|SECOND HAND SMOKING
|Year : 2010 | Volume
| Issue : 5 | Page : 43-52
Call centre employees and tobacco dependence: Making a difference
GA Mishra, PV Majmudar, SD Gupta, PS Rane, NM Hardikar, SS Shastri
Department of Preventive Oncology, 3rd Floor, Service Block, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai - 400 012, Maharashtra, India
|Date of Web Publication||9-Jul-2010|
G A Mishra
Department of Preventive Oncology, 3rd Floor, Service Block, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai - 400 012, Maharashtra
Source of Support: The study was supported by the Intramural funding grants of the Tata Memorial Hospital, Conflict of Interest: None
Context : India is known as the Business Process Outsourcing (BPO) capital of the world. Safeguarding health of millions of youngsters employed in this new growing economy is an occupational health challenge. Aims : This study was initiated in June 2007 in India with the objectives to assess the prevalence of tobacco use and study the factors responsible for initiating and continuing its use. The main aim, however, was to assess the effect of different tobacco cessation intervention strategies, thus identifying effective methods to assist these employees to quit tobacco. Materials and Methods : This is a 4-arm cluster randomized trial of 18 months duration among 646 BPO employees, working in 4 different BPO units. The employees were invited to participate in interviews following which tobacco users of each BPO were offered specific tobacco cessation interventions to assist them to quit tobacco use. Results : The prevalence of tobacco dependence is 41%, mainly cigarette smoking. The tobacco quit rate is similar (nearly 20%) in the 3 intervention arms. Significantly higher reduction in tobacco consumption of 45% is seen in Arm 4 with the use of pharmacotherapy. BPO employees change jobs frequently, hence follow-up remains a major challenge. Conclusion : Inaccessibility of pharmacotherapy in the developing countries should not deter tobacco cessation efforts as good tobacco quit rates can be achieved with health education and behavioral therapy. Tobacco cessation should be an integral activity in all BPOs, so that the employees receive this service continuously and millions of our youths are protected from the hazards of tobacco.
Keywords: BPO employees, call centers, focus group discussions, health awareness, tobacco cessation, workplace
|How to cite this article:|
Mishra G A, Majmudar P V, Gupta S D, Rane P S, Hardikar N M, Shastri S S. Call centre employees and tobacco dependence: Making a difference. Indian J Cancer 2010;47, Suppl S1:43-52
|How to cite this URL:|
Mishra G A, Majmudar P V, Gupta S D, Rane P S, Hardikar N M, Shastri S S. Call centre employees and tobacco dependence: Making a difference. Indian J Cancer [serial online] 2010 [cited 2018 Feb 20];47, Suppl S1:43-52. Available from: http://www.indianjcancer.com/text.asp?2010/47/5/43/63860
Publication of the supplement was supported by the funds from the 14th World Conference on Tobacco or Health, March 8-12, 2009, Mumbai. The Guest Editors, Editors, Authors and others involved with the journal did not get any financial or non-financial benefit from the sponsors.
The Business Process Outsourcing (BPO) industry was established in India only in the last 15 years and is rapidly expanding. The estimated turnover of the BPO sector by March 2008 was around US$10.9 billion.  Although much has been talked about the immense opportunities created by the BPOs in the developing countries, not much has been stated regarding the challenges faced by these organizations, particularly with regard to the health and safety issues that are unique to this new and developing sector. Addressing these issues and creating a healthy work environment would be a win-win situation for both employers and employees.
BPO is typically categorized as back office outsourcing, which includes internal business functions, and front office outsourcing, which includes customer-related services. The employees at the call center have to listen, watch, and speak simultaneously without a break. Erratic working hours along with sedentary job that demands sitting on a chair for long hours each day, reading prescripted conversations on the phone endlessly may result in musculoskeletal and psychologic strain. Long working hours, permanent night shifts, lack of social and family interactions, incredibly high work targets, loss of identity, coupled with high disposable income at a young age may predispose the BPO employees to different forms of dependence, including tobacco. 
Although tobacco is severely injurious to health, its use is widely prevalent in all the sections of Indian society. According to the results of the National Family Health Survey-3 (NFHS-3) conducted in 2005-2006 in which questions on tobacco use were asked to individual women and men in the sample, in the age groups 15-19 years and 15-54 years, respectively, the prevalence of tobacco use was 57% among men and 10.8% among women. The survey reports dissimilarity in the preferences of the various forms consumed by different sections. Smoking was mainly used by men, whereas women mainly used smokeless forms of tobacco.  Women in India generally do not smoke, however, with the recent wave of globalization and so-called westernization, it is not very uncommon to find women smoking in the BPO sector.
The BPO work culture embraces night shifts, smoking, drinking, pub culture, etc, which are in complete contrast to the value systems, traditions, and beliefs still nurtured by the urban middle-class in India. Although it is recognized that the BPO employees are predisposed to tobacco dependence, there is no published study on this topic. With the booming BPO industry and millions of youngsters getting employed in this sector, it has become imperative to study the prevalence of tobacco dependence and its use in different forms and reasons for initiation and continuation of the habit in this group. This trial also aims at assessing the change in knowledge, attitude, and practice (KAP) regarding tobacco use after scheduled interventions. However, the main purpose of the trial was to find out the strategies of tobacco cessation that would work well in assisting tobacco quitting among the BPO employees. The trial is especially relevant in an outsourced-job-receiving country, such as India, which is crowned as the outsourcing capital of the world.
| » Materials and Methods|| |
This is a 4-arm cluster randomized trial conducted among BPO employees working in 4 different BPO units located in Mumbai, each with a workforce of approximately 200 employees [Figure 1].
The network of different BPOs in the city was identified and discussions were held with the human resources personnel and senior officials to seek their cooperation. Four BPO units with a workforce of approximately 200 employees each, with the management interested in participating in the trial were selected. According to the inclusion and the exclusion criteria, the study participants were apparently healthy men and women above 18 years of age working in the selected 4 BPOs of Mumbai. There were no minors. The BPO employees were given introductory lectures. Discussions were held to identify their concerns, understand their work pattern and work environment. They were invited to participate in the study and were enrolled after signing the informed consent form. The primary method of data collection in the preintervention phase was personal one-to-one interviews [Figure 2]. However, many employees were lost during different phases of follow-up and in the postintervention period, mainly because of change of job to other work places. These employees were counseled on phone and their data were collected through telephonic interviews initiated by the investigators. The tobacco use and cessation data were recorded based on the self-report history. Nicotine dependency was assessed with Fagerstrom scale for all tobacco users. In addition the smoke check test was performed for all the smokers at the beginning of the study. The smoke check test was repeated during follow-up sessions, only for employees who could be followed-up personally.
The questionnaire comprised the following:
Part I: Initial Questionnaire: This included sociodemographic and occupational history, preintervention questionnaire to assess their KAP and medical history.
Part II: Follow-up Records: Tobacco use and assistance provided for quitting was recorded during each follow-up.
Part III: Postintervention Questionnaire: After the completion of 12 months, to assess change in their KAP.
Millions of youths in India are employed in the BPOs. This is a unique group comprising young, well-educated, and high income earning individuals with often erratic working hours and a completely different nature of work. Till now, all the tobacco cessation programs targeted various groups of individuals, such as school children, adult population, women, and others, but this was the first time when the cessation program was implemented on this group. We were, hence, unsure about the nature of intervention that would work in this scenario. Thus, although the interventions seem similar, the processes, as described above, vary from one another. Each group was given additional intervention from the previous group to estimate the optimal amount of intervention required for tobacco cessation. Pharmacotherapy, which is an important component of tobacco cessation in the west, is not an ideal method of tobacco cessation here, as it is expensive, not readily available nor commonly prescribed by doctors in India. Hence, it was prescribed only to a few participants in the fourth arm based on the individual need assessment, whereas for the others one or a combination of the alternative methods was used.
Each of the 4 BPO units was randomly assigned using lottery method into 4 arms to receive 4 different types of interventions depending on the group allocated. As the selected BPOs were located far away from each other, there was no chance of contamination of the study because of interaction of the BPO employees among each other.
Arm 1: (Control Group): Distribution of pamphlets (information on hazards of tobacco) to all employees.
These Health Education pamphlets had detailed information on the health hazards of consuming different tobacco products, why one should quit tobacco, the different methods of quitting tobacco, and where one can approach for quitting tobacco.
Arm 2 : Active Health Education (HE) sessions [Figure 3] followed by focus group discussion (FGD) [Figure 4]
The HE was delivered in an interactive way with the help of a slide show. The topics covered were current statistics of tobacco use, health hazards of tobacco, the different methods of quitting tobacco, and information about the trial. The entire management and all the employees in the BPO (whether they were tobacco users or not) were invited to participate in the health awareness lectures.
The FGDs were conducted in small groups of 7-10 employees. The participants were employees consuming tobacco, who volunteered to participate in the FGD. These interactive counseling sessions were conducted by an expert tobacco counselor.
Contents of FGD: The initial sessions were aimed at initiating the thought process among tobacco users regarding positive need to quit tobacco, make them reflect on their own strengths and coping capacity, how they can use the same regarding tobacco cessation, and to promote decisions toward healthy lifestyles.
Subsequent sessions focused on sharing of quitting experiences by the tobacco users and coping with withdrawals. Later sessions focused on how to prevent relapses and need to maintain sustained efforts at quitting.
Arm 3 : Active HE sessions followed by FGD and Behavioral Therapy (BT) in the form of one-to-one counseling.
Behavioral Therapy : In addition to FGD, one-to-one counseling was provided to the tobacco users in the third arm. This involved added resources in the form of separate time dedicated to each tobacco user. The rationalizations for continuing tobacco use at the individual level were addressed.
Arm 4 : Active HE sessions were followed by FGD, BT, and Pharmacotherapy (PT).
Pharmacotherapy : Pharmacotherapy in the form of bupropion was offered to tobacco users in Arm 4 based on the individual need assessment. This was offered to tobacco users in the preparatory phase.
The total duration of the study was 18 months, with the duration in each BPO being 12 months. Regular follow-up visits at intervals of 2-3 months were conducted to assess change in the KAP brought about by the interventions offered. A tobacco user is recorded as a tobacco quitter only if there is a record of tobacco cessation, which was sustained for 6 months.
The data were computerized in Fox Pro version 2.5 and analyzed using Stata 8.2. The trial was analyzed on an intention to treat basis and the participants were included in the final analysis irrespective of whether or not they could be followed-up in all the subsequent visits. Self-reported history was taken as the main criteria to assess the outcomes of tobacco cessation. Multivariate analysis was performed to identify the factors promoting the use of tobacco and quitting tobacco. The tobacco quit rates were calculated as percentages. The postintervention changes in the KAP of the employees were compared with the preintervention KAP. Groups were compared using nonparametric statistical techniques.
The sponsors of the study had no role in study design, collection, analysis, interpretation of data, writing reports, or submission for publication.
| » Results|| |
A total of 992 employees from 4 BPOs were invited to participate in the study, of whom 646 employees participated. The distribution of the BPO employees according to the different sociodemographic variables is as shown in [Table 1].
Among 43% of the employees who had history of tobacco use, 41% were current tobacco users. As seen in [Table 2], tobacco use was much more extensive among male employees (49.5%) as compared to female employees (7.9%). Among the 10 female tobacco users, 7 smoked cigarettes, 3 smoked hookahs, and 1 chewed tobacco; and 96.1% of male tobacco users smoked cigarettes, whereas 6.4% of tobacco users (2.6% of BPO employees) frequented hookah bars. Nonsmoking forms of tobacco, mainly in combination with smoking forms was used only by 25 (9.4%) tobacco users, which included chewing tobacco, gutka, betel nut, paan, and paan masala. Nine employees used a single type of smokeless tobacco, whereas 16 employees used a combination of both smoking and various smokeless forms. Alcohol use was seen among 37% of BPO employees (41.2% among males and 17.3% among females). The prevalence of tobacco and alcohol use was lower in BPO 3, which is a back office administrative BPO, while it was higher in the other 3 BPOs, which are voice-based call centers. Peer pressure was clearly the most important factor for the initiation of tobacco habit followed by stress (both domestic and at workplace) and for enjoyment. About 23% of tobacco users could not give any reason for using tobacco. The important factors for continuation of tobacco habit were identifying tobacco as a stress reliever, peer pressure, and to avoid physical discomfort on withdrawal.
[Table 3] shows the distribution of tobacco user and nonuser employees in the BPOs by important sociodemographic variables and the results of univariate and multivariate logistic regression analyses identifying factors promoting tobacco use. According to the multivariate analysis, gender (men) and presence of shift duty were identified as factors promoting tobacco use among the BPO employees.
Among the 258 (39.9%) employees using smoking forms of tobacco, 57.9% of employees had carbon monoxide levels of 0-6, 21.3% had levels of 6-10, and 20.9% had levels above 10 on the smoke check test. The Fagerstrom scores for smokers varied in the range of 0-9, and for smokeless users between 2 and 12 [Table 4]; 10% of smokers and 16% of smokeless tobacco users had Fagerstrom scores more than 5.
Although all the employees in this trial were literates, they had poor knowledge regarding specific harms of tobacco. The employees, in all the 4 arms, received information regarding hazards of tobacco, using various methods, after which a significant improvement in the knowledge of the employees was noted in the postintervention period [Figure 5]. The medical history of the employees showed a predominance of respiratory symptoms, such as cough, throat pain, bronchitis, and breathlessness, followed by gastric complaints, mainly acidity. The combination of voice-based requirement for the job in addition to the ill effects of the tobacco may be responsible for 10% of the employees presenting with hoarseness of voice.
The employees of the 4 BPOs were offered 4 different types of cessation interventions. In the Arm 1, the Control Arm, 35% of employees reduced tobacco use and 6% of the employees quit tobacco by the end of 1 year. In the Arm 2, 3, and 4, 26%, 28%, and 46% of the employees reduced their tobacco use, respectively, and 20%, 19%, and 20% of the employees quit tobacco with 12 months of intervention. In Arm 4, there were 74 tobacco users; pharmacotherapy in the form of bupropion was offered to 24 of these employees who were in the preparatory phase, based on the individual need assessment. Ten employees complied with pharmacotherapy and many complained of high irritability with its use. Based on personal interview, the observation was that more people in Arm 4 had reduced tobacco use; however, they had not quit tobacco. The tobacco quit rates were similar in the 3 Intervention Arms (Arm 2-4) and significantly higher than the Control Arm (Arm 1). However, the reduction in the tobacco use is much higher in Arm 4, with the use of pharmacotherapy. [Table 5] shows the distribution of tobacco quitters and nonquitters by the same sociodemographic variables and the results of univariate and multivariate logistic regression analysis, identifying factors leading to quitting of tobacco among the BPO employees. Accordingly, being a female was the most important predictive factor for quitting tobacco among the BPO employees.
Among the total 646 employees initially interviewed, the alcohol consumption pattern in the postintervention phase remained status quo for a majority 607 (93.9%) of the employees. There was decline in the alcohol use in 32 (4.9%) of the users, 1 (0.2%) employee quit alcohol, 2 (0.3%) employees initiated alcohol use, and 1 (0.2%) employee increased alcohol consumption in the postintervention period.
| » Discussion|| |
In India, 142 million men and 72 million women above the age of 15 years consume tobacco. With the decline in the sale of tobacco in the western countries, the tobacco industry is now targeting the large vulnerable youngster population of the developing world, especially India. Currently, 57% of men and 10.8% of women consume tobacco in the country.  Smoking by women is not culturally accepted, except in a few tribal communities. In the BPOs studied, 41% of employees were tobacco users 49% men and 8% women employees used tobacco. Cigarette smoking was seen among 39% men and 5.5% women employees, which is very high, compared with the general population in country where 32.7% men and 1.4% women smoke. 
The employees in the BPOs were mainly youngsters, coming from low income families, 83% with family income below Rs.20,000/- per month and many undergraduates. A majority of them were enrolled in the college during the day and worked in the BPOs at night to pay their tuition fees and support their families. Male employees constituted 80% of the workforce in the BPOs. The mean age of employees in the 4 BPOs was 23.1 years, with 80% of employees below the age of 25 years. The age of employees in BPOs and software industries recorded in other studies varied between 22 and 30 years, [4,5] with 60-70% being males.  Although, overall, 72.5% of employees were on shift duties the prevalence was much higher (95.4%) in voice-based call centers. BPO 3, which was an administrative back office was different, with 99% employees being graduates, many with high family income and only 19% with shift duties. Working continually on night shifts may lead to premature aging, low alertness, and deterioration in the overall performance. The medical history of the BPO employees in the present study shows predominance of respiratory and gastric complaints. The combination of voice-based requirement for the job in addition to the ill effects of tobacco may be responsible for 65 employees presenting with hoarseness of voice. Musculoskeletal, psychosocial, sleeping disorders, ear problems, and digestive and eye sight problems have been common health issues among the BPO employees. Voice loss has been a serious concern, especially in the employees of voice-based call centers. , A marked difference was noted among the characteristics of employees working in the back office and customer-related BPOs, with significantly more employees using tobacco and alcohol in the latter services. In the present study, male gender and presence of shift duty were identified as factors promoting tobacco use. According to the NFHS-3, tobacco use is high in the rural areas and among the least educated and economically poor. 
Tobacco cessation is influenced not only by the cessation programs but also by the workplace settings and organizational environment. The interiors of the BPOs in the present study were smokefree as they were centrally air-conditioned. However, employees smoked freely during their small breaks of 10-15 min, outside the doors, in the corridors and the toilets. A thick haze of smoke appeared all over during the break times during which, not only the smokers, but also the nonsmokers were exposed to smoke. In this study, peer pressure was a significant force, both, for initiation and continuation of tobacco habit. Many employees who had attempted quitting tobacco faced severe withdrawal symptoms, such as tremors and irritability due to which they relapsed. Hence, there is a need for tobacco cessation assistance and support services at workplaces to aid employees adjust to behavioral and physical changes while quitting tobacco.
Many of the BPO employees were severely addicted to tobacco with Fagerstrom scores above 5 noted in 10% of smokers and 16% of other forms of tobacco users. Twenty-one percent of smokers had smoke check scores above 10. It is important to note that although all the BPO employees were literates, they had poor knowledge regarding specific harms of tobacco. HE and awareness form the core of the intervention strategies for a healthy lifestyle. Hence, health awareness was the primary intervention used in all BPOs, which was supplemented with other strategies to test for added effectiveness of each of these interventions in assisting tobacco quitting. A simple intervention, such as creating awareness with the distribution of pamphlets in the control arm, led to the reduction in tobacco use in 35% and quitting in 6% of the tobacco users. Although people quit tobacco with self-help interventions and social support, these interventions are less effective.  Therefore, every tobacco user should be offered at least a brief tobacco cessation intervention treatment.  The tobacco quit rates of nearly 20%, similar to the study by Cruse et al, were achieved in all the 3 intervention arms indicating that FGDs, one-to-one counseling, and pharmacotherapy lead to a significant increase in the tobacco quit rates over and above only health awareness. In a tobacco cessation program of 10 weeks with one-to-one support sessions and access to Nicotine Replacement Therapy (NRT) at the workplace, a quit rate of 20% was achieved at the end of 1 year.  According to Cochrane review, proven stop-smoking methods, such as group therapy, individual counseling, and NRT, are equally effective when offered in the workplace.  Lang et al demonstrated 36% higher cessation rate with a brief face-to-face intervention as compared with simple advice.  Group counseling and even short seminars achieved high quit rate without additional pharmacotherapy when offered at the workplace.  The results of the present trial also indicate that unavailability of pharmacotherapy should not deter one from conducting a tobacco cessation program, as, sufficiently good results can be achieved with a combination of different forms of BT. Being a female was the most important predictive factor of quitting tobacco among the BPO employees according to multivariate regression analysis. Although many tobacco users want to quit, not all make serious quit attempts and not all respond to the same program for quitting. Due to this diversity, there should be options available for employees, as demonstrated in this study, by using different strategies in different BPOs. Previous studies have demonstrated that male participants of higher age with lower number of pack-years  or light to moderate smokers  are more successful in quitting tobacco.
The major challenge in this study, was the high attrition rate among the BPO employees, which made follow-up very difficult. Turnover rates as high as 30% have been previously recorded, for various reasons, such as boredom due to repetitive nature of the job, better prospects, better monetary benefits, lack of career opportunities, minimal vertical growth, or lack of efforts on the part of the BPO management to retain the employees.  Most employees leave within 2 years.  In the present study, 52.4% of the tobacco users who were on follow-up had changed their jobs by the end of 1 year, 14.4% had quit within 1 month, and 32.6% quit within 3 months of enrollment. These young employees not only change to other BPOs but many change their nature of job as well. Follow-up and counseling was done on phone for the employees who had changed their jobs.
It has been recommended that all health insurance plans should include counseling and effective pharmacotherapeutic treatments for tobacco cessation as a reimbursable benefit.  Some BPOs now provide free healthy nutritious food, transport conveniences, facilities, such as gym, yoga workshops, counseling sessions, library to de-stress, and support the culture of health. Additionally, we recommend that BPO employees be provided with education on concepts of ergonomics, healthy lifestyles, and dealing with psychosocial problems. High rates of tobacco use among BPO employees, necessitates tobacco cessation services to be incorporated as an extended benefit, so that the employees receive this service continuously even when they change their jobs. A comprehensive health policy needs to be formulated, which incorporates facilities at the work site for tobacco cessation, to protect millions of our youngsters from the health hazards of tobacco.
| » Acknowledgement|| |
We sincerely acknowledge the co-operation and support received from the management and employees of all the BPOs. We thank Dr.Kalpesh Solanki, Ms.Vithista Dhar, Dr.Pallavi Uplap, Dr.Nilesh Ingole and Mrs.Raksha Parte for participating in the activities of tobacco cessation at the BPO. The study was supported by the Intramural funding grants of the Tata Memorial Hospital.
| » References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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