Employer initiatives to stop smoking: as more employers take aggressive steps to reduce health care costs arising from employees' tobacco use, EAPs can and must help ensure the process goes smoothly and meets the needs of all parties involved.

John is a 48-year-old who has worked for 25 years in the auto assembly field. He has smoked a of cigarettes daily since his teens. He has tried multiple times to quit, but has never been able to maintain abstinence for more than a few weeks.

John recently became concerned about a swollen lymph node and had it checked by his doctor. A biopsy revealed squamous cell carcinoma, a form of cancer. He is facing radical neck dissection surgery, followed by radiation.

Stories similar to John's are unfolding for many aging baby boomers who are experiencing the health consequences of years of tobacco use. According to the U.S. Centers for Disease Control and Prevention (CDC), tobacco use is the leading cause of preventable death in the United States, responsible for one in every five deaths. (1) Tobacco kills more Americans each year than alcohol, cocaine, crack, heroin, homicide, suicide, car accidents, fire and AIDS combined. (2) On average, male smokers die 13.2 years prematurely, while female smokers die 14.5 years early. (3) More than 50 diseases have been linked to smoking, including cancers, heart disease and lung disease. (4)

The financial costs associated with tobacco use are equally staggering: Direct medical costs related to smoking in the United States total roughly $75 billion a year. (5) The CDC estimates that companies spend $3,856 per smoker per year in direct medical expenses and lost productivity resulting from premature death for people with smoking-related diseases. (6)

Given the adverse social and medical consequences of tobacco use, why don't more smokers quit? Because nicotine, the drug in tobacco that causes addiction, (7) is at least as addictive as heroin or cocaine. If a regular smoker abruptly stops using tobacco or greatly reduces the amount smoked, withdrawal symptoms such as depression, anger, irritability, and gastrointestinal discomfort may occur. (8) The difficulty of dealing with these symptoms lead many would be quitters to resume smoking.

It's no wonder, then, that nearly 21 percent of adult Americans currently smoke (9) and that each year only about 3 to 5 percent of smokers quit for a year or longer or for good. (10) Quitting involves reducing the physical dependence on nicotine as well as making major behavior changes to help break the psychological reinforcement resulting from tobacco addiction. It takes most smokers several attempts to stop smoking permanently

HOW EMPLOYERS ARE RESPONDING

In spite of evidence that tobacco cessation programs can help reduce employers' costs and improve workers' health, a Deloitte & Touche survey found that just over half of employers offer smoking cessation programs, (11) while the National Business Group on Health reports that only 24 percent of employers cover medical costs associated with tobacco use treatment. (12) Recently, however, more employers have begun to realize they can no longer ignore the impact of smoking on their bottom line. Following are examples of how some employers are dealing with this issue:

Banning smoking on company property. A growing number of states are banning smoking in most workplaces. The potential advantages of such bans include improved morale among non-smokers, reduced liability from lawsuits by non-smokers (for exposure to second-hand smoke), better air quality, and lower building maintenance fees.

One manufacturing firm prohibits not only the use and possession of tobacco in company buildings but also the presence of "tobacco residuals-emitting persons." Under this ban, any employee, visitor, or customer who has used a tobacco product within two hours of entering a company facility is automatically turned away. (13)

Before implementing smoking bans, employers should offer resources for smokers who will be affected by the ban and revise their policies and benefits to recognize that permanent smoking cessation will often require ongoing support. Employers should be especially sensitive to the impact of smoking bans on workers who have to remain tobacco-free for several hours to a row or during their entire shift.

Refusing to hire smokers or terminating smokers. Many private companies, municipal governments, and police departments refuse to hire smokers, with some requiring signed affidavits or using lie detector tests to enforce this policy One employer, Weyco, Inc., an insurance consulting firm based in Michigan, gave its employees 15 months to quit smoking entirely (not just at work) and offered a smoking cessation program. After the deadline, Weyco subjected its employees to random nicotine testing and terminated anyone who tested positive. In the end, 20 employees successfully stopped using tobacco, but four others who didn't lost their jobs.

Another employer that refuses to hire smokers offers tobacco-using applicants a bonus of $500 if they participate in a smoking cessation program and remain smoke-free for six months after being hired. This has worked in the case of at least one highly qualified applicant who agreed to quit smoking if hired--and did. (14)

Before instituting these or related hiring policies, employers should confirm they do not violate state law. Employers should also consider that such policies may make it more difficult to attract qualified candidates, necessitate monitoring employees' after-hours activities, and increase exposure to lawsuits related to claims of discrimination and invasion of privacy.

Charging smokers higher insurance premiums. Higher insurance premiums can be a powerful motivator for workers to quit smoking, especially if employers complement them with smoking cessation programs. For example, Bank One charges smokers higher fees for health and life insurance and uses the additional fees to fund wellness programs and offset higher health care expenses. (15)

Requiring employees to complete a health risk assessment and participate in wellness programs based on results. An employer may require workers to complete a health risk assessment (HRA) to become eligible for health benefits. A variation of this is to offer health insurance at no cost to employees who complete an HRA.

Offering tobacco cessation programs. Many employers understand that employees need "carrots," not just "sticks," to quit their addiction to tobacco. One such company is Oil States International, which manufactures and distributes oil-drilling equipment for land-based and offshore operators. Thanks to a smoking cessation program, the firm's employees and dependents are beginning to learn the "line of sight" between smoking, increased use of the health plan, and higher employee insurance premiums.

"We estimate 30 percent of our employees smoke, compared to the national average of 21 percent," says Doug Powers, manager of compensation and benefits for Oil States. "Our strategy is to contain health plan expenses and increase our employees' quality of life through chronic disease management and wellness initiatives, including a company-sponsored smoking cessation program. It appears a program that includes phone counseling, health risk assessments, and support group resources offers the best return on investment. We 'test drove' one program last fall and will do the same with others that include phone counseling that fits the schedule of our hourly employees."

Full or partial sponsorship of smoking cessation programs is a "win-win-win," Powers says. It lowers employers' health plan expenses, improves the quality of employees' lives, lowers employees' health insurance premiums, and improves employees' energy level during their free time. According to a 2005 survey of 365 leading U.S. companies, 56 percent offer smoking cessation programs. (16)

Offering incentives for quitting smoking. Bank One implemented a smoking cessation program that consists of four class sessions. Employees who complete the program (regardless of whether they quit smoking) are eligible for the nonsmoker's discount on health and life insurance premiums. (17) This demonstrates the company's commitment to partnering with workers to address the harmful consequences of tobacco use, both to the individual and to the company's bottom line.

THE ROLE OF EAPS 

Employee assistance programs can support employers' efforts to reduce or eliminate smoking by helping them design and implement effective policies and programs while minimizing disruption to workforce productivity and ensuring that all employees feel they are being fairly treated. The following suggestions can help EAPs accomplish these goals:

1 Remind employers that with any smoking policy, companies must send a clear message that they care about the health of their workers. By providing support to help smokers quit, employers strengthen this message and reassure smokers that the company is not trying to stigmatize them.

2 After establishing a smoking policy, employers must clearly communicate the policy and its rationale, a timetable for implementing the policy, and sanctions for noncompliance. Designated personnel should monitor, enforce, and adjust the policy as necessary. Compliance is typically higher if employees have helped develop the policy and are well informed about its rationale.

3 Employees who smoke will be the first to feel the effects of implementing a smoke-free policy The following suggestions can help them adjust to changes introduced by the policy:

* Inform employees well in advance (ideally four to six months prior to implementation) that a new policy is being developed.

* After implementing the policy, let smokers know that the organization appreciates their efforts to comply with it.

* Offer tobacco cessation assistance.

* Encourage non-smoking employees to support smokers in their efforts to quit.

* Communicate changes to policies and benefits plans that show a continuing commitment to support smokers in their efforts to quit.

THE KEYS TO SUCCESS

The following elements are critical to determining whether a workplace-based tobacco cessation program will succeed:

Counseling and coaching. Whether delivered face to face or by telephone, counseling can help individuals develop their own quitting strategy based on their unique concerns and patterns of use. Telephone counseling is one of the most successful and cost-effective forms of cessation treatment. The effectiveness of services increases as the number and length of sessions increase. (18)

Nicotine replacement therapies and medication. Research shows substantially greater success rates when counseling is paired with nicotine replacement therapies (NRT) or other cessation medication. Employers can increase the number of successful quitters by making it easy for employees to obtain these approved medications at no cost. (19)

Effective communication. Employers should make employees aware of the resources available to help them quit using tobacco. Frequent communication using a variety of methods and conveying consistent messages are important factors in an effective communication strategy.

Incentives to quit smoking. Even small rewards or recognition programs can help individuals succeed in quitting. (20) These might include providing nicotine replacement products at no cost, reducing insurance premium differentials between smokers and non-smokers, or adding cash to a flexible spending account to pay for enrolling in a tobacco cessation program.

An integrated approach. Integrating tobacco cessation programs with counseling, disease management, and wellness programs and revising company policies and health plans to ensure continuing support of smokers' efforts to quit greatly increases their likelihood of Success.

Supportive workplace environment. It is important that the workplace environment not stigmatize or blame tobacco users. In addition, if the leadership within an organization can demonstrate support of a smoking cessation program, such modeling can have an extremely positive impact on overall employee participation and success.

Ability to access multiple interventions. Policies and programs should cover multiple "quit" attempts during a year, as most smokers need to make several attempts before they stop smoking for good.

A variety of resources. Resources should be made available to individuals who are in various stages of smoking cessation--e.g., current users, those who are actively quitting, and former tobacco users who want to remain abstinent from tobacco. (21)

Breaking nicotine addiction is a challenge. The workplace provides a great venue to help people quit smoking and remain tobacco-free. Research demonstrates that paying for an employee's tobacco cessation treatment provides a greater return on investment than any other treatment or prevention benefit. (22) EAPs can be a valuable partner in consulting with and guiding employers in addressing this challenge.

References

(1) National Center for Chronic Disease Prevention and Health Promotion. 2005. Tobacco Information and Preventions Source (TIPS). Atlanta, Ga: Centers for Disease Control and Prevention. Online at www.cdc.gov/tobacco/issue.htm.

(2) American Cancer Society 

(3) Centers for Disease Control and Prevention. 2002. "Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Economic Costs: United States, 1995-1999." Morbidity and Mortality Weekly Report, 51(14).

(4) U.S. Surgeon General.

(5) Centers for Disease Control and Prevention.

(6) National Business Group on Health. [YEAR.] Reducing the Burden of Smoking on Employee Health and Productivity. Washington, D.C.: National Business Group on Health, [PAGE#].

(7) National Institute on Drug Abuse. 2003. NIDA InfoFacts: Cigarettes and Other Nicotine Products. Bethesda, Md.: National Institutes of Health. Online at www.drugabuse.gov/Infofax/tobacco/html.

(8) American Cancer Society.

(9) Centers for Disease Control and Prevention. 2005. "Cigarette smoking among adults: United States, 2004." Morbidity and Mortality Weekly Report, 54(44): 1121-1124.

(10) U.S. Department of Health and Human Services. 2000. Reducing Tobacco Use: A Report of the Surgeon General. Washington, D.C.: Department of Health and Human Services.

(11) Deloitte & Touche LLP 2005. Survey: U.S. Employers Turning to Wellness Programs to Manage Health Care Costs. Washington, D.C.: Deloitte & Touche. Online at www.deloitte.com.

(12) National Business Group on Health.

(13) Cadrain, D. 2004. "HR caught between conflicting laws on smoking and the workplace." Alexandria, Va.: Society for Human Resource Management. Online at www.shrm.org.

(14) Cadrain, D. "HR caught between conflicting laws on smoking and the workplace." Society for Human Resource Management.

(15) National Business Group on Health, Center for Prevention and Health Services, Issue Brief, Volume 1, Number 5, Reducing the Burden of Smoking on Employee Health and Productivity, p. 6.

(16) Deloitte & Touche LLP 2005.

(17) National Business Group on Health, Center for Prevention and Health Services, Issue Brief, Volume 1, Number 5, Reducing the Burden of Smoking on Employee Health and Productivity, p. 6.

(18) National Heart, Lung and Blood Institute.

(19) National Heart, Lung and Blood Institute.

(20) U.S. Department of Health and Human Services, Office of the Surgeon General.

(21) U.S. Department of Health and Human Services, Office of the Surgeon General.

(22) National Business Group on Health, Center for Prevention and Health Services, Issue Brief, 2003.

Mary Hill is regional manager of Health and Performance Solutions in ValueOptions' Employer Solutions Division and is responsible for supporting the division in the delivery of workplace-based services. She has been involved in the EA field for more than 11 years. She can be reached

at [phone] or at [e-mail]. She would like to acknowledge Sandy Werner, manager of Health and Performance Solutions Communications at ValueOptions, for her contributions to this article.