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SMOKING: A CHALLENGE TO WORKSITE HEALTH MANAGEMENT Anne Kiefhaber & Willis Goldbeck INTRODUCTION New knowledge about the medical, economic, and human costs of smoking has com- bined with growing public awareness of the problem, and with empirical evi- dence of the return-on-investment from smoking control policies and programs, to indicate that we stand at the threshold of real progress. This brief paper examines one aspect of our effort to cross that threshold and counteract the smoking menace: Smoking Control at the Worksite._ Worksite programs are a response to the convergence of several factors: 1. People spend a very large portion of their lives at work and thus are "reachable" in this setting. 2. Employers have a large number of incentives to help employees stop, or reduce smoking. 3. The early leaders in worksite programs realized considerable success, using a variety of measures, and thus provided models for their less adventurous business brethern. 4. Pressure for employer action has been increasing from government (OSHA), the media (lots of positive attention paid to those with programs), wor- kers (agitation for smoke-free environments), and the courts (which have spoken both for and against anti-smoking policies). 5. Awareness about the cost of smoking is increasing as is the availability of community resources to which a company can turn for assistance. The American Cancer Society, Lung and Heart Associations, hospitals, YMCA, and various proprietary firms are actually competing to provide smoking ces- sation resources to business. Growing employer involvement mirrors the increased attention being given to the smoke-free environment movement through our society. Surveys report a 'decline in the portion of the population that smokes, and there are ever-in- creasing smoking restrictions in elevators, restaurants,,airplanes, and even business meetings. The message is clear: societal values are making the smoker increasingly out of vogue. We must be careful, however, not to be entfapped by the appearance of success. The fact remains that only a fraction (39.) of all employers actually have or sponsor smoking programs. And, far fewer have taken the more important step of creating a corporate smoking policy with the concomitant action strategy. TIMN 0086513 1Danaher, Brian, G. PhD., "Smoking Cessation programs in Occupational Set- tings", Public Health Reports, March-April 1980, Vol. 95, No. 2. -128- 13~,~4 '~

Throughout the paper, we are speaking of corporate policies and programs. The latter are courses, classes, or systems provided by the company, or by an out- side agency, that seek to help employees reduce or stop their smoking. By policy, we mean a corporate position that may be as simple as a policy that no smoking will be allowed or as complex as a total strategy for creating a smoke -free environment and assisting employees to stop smoking through the provi- sion of specific programs. Many barriers to program enhancement and expansion can be identified. Even here, the problem is hard to define. Barriers to a smoking cessation program may include the absence of a corporate smoking policy. However, the attain- ment of such a policy is dependent on overcoming other barriers that, by them- selves, may have no impact upon the decision or ability to conduct a specific smoking program. Further, the barriers vary according to the location of the worksite, its leadership, type of products, other demands on resources, and factors which are exogenous to smoking, but very relevant to corporate de- cision making. In the pages which follow, the authors, both of whom work for the Washington Business Group on Health and do private consulting in the health field, will give the participants in the American Cancer Society's Conference on "Smoking OR Health" a review of the literature, statistics, trends, and case examp'les of' smoking control at the worksite. Barriers to smoking control are discussed and the paper concludes with recommendations designed to fuel conference dia- logue. GOAL, OBJECTIVES, AND BARRIERS An initial task for the Conference workgroup is to reach agreement on the pri- mary goal for worksite smoking policies and programs and, subsequently, to prioritize a set of objectives to support the goal. Once this is done, the most harmful barriers can be identified and appropriate solutions selected. Following are a goal, objectives, and barriers presented to stimulate--perhaps guide-the Workshop.dialogue. GOAL: To reduce smoking at the worksite. Justification: This is the only goal statement that encompasses all the varied employer motivations for worksite programs or policies. • OBJECTIVES: (the attainment of which would support the above goal) A. To have more employers establish smoking reduction 1) policies 2) programs 5~~~5 TO3~~~~ TIMN 0086514 -129-

B. To reduce corporate expenses as measured by 1) medical benefits 2) absenteeism 3) other insurance costs 4) safety and product quality 5) productivity 6) janitorial/maintenance NOTE: These are also by-products of attaining the goal. C. To provide a service for employees in response to 1) their demand 2) feeling of corporate responsibility BARRIERS: The barriers are a synthesis of those that appear most frequently in the literature, in the four surveys discussed in this paper, and in inter- views conducted by Anne Kiefhaber. All relate to the difficulties of estab- lishing policies: some also hinder program development. 1. Cost. Cost is the most frequently reported barrier. The problem is com- pounded by the desire of many very large employers to provide benefits in which all can participate equally. Comment: This seems more an excuse than a true problem, especially with reputable programs available at little or no cost from such organizations as the American Cancer Society, the Heart and Lung Associations, and other voluntary organizations. Even the highest cost program (Campbell Soup's $500 per quit) is very inexpensive compared to the medical or administra- tive cost savings. 2. Lack of Knowledge. Surveys show that a remarkably 9mall percentage of the population know and believe the dangers of smoking. Similarly, many em- ployers simply do not have sufficient information to really understand the issues--and potential benefits--at the level where they would feel com- fortable making the decision to initiate a policy or program. Comment: It is the absence of accurate, timely, and comprehensive infor- mation that feeds the perpetuation of such myths as: "We do not have proof that smoking is the direct cause of disease", or "How do we know the program will be cost effective?" This barrier is especially difficult to overcome when the corporate leaders are smokers and, thus, find "ignor- ance" to be supportive of their own lifestyles. 3. Resources. Many large communities have a wide range of programs competing for corporate reimbursement. However, many others are "resource poor". Comment: Employers are reluctant to get into the smoking control business, preferring to wait for community resources to which employees can be referred. This barrier is falling to the growth of new prc+grams in 2 Fullerton, Jane, Paper for the ACS Conference Smoking OR Health, Fall 1981 -130- TIMN 0086515 T013" ~~,,646

pursuit of corporate dollars and to the leadership of such companies as IBM whose wellness strategy supports community resource development that subsequently is available to other employers. 4. Effectiveness. Not enough is known about those programs that work and too much attention is paid to those that either fail or are marginal. Many employers claim to be waiting for proof of effectiveness before offering any program. Comment: Employers do not agree upon what constitutes success. a) high levels of participation b) reduced smoking c) quit rates, for specified durations d) increased awareness of health hazards e) other measures of benefit to the company 1) reduced cost 2) improved morale They are equally uncertain about the cost factors that should be "charged" to the smoking program. Finally, it can fairly be said that the cost- effectiveness ratio is of less significance than developing easy to under- stand measures by which programs can be compared. Employer-employee com- munication is another element of the effectiveness issue. Regardless of the smoking cessation program used, success will be significantly deter- mined by the methods the employer uses to communicate the importance of participation to the employees. If dependents are to be included, this is all the more complex. 5. Labor-Management Relations. Many employers shy away from establishing no- smoking policies or urging participation in smoking cessation programs be- cause they fear employee opposition. This opposition is compounded when labor unions attack management for using smoking programs as a cheap es- cape from major investments in worker safety. Comment: No doubt, some employers may have attempted to use smoking pro- grams as the unions suggest. Such unconscionable acts can never be de- fended, even by other employers. As exceptions, however, these instances should not become the guide for labor-management relations on the smoking issue. The facts demand a different perspective and a cooperative labor- management approach. Fact:. It is acceptable to ban any employee behavior that is known to be unsafe to either that worker or fellow workers. Smoking is clearly such an activity. Fact: For employees who work in high-risk environments, no matter how lax the employer has been, the facts are that the employees who smoke are far more likely to become ill or die than are their nonsmoking compatriots. (97 times more in the case of asbestos workers, for example.) 131- TIMN 0086516 -131- rf

Therefore, the facts urge a new definition of employee benefits, one which stipulates that a no-smoking policy is a labor-management accomplishment of which both sides can be proud,even if some individuals are inconven- ienced. 6. Liability. Concern for liability if employees do smoke in a high-risk environment is a stimulant for no-smoking policies; concern for liability if nonsmoking policies are interpreted as an infringement on empioyees' rights is an excuse for delaying or rejecting such policies. Comment: Until the courts become consistent in their decisions, many em- ployers will remain reluctant to set restrictive policies. This is the larger issue since most employees do not work in high-risk environments. If we are to meet our goal, it will be necessary to encourage smoking ces- sation programs on the basis of an employee health benefit freely selected and, simultaneously, to develop a unified labor-management approach to the courts. In order to posit strategy for business leaders to remove these barriers, it will be useful to arrive at a common understanding of the health and economic aspects of smoking, and of the current state of corporate activities. THE PROBLEM What is the problem? At first the answer seems so simple: smoking. However, when trying to come to grips with smoking at the workplace-,.the problem be- comes more nebulous. Several problems are identifiable: 1. The health consequences (and resulting financial consequences) for employ- ees who smoke. 2. The costs to the company of employees who smoke. 3. The lack of smoking cessation programs for workers. 4. The lack of corporate smoking policies such as those that prohibit smoking in all but selected areas. 5. Values related to employee rights, privacy, and dependent involvement in company programs. 6. Labor-management relations. Though all o,f the above problems are related, each has its own complexities, barriers, and solutions. THE HEALTH CONSEQUENCES OF SMOKING Human capital is every nation's greatest asset. who comprise the workforce directly affects the that product may be. Approximately 33% of the working population is able cause of death and disability: cigarette quences are awesome: 3The American Cancer Society -132- The well being of the people final product, no matter what addicted to the most prevent- smoking.3 The health conse- TIMN 0086517 r a3,~48 f

.325,000 early deaths from cancer, and other diseases of4the lung and circulatory system are attributed to smoking each year. .Smoking is related to 90'/% of all lung cancer cases; 30% of arterio- 5 sclerosis cases; 75% of bronchitis cases; and 807. of emphysema cases. .Smokers have twice the risk of death due to coronary heart disease, and 10 times the risk of developing lung cancer. They also have longer con- valescent periods from respiratory infections and, if surgery is requ~r- ed, are more likely to develop post operative respiratory infections. Smokers are, therefore, far less healthy workers than nonsmokers. The effects of unhealthy workers are felt at the worksite in many ways: increased absent- eeism, less than optimal productivity, increased medical costs, and early loss of workers through premature death. THE ECONOMICS OF SMOKING The economics of smoking, for the individual, is a subject of little interest and is often reduced to mere concern for the price of a pack of a favorite brand. Tb a significant degree this is due to employer-based health insurance which hides the real cost of ill health that can be attributed to smoking. For employers, however, and those who are in positions to make resource allo- cation decisions, the economics of smoking are sufficiently staggering that anyone responsible for a"Bottom Line" is left with one unmistakable conclus- ion: reducing, much less stopping, smoking is virtually guaranteed to produce a very welcome return-on-investment. Statistics and studies abound. Consider just these few which give a collec- tive view of the magnitude of the opportunity facing the stop-smoking effort. 1. Each year, over 80,000,000 work days are lost due to smoking.7 2. Using $190.90 as an average weekly wage, the government estimateg that some $3 billion was lost in 1977 to cigarette related illnesses. 3. Using 1980 dollars, Dr. Kristein of the American Health Foundation and NIH, has estimated that.the total annual cost of cigarette smoking is $47.5 billion. This represents a loss to our community of $1.56 for every pack smoked, not counting the actual cost of cigarettes themselves. Of the $47.5 billion, $11 billion is excess medical expenses incurred by smokers (the cost of illness to exposed nonsmokers is not even included); and $36.5 billion is indirect cost que to early death, premature retire- ment and losses due to absenteeism. 4The Smoking Digest, U.S. Department of Health Education and Welfare (DHHS), 1977. 5Ibid. 6lbid. 7The Smoking Digest, op.cit. 8The Smoking Digest, op.cit. 9 TIMN 0086518 Kristein, Marvin, M., Ph.D., "How Much Can Business Expect to Earn From Footnote Cont'd -133-

10 per year. 4. Each smoker costs his or her employer approximately $624 These are totally wasted dollars that could otherwise be given to the employees as compensation or improved health benefits, shared with stockholders, or otherwise allocated to business development for a stronger national economy. The $624 consists of: A. Excess insurance costs $274.00 1) health ($204) 2) fire ($10) 3) worker's compensation ($40) 4) life and disability ($20-$35) B. Absenteeism 80.00 Smokers average 33-45% more absenteeism than nonsmokers C. Reduced productivity •166.00 Smokers have increased eye irritation and carbon monoxide levels, reduced attentiveness, lowered cognitive and exercise capacity that has been measured to cost each smoker 8 minutes per day of productivity D. Involuntary smoker impact 104.00 -insurance ($55.00) -other (149.00) 5. For those who believe the health and productivity measures are too ob- scure, the experience of Merle Norman Cosmetics provides a simpler measure that any employer can quickly understand. They estimate savings in a small plaq in excess of $13,500 in 1976 as a result of reduced janitorial services. Similarly, the work of Weis and Fleenor found that "employers expected to save at least $500 per smoker per year from incremental replacement of furnishings and equipment, not counting occasional patch-up work on re- cently acquired cf1peting which, according to Unico, can run as high as $100 per repair." Smoking Cessation", presented at the National Interagency Council on Smoking and Health's Workshop: "Smoking and the Workplace", January 9, 1980, Chicago, IL. lOIbid 11Kelliher', E.V.: Fewer workers now are singing "Smoke Gets In Your Eyes", Wall Street Journal:1 and 33, November 7, 1978 12Weis, William L.: "Can You Afford to Hire Smokers", Personnel Administra- tor, May 1981. ~ -134- 1 ;)V..~.:!d,'6 TIMN 0086519

6. Insurance companies, by offering premium reductions in life, health, fire, and casualty policies, offer the final proof that nonsmoking actually pays off. These companies base their decision on data, actuarial analysis, and "impirical evidence based upon the experience of many thousands of policy holders. Although not yet a majority, the trend toward these incentives is growing. 7. New York Telephone estimates an annual savings in absence and treatment costs for smoking related diseases of $645,000 for cardiovascular diseases and $1,400,000 for pulmonary diseases. This is not taking into account the iTgact on well-being, productivity and roughly 15 lives saved annu- ally. 8. Finally, another composite look at the costs, per smoker, to employers as compiled by Weis: Additional Annual Cost of Employing Smokelr4s and Allowing Smoking at the Work Place. Cost Sources Annual Cost per Smoker Absenteeism $ 220(a) Medical Care 230(b) Morbidity and Early Mortality (discounted lost earnings) 765(b) Insurance (excluding health) 90(c) On-the-Job Time Lost 1,820(a) Property Damage and Depreciation •500(d) Maintenance 500(d) Involuntary Smoking 486(c) Total Cost Per Smoker per year`, $4,611 All costs are in January 1981 dol~lars a) Assumes that total personnel cost to employer, including fringes and payroll taxes, equals $20,000 per employee. b) Based on Luce and Schweitzer (1978) adjusted for 1981 dollars c) Based on Kristein (1980) adjusted for 1981 dollars d) Based on interviews by author (Weis) e) Based on White and Froeb (1980), Wynder and Stellman (1977), and Luce and Schweitzer (1978) Trying to satisfy the skeptic that all these studies are accurate is a battle best left unengaged. One fact remains unchallenged: no matter how it is mea- sured, smoking is a terrible drain on our economic resources, the limits of which we are increasingly aware of. 13Wood, Loring, M.D., "Lifestyle Management Strategies at New York Telephone", Unpublished paper presented at the "Leadership Strategies Health" Conference at the Institute for Health Policy Study, Project Hope, 1980. 14 Weis, op.cit., p.77 -135- TIMN 0086520 T 0 3~w~51

Faced with the economics of smoking, it becomes difficult to claim our country cannot afford to provide basic health and medical services, or to call for sa- crifices in social programs and employee compensation when we do so little to stop a minority of our population from wasting so much. THE LACK OF SMOKING PROGRAMS FOR WORKERS Programs to assist cessation A concise definition of what constitutes a smoking cessation program compli- cates reporting the magnitude of the problem. Three separate surveys of employers reported the percentages of worksites with programs differently: 1. A survey of 128 large companies in Massachusetts reported that 8% of the surveyed companies provided counseling for those employees who wished to quit smoking; 12% or ten companies had provided programs for those who wished to stop smoking; two were onetime lectures, three were operated by the Seventh Day Adventists, and five by SmokEnders. Eight of the ten were run on employses' own time and only three employers paid part of the pro-, gram's cost. 2. The National Interagency Council on Smoking and Health surveyed 3,000 com- panies of varying sizes and locations. The survey reported that 14.7% or 124 of the responding companies indicated that they have or had a health education or promotion program on smoking. These programs took the fol- lowing shapes: -•32.3% were physician counseling ~ 33.1% were other counseling - 56.5% were "How to Quit" materials - 22.67. were single-sessioniglinics - 10.5% were in other forms 3. The Washington Business Group on Health survey of its member companies reported P%of the responding corporations had a "smoking cessation program." Generalizations about educational material and smoking control courses offered at the worksite can be made: 15 Bennett, Diane, Med. and Barry L. Levy, M.D., "Smoking Policies and Smoking Cessation Programs of•Large Employers in Massachusetts", AJPH June 1980, Vol. 70, No. 6. 16 The National'Interagency Council on Smoking and Health, "Smoking and The Workplace, A Business Survey", December, 1979. 17 The Washington Business Group on Health,-"A Survey of Industry Sponsored Health Promotion, Prevention and Education Programs." December, 1978. ; TIMN 0086521 -136- ~ ^ ~ T03.Sti

.most are on a onetime only or sporadic basis .most are implemented through the medical departments (699% according to the WBGH Survey) .companies with more than one location leave the decision to have a pro- gram to the discretion of each location .most companies use outside resources to conduct the programs. Fre- quently used are the American Cancer Society, American Lung Associa- tion, American Heart Association, SmokEnders, and hospital programs such as the Seventh Day Adventists. .if a fee is attached to a course, employees are usually responsible for the payment. When the company does make a financial contribution, it is usually only a portion of the total cost. .most programs are not conducted on company work time. Corporate Examples: High Risk & General Programs Campbell Soup Company: The Campbell Soup Company offers employees, in almost all of its locations, opportunities to participate in a smoking cessation pro- gram. In addition, most all locations publish information about smoking in the corporate newspapers and offer self-help pamphlets with nurse support for employees who would like help to stop smoking without participating in a for- mal course. Many of the locations contract with local providers for the courses. The cor- porate office contracted with the Center for Behavioral Medicine at the Uni- versity of Pennsylvania to conduct a series of smoking cessation classes and to train the corporate staff to conduct the programs in the future. The pro- gram was designed to attract a large number of participants. Campbell Soup had 71 employees enrolled in the most recently offered program. The company paid $30 of the program costs while the employee paid $20. Time for the program was split, half on worktime and half on the employees' time. After one year, 207. of the participants were nonsmokers. Dr. Roland Wear, the corporate medical director, attributes the relatively low success rate of the program to its emphasis on attracting large numbers of "hard core" smokers rather than only those who are already dedicated to giving up the smoking habit. The cost of the program to the company was estimated to be $500 per successful employee. The laf§est cost contributing to this figure was the employees' time off the job. IBM. IBM Corporation recently launched a health promotion program for all of its employees, retirees, and their dependents (with some restriction on the third group). Smoking cessation is included in the package of programs to be coordinated with a community group and offered to IBMers. If a given location cannot arrange for a course to be taught, or if an eligible person cannot par- ticipate in an arranged program, they may receive up to $75 tuition reimburse- ment for attending a course designed to help smokers understand their habit 18This information was gathered through a phone conversation with Dr. Roland Wear, Medical Director, The Campbell Soup Company. -137- TIMN 0086522 TO3~~~53