Cancer Prevention and Worksite Health Promotion: Time to Join Forces

The workplace is recognized as a setting that can profoundly influence workers’ health and well-being (1,2). The Centers for Disease Control and Prevention (CDC) workplace health promotion efforts address cancer prevention by focusing on cancer screening programs, community–clinical linkages, and cancer risk factors (eg, tobacco use, physical inactivity) that also influence risk for other chronic diseases (http://www.cdc.gov/workplacehealthpromotion/). Some efforts focus specifically on cancer; some focus on general chronic disease prevention. Additionally, the National Institute for Occupational Safety and Health (NIOSH), part of CDC, provides research and recommendations to address workplace hazards posed by chemicals that may increase cancer risk (http://www.cdc.gov/niosh/topics/cancer/policy.html).


Introduction
The workplace is recognized as a setting that can profoundly influence workers' health and well-being (1,2). The Centers for Disease Control and Prevention (CDC) workplace health promotion efforts address cancer prevention by focusing on cancer screening programs, community-clinical linkages, and cancer risk factors (eg, tobacco use, physical inactivity) that also influence risk for other chronic diseases (http://www.cdc.gov/workplacehealthpromotion/). Some efforts focus specifically on cancer; some focus on general chronic disease prevention. Additionally, the National Institute for Occupational Safety and Health (NIOSH), part of CDC, provides research and recommendations to address workplace hazards posed by chemicals that may increase cancer risk (http://www.cdc.gov/niosh/topics/cancer/policy.html).
Existing resources can be leveraged to expand the scope of workplace initiatives to address additional cancer risk factors and disparities. Changes to the physical and social characteristics of work environments are likely to have greater impact than health education alone (3). Given the aging US population (which is expected to result in a marked increase in the number of cancer diagnoses over the coming decades) and the prevalence of numerous risk factors among working-aged adults (4,5), a multifaceted approach to cancer prevention in the workplace is timely and needed. In addition, community-based prevention efforts may offer unrealized opportunities to reach vulnerable working populations who are not served by workplace health promotion programs. In this essay, we draw attention to a wide variety of available CDC resources and provide ideas for new efforts to advance primary cancer prevention among working adults.

Factors Related to Cancer Risk
Many cancer risk factors could be influenced through efforts targeting the work environment, including facilities, services, and policies. Table 1 shows examples of risk and protective factors that may be amenable to workplace interventions. Some examples are specific to the work environment, such as exposure to known carcinogens (eg, diesel exhaust), higher levels of which are often permitted in the workplace compared with the general environment. Others are behaviors (eg, tobacco use) or chronic conditions (eg, obesity) that may increase cancer risk. The table also provides examples of protective factors (eg, staying physically active) that may reduce cancer risk. These factors affect a high percentage of US workers, so even small changes could have a large impact at the population level. Many of the examples are also related to other health outcomes, and the benefits of addressing them would extend well beyond cancer prevention.

Integrating Health Protection and Health Promotion
Traditionally, workplace health promotion programs have focused on health-related behaviors (eg, tobacco use cessation), while health protection programs have focused on addressing safety and health risks and hazard mitigation. New research provides evidence that integrating these 2 approaches may enhance program effectiveness to improve employee health, safety, and well-being (2). As discussed in the National Prevention Strategy (http://www.surgeongeneral.gov/initiatives/prevention/strategy/), efforts to ensure worker safety on the job while also providing a work environment that supports healthy behaviors can create a culture in which worker health is viewed as a priority and healthy behaviors are more likely to be adopted by employees. NIOSH conducts research and develops programs to advance this integrated approach through the Total Worker Health program (http://www.cdc.gov/niosh/twh). Because many cancers share risk factors with other diseases and chronic conditions, cancer prevention efforts in the workplace may also be enhanced by coordination with initiatives to address other diseases and chronic conditions. For example, the role of obesity as a risk factor for cancer and type 2 diabetes has been explored in occupational settings (33). This integrated and comprehensive approach maximizes program success and potential for sustainability over time.

Linking With Community Resources
Given the "spillover" that often occurs between work and family lives (2,34), a systems approach addressing the interrelationship between work, family, and community can maximize benefits. For example, employers can partner with organizations in the surrounding community to offer health-related programs and services to employees that complement workplace interventions (http://www.cdc.gov/workplacehealthpromotion/assessment/assessment_interviews/index.html#5). These linkages can extend support to employees when outside the workplace and provide services that are beyond the capacity or expertise of the employer (eg, partnering with local fitness facilities to provide discounted memberships to employees, promoting local farmers markets for access to fresh produce) (35).
Public-private partnerships may also contribute to effectiveness by bringing specialized skills and resources to an intervention (36). Community linkages are particularly important for small and mid-sized employers for whom a lack of resources can be a barrier to implementation and sustainability.
Disparities Across the Workforce Differences across industries, workplace settings, and types of work create challenges to reaching certain groups and can contribute to cancer health disparities. For example, certain jobs expose workers to chemical and physical hazards (eg, second-hand smoke, excessive sun exposure) or require nonstandard work hours (eg, night shift work) that can contribute to an increased cancer risk (34). Furthermore, not all occupations are found in centralized work locations. Those working outside the typical office setting or without permanent worksites (eg, transportation and construction workers) may benefit from programs that are tailored to their work circumstances and link to other community resources. Additionally, telecommuting has become common among workers, and although the flexibility to telecommute may lend certain benefits, it may also create barriers to reaching employees through traditional worksite wellness programs (34,37).
Health disparities among low-wage and low-income (LW/LI) workers are particularly concerning, as these workers may lack certain protections and worksite benefits available to higher-earning workers and be ineligible for government antipoverty supports (38). Temporary contract workers, seasonal workers, and part-time workers earning low wages tend to face worse working conditions and receive fewer benefits than workers in more permanent positions (34). Women and racial/ethnic minorities are overrepresented among LW/LI workers, further exacerbating health disparities among these groups (34). Health promotion and protection efforts targeting LW/LI workers may help reduce disparities. Such efforts will require buy-in from employers and managers, and potential benefits to employers (eg, reductions in absenteeism) should be highlighted.
Almost half of cancer survivors, individuals who have been given a cancer diagnosis at some point in their lives, are of traditional working age (ie, 18-64 years) (http://cancercontrol.cancer.gov/ocs/prevalence/prevalence.html#age). Although the unique needs of cancer survivors are outside of the scope of this essay, workplace prevention efforts may also reduce the risk of second primary cancers or cancer recurrence among cancer survivors.

CDC-Supported Program Activities
CDC's National Comprehensive Cancer Control (CCC) Program supports states, tribes, and territories to establish coalitions, assess the burden of cancer, determine priorities, and develop and implement cancer plans (http://www.cdc.gov/cancer/ncccp/). A scan of activities conducted by CCC programs indicated that only 15 (22%) of 69 programs are engaged in efforts to promote primary cancer prevention in the workplace (J. Townsend, A. Neri, MD, oral communication, July 2013). CCC activities targeting the workplace include general adoption of worksite policies and provision of information about physical activity and nutrition. Some programs are seeking to expand existing prevention-related policies to reach more community members through the workplace setting; others are focused on specific worksites (eg, sun-safety at ski resorts, tobacco exposure in casinos). Identifying low-cost strategies and making them easily available may facilitate further adoption. CCC grantees also provide a strong network for information dissemination through their coalitions as new resources become available.
NIOSH conducts research and develops programs to improve workplace conditions and practices to lower the incidence of occupationally related cancers. NIOSH focuses primarily on industrial sectors, occupations, and populations with elevated risk through basic bench research, on-site health hazard evaluations, recommendations for occupational exposure limits, timely health alerts, and training programs.

CDC-Supported Resources
Many CDC-supported workplace health promotion and protection resources are available (Table 2). For example, CDC provides guidance on smoke-and tobacco-free workplace policies that reduce tobacco use, initiation of tobacco use, and secondhand smoke exposure. Although not necessarily framed in the context of cancer prevention, many other CDC-supported resources address physical inactivity, diet and nutrition, and tobacco use, and some address cancer screening and early detection and weight management. Concerted efforts to share these resources with CCC programs and other funded partners may increase their dissemination and use at the state and local levels. Additionally, the CDC-supported Guide to Community Preventive Services provides evidence-based recommendations for worksite health promotion strategies (http://www.thecommunityguide.org/worksite/index.html). Continuing to link CCC grantees with relevant resources and expertise available in other parts of CDC may help maximize the impact of CDC's prevention work targeting adults.

Conclusion
The workplace is a key setting for efforts to reduce cancer risk among adults. Although some cancer risk factors have garnered attention in worksite health promotion, others have been somewhat overlooked and may be worth considering for future interventions. More could be done to take advantage of existing resources and prevention networks. Efforts to promote cancer prevention in the workplace may need to take an integrated and comprehensive approach by addressing individual behaviors, organizational culture, policies, and other environmental factors that influence cancer risk. We hope that the information and resources described in this essay will be useful to those working in health promotion and cancer prevention programs targeting adults.
An estimated 1.3 million construction and general industry workers are potentially exposed to asbestos (9).

Diesel exhaust
Lung (12) The amount of diesel exhaust adults are exposed to varies greatly, but some of the highest levels of exposure are among certain types of workers (eg, truck drivers, miners).

Obesity
Colorectum, endometrium, esophagus, gallbladder, kidney, pancreas, postmenopausal breast (6) More than one-third of adults are obese (13). This list is not intended to be exhaustive but rather to provide examples of cancer risk-related factors that could be addressed in workplace health promotion and protection efforts.
Binge drinkers are defined as men having 5 or more drinks on 1 occasion and women having 4 or more drinks on 1 occasion.
Heavy drinkers are defined as men having more than 2 drinks per day or more than 14 drinks per week and women having more than 1 drink per day or more than 7 drinks per week. The most recent estimates of occupational exposure are based on data from 1981-1983 and indicate that, at that time, approximately 1.35 million US workers were occupationally exposed to the combustion products of diesel fuel (http://www.cdc.gov/niosh/docs/88-116/#niosh1983).