In 2018, approximately 11.2 million people worked in the U.S. construction industry,¹ and about 8.3 million workers held construction trades occupations such as carpenter, electrician, plumber, glazier, carpet installer, roofer, sheet metal worker, or construction equipment operator.² The remaining construction industry workers had non-production occupations such as architect, accountant, or secretary.

Previous research has identified the increased prevalence of some health risk behaviors among construction workers compared to other workers or the general population. These behaviors include tobacco use,^3–10 alcohol consumption,^{7–9, 11–14} and not always using a seatbelt.^9,15,16 Data from the 2014–2016 National Health Interview Survey (NHIS) indicated that tobacco use was higher among construction workers than among all workers: 25.8% of workers in construction and extraction occupations smoked cigarettes in contrast to 15.4% of all workers, and 9.0% of workers in construction and extraction occupations used smokeless tobacco as compared to 3.0% of all workers.^3,10

In the 2005 California Health Interview Survey, construction workers had a 14.8 percentage point higher risk of binge drinking than professional workers.¹¹ The 2006 wave of the National Longitudinal Survey of Youth (a cohort born in 1957–1965) found that men working in high physically demanding jobs drank more frequently, drank more on usual drinking days, and drank six or more drinks more often than men in lower physically demanding jobs.¹³ Problem drinking among construction workers may be longstanding: in a household survey conducted in the U.S. in the early 1980s, 6.5% of the general population had alcohol dependence or abuse disorder; construction laborers had the highest prevalence (28.0%), and four other construction occupations had prevalences of 9.8% or higher.¹²

Construction and extraction workers had among the highest crude prevalences of not always using a seatbelt by occupation in the 2013 BRFSS survey,¹⁶ and a 1999 observational study of seatbelt use in Michigan reported anecdotally that a large majority of drivers and front seat passengers in light commercial, construction-related, vehicles did not use seatbelts.¹⁵

In addition to these findings for construction workers, blue-collar workers in general have been found to participate in less leisure-time physical activity (LTPA) than professional or white-collar workers,¹⁷ although it should be noted that construction is one of the most physically demanding industries.^18–20 In contrast to these behaviors, construction has not been reported among the industries or occupations with the highest prevalence of short sleep.²¹

Most previous studies either examined construction workers as a group^{3,5–7,10,11,16} or focused on one or two specific occupations.^4,8,9 The purpose of this study was to assess the prevalence of six health risk behaviors (smoking, smokeless tobacco use, binge drinking, no LTPA, short sleep, and not always using a seatbelt) among workers in a wide variety of specific construction occupations, as well as the specific occupations as a group and all workers in the construction industry as a group and to compare them to the prevalence among workers in other industries. This study was exploratory; the null hypotheses were that these prevalences among workers in the various construction groups were not statistically different from the prevalences among workers in all other industries. The large sample of currently employed workers with industry and occupation information available in BRFSS over a four year period enabled this assessment. This is the first study to examine selected health risk behaviors among specific construction occupations using a large population-based sample.

The following criteria were used in reporting results. Estimates with a relative standard error (RSE) >50% are not reliable and are not reported. Estimates with an RSE >30% and ≤50% should be interpreted with caution; they are shown in Supplemental Digital Content 1 but are not discussed.

This study assessed, for the first time, a set of health risk behaviors among construction workers employed in a wide variety of occupations in 32 U.S. states. The study used four years of data from BRFSS to estimate the prevalence of six health risk behaviors by occupation among construction workers and compared them to workers in all other industries. The prevalences of five of the six behaviors were significantly higher for workers in the groups “selected occupations” and “construction industry” compared to workers in “all other industries.”

The results for the group “selected occupations” are somewhat comparable to the results in other studies for “blue-collar workers,” since most of the 38 selected occupations could be considered “blue-collar.”³⁰ The “construction industry” group is equivalent to assessments of construction workers as an industry group in other studies. This study shows the value of assessing behaviors by individual occupation in addition to the more general blue-collar and construction industry categories because this approach can identify individual occupations with high prevalences and facilitates follow-up by targeted health promotion/health protection interventions.

No single construction occupation stood out as particularly high or low across all behaviors, but several had elevated prevalences for multiple health risk behaviors. Construction managers had statistically elevated prevalences for four of the six behaviors (smoking, smokeless tobacco use, binge drinking, and not always using a seatbelt). Construction managers plan, direct, and coordinate construction projects, overseeing their organization and overall performance. Because of their important leadership roles, behavior changes among construction managers could have positive effects on the safety and health culture in the construction industry. The next highest leadership occupation, first-line supervisors/managers of construction trades and extraction workers, also had statistically elevated prevalences for the same four behaviors as construction managers.

Three occupations (carpenters, construction laborers, and roofers) all had significantly elevated unadjusted prevalences for five of the six behaviors (all except short sleep). It is not clear why these occupations had significantly high rates for so many behaviors. Since construction laborers is the largest construction occupational group, this study may have had sufficient statistical power to detect significant differences among laborers from workers in all other industries; however, since this is not a well-defined occupational category, it is not clear how to interpret these findings.

Roofers, as well as electrical power-line installers and repairers, had significantly elevated unadjusted prevalences for binge drinking and are also among the ten civilian occupations with the highest fatal work injury rates in 2017.³¹

Electrical power-line installers and repairers had the highest unadjusted prevalences of all the occupational groups for smoking and smokeless tobacco use (p<.001). This occupational group is small, occurring primarily in the utilities and construction industrial sectors, and the current study may be the first to have identified their potentially high rates of tobacco usage and binge drinking.

Operating engineers, who operate and maintain heavy earthmoving equipment, also had very high rates (both unadjusted and adjusted) for smokeless tobacco use. A 2008 cross-sectional survey of 498 Michigan operating engineers found that younger age, male sex, and lower rates of past month cigarette use were significantly, and higher alcohol intake was not significantly, associated with use of smokeless tobacco.⁴

The two occupations with the highest significantly elevated adjusted prevalences for not always using a seat belt were operating engineers and driver/sales workers and truck drivers (in the construction industry, the latter are primarily truck drivers). It is not clear how operating engineers and construction truck drivers interpreted the BRFSS seatbelt question (How often do you use seat belts when you drive or ride in a car?) since the question specifies only “car” and does not address work-related versus personal driving. However, a low prevalence of seatbelt use among these workers is especially concerning since their occupations involve driving. For operators of earthmoving equipment, lack of functioning seatbelts or nonuse of seatbelts have been found to contribute to occupational fatalities,³² and in a study of construction fatalities involving dump trucks,³³ over a quarter of dump truck operators who died in roadway accidents did not fasten their seat belt.

Short sleep, which was prevalent among all workers, stood out as the one health risk behavior assessed where construction workers overall had a significantly lower prevalence than that for workers in all other industries combined. Only structural iron and steel workers and welding, soldering, and brazing workers had significantly elevated prevalences for short sleep, and these became non-significantly elevated after adjusting for confounders. It is not clear why construction workers were less likely to experience short sleep, especially since their worksites are transitory and may sometimes require getting up early to get to work on time. On the other hand, their occupational physical activity (OPA) may have helped them sleep, although this is not consistent with some findings for workers with high OPA.³⁴ Also, most construction workers work during the day, whereas many workers in other industries are shift workers, which is associated with a higher prevalence of sleep problems.²¹

The risks to the general population of the health behaviors we assessed in workers are well documented and have been targeted for interventions to improve the health of adults in the U.S.^35–39 Tobacco use is known to cause many adverse health effects including multiple types of cancer, non-malignant respiratory diseases, cardiovascular disease, and other diverse conditions.⁴⁰ Heavy or binge drinking may be associated with short-term effects such as injuries and long-term effects such as cirrhosis of the liver.⁴¹ Physical activity is considered healthful for many reasons, including reductions in all-cause mortality.^42,43 However, it is a paradox that while LTPA is beneficial, OPA sometimes has adverse health effects.^18,44–46 Inadequate sleep can contribute to the occurrence of injuries as well as various chronic health problems.⁴⁷ Seatbelt use has been shown to be an effective method to reduce injuries to motor vehicle occupants.⁴⁸

Construction workers are potentially exposed to a wide range of chemical hazards at work including asbestos, silica, welding fumes, paints and solvents, and other dusts, fumes, gases, and vapors,^49,50 as well as physical hazards (e.g., falls from height, repetitive motion, vibration, noise exposure).^51,52 The interaction between job hazards and health risk behaviors is not fully understood, but previous studies suggest that construction workers who exhibit some health risk behaviors are more likely to experience work-related injuries.⁵² A study of construction workers aged ≥50 years⁴⁹ found a significant excess of respiratory cancer and non-malignant respiratory disease among smokers. Menvielle et al.⁵³ found that asbestos exposure in combination with smoking and alcohol drinking had a more than additive, but not multiplicative, joint effect on laryngeal cancer in a French case-control study. Lee et al.⁵⁴ reported that, even though there was a potential synergistic effect between construction workers’ occupational exposures and smoking on lung disease, healthcare providers advised relatively few construction workers to cease smoking.

Total Worker Health™ (TWH) is the integration of occupational health and safety with a broader approach to worker well-being such as environmental and organizational factors that can impact worker health.^55,56 These factors could include worksite safety culture, tobacco use policy, and stressors such as job or income insecurity or lack of control over work schedules. The TWH approach to the health risk behaviors assessed in this study would include health promotion activities^57–60 as well as organizational or policy changes and healthy job design to support workers’ choice to adopt more healthful behaviors or reduce health risk behaviors.^61–63 For example, in an analysis of Current Population Survey data, Ham et al.⁶⁷ found that workplace smoking bans and smoking cessation programs that addressed cultural factors appeared to reduce tobacco use among construction workers. Peters et al.⁶⁸ reported that a TWH program among commercial construction workers which combined a worksite ergonomics program with health promotion produced improvements in ergonomic practices, health behaviors, and pain and injury. Anger et al.⁶⁹ conducted a 14-week pilot TWH intervention that resulted in improvements in safety, health, and well-being among construction workers. It provided healthy lifestyle training for supervisors and employees, and it taught supervisors to support employees in their home life as well as to reinforce safe work practices.

Because of the nature of construction work for many workers (temporary jobs and work sites, multiple employers over a career or at one worksite, small employers, self-employment, working alone or with a few others), it can be challenging to reach construction workers with a health promotion/health protection program. Health interventions aimed at construction workers have been tried through unions and employers, including utilization of apprentice or training programs, with most focusing on tobacco use.^59,64–66

A strength of this study was its very large population-based sample of current workers, which allowed analysis of risk behaviors by selected occupation within the construction industry. Other advantages to using BRFSS are its standard methodology by all states and use of industry and occupation questions by self-selected states. However, this study had several limitations. All BRFSS data were self-reported and may have been subject to social desirability or other biases, especially regarding the health risk behaviors. There also could have been misclassification bias due to errors in coding the industry and occupation text fields, particularly if the participants did not provide clear responses. BRFSS does not collect work-related factors such as job stress, working conditions, and physical demand that may affect some behaviors and which could have provided some context for the reported estimates; these issues could be addressed in future research using different methodology.

Overall, a higher percentage of construction workers smoke, use smokeless tobacco, binge drink, do not participate in leisure time physical activity, and do not always use a seatbelt than workers in all other industries. In contrast, a lower percentage of construction workers experienced short sleep than other workers. There was substantial variability in adjusted prevalences for the six health risk behaviors among construction occupations. Construction workers in occupations with higher prevalences, including managers and supervisors, may benefit from targeted health promotion/health protection activities to reduce the prevalences of health risk behaviors. Further study with more years of BRFSS data would be useful to improve the precision of health behavior estimates and might allow assessment of smaller construction occupations.