Allison Erickson
MPH 515
Using the Social Cognitive Theory to Reduce Smoking Prevalence among Night Shift Workers
Principles of Health Behavior
Dr. Kimberly Brodie

Smoking is the number one leading cause of preventable death in the United States, leading to more than 440,000 deaths per year, according to the Centers for Disease Control and Prevention (CDC)
(2013). More men than women use cigarettes and the behavior is more prevalent among American
Indians, adults between ages 25 and 44 years old, and among adults who are living below the national poverty level. This behavior is more prevalent in the Midwest and Southeast regions of the United States
(CDC, 2013). Using tobacco causes chronic disease such as cardiovascular disease, high blood pressure, diabetes, and respiratory diseases like chronic obstructive pulmonary disease (COPD) and asthma.
According to the CDC (2013), “Smoking causes an estimated 90% of all lung cancer deaths in men and
80% of all lung cancer deaths in women.” In addition, 90 percent of deaths that are caused by COPD are the result of smoking. When examining cardiovascular disease, it has been determined that the chemicals and carcinogens found in cigarettes narrow blood vessels, which reduces the blood flow to tissues and organs. This reduction in blood flow can lead to muscle and tissue death, as well as a stroke and heart attack. In fact, smokers are two to four times more likely to have a stroke or coronary heart disease (CDC,
2013). With such information about the deadly effects of tobacco use, health departments across the country, with the partnerships of local organizations and companies, are working at reducing the prevalence of such damaging and deadly behaviors.
The United States is a country that works 24 hours per day, seven days a week. Because of this drive for productivity and production, many of the employees in the United States have irregular working hours. These irregular working hours, also known as shiftwork, are the hours before seven in the morning and after six in the evening. In other words, shift work is working anything from 6:00pm to 7:00am any day of the week. “Many shift workers ‘rotate’ around the clock, which involves changing work times from day to evening, or day to night” (CDC, 1997, p. 2). According to McMenamin (2007), about 21 million, or 17.7 percent, wage and salary workers work alternative shifts. More specifically, 6.8 percent work between 2:00pm and 12:00am, 3.8 percent have irregular schedules, 3.1 percent work between
9:00pm and 8:00am, and 2.7 percent of the employees work hours that change periodically (McMenamin,
2007). Among the employees that are considered “shift workers,” 52.7 percent work in the hospitality and
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leisure services, 33.0 percent in entertainment and recreation, 31.5 percent in mining, and 31.5 percent in the warehousing and transportation industries (McMenamin, 2007). When examining gender and race in relation to shift workers, McMenamin (2007) indicates that men are more likely than women and non-
Hispanic blacks are the most prevalent race in such positions making up 23.2 percent. The next most prevalent race is Hispanics at 18.1 percent.
Due to the vast number of individuals working irregular hours, researchers and medical professionals have carried out numerous studies examining the health risks associated with the irregular hours. One such health concern is cardiovascular disease (CVD). Wang, Armstrong, Cairns, Key, and
Travis (2011) indicate that there is a 40 percent increased risk of CVD among night and rotating shift workers when compared to day workers. There was also indication that the number of myocardial infarction increase among populations of shift workers, as well. As stated by Nabe-Nielsen, Garde,
Tuchsen, Hogh, and Diderichsen (2008),
It has been suggested that the pathway between shift work and CVD partially proceeds through behavioral changes caused by shift work. Results from earlier studies—most often men—show that several major cardiovascular risk factors [smoking, hypertension, diabetes, and high cholesterol concentration] are more prevalent among shift workers than among day workers. (p. 206)
There is also a strong link between night shift workers and increase in tobacco use. Nabe-Nielsen et al. (2008) indicate that one prospective studied showed that the number of cigarettes smoked per day increased among shift workers than day workers. Thus, it is seen how the higher prevalence of CVD among night shift workers can be linked to the increase in tobacco use among this population.
Researchers in Sweden studied a group of night shift workers at a paper mill. The results indicated that,
“the longer people worked night shifts, the more likely they were to develop heart disease” (CDC, 1997, p. 18). However, the researchers indicated that because of an irregular work schedule, the stress the employees were feeling could be an underlying factor for heart disease. Nonetheless, there is report that a combination of the stress, eating behaviors, smoking, and other stress factors may play a large role in the increase in heart disease among this population.
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The behavioral risk factor of most interest among this population of shift workers is tobacco use, specifically cigarette use. According to Circadian Age, Inc. (2009), about twice as many night shift workers smoke compared to daytime workers. Circadian Age, Inc. (2009) mentions that when an individual craves a cigarette that craving impairs the concentration skills of the individual. A study from the University of Pittsburgh found that when an individual craves a cigarette, they are not only unaware of the lack of concentration, but also on the lack of the ability to focus (Circadian Age, Inc., 2009). Moving forward, those that work irregular shifts also report having difficulty with sleeping during the daytime when not working. Although one’s circadian rhythm may be interrupted due to work schedule, research has begun to examine how smoking behaviors may play a part in the disrupted sleep patterns when one is not working. Free radicals from cigarette smoking have been shown to antioxidative capacity of serum levels of certain enzymes and in melatonin levels. Ozguner, Koyu, and Cesur (2005) studied this relationship between smoking and antioxidant capacity in melatonin. Results indicated that smoking causes high oxidative stress, which decreases melatonin levels (Ozguner et al., 2005). Thus, from this information, one can see how smoking among shift workers will more greatly impact sleep behaviors than non-smoking shift workers.
Previous and current literature has implemented health promotion program designs to impact the tobacco use of employees both in night shift and regular working hours. Zheng et al., (2007), used the
Social Cognitive Theory for the implementation of a smoking cessation program among smokers in
China. Baseline questionnaires were distributed to participants prior to program implementation. All participants were divided randomly to the control or the intervention group. Among the participants, 118 smokers were in the intervention group and 107 were in the control group. Within the program design,
Zheng et al., (2007) focused on self-efficacy, information about smoking habits, intention of quitting, and health risks that come from smoking. In addition to the focus areas mentioned, Zhen et al., (2007) also evaluated the participant’s stage change using the Transtheoretical Model of Change. “Self-efficacy (SE) in smoking cessation was assessed by SE scales. All SE items were measured on a 7-point scale and scored from ‘not at all sure I am able to” (-3) to ‘very sure I am able to’ (+3)” (Zheng et al., 2007, p. 149).
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Not only was self-efficacy evaluated, but self-belief was also examined on a seven-point scale. General health status was also asked by the researchers. The intervention comprised of five, two-hour sessions with three health education professionals. Each session also included four or five activities that promoted self-efficacy, provided knowledge about the health risks of smoking, and discussed advantages and disadvantages to smoking. Other activities included writing farewell letters to cigarettes and learning coping strategies to manage cravings and stressful situations (Zheng et al., 2007). Results indicated that the average daily cigarette consumption decreased significantly in the intervention group compared to the control group. Also, actual smoking cessation occurred more frequently in the intervention group (Zheng et al., 2007). Self-efficacy was also reported to be higher among the intervention group following a sixmonth follow-up from the program. A limitation noted by the researchers was that the participants for both the control and intervention group lived in the same community, some even neighbors. Therefore, there is report that there could have been bias formed in the intervention group knowing they were receiving an intervention. Another potential limitation was that the control group began receiving intervention after six months of being in the control group. Therefore, after 12 month follow-ups, the researchers had a difficult time correctly comparing the two groups. However, the previous limitation could be considered a strength of the program design as it showed to improve the reduction and cessation of smokers within both groups.
Continuing, Nishiura et al., (2009) studied how smoking prevalence at a workplace effects individual smoking cessation. Using aspects of the ecological theories, Nishiura et al., (2009), “attempted to identify the effect of environmental conditions on individual smoking cessation behavior” (p. 49). The total number of participants was 12,124 workers from 230 different work units. Outcomes that Nishiura et al., (2009) were looking for was a change in smoking status. “A self-administered questionnaire was distributed at the time of the health checkup to obtain smoking status, time to first cigarette after waking up, desire to quit smoking, the number of cigarettes smoked per day, and respiratory symptoms”
(Nishiura et al., 2009, p. 50). Out of all 230 work units, blue-collar workplaces showed a smoking prevalence of 55.2 percent compared to 31.3 percent of white-collar workplaces. “Smoking prevalence
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was lower among females and higher among night shift workers” (Nishiura et al., 2009, p. 50). Although there was no formal health program implemented among the populations studied, Nishiura et al., (2009) indicate that one’s social environment, especially in the workplace, can impact smoking behaviors.
Nishiura et al., (2009) indicate,
Smoking prevalence is presumed to reflect the degree of group norms for or against smoking. In a work unit with lower smoking prevalence, smoking would be regarded as unacceptable behavior since smoking during work hours would mean a temporal excuse from work. Social pressure against smoking would lead to a stronger motivation to quit and a higher likelihood of quitting. (p. 54)
Lastly, Nishiura et al., (2009) propose that the study results may bring to light important implications for health program planning and implementation in which workplaces can impact the smoking behaviors of employees. “In such cases, education should be individually tailored and reinforced by taking the social environment into account” (Nishiura et al., 2009, p. 54). One limitation of the study was that the researchers were unable to correctly identify if the workplace influenced smoking behaviors directly or if the smoking behaviors influenced the workplace environment.
The final literature under review occurred in 1982 among the membership of Group Health
Cooperative of Puget Sound (GHC) which served about 325,000 people in the Puget Sound region in
Washington State. A year-long study influenced the GHC to ban smoking on all hospital campuses and facilities (Rosenstock, Stergachis, and Heaney, 1986). After communication was sent to employees of the hospital facilities, program administered stated that the ban would occur one year from communication.
Decision to prolong the ban for one year was for the health educators to provide educational opportunities for smoking cessation for the employees. After reviewing the literature, there was no indication of any specific theory that was used. However, the program implementers utilized educational opportunities prior to the smoking ban. Stage one focused on providing employees with information about the smoking ban. There were open meetings held at different sites to ask questions and discuss the best ways to implement the ban. In stage two members of the program implementation focused on self-help printed materials and smoking cessation classes. The final stage, stage three, was the smoking ban that occurred
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in the GHC facilities. The ban on smoking resulted in an acceptance rate of 85 percent of the employees of GHC. Of these, 21 percent believed the ban improved their quality of work. In addition, 67 percent of the smokers prior to implementing the ban indicated that the ban was a catalyst to quit smoking. A limited noted from the study was the low participation numbers for the smoking cessation classes. Only two individuals participated. Because of such low participation, Rosenstock et al., (1986) indicate that the number of employees who successfully quit was lower than expected. Nonetheless, there is also indication that the ban helped individuals reduce the number of cigarettes consumed per day.
The population that will be the aim to change will be night shift workers who are cigarette users.
Based on the aforementioned information, reducing tobacco use among this population will alleviate health risks, improve working capability, improve sleep behaviors, and save both the individuals and company money. In a suburb of a metropolitan area is a small manufacturing company of around 50 fulltime employees. Of the 50 employees, many work at night as the corporate office in the city houses all the day time employees. Around two-thirds, or 33 individuals, of the night shift staff are smokers.
Contractually, employees receive one 30 minute break and two 15 minute breaks when working an 8 hour shift from 9:00pm to 5:00am. However, out of the smokers in the company, many will sneak a few five minute smoke breaks. A team of wellness professionals has been contacted by the corporate office of the company to develop and implement a smoking cessation program for the employees. The managers and
Chief Executive Officer (CEO) of company have received several complaints from non-tobacco users about the frequent breaks and how the smell of smoke is quickly traveling from outside to the manufacturing building. This has been causing distraction and respiratory concerns among the nonsmoking staff. Also, with the frequent breaks, management is realizing the loss of production time and money.
The team of wellness professionals utilizes the Social Cognitive Theory (SCT) for program development. “Social cognitive theory was developed and has been refined to apply to health behavior by
Albert Bandura” (DiClemente, Salazar, and Crosby, 2013, p. 165). SCT is useful in health behavior change because it focuses on one’s social environment, one’s personal characteristics, and behavioral
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interactions with others. Within the SCT there are five key constructs: Knowledge, perceived selfefficacy, outcome expectations, goal formation, and sociostructural factors (DiClemente et al., 2013). The team of wellness professionals decides to name the program “Quit for YOU!” This name suggests that although the company is enforcing the classes, the program goal is, first and foremost, to quit for oneself and for the benefits all around.
Beginning with knowledge, the public health officials will, first, receive knowledge about how tobacco use is beneficial to the night shift workers. By gaining this information, the intervention can be more attentive to the needs and desires the employees are seeking. Using motivational interviewing (MI) techniques, the wellness professionals will create a gateway of knowledge about why changing the behavior will be beneficial from a health prospective and from an employment standpoint. This technique will also be used in conversation with the program participants about what is important to them about quitting and an opportunity to share knowledge about the effects of smoking physically, mentally, and financially. In addition, using posters, brochures, and quick facts around the workplace will influence the knowledge of the employees aiding in the influence to change the behavior.
Next, perceived self-efficacy will be evaluated through one-on-one conversation with the employees. The wellness staff will evaluate the employee’s perceived ability to make the change based on past quit experiences including quit attempts and what has worked or not worked. Questions will ask about task-specific understanding. For example, questions will evaluate if the individual has a high selfefficacy in quitting completely or in reducing the number of cigarettes smoked per day. These questions will help to tailor the program to individual needs and desires. The goal in this stage is to increase selfefficacy individually and through the group. By increasing self-efficacy within a group of people, the employees will feel a greater sense of ability because other people around them are quitting, too. In addition to this, the program developers will have large group settings with those that have high and low self-efficacy to allow for learning opportunities from each other. Creating group-efficacy will allow for greater maintenance and accountability from each other when finally making the change. Finally in this stage, the program will focus on positive messaging like, “YES! You CAN do this!” or “I will feel
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(something positive here) when I make this change!” These messages aid in verbal persuasion and acknowledgement that the change is possible through positive self and group talk.
Outcome expectations will focus on the benefits of making this change. Benefits will be examined on the personal, familial, workplace, financial, and workplace levels. Again, the goal of the program is to allow the employee to see that making this change benefits the individual first with the other benefits following closely behind. By tying in the positive messaging, the program will encourage participants to use messages such as, “If I quit smoking, then I will have whiter teeth” instead of “If I quit smoking, I will be tired all the time.” Encouraging these messages for outcome expectations will increase the perceived susceptibility that the individual is making a change for good, rather than bad. This step will also be evaluated from a group standpoint within group settings. The group will discuss with one another about what the perceived outcome should be and how making this change as a benefit will be a benefit to the whole, rather than a detriment. Outcome expectations will be evaluated at the beginning of program implementation to evaluate what the employees hope to receive from the program.
In the goal formation process, the wellness professionals begin to assist the employees in goal setting. The focus will be to individually set goals with the participants, but we also want to set group goals to be working on collectively. Individual goals will make the progress personal and group goals will make the progress and success collective. Wellness professionals will utilize the SMART goal format setting Specific, Measurable, Attainable, Realistic, and Timely goals for long-term success. Because of the specific and individualistic nature of setting a SMART goal, the wellness professionals determine those goals will be used only for individuals and not groups. The groups will set goals that are more target oriented and group developed. The individual’s goals will have parameters and time frames to be met by a specific time designated by the individual. As goals are met, the goal would be for self-efficacy to increase as well for the individual and the group together.
The sociocultural factors step in the process will be implementing throughout the program. One of the long-term goals of the program is to begin to change the culture from a smoking culture workplace to a workplace of intolerance toward smoking. This will begin as the employees have a sense of urgency
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to make the changes based on knowledge, self-efficacy, and the outcome expectations. Program developers see this occurring as the employees begin to share successes and struggles with one another throughout the quitting process. Developing a sense of unity in making the changes will begin to change the culture to one of success in quitting rather than one that cannot make the changes. Furthermore, the wellness staff will utilize leadership from the company to cheer the employees on and engage with them in conversation about how this will impact the life of the employee personally, but also how the change will impact the culture of the workplace for good. Bringing in leadership during this stage offers the employees the confidence that people from the top of the company are helping change the sociocultural factors in the work environment.
Within the SCT is the Reciprocal Triadic Causation Model. This model consists of three aspects:
Person, Environment, and Behavior. The “person” part of this model was discussed in detail in the above program design for smoking cessation. Among the “environment” this can be linked to the sociocultural factors and how the wellness professionals will include management and leadership of the company to help in changing the working environment. Another way that the environment will be changing is that management will allow for only one designated smoking break areas farther away from the building. This requires the employees to walk further to take a smoking break. Leadership sees that this will aid in reducing the number of “five minute breaks” employees are taking in addition to allowed breaks. While brainstorming, management also decides with the wellness team that the employees have to clock out every time a smoke break is taken. This will include the breaks already designated, however, these breaks will not dock pay, the extra breaks will. Finally, the changes in behavior have also been discussed prior.
Through the use of setting SMART goals, meeting in group and individual sessions, and implementing the program for a full year, the behaviors of smoking will begin to change.
Throughout program implementation and follow-up, the wellness professionals will survey and evaluate the employee’s satisfaction with the program, satisfaction with the job, and overall health status.
By examining these factors throughout the program, the staff will be able to adjust and accommodate the needs of the employees and management for long-term success.
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Smoking is the leading preventable cause of death in the United States. The behavior has been shown to lead to chronic disease like CVD, diabetes, hypertension, and COPD. Among night shift workers, smoking is two times more likely, when compared to dayshift workers. Although night shift workers suffer from sleep problems, stress, and other health concerns, tobacco use has been shown to worsen these conditions. Therefore, program development for smoking cessation among this population will not only aid the employee personally, but will save the employer thousands, if not millions, of dollars every year. According to Professional Assisted Cessation Program (PACP) (n.d.), in 1999 the CDC reported that a total of $157 billion was lost due to tobacco use. This figure was a combination of lost productivity and medical expenses. With this information, the push for more wellness programs among the workplace is vitally important for the physical, mental, and financial health of employees and employers. Utilizing health behavior theory for program development and implantation, health professionals will be able to effectively and scientifically assist positive health behavior change.
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References
Centers for Disease Control and Prevention. (2013). Health effects of cigarette smoking. Retrieved from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.
htm
Centers of Disease Control and Prevention. (1997). Plain language about shift work. Retrieved from: http://www.cdc.gov/niosh/docs/97-145/pdfs/97-145.pdf
Circadian Age, Inc. (2009). Working nights. Retrieved from: http://www.workingnights.com/blog/2009/12/17/new-shift-work-information-on-weight-lossand-apnea-craving-a-smoke-and-the-combined-effects-of-caffeine-and-alcohol/#more-1180
DiClemente, R.J., Salazar, L.F., & Crosby, R.A. (2013). Health behavior theory for public health.
Burlington, MA: Jones and Bartlett.
McMenamin, T.M. (2007). A time to work: Recent trends in shift work and flexible schedules. Retrieved from: http://www.bls.gov/opub/mlr/2007/12/art1full.pdf
Nabe-Nielsen, K., Garde, A.H., Tuchsen, F., Hogh, A., & Diderichsen, F. (2008). Cardiovascular risk factors and primary selection into shift work. Scandinavian Journal of Work, Environment, &
Health, 34(3), 206-212.
Nishiura, C., Narai, R., Ohguri, T., Funahashi, A., Yarita, K., & Hashimoto, H. (2009). The effect of smoking prevalence at worksites on individual cessation behavior. Journal of Occupational
Health, 51, 48-56.
Ozguner, F., Koyu, A., & Cesur, G. (2005). Active smoking causes oxidative stress and decreases blood melatonin levels. Toxicology and Industrial Health, 21, 21-26.
Professional Assisted Cessation Therapy. (n.d
.) Employers’ smoking cessation guide: Practical approaches to a costly workplace problem.
Retrieved from: http://www.endsmoking.org/resources/employersguide/pdf/employersguide-2nd-edition.pdf
Rosenstock, I.M., Stergachis, A., & Heaney, C. (1986). Evaluation of smoking cessation policy in a health maintenance organization. American Journal of Public Health, 76, 1014-1015.
Wang, X.S., Armstrong, M.E.G., Cairns, B.J., Key, T.J., & Travis R.C. (2011). Shift work and chronic disease: The epidemiological evidence. Occupational Medicine, 61, 78-89.
Zheng, P., Guo, F., Chen, Y., Fu, Y., Ye, T., & Fu, H. (2007). A randomized controlled trial of group intervention based on social cognitive theory for smoking cessation in China. Journal of
Epidemiology, 17(5), 147-155.
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