Introducing a successful smoking cessation programme in the workplace can not only help to improve staff health, it can also provide business benefits, say Michael T Halpern and Hayden McRobbie.
It's a familiar sight: outside an office, a group of workers gathers near the entrance for a cigarette break. On a building site, a worker lights up under the designated shelter. Even at health centres, workers can be found smoking at shift end. Employees from all occupations smoke; in fact, around 1.3 billion people use tobacco worldwide (World Heart Federation, 2010).
The cost of tobacco use to business, in terms of decreased productivity, increased absenteeism and increased medical care costs for employees and their families, is well documented (World Health Organisation (WHO), 2011). However, there are some simple steps that employers can take towards achieving a smoke-free workforce, and with legislation preventing smoking in workplaces across much of Europe, now is a beneficial time for employers to consider smoking cessation programmes within their worksites.
This article discusses the rationale and benefits of implementing such a programme, and draws upon a case study at pharmaceutical company Pfizer, which implemented a cessation programme pilot across Europe to share experience and offer recommendations for rolling out cessation support within the workplace.
Rationale: why the workplace?
It is estimated by QUIT, a charity that helps people to stop smoking, that half of all people who smoke tobacco will die as a consequence of smoking. Furthermore, in 2000, smoking killed almost two million people in developed countries. Half of these people died in middle age (35 to 69 years old), losing, on average, 22 years of their life (Peto et al, 2006). In response to the global tobacco epidemic and calls for global progression towards tobacco control, the WHO introduced the first international health treaty that focuses on tobacco control (Framework Convention on Tobacco Control; FCTC). To date, more than 170 states are party to the treaty. The FCTC stresses the importance of providing cessation services to tobacco users, and endorsing parties of the treaty are called upon to protect people from tobacco smoke exposure in public places.
Many governments across Europe (including France, Spain, Ireland and Portugal) have subsequently initiated smoke-free legislation with a goal of stopping workplace smoking and second-hand tobacco exposure. At an EU level, many occupational health and safety directives concern the regulation of smoke-free workplaces, which are legally binding to member states (WHO, 2006).
Tobacco control legislation at an EU level also consists of nonbinding resolutions and recommendations. For example, the Council of the European Union's 2009 recommendation on smoke-free environments relates in part to improvements in the safety and health of workers. It recommends that member states introduce measures to provide effective protection from exposure to tobacco smoke in indoor workplaces, which may include taking measures to promote cessation of tobacco use and treatment for tobacco dependence (Council of the European Union, 2009).
Worksite smoking cessation programmes offer economic, health and political/legal benefits for employers. Previous literature reports the health and economic value of such programmes, with evaluations demonstrating improvements to workers' health and net economic savings that frequently exceed programme costs within a few years.
Worksite smoking cessation programmes offer economic, health and political/legal benefits for employers."
As described by Action on Smoking and Health, smoking cessation in the workplace is not a revolutionary idea, but it is a timely one. Dr Grant Mayho, occupational health director, Pfizer, explains: "Smoking cessation in the workplace has been around for years and is not new. In the 1980s, smoking cessation was innovative and simple techniques such as individual and group counselling, nicotine patches and gum were easy wins for employers. Since then, progress has slowed and enthusiasm has waned. However, the cost of smoking to businesses is now widely recognised, and the legal position with smoking bans across Europe is starting to bite. There are also new and exciting developments in smoking cessation strategies. Businesses are therefore once again taking a close look at the advantages of providing smoking cessation programmes to their employees."
The economic cost of smoking has been widely demonstrated; for example, the WHO recently estimated the overall economic costs of tobacco use in the UK to be £13.74 billion annually. This comprises: treatment of smoking-related illness; loss of productivity due to illness and smoking breaks; increased absenteeism; the costs of cleaning up cigarette butts and fighting smoking-related fires; and the loss of economic output from people who die from diseases related to smoking or exposure to second-hand smoke.
An additional rationale for employers to support smoking cessation programmes comes from smokers themselves. Pfizer commissioned a survey of European employees regarding smoke-free policy: 29% of the respondents reported that they smoked, 65% of whom reported wanting to stop. A separate international survey revealed that nearly half (48%) of employees who smoke and more than two-thirds (69%) of employers think that their company should support smoking cessation efforts (Halpern MT et al, 2010).
Most adults spend the majority of their waking hours at work, and therefore the workplace has several distinct advantages over health services as a route for providing cessation support. These include:
Access: Worksites provide opportunities to reach smokers, especially otherwise healthy adults who may not engage regularly with health services.
Flexibility: Smoking cessation programmes can be tailored to fit the circumstances and preferences of adults who may struggle to fit healthcare appointments into busy schedules.
Influence: Workplace policy and culture can shape employees' day-to-day environments and influence behaviour, including health practices, in a way that health services cannot. For example, smoke-free workplaces can discourage or stop an employee from smoking during the entire work day.
Establishing a smoking cessation programme
There are many variations of smoking cessation programmes, meaning that all employers may be able to find a design to best suit their workplace. When establishing a smoking cessation programme, employers and human resource professionals may want to consider the following phases:
Review the smoke-free policy of your workplace: Ask whether or not the policy is fit for its purpose; is it outdated and could it be improved? The Global Smokefree Partnership toolkit contains useful checklists to assist with a workplace situation analysis and policy assessment.
Conduct a survey of all employees on site: The findings should be used to gauge employees' interest, assess the types of smoking cessation support that employees would find most helpful and shape the final cessation programme.
Even the best smoking cessation programmes won't be successful if smokers are not aware that they are available."
Investigate options for providing smoking cessation counselling and treatments and identify sustainable funding: Employers can consider (a) utilising national or local smoking cessation services, or (b) offering an "in-house" smoking cessation programme. The programme should ideally combine behavioural support (eg face-to-face or telephone counselling) and pharmacotherapy - a variety of therapies are available. Explore possibilities for obtaining resources from the Government, or sourcing funding from health insurance schemes. Employers may also want to explore internet-based smoking cessation programmes, given that many employees spend at least part of their working lives behind computer screens. Online programmes may contain a stop-smoking plan, modules on social support (often offering technology-enabled counselling or "ask-an-expert" sessions via online chat or email), information on cognitive behavioural coping skills and references for further support sources and materials (motivational materials, for example). In an evaluation of one internet-based smoking cessation programme, the social support component was used most frequently and the benefits of being able to access the online programme at any time of day were recognised (Feil EG et al, 2003). A separate study concluded that online, interactive interventions can be effective in aiding cessation and are particularly effective in smokers that are motivated to quit.
Implement the smoking cessation programme: Employers, managers, HR professionals and OH experts should work closely to ensure the programme is successfully implemented. "Buy-in" from all levels of management is needed. There may be national or local regulations that need to be followed, especially around the supply of pharmacotherapy and extending the programme to an employee's family members.
Promote the smoking cessation programme internally to ensure maximum uptake: Even the best smoking cessation programmes won't be successful if smokers are not aware that they are available. Ideas for promotion include an email to all employees, dissemination of flyers, the display of posters across worksites, or information published within a company magazine.
Evaluate the programme based on participation, cessation rates, cost and participant satisfaction: Tailor the programme according to feedback - as much as is feasible and as far as budgets allow, the programme should accommodate the needs of employees in terms of type of support, its timing and support locations. Consider longer-term follow-up after participation to assess the need for additional intervention to prevent recidivism (ie resuming smoking after successfully quitting).
Lessons learned from experience
In 2009, Pfizer reviewed its smoke-free policy; considering the phases above, the following lessons can be taken from the organisation's experiences:
1. The CEO Cancer Gold Standard is a series of recommendations to fight cancer in workplaces. Part of this standard involves encouraging employees to maintain an active lifestyle, eat a healthy diet and not use tobacco. To align with the first pillar of the standard (see box), the organisation piloted internal smoking cessation programmes for its worksites in Germany, Belgium, Spain and France.
2. To ensure that the programmes met employee needs and preferences in different countries and settings, an online questionnaire was made available to all employees in the sites chosen. The survey received a response from 22% of the workforce (Pfizer in partnership with the World Heart Federation, 2009). The answers provided baseline information to shape the smoking cessation programmes.
3. As a result, programmes offered 12 weeks of cessation support to employees who enrolled. National differences in legislation, guidelines, reimbursement and work culture were taken into account when designing and implementing evidence-based cessation interventions. Programmes were to be paid for in full by the company.
4. In all four pilot countries, the programme used local independent stop-smoking programmes that offered medication and behavioural support. Services offered included face-to-face, group, telephone and online (using webcam and email) counselling. They varied from country to country and in some cases within countries, depending on access to resources, guidelines and usual clinical practice, employee preferences and other practical considerations. A total of 154 employees enrolled in the programme: 32 in Spain; 32 in Germany; 73 in France; and 17 in Belgium.
5. Senior management endorsed the programmes and was involved in internal promotion of them. Programme materials were adapted for use in each country.
CEO Cancer Gold Standard
Pillar 1: Tobacco use
- Establish and enforce tobacco-free policies.
- Provide coverage for, at either no cost or at a reasonable cost-sharing level, evidence-based cessation treatments (counselling and FDA-approved prescription/non-prescription medication).
- Provide employer-sponsored tobacco cessation programming.
See The Five Pillars of the CEO Cancer Gold Standard for more information.
6. Following the intervention, quit rates (defined as not having smoked more than five cigarettes since quit date) were recorded after three months, with 40% successful quitters in France, 50% in Germany and 66% of those that enrolled in Spain (Pfizer in partnership with the World Heart Federation, 2009). Outcome data on the 17 employees enrolled in the Belgium stop-smoking programme were unavailable.
Participants and specialists providing cessation services were also surveyed about their experiences. For those smokers participating in counselling, most people reported no preference about whether this was provided on or off the worksite; while on-site counselling was convenient, off-site services also allowed the participation of family members. Programmes with more rigid requirements, such as obliging participants to receive counselling, had lower rates of participation.
As part of its ongoing commitment to improving cardiovascular health within the workplace, the World Heart Federation has worked with Pfizer to analyse the pilot results. Based on this analysis and the team's existing knowledge, lessons were devised for future programme implementation, including:
Worksite cessation programmes are among the best ways for employers to improve employee health. Worksite cessation programmes are needed and appreciated by employees and are effective in increasing smoking cessation. In most parts of Europe, smokers still encounter many practical and financial barriers to obtaining effective cessation support, and employers can play an important role in helping smokers to get the help that they need. However, cessation activities need to be supported by a comprehensive and enforced workplace smoke-free policy.
There is no "one-size-fits-all" programme for worksite smoking cessation. National and local differences in law, guidelines, healthcare provision and reimbursement, custom, workforce profiles and other factors affect the feasibility, acceptability and cost-effectiveness of smoking cessation programmes. It is therefore recommended that when devising the cessation programme you not only align it to business goals and strategies but also national guidelines and legal requirements.
It is also vital that the smoking cessation programme is specifically targeted to employees. Convening a working group (including senior management, human resource professionals, occupational health professionals and employees, among others) for the development of your organisation's smoking cessation policy is recommended to ensure that a programme is based on your workforce's needs and preferences. This is where a workplace survey can be helpful. It is also recommended that you cultivate a smoking cessation champion to promote and explain the programme and share success stories.
Convenience and flexibility far outweigh other considerations for employees. The programmes that were best aligned to employee preferences and offered the most flexible forms of counselling had both better participation rates and better quit rates. Employee input into planning phases can identify preferences from different groups, and these should be accommodated whenever feasible.
Support from top-level management is key. It improves employee participation and assists with the facilitation of programme planning and implementation. However, research has shown that although both employers and employees value smoke-free workplace programmes, they differ regarding appropriate or preferred methods for encouraging cessation (Halpern MT and Taylor H, 2010). Programmes should therefore be multi-pronged and incorporate a variety of smoking cessation components, including environmental aspects (worksite smoking bans) and individual aspects (counselling, social support and, where possible, pharmacotherapy). Management should also set targets for smoking prevalence in the company and mark them, to ensure that programmes are prioritised and effective.
Smoking cessation programmes should form a core element of a business's workplace wellness policy."
Telephone and internet counselling are practical for worksite interventions. These types of counselling appeared to be as successful as face-to-face counselling and they are generally more cost-effective. However, combining counselling and medication makes each approach more effective, so it is recommended that both options are offered in the programme.
Ongoing cessation programmes have a more effective reach. Having a one-time programme with fixed registration cut-off dates meant that the programme excluded not only smokers who were not ready to quit during the time period specified, but others for whom it was inconvenient or impractical for other reasons (taking holidays, etc), as well as individuals who quit but later resumed smoking. Where possible, provide an ongoing programme with constant access to support.
Smoking cessation programmes should form a core element of a business's workplace wellness policy, and should be integrated into broader wellness programmes to address other chronic disease risk factors, such as promoting a healthy diet and increasing physical activity. The above case study offers valuable insight into establishing a smoking cessation programme and demonstrates that such programmes can be implemented successfully.
For organisations of all sizes, smoking cessation programmes are a highly valuable investment. Research shows that employees do want smoking cessation programmes and they are of huge value to people who want to stop smoking. Their introduction is therefore an effective human resources strategy that can increase the motivation and loyalty of the workforce.
Furthermore, these programmes will help to maintain a healthy and productive workforce, decrease costs associated with employee tobacco use, and enhance corporate social responsibility by helping promote a tobacco-free world.
Michael T Halpern MD PhD MPH is senior fellow at RTI International, health services and social policy research. Hayden McRobbie MB ChB PhD is reader in public health interventions, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London. Michael Halpern does not have any conflicts of interest to declare. Hayden McRobbie has received research funding from, and provided consultancy to, manufacturers of smoking cessation medications. Writing support was provided to the authors on behalf of the World Heart Federation. This article has been funded by Pfizer.
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XpertHR provides a useful health and safety policy that helps organisations to set out rules on smoking.