Assessing Tobacco Use Policies in the Workplace

1. Assessing Tobacco Use Policies in the Workplace Carol A. Riker, RN, MSN Associate Professor riker@uky.edu Kathy Begley, BA Data Manager kathy.begley@uky.edu Ellen J. Hahn, DNS, RN Professor ejhahn00@email.uky.edu www.mc.uky.edu/tobaccopolicy/

2. Kentucky Continues to be a National Leader in Adult Cigarette Smoking 2007 estimates, Centers for Disease Control and Prevention, 2008

3. Most Kentuckians are Regularly Exposed to Secondhand Smoke at Work and/or in Public Places Most (75%) do NOT smoke cigarettes. Yet most (70%) ARE exposed to secondhand smoke.

4. Smoking on the Job Smoking when combined with workplace chemicals and other toxic agents is particularly harmful. Nonsmokers exposed to secondhand smoke on the job increase their heart disease and lung cancer risk by 20-30%.

5. Effects of Secondhand Smoke (SHS) Those exposed to SHS, at work or at home, have an increased risk of developing asthma. SHS contributes to the severity and exacerbation of existing asthma among adults. (Jaakkola, 2002)

6. SHS and Heart Disease Short term exposure (5 min.-2 hrs.) can increase risk of heart attack and stroke. Affects platelets, endothelium, and heart rate variability (narrowing of blood vessels and clot formation) An estimated 46,000 U.S. cardiac deaths are attributed to secondhand smoke exposure each year (Surgeon General’s Report, 2006).

7. SHS and Lung Cancer There is a clear dose-response relationship between duration of exposure to SHS and increased lung cancer risk in never smokers. Those ever exposed to spousal SHS are 18% more likely to get lung cancer; those with long-term exposure are 23% more likely. Reducing exposure to SHS results in decreased opportunities to smoke, thus reducing active smoking levels (Brennan, et al., 2004) Stayner’s (2007) meta analysis showed a 24% increase in lung cancer risk among workers exposed to SHS (two-fold increase for those highly exposed).

8. Smoking in the Workplaceand Disparities Significantly lower likelihood of smoke-free workplace policy protection among: Young - <$50,000 annual income Males - H.S. education or less Non-whites - Everyday smokers Heavy laborers - Southern & Midwestern workers (Delnevo, Hrywna, & Lewis, 2004)

9. Smoking’s Adverse Impactsin the Workplace Increased health care costs and disability Greater absenteeism Decrements in job performance Increased risk of injury Secondhand smoke exposure (Osinubi & Slade, 2002)

10. Costs of Smoking in the Workplace Smoking costs the U.S. $193 billion in direct health care costs and productivity losses each year (CDC, 2009). Productivity losses account for about $96.8 billion of the total costs (CDC, 2008). Additional cost estimates in 2005 dollars Housekeeping and maintenance per 1000 sq. ft. of assembly or warehouse space: $305-$441 Annual fire insurance losses per smoker: $11-15 Annual cost for “ventilation” per smoker: $84 (Javitz et al., 2006)

11. Benefits of a Smoke-free Workplace Totally smoke-free workplaces associated with 3.8% reduction in prevalence of smoking and 3.1 fewer cigarettes smoked per day per continuing smoker. (Fichtenberg & Glantz, 2002) Similar reductions would require the tax on a pack to increase from $0.76 to $3.05 in the U.S. Smoke-free workplace policies about 9 times more cost-effective per smoker than free NRT programs (Ong & Glantz, 2005) Bauer et al. (2005) found that those working in environments with S-F policies were 2.3 times more likely to quit than those not working in such environments.

12. Worksite Smoke-free Policies Help Smokers Quit Smoke-free environments help smokers quit or cut back (Osinubi & Slade, 2002)

13. The Ventilation Lie No feasible ventilation system can reduce SHS exposure to safe levels Simply separating smokers and nonsmokers is not effective The current indoor air standard set by ASHRAE assumes no smoking

14. The National Ambient Air Quality Standard (NAAQS) for PM2.5 is 35 µg/m3 for 24 hours

15. Tobacco Policy in Kentucky Manufacturing Facilities, 2002-2008 Percent

16. Smoking Policies in ALL Worksites in Kentucky, 2008 Over half (70%) of ALL worksites were smoke-free in Kentucky, similar to worksites nationwide (ALA,2006)

17. Workplace Tobacco Policy Interview: Purpose To collect workplace policy data for planning and monitoring change over time To lay the groundwork for helping manufacturers with tobacco policy change To recruit partners for your tobacco prevention and cessation coalition

18. Elements of the Workplace Tobacco Policy Interview, 2010 Presence of a WRITTEN policy How the policy is communicated Where and when employees are allowed to smoke How the policy is enforced How violators are handled Existence of cessation resources

19. Workplace Tobacco Policy Interviews: Methods in a Nutshell Recruit Human Resource Managers Record all contact attempts on Disposition Sheets Phone Interview with Human Resource Manager &/or Other Administrative Personnel Use online form to submit data Email Kathy once you have completed data collection and we will send you a mailer for returning all paperwork to UK Follow-up with interested manufacturers

20. Conduct the Phone Interview Get complete information…ask clarifying questions if needed. If person being interviewed is uncertain about an answer, complete the interview and ask them to get the information and call them back. You may need to talk with more than one person to get the correct information! Wait until AFTER the interview to discuss issues or follow-up desired by the company.

21. Averting Refusals If hesitant to participate: “You sound busy….when is a more convenient time to call?” “There are no right or wrong answers. We are just interested in what you are doing, so that we can be more effective in planning our health programs.” “The information will be kept confidential. The information will be summarized by health department service area, not by individual manufacturer.”

22. Proper Phone Etiquette Find the most convenient time Be sensitive to time constraints Be polite Use nonjudgmental approach

23. Human Subjects Protections Voluntary participation Minimize barriers to participation Understanding the benefits of participation Right to withdraw or refuse to answer Confidentiality No names or addresses of the interviewees on the actual interview form!

24. Submitting Forms Onlinewww.mc.uky.edu/tobaccopolicy Go to Data Collection Forms and enter your log in information (case-sensitive). To get a log in ID and password, you must first complete the 2010 Workplace Policy Training. Be sure to mark yourself as complete. We will check the course roster regularly and email passwords to individuals who have completed the training. If you have not received your log in credentials, email Kathy at kathy.begley@uky.edu. Click on 2010 Workplace Tobacco Policy Study.

25. Submitting Forms Onlinewww.mc.uky.edu/tobaccopolicy • Click on your county(ies) to print out the list(s) of Manufacturers. • Print and complete a disposition sheet (available online) for each manufacturer to keep track of each contact attempt. The disposition sheet is a fillable PDF. If more than one person will be conducting interviews, you should create and distribute a disposition sheet for each manufacturer first to prevent duplicating interviews. • Select 2010 Workplace Tobacco Policy Interview Guide: Online version.

26. Submitting Forms Onlinewww.mc.uky.edu/tobaccopolicy Click on the circles to answer and type in specifications. Type any additional comments in the space provided at the end. Most of the front page info and “Time Interview Ended” are required to submit the survey. Pay attention to SKIP patterns.

27. Check over the entire form before clicking “submit” to double-check that all questions are answered. If you have used the “other” field, make sure you check the “other” box. If you collect the information on paper and then submit online, send the paper forms to UK in the mailer provided. If you submit online as you conduct the interview, your disposition sheets are the only thing you’ll send. Submitting Forms Onlinewww.mc.uky.edu/tobaccopolicy

28. When ALL Interviews are Complete When all interviews are completed, mail all disposition sheets and any interview forms you have written on to UK in the mailer. Keep a copy of the MANUFACTURER LIST for future contacts…make notes about which manufacturers are interested in more information. Do not keep copies of the interview forms. Shred any extra copies of the interview form.

29. If you are training a helper to conduct interviews… Train them using this PowerPoint located on the Workplace Policy page on our website (www.mc.uky/tobaccpolicy). The Workplace training video conference will be archived on KY TRAIN, so helpers can access this training. Emphasize the Human Subject Protections. Access our website and show them how to submit data online (or print forms for faxing). SUPERVISE their initial interview. Continuously monitor their progress to ensure that they are following protocol.

30. Follow-Up Contacts with the Manufacturing Facilities Send thank you letters. Gather materials on workplace tobacco policy or other info requested. Send information packets with cover letter. Follow up with phone contact. Involve coalition partners.

31. Linking Data to Policy Change Share data with coalition and manufacturers. Present data at interested worksites. Use data as a media opportunity, if appropriate. Meet with media leaders. Identify local newsletter/neighborhood bulletins for a summary of the results. Specify and evaluate targets using baseline data.

32. Manufacturers Expressing Interest in Changing Policy Although most manufacturers were satisfied with their current policy in 2008, 19.2% expressed interest in changing policy and 52.6% were interested in effective cessation programs. The opportunity exists to motivate and help with voluntary policy change that can then promote community readiness for a smoke-free ordinance campaign. Find your friends!

33. How to Frame the Issue with Manufacturing Facilities Health effects of SHS justify smoke-free policy Other good reasons include: Cuts cleaning and maintenance costs Improves employee morale Provides an incentive to stop smoking Providing cessation resources demonstrates the manufacturer’s commitment to employees Reinforcement of non-smoking norm helps the community by increasing public awareness of the dangers of smoking (Evans, 1999).

34. Model Workplace Tobacco Policy Rationale for Policy (Effects of SHS) Types of Tobacco Product Covered When and Where Tobacco Allowed How Policy is Communicated How Violators are Handled What Department Provides Cessation Resources To Whom it Applies

35. Employer Action Steps (CDC, 2003) Plan your approach Designate key staff person to study, plan and propose the policy Communicate SHS info to influential personnel from key areas (smokers and non-smokers) Consult with union, if applicable Take a sympathetic approach to smokers and offer cessation help Focus on Secondhand Smoke (SHS), not smokers

36. Employer Action Steps 2. Gather facts and information on: SHS Ventilation science Costs and consequences (business, health, liability) Benefits of going smoke free Support for smokers, including cessation resources and insurance coverage for cessation Model Policy

37. Employer Action Steps 3. Assess readiness Conduct survey to help tailor efforts and plan education, policy and enforcement mechanisms. 4. Educate Take into account organizational readiness and level of knowledge.

38. Employer Action Steps 5. Implement the plan Complete implementation is key; incomplete implementation leads to confusion. Give four weeks notice. Emphasize protection of employee’s health. Distribute the complete policy, with a letter from the CEO. Post signs at all entrances and stairwells. Conduct awareness programs and distribute materials clearly describing all procedures.

39. Employer Action Steps 6. Enforce the policy • Be fair and equitable. • Give all new employees written information on the policy to read and sign.

40. Manufacturers with Unions Unions are interested in meeting the needs of all employees (smokers, non-smokers, and those who want to quit). Target both the manufacturers and their unions for assessment of policy and discussion of policy options.

41. Unions as Potential Partners Unions are potential partners, as evidenced by the strong advocacy of flight attendants in making airline travel smoke-free. (Pan et al., 2005) Sorensen et al (2000) national phone survey of local union leaders found 48% of local unions supported smoke-free worksite policies or smoking restrictions. Visit American Nonsmokers’ Rights Foundation for helpful information on how to partner with unions: http://www.no-smoke.org/pdf/Smokefree_Air_is_a_Union_Issue.pdf.

42. Workplace Cessation Tiede et al. (2007) interviewed 22 small business employers, conducted focus groups with 59 smokers and found: Despite barriers, both employers and employees thought it desirable to promote cessation resources to those wanting to quit Both groups were unaware of cessation resources available through health plans or in the community.

43. Workplace Cessation Moher, Hey, & Lancaster (2003) systematic review of workplace interventions showed: Strong evidence that programs directed toward individuals (group therapy, individual counseling, & NRT) increased likelihood of quitting. Self-help less effective. Limited evidence that participation can be increased by competitions and incentives Consistent evidence that workplace policies & bans decrease smoking during the day and decrease exposure to ETS

44. Workplace Cessation Simple, generalizable intervention (N=217) resulted in 20.2% continuous abstinence (CO confirmed) at 12 mos. compared to 8.7% in control group using intent to treat analysis Nicotine patches for 3 months Adapted to smokers’ tobacco dependence (minimal structured counseling at 1st visit – 5 to 8 minutes) 3 sessions to reinforce abstinence (2-3 minutes) (Rodriguez-Artalejo et al., 2003)

45. Workplace Cessation Couple cessation messages with safety messages Sorensen et al (2003) found smoking quit rates among blue-collar workers comparable to those of white-collar workers at worksites integrating health promotion with occupational health and safety (avoiding occupational exposures).

46. Benefits of cessation Decreased rates of smoking-related diseases Total savings (lower health care and workplace costs) exceeded costs of the benefit in 4 years Total savings per smoker: $350-$582 @ 10 yrs and $1152-$1743 at 20 years (Halpern ,Dirani, & Schmier, 2007)

47. Other Factors in Work Environment High job demands associated with higher frequency of smoking and increased likelihood of cessation Resources at work and social support positively associated with cessation negatively associated with relapse and amount smoked Combine workplace environment change with health promotion interventions. (Albertsen, Borg, & Oldenburg, 2006)

48. Helpful Websites http://www.cdc.gov/tobacco/secondhand_smoke/workplace_guide.htm http://www.no-smoke.org/pdf/modelworkplacepolicy.pdf (2 pages) http://www.cancer.org/docroot/PED/content/PED_10_2X_Smoking_In_The_Workplace.asp?sitearea=PED(3 pages) http://endsmoking.org/resources/employersguide/pdf/employersguide-2nd-edition.pdf http://www.no-smoke.org/pdf/Smokefree_Air_is_a_Union_Issue.pdf

49. References Albertsen K, Borg V, Oldenburg B. A systematic review of the impact of work environment on smoking cessation, relapse and amount smoked. PrevMed. 2006 Oct;43(4):291-305. Bauer JE, Hyland A, Li Q, Steger C, Cummings KM. A longitudinal assessment of the impact of smoke-free worksite policies on tobacco use. AJPH 2005 Jun;95(6): 1024-9. CDC, State Specific prevalence trends in adult cigarette smoking, US 1998- 2007. MMWR 2009;58 (09) 221-226.

50. References Delnevo CD, Hrywna M, Lewis MJ. Predictors of smoke-free workplaces by employee characteristics: who is left unprotected? AmJIndMed.2004 Aug; 46(2): 196-202. Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ; 2002 Jul 27; 325(7357):188 Halpern MT, Dirani R, Schmier JK. Impacts of a smoking cessation benefit among employed populations. JOccupEnvironMed; 2007 Jan;49(1):11-21. Javitz HS, Zbikowski SM, Swan GE, Jack LM (2006). Financial burden of tobacco use: an employer’s perspective. Clinics in Occupational and Environmental Medicine. 2006;5(1):9-29.