptober campaign was associated with

favourable changes in attitude, self-efficacy, social norms, and habit strength (45). However, in

chapter 7 we found that ongoing support is needed to increase long-term abstinence. At the

meso-level, participants reported a need for more face-to-face contact, by using their current

social networks, for example colleagues, to stop smoking collectively or by facilitating local

Stoptober networks (46). In line with our respondents, studies on online smoking cessation

support suggest that face-to-face contacts may have added value for remaining abstinent (47,

48), especially for smokers who lack support in their own social circle (49). To establish such

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contacts, Stoptober could encourage participants to use their current social networks to stop

smoking collectively (e.g. together with work colleagues) or facilitate participants building an

additional social network (e.g. through local Stoptober meetings).

Micro-level

At the micro-level, smoking cessation can be encouraged through interventions on a household

and individual level. This thesis mainly focused on macro- and meso-level measures. However,

from chapter 7, we concluded that Stoptober could be improved by intensifying activities

at the micro-level. Connecting Stoptober participants to local smoking cessation services

may improve the long-term abstinence rates after the campaign. This could help smokers to

overcome barriers to using these services (50) and increase the likelihood of taking advantage

of professional support. Furthermore, by referring participants to primary caregivers, they can

receive pharmacological interventions, such as nicotine replacement therapy (NRT), bupropion,

varenicline, and cytisine. This would improve their chance of quitting, with low risk of adverse

effects (51).

Encouraging smoking cessation in the occupational setting

In this thesis, smoking cessation was approached from both a public health perspective (chapters

4 to 7) and from an occupational health perspective (chapters 2 and 3). However, public health

and occupational health are strongly interrelated. Work-related factors such as income, benefit

packages, physical demands, work stress, job insecurity, and exposure to occupational hazards

can lead to an increase in adverse health behaviours and health outcomes (52, 53). Furthermore,

through income, power, occupational prestige, and social connectedness, work largely influences

socioeconomic position, an important determinant of health behaviour (54). Worksite health

promotion and public health prevention have developed as rather separate domains (55, 56).

However, integrating these fields has major advantages, such as the possibility to reach specific

populations, provide new venues for health interventions, and promote the wellbeing of working

populations in a more holistic way (54, 57). Therefore, in this section the role of occupational

health in strengthening public health by encouraging smoking cessation will be discussed.

First, the benefits of using the workplace as a setting for smoking cessation and the factors

that influence successful implementation of smoking cessation interventions in the workplace

are discussed. Seconds, the benefits and drawbacks of implementing smoker-free workplace

policies, policies that do not focus on restricting or banning the act of smoking, but instead aim

to ban smoking employees from the workplace, are considered.

Benefits and implementation factors of encouraging smoking cessation at the workplace

Approaching smokers at the workplace has the potential to reach large groups of people and

specifically target vulnerable populations (58). In developed countries, smoking prevalence

and tobacco consumption levels are much higher among individuals with a low SEP. Therefore,

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they form an important target group for smoking cessation interventions. However, low SEP

smokers are hard to reach, less willing to participate in smoking cessation interventions,

and less likely to be successful in quitting smoking. For example, while smoking occurs more

frequently among lower educated adults, relatively more smokers with a higher education level

participated in Stoptober. Since people with similar cultural, social, and economic backgrounds

are often concentrated in occupational groups, the workplace can be used to specifically target

employee groups with a high smoking prevalence, such as blue-collar workers (59, 60). However,

individuals with a low SEP are more likely to be unemployed. In order to access this group of

vulnerable smokers, alternative strategies at the meso and micro-level should be used, such as

referral by primary care workers and active recruitment by local smoking cessation support

services (61).

Next to the potential to reach large groups and target specific groups of smokers, utilizing the

workplace as a setting for smoking cessation has several other advantages. First, the available

organisational structures, and communication channels can be used. For example, key persons can

be identified easily to help with development and implementation of the intervention, and email

messages, notification boards, or team meetings can be used to disseminate the intervention

(59, 62). Second, since most people spend a large part of the week at their work, workplace

interventions have the potential for high exposure rates. Furthermore, the already existing

social networks can be used to promote the intervention, provide peer support and influence

social norms (40, 63). Co-workers can either positively influence their colleagues, by quitting

together or providing support and shared experiences (63). Social norms at the workplace,

either descriptive of subjective, can facilitate behaviour change (64). Fourth, occupational

health professionals can also play an important role in the design and implementation of

smoking cessation interventions (58), since they have expertise in worksite health promotion,

are familiar with the working conditions, and have knowledge of the organisational structures.

Finally, employers can support participants by providing opportunities and incentives to their

employees (63). The evidence on using financial incentives to increase participation rates is

mixed. One recent RCT on the use of financial incentives found significant increases in long-

term abstinence rates (65).

Smoker-free workplace policies

More recently, some organisations have increased their efforts to decrease smoking prevalence

among their employees by implementing a smoker-free workplace policy. These policies do not

focus on restricting or banning the act of smoking, but aim to ban smoking employees from the

workplace instead. In practice, this often means that companies refrain from hiring smokers

and ask smoking employees to quit within a designated time period. Officially, employers are

not allowed to select potential employees based on their lifestyle, unless there are specific

demands placed on the job. Work settings that could entail specific demands concerned with

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smoking are for example submarines (66), and the offshore petroleum industry. In the past, some

organisations were allowed to implement a smoker-free workplace policy, since hiring smokers

would be against their organisational philosophy and exemplar role (67). For example, in 2005,

the World Health Organisation stopped hiring smokers (68).

Employers might also be motivated to implement smoker-free policies because of the potential

cost savings from the reduced productivity of smokers, as shown in chapter 2. The wider

implementation of smoker-free policies has far-reaching consequences. Several of these

consequences are positive. For non-smokers, their exposure to second hand tobacco smoke

will decrease. For smokers who quit after the implementation, the policy might also have positive

consequences, since their health status will most likely improve, which might cause an increase in

their productivity level (chapter 2). Furthermore, they would be less likely to relapse because the

lack of cues to smoke at the workplace and the potentially severe consequences of continuing

to smoke.

However, from an ethical and public health perspective, smoker-free policies are a controversial

method to encourage smoking cessation (69), even when the implementation of such a policy

would be paired with extensive smoking cessation support. Employees unable or unwilling to

stop smoking might find themselves being let go and unemployed. Unemployment can lead to

an increase in adverse health behaviours and health disparities (52, 68). Furthermore, smoking

rates are significantly higher among individuals with a lower SEP. Therefore, discrimination

based on smoking status might lead to increases in social inequalities and further stigmatization

of an already marginalised and often vulnerable group (70). Finally, by allowing employers to

discriminate based on smoking, a gliding scale might be introduced, where employees might also

want to control other off-duty lifestyle aspects, such as nutrition, physical activity and alcohol

intake (71).

Therefore, we do not support smoker-free policies, unless hiring smoking employees would be

seen as hypocritical, for example a smoking tobacco control advocate, or when smoking would

be hazardous, for example at the offshore petrochemical industry (72). Instead, if employers

want to reduce smoking prevalence among their employees, they should offer smoking cessation

interventions at the workplace. To increase participation rates they could offer the intervention

free of charge and during working hours.

Considerations for the future

Multiple effective and cost-effective measures are available to encourage smoking cessation,

and for most Western countries smoking prevalence rates are projected to decline in the

coming decades. However, according to a Dutch report, without the implementation of new

smoking cessation measures, the decline in smoking prevalence would stagnate in the next

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08

decade (Figure 1) (74). Smokers might become less sensitive towards already existing measures.

Therefore, more extensive measures and more comprehensive measures are necessary to

decrease smoking prevalence.

The most effective way to decrease smoking prevalence is the implementation of the World

Health Organisation MPOWER measures, including monitoring of tobacco use, a complete ban

on smoking in public places, free and easily accessible cessation advice and help from healthcare

workers, graphic pictorial health warnings on tobacco products, mass media campaigns, a

complete ban on tobacco marketing, and a tax increase on tobacco products. This could decrease

smoking prevalence in the Netherlands up to 5% in 2050 (Figure 1). The findings from this thesis

contributed to the body of evidence on the effectiveness of smoking bans in public places, or

more specifically the hospitality industry, the reimbursement of smoking cessation advice or

support, and smoking abstinence mass media campaigns.

In 2018, the Dutch Government, together with multiple stakeholders, presented the National

Prevention Agreement (“Nationaal Preventieakkoord”). The National Prevention Agreement

aims to lower smoking prevalence up to 5% by 2040, with taxation, point of sale display bans,

plain packaging, reducing points of sale, legislative smoking bans for schools, playgrounds,

kindergartens, petting zoos, sports clubs, and healthcare organisations. Furthermore, the

agreement aims to lower financial barriers to smoking cessation support, to encourage

companies to become smoke-free, and to encourage the development of smoking cessation

tools for occupational health professionals and to share best practices (23).

According to projections of the Dutch National Institute of Public Health and the Environment,

implementation of all measures proposed in the National Prevention Agreement might indeed

lower smoking prevalence to 5% by 2040. However, in order to eliminate smoking among

adolescents and pregnant women, two secondary aims of the National Prevention Agreement,

more extensive strategies are necessary, such as further tax increases, smoking bans, and point

of sale reductions (75).

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0

5

10

15

20

25

2015 2017 2020 2030 2040 2050

Smok

ing

prev

alen

ce %

Year

Reference (continued implementation of current policies)

Tax increase 5%

Tax increase 10%

Annual mass media campaign

WHO MPOWER measures + 5% tax increase

WHO MPOWER measures + 10% tax increase

No one starts smoking

Figure 1. Projected effects of tobacco control policies on smoking prevalence in the Netherlands (74).

General discussion

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08

IMPLICATIONS FOR POLICY AND PRACTICE

As mentioned above, the National Prevention Agreement aims to lower smoking prevalence up

to 5% by 2040. The full implementation of all measures proposed in the agreement might lead to

this reduction. Each smoker that quits today brings us one step closer to a healthier, more equal,

and more productive society. Therefore, it is important to critically evaluate the potential of

settings and interventions to encourage smoking cessation and to identify ways to increase their

effectiveness. From this thesis, several recommendations can be derived for policy and practice.

Continued implementation of Stoptober

The results from this thesis suggest that the Stoptober campaign, given its large reach and

relatively low costs, might be effective in encouraging smoking cessation at the macro-level.

Therefore, it is recommended to continue the implementation of Stoptober with similar or

increased efforts and resources. The reach and effectiveness of the campaign could be increased

by integrating the campaign with other smoking cessation measures. The time period of the

Stoptober campaign could be used as a window of opportunity for interventions targeted at

smokers who contemplate smoking cessation. For example, at the macro-level the government

could inform the public about the reimbursement policy for smoking cessation support or use

October 1st as the first day to implement a tobacco taxation increase in order to encourage

smokers to participate in Stoptober and quit smoking.

On a meso-level, Stoptober could be implemented in the occupational setting by employers.

During the first phase of Stoptober, employees can be encouraged to participate in Stoptober.

Promotional material could be supplied to employers by Stoptober and could be disseminated

by occupational health professionals through the already available communication channels.

Furthermore, employers could appoint Stoptober ambassadors. These ambassadors are

employees who quit smoking themselves and are willing to encourage their co-workers to quit

smoking too. In collaboration with occupational health professionals, these ambassadors could

set up a support group of employees that want to participate in Stoptober. The members of

this social support group could supply social support to each other during Stoptober and in

the following months. Employers could provide incentives to their employees to encourage

participation and successful smoking cessation, for example by allowing the group to meet

during working hours and providing rewards for each week or month that participants remain

abstinent.

On a micro-level, Stoptober participants could be connected to local smoking cessation services.

This could help smokers to overcome barriers to access support and may improve the long-term

abstinence rates after the campaign. Primary care workers could actively advice their smoking

patients to quit and refer them to local smoking cessation support service. Furthermore, if

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Stoptober participants are encouraged to visit their primary caregiver for quit advice, they

could receive pharmacological interventions, which would improve their chance of quit success.

Furthermore, at the meso-level, Stoptober could facilitate the formation of local Stoptober

meetings in order to increase social support.

The outcomes of this thesis suggest that temporary abstinence campaigns such as Stoptober

can contribute to tackling smoking at the population level. These results support the wider

implementation of the campaign in other countries. Currently, Stoptober has been implemented

in the United Kingdom, France, New Zealand, and the Netherlands. However, other countries

with high access to traditional and social media channels, where a significant part of the smoking

population reports wanting to quit smoking, might also benefit from the implementation of

Stoptober. To increase implementation success in other countries, an international advisory

board for Stoptober could be installed to coordinate communications and activities, and to share

best practices.

Opportunities for the occupational setting

Even though the findings of this thesis on the relation between smoking and work productivity

are inconclusive, generally, smokers have a lower work productivity compared to non-smokers.

If employers want to reduce smoking prevalence among their employees, they should offer

smoking cessation interventions at the workplace. As argued in this thesis, implementing

smoking cessation interventions in the occupational setting has the potential to be highly

effective. To increase participation rates they could offer the intervention free of charge and

during working hours.

Legislative measures

According to the National Institute for Public Health and the Environment, to eliminate smoking

among vulnerable groups such as adolescents and pregnant women, more extensive strategies

are necessary, such as further tax increases, smoking bans, and point of sale reductions (74).

However, these strategies have the potential to further increase social inequalities. Further

smoke-free legislation, such as the smoking ban on premises of schools, petting zoos, and child

day-care centres that are included in the National Prevention Agreement, could be an effective

measure to reduce tobacco prevalence. In order to avoid marginalization and stigmatization of

already vulnerable groups, smoke-free legislation should be framed positively. A similar case can

be made for the implementation of further tax increases for tobacco products, which are also

part of the National Prevention Agreement. Tax increases place a heavier financial burden on

lower SEP individuals. In order to not further increase socioeconomic inequalities, they should

be paired with improved access to smoking cessation support that is specifically targeted to

lower SEP individuals and free of charge.

General discussion

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RECOMMENDATIONS FOR FUTURE RESEARCH

Based on this thesis, several recommendations for future research can be formulated. First,

the diverging results from chapters 2 and 3 indicate that the relation between smoking status

and work productivity is complex. Therefore, more research is needed on the short- and long-

term effects of smoking cessation on work-related outcomes, in populations from different age

groups and different occupational settings, is necessary to formulate conclusions on the relation

between smoking cessation and work productivity.

In this thesis, two chapters researched the impact of smoking cessation policies and interventions

using Google Trends data. These chapters serve as examples of the potential of big data and

natural experiments in evaluating smoking cessation policies and interventions. This type of data

and methodology could be used to assess the impact of various measures at the national level,

including aspects from the National Prevention Agreement. However, as mentioned before, it

remains uncertain to what extent an increase in online searching for information on smoking

cessation reflects an increase in actual smoking cessation. Therefore, a nationally representative

panel of smokers who report their smoking status on a weekly basis should be composed. The

information derived from this panel should be compared to the weekly volume of online searches

for smoking cessation. In this way, online searching for information on smoking cessation could

be validated as a proxy for actual smoking cessation.

Three chapters in this thesis were based on the Stoptober campaign. In chapter 6, we evaluated

the effects of Stoptober after three months. Due to high drop-out rates we were not able to

evaluate the long-term effectiveness of Stoptober. Therefore we had to estimate the abstinence

rate after one year. Another drawback of this study was that smoking status was only reported

at a very limited number of moments, which makes it difficult to draw conclusions on the process

of smoking cessation during temporary smoking abstinence campaigns such as Stoptober.

Therefore, a new longitudinal study should be conducted to accurately map smoking cessation

trajectories until one years after the campaign. To avoid high drop-out rates, a smaller, more

selective sample of smokers should be recruited and actively approached, by telephoning or text

messaging, to complete all questionnaires. By using very brief surveys, that only include a few

simple questions participants can answer on their phone, we might be able to obtain daily data on

smoking status during Stoptober and weekly data for up to one year after. Additionally, qualitative

research among Stoptober participants, especially among participants who relapsed during or

after Stoptober, could increase insight in the timing and triggers of relapse. This information

could be used to improve the campaign and increase the effectiveness of Stoptober and other

smoking cessation interventions. A final recommendation to encourage smoking cessation is to

conduct research on the reach and effectiveness of Stoptober in different national, local, and

occupational settings.

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CONCLUSION

During the past decades, smoking has been increasingly recognised as an unprecedented

population health problem, due to its negative influence on health status, work productivity,

and societal costs. This thesis aimed to contribute to the development of smoking cessation

services in national, local and occupational settings, by evaluating the potential effects of

smoking cessation policies and interventions at national and local levels, including occupational

settings. We found evidence that smoking increases both the risk and number of sickness

absence days in the working population, but did not find evidence that smoking cessation

improves work-related outcomes. Therefore, more research is needed on the relation between

smoking cessation and work-related outcome in different populations. The smoking ban in the

hospitality industry, the reimbursement of smoking cessation support, and the yearly Stoptober

campaign were associated with increases in searching for information on smoking cessation in

the Dutch population. We found that about half of the Stoptober participants had quit smoking

after three months and that the campaign supported its participants according to its theoretical

principles. In order to further reduce smoking prevalence, employers should offer smoking

cessation interventions at the workplace, further smoke-free legislation should be implemented,

and the costs of smoking cessation services should be reimbursed. Furthermore, the reach and

effectiveness of the Stoptober campaign could be increased by cooperating with employers,

local smoking cessation services, and primary care givers.

.

General discussion

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