AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 46:170–179 (2004)

Reducing Occupation-Based Disparities Related to Tobacco: Roles for Occupational Health and Organized Labor Elizabeth M. Barbeau, ScD, MPH,1,2 Deborah McLellan, MHS,1 Charles Levenstein, PhD, MSOH,3 Gregory F. DeLaurier, PhD,3 Graham Kelder, JD,1 and Glorian Sorensen, PhD, MPH1,2

Background Persistent and growing occupation-based disparities related to tobacco pose a serious public health challenge. Tobacco exacts a disproportionate toll on individuals employed in working class occupations, due to higher prevalence of smoking and exposure to secondhand smoke among these workers compared to others. Methods We provide an overview of recent advances that may help to reduce these disparities, including research findings on a successful social contextual intervention model that integrates smoking cessation and occupational health and safety, and a new national effort to link labor unions and tobacco control organizations around their shared interest in reducing tobacco’s threat to workers’ health. Conclusions Implications of these efforts for future research and action are discussed. Am. J. Ind. Med. 46:170–179, 2004. ß 2004 Wiley-Liss, Inc. KEY WORDS: tobacco control; organized labor; occupational health; health protection-health promotion

INTRODUCTION The prevalence of current smoking shows a clear and inverse occupational gradient. Tobacco exacts a disproportionate toll on individuals employed in working class

1 Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts 2 Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts 3 Department of Work Environment, University of Massachusetts Lowell, Massachusetts Contract grant sponsor: American Legacy Foundation, Consortium on Organized Labor and Tobacco Control; Contract grant number: 6263; Contract grant sponsor: National Cancer Institute; Contract grant numbers: 5 RO1CA68087, 5 P01CA75308; Contract grant sponsor: Larry and Susan Marx Foundation. *Correspondence to: Elizabeth Barbeau, Center for Community-Based Research, DanaFarber Cancer Institute, 44 Binney Street, Boston, MA 02115. E-mail: [email protected]

Accepted 20 March 2004 DOI 10.1002/ajim.20026. Published online in Wiley InterScience (www.interscience.wiley.com)

 2004 Wiley-Liss, Inc.

occupations, due to higher prevalence of smoking and exposure to secondhand smoke among these workers compared to others. The United Kingdom’s new occupational classification schema, explicitly ‘‘constructed to measure employment relations and conditions of occupations,’’ and employing five categories that span from ‘‘managerial and professional’’ (Class 1) to ‘‘semi-routine and routine’’ (Class 5) [Office for National Statistics, United Kingdom, 2003], was used to examine the prevalence of current smoking among the total US adult employed population in 2000. Prevalence was highest among workers in classes 4 and 5 (36.8 and 32.4%, respectively) and lowest among workers in class 1 (17.8%) [Barbeau et al., 2004]. Similar gradients were observed for the three largest racial/ ethnic groups in the US (non-Hispanic Whites, non-Hispanic Blacks, and Hispanics), and for women and men. These differences in smoking prevalence by occupation persisted even when controlling for income, education, race/ethnicity, age, and gender, thereby indicating an important and distinct relationship between current smoking and occupational

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class. These findings are consistent with prior US national studies on smoking and occupation [Sterling and Weinkam, 1976, 1990; Brackbill et al., 1988; Levin et al., 1990; Anonymous, 1992; Nelson et al., 1994; Leigh, 1996; Giovino et al., 2000; Bang and Kim, 2001], which have grouped occupations in relation to skill and industry, e.g., ‘‘whitecollar’’ versus ‘‘blue-collar,’’ or specific types of jobs, e.g., ‘‘construction laborers.’’ That is, whether occupations are classified by the UK or US schema, the findings are strikingly consistent: those employed in working class occupations are more likely to smoke than other workers. Furthermore, bluecollar workers smoke more heavily [Giovino et al., 2000] and are less successful in quitting despite a similar rate of quit attempts, compared to other workers [Giovino et al., 2000; Barbeau et al., 2004]. Over time, blue-collar workers’ rates of smoking have declined more slowly than those of other workers [Giovino et al., 2000], creating a growing gap in smoking between blue-collar and white-collar workers. Raising the salience of tobacco’s burden on these workers is the fact that smoking prevalence and exposure to occupational hazards, some of which interact synergistically with tobacco [National Institute for Occupational Safety and Health, 1979], are positively related, thereby posing a dual threat to workers’ health [Sterling and Weinkam, 1990; Sorensen et al., 1996a; Sorensen, 2001]. Additional tobacco-related health risks among the working class stem from a lack of protection from secondhand smoke. Blue-collar and service workers are more likely to be

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employed in worksites that permit smoking [Gerlach et al., 1997]. Persistent and growing occupation-based disparities related to tobacco pose a serious public health challenge. Addressing this challenge is a complex task, and here we discuss recent advances that may help to reduce these disparities. We present research findings on a successful social contextual intervention model that integrates smoking cessation and occupational health and safety, and a new national effort to link labor unions and tobacco control organizations around their shared interest in reducing tobacco’s threat to workers’ health. We also discuss implications of these efforts for future research and action.

A SOCIAL CONTEXTUAL FRAMEWORK FOR REDUCING OCCUPATION-BASED DISPARITIES IN SMOKING PREVALENCE To date, little research has been conducted to develop effective methods to reduce occupational disparities in smoking. Drawing on a range of social and behavioral theories and lessons from social epidemiology [Glanz et al., 1990; Krieger, 1994; Bandura, 1977, 1997; Prochaska et al., 1997; Berkman and Kawachi, 2000; Krieger, 2001; Sorensen et al., 2004], we have articulated a theoretical framework to explicate the social contextual pathways by which socioeconomic position, including occupation, may influence smoking behavior (Fig. 1) [Sorensen et al., 2004]. Illuminat-

FIGURE 1. Social contextual model for smoking cessation.

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ing the pathways by which occupation may influence smoking behaviors may improve the relevance and salience of smoking cessation interventions for workers most at risk of smoking and thereby enhance the efficacy of these efforts. The framework identifies a set of mediating and modifying mechanisms that may help to explain the link between occupational status and smoking. Mediating mechanisms are targeted by the intervention program itself, under the hypothesis that changes to the mediating mechanism will lead to changes in the intended health or behavioral outcomes. Modifying conditions, in contrast, independently impact outcomes but are not targeted for change by the intervention. Considering the relationship between occupation and smoking, one could identify through the peer-reviewed literature a range of potential mediating and modifying mechanisms that may be useful in crafting interventions to reduce smoking among blue-collar workers. Using a social ecological framework, we organize mechanisms or factors of particular relevance to blue-collar workers across multiple levels of influence spanning individual, interpersonal, organizational, neighborhood, and societal levels (See Fig. 1) [McLeroy et al., 1988; McKinlay, 1993; Stokols, 1996; Sallis and Owen, 2002]. At the individual level, these workers may have less access to material resources to help them quit smoking. According to 1997 NHIS data, bluecollar workers were less likely than white-collar workers to be offered assistance with smoking cessation by their employers [Giovino et al., 2000]. Also at the individual level, the functional meaning of smoking for blue-collar workers may be tied to being able to take a ‘‘smoking break’’ or to escape from pressures imposed by the job. At the interpersonal level, there may be strong social norms that support smoking behavior within certain occupations. In a study of 44 worksites, Sorensen et al. [2002a] found that compared with other workers, blue-collar workers reported less pressure to quit smoking, less social support for quitting, and more acceptability of smoking among their co-workers. Pressure to quit and support for quitting were associated with intention to quit smoking, illustrating the importance of social norms in shaping workers’ smoking behaviors. At the organizational or workplace level, a host of factors may influence smoking behaviors. As previously noted, bluecollar workers are more likely to be employed in worksites that permit smoking [Gerlach et al., 1997]. This is significant because studies have demonstrated that worksite policies that restrict or ban smoking reduce the prevalence of smoking among active smokers [Biener et al., 1989; Borland et al., 1990; Marcus et al., 1992; Brenner and Fleischle, 1994; Brigham et al., 1994; Jeffrey et al., 1994; Hammond et al., 1995]. Smoking behavior has also been shown to be associated with increased job strain [Green and Johnson, 1990; Landsbergis et al., 1998] stemming from the way that jobs are structured. A key organizational-level factor that

may link occupational status and smoking behavior is exposure to occupational health and safety hazards. As noted earlier, workers who smoke are more likely to work in jobs that entail exposure to job hazards [Sterling and Weinkam, 1990; Sorensen et al., 1996a; Sorensen, 2001], and prior research has shown that blue-collar workers exposed to and concerned about job hazards are also more likely to be thinking of quitting smoking or taking action to quit smoking, controlling for gender, race, and education [Sorensen et al., 1996a]. Applying the social contextual model depicted in Figure 1 in smoking cessation trials among blue-collar workers, Sorensen et al. [2001] have conducted a series of studies to test the effectiveness of interventions aimed at tobacco control as well as at reducing hazardous occupational exposures, a key priority for many blue-collar workers. Reductions in occupational hazards were conceptualized as a mediating mechanism, based on the hypothesis that interventions to reduce occupational hazards would contribute to improvements in smoking cessation rates among these workers. There are several reasons to address occupational health and safety as a mediating mechanism in smoking cessation programs for blue-collar workers [Sorensen, 2001]. First, exposure to both job hazards and cigarettes increases workers’ overall risk of disease [National Institute for Occupational Safety and Health, 1979], and therefore addressing both of these hazards reduces overall health risks. Second, workers may view their personal smoking behaviors as within a ‘‘zone of nonacceptability’’ for management actions, while job-related health and safety issues may be seen as a too-often ignored responsibility of management [Barnard, 1968; Green, 1988; Youngstrom, 1996]. Skepticism about management’s commitment to improve worker health may reduce workers’ interest in participating in individually-focused health promotion programs at work, particularly when occupational exposures are not addressed [Sorensen et al., 1995; Warshaw and Messite, 1998; Morris et al., 1999]. Intervening with management to reduce occupational health and safety issues is a more holistic approach to workers’ health than intervening with workers alone, and may increase the credibility and acceptance of messages for workers about individual health behaviors [Green, 1988; Sorensen, 1998]. Finally, workers may experience a sense of futility in improving health habits, such as quitting smoking, when faced with the dual exposure to workplace hazards. The first of the studies by Sorensen et al., WellWorks, was part of a multi-center trial (the Working Well Trial) testing the effects of a comprehensive worksite cancer prevention model aimed at nutrition and smoking, using a randomized controlled design in 114 worksites nationwide, including 24 at the WellWorks sites [Abrams et al., 1994]. Only the WellWorks project tested the effectiveness of a model integrating health promotion and occupational safety

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and health protection [Sorensen et al., 1995]. This intervention integrated messages on tobacco control, nutrition, and occupational health in programs for both workers and management. The WellWorks project was the only one of four study centers in which a significant result for smoking cessation was observed; the 6-month quit rate in the intervention worksites was 17.3%, compared to 12.7% in the control sites (P ¼ 0.037) [Sorensen et al., 1996b]. This study was followed by a second study to assess whether the integration of occupational health and safety and health promotion programs (including tobacco control) was more effective than health promotion programs alone [Sorensen et al., 2002b]. The WellWorks-2 Study used a randomized, controlled design with the worksite as the unit of assignment and intervention; analyses were conducted controlling for worksite. After baseline assessments, 15 manufacturing worksites were randomly assigned to one of two conditions: (1) worksite health promotion only (HP Group; eight worksites); and (2) worksite health promotion plus occupational safety and health (HP/OSH Group; seven worksites). An a priori hypothesis was that the HP/OSH intervention would have the most relevance, and thus be more effective, for workers in hourly jobs where exposures to hazards on the job were more common than among salaried jobs. Results of this study for smoking cessation outcomes among blue-collar (hourly) and white-collar (salaried) workers are presented in Figure 2. Smoking quit rates among hourly workers in the HP/OSH condition more than doubled relative to those in the HP condition (11.8% vs. 5.9%; P ¼ 0.04), and were comparable to quit rates of salaried workers. There were no differences in quit rates between groups for salaried workers. Thus, this approach holds great promise for reducing disparities in prevalence of smoking and success in quitting between blue-collar and white-collar workers. Affirming that the HP/OSH intervention resonated more strongly with workers, we found that workers were significantly more likely to attend intervention programs in the HP/OSH condition than in the HP condition [Hunt et al., 2004]. Another important finding of this study relative to workers’ overall health status was that worksites in the intervention condition made statistically significant im-

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provements in their health and safety programs, compared to control sites [LaMontagne et al., 2004]. The sample size of worksites in the study was too small to provide sufficient statistical power to detect relationships between these improvements and worksite-level smoking cessation rates. The results, however, are important because they demonstrate a positive change in overall worksite health and safety, which was identified as a key social contextual mediating variable in the intervention. This social contextual approach integrating health promotion with occupational health protection responds to increasing calls for a comprehensive approach to worker health that addresses health behaviors such as smoking within the overall aim of creating healthy workplaces [Robins and Klitzman, 1988; Walsh et al., 1991; DeJoy and Southern, 1993; Blewett and Shaw, 1995; Sorensen et al., 1995; Baker et al., 1996; Chu et al., 1997]. Reinforcing a call issued by the US National Institute of Occupational Safety and Health (NIOSH) some 20 years ago [National Institute for Occupational Safety and Health, 1984], John Howard, current director of NIOSH, recently endorsed comprehensive workplace illness and injury prevention programs that integrate health promotion and health protection [Howard, 2003]. Over the past 20 years, there have been growing numbers of worksite programs that integrate efforts to reduce behavioral risks, including smoking, with health protection initiatives such as occupational health and safety programs [Marcus et al., 1986; Roter et al., 1986–1987; Schenck et al., 1987; Maes et al., 1998; Sorensen, 1998]. Sorensen’s research provides a model of a worksitebased health promotion-health protection intervention that is likely to improve smoking cessation rates among blue-collar workers and to improve overall health and safety conditions. There are numerous additional pathways to be explored in the social contextual model presented here, such as the potential mediating influences of job strain and other features of work organization, workers’ social support and norms [Gottlieb and Nelson, 1990; Green and Johnson, 1990; Baker et al., 1996; Morris et al., 1999; DeVries and Lechner, 2000], management commitment to workers’ health [O’Donnell et al., 1997; Emmons et al., 2000; Allen, 2002], social contextual factors outside of work, and the role of labor unions [Sorensen et al., 2000; Barbeau et al., 2001a; Siqueira et al., 2003–2004].

A ROLE FOR ORGANIZED LABOR IN TOBACCO CONTROL

FIGURE 2. WellWorks-2 results: Adjusted 6-month quit rates at final by intervention and job type (cohort of smokers at baseline: n ¼ 880) [Sorensen et al., 2002b].

Research studies such as those described above provide an important foundation for action to reduce tobacco’s toll on the working class, but research alone will be insufficient to stem the growing gap in smoking prevalence and the disparities in workers’ exposures to secondhand smoke by occupation. Addressing this problem will require action and

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advocacy. The potential for organized labor to engage in tobacco issues on behalf of its predominantly working class constituency has been largely untapped. And yet for several reasons, unions can be strong partners for tobacco control advocates [Barbeau, 2001]. First, unions have a longstanding commitment to worker health, as evidenced by their advocacy around worker health and safety [Levy and Wegman, 2000] and the support that many unions demonstrate for worksite tobacco control programs and policies [Sorensen et al., 2000]. Second, unions are likely to understand the day to day realities of their members’ lives, and can help to make tobacco control issues more relevant to workers’ concerns. As the president of the Laborers International Union of North America put it:

At our union we have accepted the challenge of addressing our members’ health issues head on. Our programs in this area demonstrate that unions can tackle tobacco control and cancer prevention in ways that make sense within a union environment . . . The message we get out is this: smoking not only can ruin your health, it can shorten your career and endanger your ability to provide for your family [O’Sullivan, 2001]. Third, unions are positioned to bargain with employers for protection of workers from secondhand smoke [Siqueira et al., 2003–2004] and for insurance coverage for smoking cessation services [Barbeau et al., 2001a; Ringen et al., 2002]. Fourth, based on the prevalence of smoking among working class workers (about 35%) and the number of unionized workers in the US (16.3 million) [Bureau of Labor Statistics, 2000], we estimate that unions represent 5.6 million, or about one in eight smokers in the US. Unions may be a reliable and trusted source of information on tobacco issues. And fifth, unions have an established infrastructure for communicating with and mobilizing their members to action. Prior to 2001, there was little evidence of union advocacy for tobacco control, with notable exceptions being the flight attendant union’s important role in banning smoking on airlines and efforts by Local 1199 of SEIU to increase tobacco taxes in New York State [Barbeau et al., 2001b]. Moreover, there was little effort by public health and tobacco control organizations to involve unions in tobacco issues. But this lack of union involvement and effort on behalf of tobacco control organizations to reach out to labor unions is beginning to change.

THE ORGANIZED LABOR AND TOBACCO CONTROL NETWORK In 1995 and 2000, we convened national conferences of individuals and organizations interested in labor and tobacco

issues [Sorensen and Youngstrom, 1996; Barbeau et al., 2001b]. At the latter of these, conference attendees developed recommendations for action, including the establishment of a coordinating center focused on labor and tobacco. Based on this recommendation, in 2001, the American Legacy Foundation, a national tobacco control organization, provided seed support to the Dana-Farber Cancer Institute and the University of Massachusetts Lowell to build the Organized Labor and Tobacco Control Network (the Network). The first organization of its kind, the Network’s mission is to reduce class-based health disparities due to high rates of tobacco use and exposure to secondhand smoke among working people and their families. It aims to spark a national dialogue and action aimed at bringing labor unions and tobacco control organizations together to reduce health disparities related to tobacco. The Network is guided by an advisory board of high-ranking leaders of the labor and tobacco control movements, including the general president of the Laborers’ International Union of North America (LIUNA), president of the Massachusetts AFL-CIO, director of collective bargaining for the National Education Association (NEA), executive director of the New York Committee on Occupational Safety and Health (NYCOSH), director of the respiratory health division of NIOSH, president of the California Building and Construction Trades Council, and director of California’s tobacco control program, among others. The priorities of the Network are to increase tobacco cessation among working people and their families, support financial coverage for tobacco treatment through health insurance plans offered by employers or through Taft-Hartley funds, and reduce exposures to secondhand smoke and other hazards at the worksite. It accomplishes its mission through inter-connected research and capacity building programs. Major goals of the Network’s research program are to discover ways to reduce class-based disparities in smoking through behavioral and policy research and to foster a network of investigators interested in labor and tobacco issues. Current research projects include a randomized controlled trial conducted in collaboration with LIUNA to test the effectiveness of a telephone-based tailored smoking cessation and nutrition program for construction laborers, a pilot project to test the feasibility and effect size of a smoking cessation intervention that integrates information about tobacco and work-related toxics for apprentices in the building trades (based on a program originally developed by and for the California Building and Construction Trades Council), and research based on tobacco industry documents directed toward developing a nuanced understanding of tobacco industry and public health efforts to work with organized labor. Through its capacity building program, the Network seeks to educate and enhance the ability of unions to engage in tobacco-related issues and to raise awareness among tobacco control and public health organizations of the importance of

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involving unions in their work. The Network staff accomplish these objectives by meeting with labor and tobacco control leaders, conducting training and educational sessions with small groups and at national conferences, disseminating written materials and fact sheets on key issues, providing educational materials that aid in understanding proposed regulations or legislation, and creating opportunities for leaders from these two movements to meet and share resources. We note here a few examples of the Network’s activities. Based on introductions made by the Network, the national Campaign for Tobacco Free Kids has awarded NYCOSH with a grant to garner union support for a statewide worksite smoking ban. NYCOSH’s executive director had successfully mobilized several unions to testify in support of the New York City smoking ban as a means of reducing bar and restaurant workers’ exposure to secondhand smoke. The Campaign was impressed by NYCOSH’s city campaign and has partnered with it to deepen and expand support across the state. In Massachusetts, the creation of a labor-tobacco control collaboration resulted in a labor leader testifying in support of several local ordinances for worksite smoking bans in large cities that were seen as pivotal in the ongoing effort to pass a statewide worksite smoking ban in Massachusetts. At the national level, the network has helped to craft tobacco control objectives specifically related to blue-collar and service workers as part of the Center for Disease Control and Prevention (CDC) Healthy People 2010 Objectives for the Nation [Healthy People 2010, 2003; Kelder and Barbeau, 2003].

FUTURE PRIORITIES Reducing and eliminating occupation-based disparities in smoking prevalence and exposure to secondhand smoke will require a concerted national effort focused on research and action, drawing on the energy and skills of a range of interested entities. Here we outline future research and action priorities, as well as obstacles and opportunities for achieving these priorities.

Future Research Priorities In this study, we summarized recent epidemiologic findings [Barbeau et al., 2004] that highlight the need to continue to monitor smoking rates by occupation. That there is a separate and independent effect of occupation on smoking prevalence provides further evidence that income and/or education are not stand-in measures for occupational class [Barbeau et al., 2004], as has been reported elsewhere as well [Krieger et al., 1993; Kington and Nickens, 2001; Williams, 2002; Krieger, 2003; Williams, 2003]. It is vital that Healthy People 2010 continue to set and monitor progress toward national objectives for reducing smoking among blue-collar and service workers.

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We also presented a social contextual model to illuminate pathways between occupation and smoking behavior [Sorensen et al., 2004], a model that can be used to conceptualize and test interventions aimed at reducing occupation-based disparities in smoking. Guided by this model, Sorensen has found that when smoking cessation programs are integrated with efforts to reduce job-related health and safety hazards [Sorensen et al., 1995], blue-collar workers are significantly more likely to quit, compared to workers exposed to a smoking cessation-only program [Sorensen, 1998; Sorensen et al., 2002b]. If this intervention were disseminated to the population of blue-collar smokers in Massachusetts alone, an estimated 2,880 cases of lung cancer could be avoided, with additional benefits expected to accrue in other tobacco-related diseases [Colditz, 2002]. An important next step in this research is to find ways to achieve broad-based dissemination of this intervention model. Promoting smoking cessation in this way also holds great promise for improving occupation-based health inequalities, particularly because smoking prevalence and exposure to occupational hazards are positively related [Sterling and Weinkam, 1990; Sorensen et al., 1996a]. The social contextual model presented here includes additional pathways to be explored in future intervention research. Documenting occupation-based inequalities in smoking behavior is in and of itself insufficient to reducing those disparities. It is critical that researchers investigate the underlying causes for those inequalities and discover effective ways to intervene based upon this knowledge. In doing so, it is important to take into account that occupational disparities in smoking are not identical across all racialethnic groups, and thus it will be important to tailor interventions accordingly [Barbeau et al., 2004]. In addition to behavioral research priorities, there is also a need to address important future policy questions. These might include: identifying organizational-level reasons underlying occupation-based differences in worksite smoking policies and ways to redress them; assessing and intervening with employers to discover ways to promote holistic approaches to workers’ health, rather than approaches that target individual behaviors in isolation from occupational safety and health hazards; discovering ways to increase blue-collar and service workers’ access to smoking cessation programs through employers, unions, health insurers, and/or community-based venues; and whether and how tobacco tax increases differentially impact purchasing behavior among various occupational classes. As we have noted, unions can play a key role in the research process. Research questions might include: Are unions an effective community-based channel for providing smoking cessation interventions, whether through apprenticeship training programs, health and welfare funds [Dement et al., 2003], retirees councils, or other union-based vehicles? What is the level of coverage for smoking cessation

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services among Taft-Hartley funds and how can this be increased to provide members with needed services? Can union-based member assistance programs be encouraged to treat tobacco addiction as well as other addictions? What, if any, success has the tobacco industry had in persuading unions to adopt pro-tobacco policy positions in the past and how can public health ‘‘re-engineer’’ these approaches to engage unions in tobacco control policy campaigns? Tackling these research priorities will require an interdisciplinary approach that spans many fields, including health promotion and occupational health and safety [Israel et al., 1996; Sorensen, 2001, 2002; Sorensen et al., 2004], two disciplines that have at times been at odds with one another, despite a shared interest in workers’ health [Quinn, 2003]. Experts in these areas read different journals, convene at different professional meetings, apply different research methodologies, and perhaps most significantly, hold differing ideological approaches to and understanding of responsibility for worker health. Starting with the assumption that worker health begins (and ends) with individual behavior change leads to a different set of intervention strategies than the starting point that management bears primary responsibility for worker health [Sorensen, 2001, 2002]. And conversely, assuming that workers are not interested in individual behavior changes, such as quitting a powerful addiction to tobacco, is a missed opportunity at best and a paternalistic miscalculation at worst. The challenge is to find ways to use a ‘‘both/and’’ rather than an ‘‘either/or’’ approach to improving workers’ health. Overcoming the segmentation of these fields ultimately will require a common model of work and health, providing for resolution—or at least understanding—of our different assumptions, vocabulary, research methods, and intervention approaches.

Future Action Priorities We highlight here three broad-based suggestions to stimulate potent and sustained action aimed at eliminating occupation-based disparities related to tobacco. First, we call for those interested in these issues to advocate for an increased focus within the tobacco control movement on the class-based dimensions of tobacco, as well as on race/ ethnicity, age, and gender. In recent years, national tobacco control organizations have funded initiatives intended to reduce tobacco’s burden on ‘‘priority’’ populations, typically including African–Americans, Hispanics, Asian and Pacific Islanders, American–Indians/Alaskan Natives, women, lesbian/gay/bisexual/transgendered individuals, and lowincome groups [American Cancer Society, 2003; American Legacy Foundation, 2003]. Some assume that the ‘‘lowincome’’ group captures the working class, but this is not necessarily the case. The average hourly wage of blue-collar workers in 2001, a population with a high smoking prevalence, was $13.73 per hour (equivalent to $28,558 per

year) [US Department of Labor and Bureau of Labor Statistics, 2001], placing them at 1.6 times (i.e., 100–199% of) the 2001 poverty line of $17,960 for a family of two adults and two children [US Bureau of the Census, 2001], and thus out of the ‘‘low-income’’ group. For tobacco control organizations to tailor tobacco control activities to the lived experiences of blue-collar and service workers—inside and outside of work—will require the active involvement of new partners. As noted in this study, labor unions can be a vehicle for reaching out to blue-collar and service workers, but they also represent members of these ‘‘priority populations,’’ including women, people of color, and members of the LGBT community. In addition to unions, other groups may be helpful to enhancing tobacco control efforts, including COSH groups, and occupational health researchers and advocates. A second priority for action is building strong coalitions in support of workers’ health at national, state, and community levels. While the Network has helped to spark new labor-tobacco control partnerships in selected states, more work remains to sustain and to adapt such partnerships for broader dissemination and adoption in other states. These labor-tobacco control partnerships–which might include COSH groups, labor unions, voluntary and governmentbased health and tobacco control organizations, occupational health and tobacco researchers as well as advocates—can undertake a range of tobacco and worker health issues. For example, they may work together on passing worksite smoking policies to protect workers from secondhand smoke, gaining union acceptance of and support for such legislation once passed, working for adequate and appropriate smoking cessation coverage for blue-collar workers, and offering smoking cessation programs tailored to workers’ social context. Identifying shared concerns around tobacco, and importantly a broader range of topics, will be critical to the success of these partnerships. Working with other organizations, tobacco control advocates can extend their work to address a broader range of working class concerns in addition to tobacco, such as reducing social inequalities, full employment, a living wage, and the right to organize. For unions, building broader coalitions and dealing with tobacco as a major health issue of our time may help with efforts to bolster general public support for unions and potentially attract new members. And finally, full implementation of these action and research priorities will require that these coalitions advocate effectively for resources dedicated to reducing tobacco’s toll on the working class. Funders of research will need to be persuaded to change the way they view workers’ health, tobacco control, and occupational health. One outcome of successful advocacy in this area might be for NIOSH and the National Cancer Institute to come together to support a research agenda related to workers’ health and tobacco. Another outcome would be for tobacco control funders to

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issue requests for proposals specifically aimed at reducing class-based disparities, and that would involve ‘‘nontraditional’’ partners such as labor unions and occupational health advocates.

ACKNOWLEDGMENTS We thank Richard Martins for administrative support in preparing this article.

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