BUILT: Quitting Tobacco - The Next Step: Employer's Toolbox for Building a Cessation Program

About This Booklet

The California Labor Code requires all indoor worksites to be smoke-free. A construction site is considered “indoor” when there are four walls and a ceiling. But increasing numbers of outdoor worksites are also going smoke-free for a variety of reasons. Refineries have always enforced smoking restrictions, but now some school districts, hospitals, and construction projects in high-fire areas are also becoming smoke-free both indoors and outdoors.

If a worker who smokes goes to a non-smoking worksite, he or she has two choices: start chewing tobacco to satisfy the cravings or quit, at least during working hours. Since chew is at least as addictive as cigarettes and can lead to oral cancers, quitting is clearly a better option — for the worker and his or her family, for the employer, and for the Health and Welfare Trust Fund.

The purpose of this guide is to help construction employers establish worksite tobacco cessation programs that will benefit your employees and your own bottom line.


Table of Contents

Cessation Programs Are Good Business
The Workplace Cessation Toolbox
Employer Programs That Work
Options for Your Worksite
Evaluating Outside Providers
Summing Up
Resources

Cessation Programs Are Good Business

Tobacco Is a Health and Safety Issue

Most employers care about the health and safety of their workers and emphasize safety on the job. You design jobs to be as safe as possible, provide personal protective equipment, and hold regular safety meetings. But did you know that tobacco is a greater cause of death and disability than any other hazard in the workplace?

• Of the more than 4,000 chemicals in tobacco smoke, at least 50 have been linked to cancer, heart disease, and other illnesses.
  
• Tobacco adds to the effects of other toxic substances found on the job. For example, an asbestos worker who doesn't smoke has 5 times the risk of lung cancer as the general population, but the risk jumps to 50 times for an asbestos worker who smokes.

Dollars and Sense

Getting the job done on time and on budget is your top priority. But did you know that workers who smoke may negatively impact your bottom line? According to national studies:

• Smokers have higher absenteeism rates, averaging 34% more absences from work than non-smokers. Non-smokers exposed to secondhand smoke also have a higher rate of illness.
  
• Smokers are 29% more likely to have industrial accidents and 40% more likely to suffer injuries at work. This translates into higher health insurance, life insurance, and workers’ compensation claims.
  
• 6 to 12% of health and welfare fund costs are for treating smoking-related illnesses — that’s your money.
  
• Employees who smoke (on or off the worksite) can cost employers up to $2,000 a year.
  
• Health and fire insurance premiums can be 25 to 35 percent lower for smoke-free businesses.

Workers Want To Be Healthy

Polls show that more than 70% of smokers would like to quit. Almost 50% of smokers try to quit for at least one day a year.While building trades workers smoke at a rate that is 60 to 87 percent higher than the general population, depending on the trade, they want to quit just as much as other smokers.When designed to meet their needs, smoking cessation programs attract as many construction workers as any other population group.

Focus groups and interviews show that most union construction workers expect to be able to quit without help. In some cases, smokers can quit on their own. But most smokers need help. Often smokers end up quitting because they have a serious health event that’s caused by their smoking. We can do better than that. We can offer smoking cessation programs that help smokers quit before they become sick.

Cessation depends upon repeated attempts. Nicotine may be the most addictive drug known to man and it is very difficult to “just quit.” Those who quit successfully have made an average of six or seven attempts.Many smokers don’t realize this. After one or more failed attempts they become fatalistic and believe they can’t quit. By providing positive reinforcement we can counter such beliefs.


Smoke-Free Worksites Encourage Cessation

Construction workers try to quit as often as white-collar workers, but have a much lower success rate. One reason is the lack of a supportive work environment. By providing a smokefree workplace and encouraging smoking cessation, you’ll go a long way toward providing a supportive environment. You’ll also have a healthier crew and save money.

People need to be educated, encouraged, and supported through repeated quit attempts. Working environments that encourage cessation are key to a worker’s ability to quit. Tobacco cessation is the most cost effective health program there is. For every dollar spent on smoking cessation programs, there is a return of $15 in reduced medical expenditures alone.


The Workplace Cessation Toolbox

Quitting tobacco is not easy because the nicotine in cigarettes and chewing tobacco is a very addictive drug. Most people attempt to quit “cold turkey” but only 3% succeed without help. National Clinical Guidelines for smoking cessation document the effectiveness of various types of smoking cessation programs. Many programs and products are available that will increase the success rate substantially. These can generally be divided into six types:

Self-Help Programs	These are available over the internet or by mail, and are attractive to many smokers because they offer privacy and flexibility. Many self-help materials (booklets, videotapes, and quit kits) are appropriate for use as part of a worksite program. Good self-help materials should provide employees with information to help understand their smoking patterns, set quit dates, identify and resist smoking cues, explore alternatives to smoking, control weight gain, manage stress, and prevent relapse.
Group Programs	Some smokers need the guidance and support provided by structured programs. Group meetings offer reinforcement and counseling. The individual goes through the step-by-step quitting process with the help of the group and its leader. The employer may bring outside providers to the worksite to conduct group programs, or workers can be given a list of programs in the community.
Telephone based Programs	The most effective smoking cessation programs for construction workers have been telephone-based counseling programs. They are well received because they are convenient (pick up the phone!) and very private. In many cases, health and welfare funds contract with private providers to offer telephone-based counseling to their participants. California offers the California Smokers’ Helpline, which is a free and confidential telephone-based counseling program. Its toll-free number is 1-800-NO BUTTS.
Pharmacological Aids	Because nicotine is a physical addiction, many smokers are better able to quit with Nicotine Replacement Therapy (NRT) products. In fact, the most recent National Clinical Guidelines on smoking cessation recommend that smokers who try to quit use these aids unless they have a medical condition that prohibits using them. These aids include nicotine gum, nicotine patch, nicotine inhaler, or other FDA approved products. Many of these are available without a prescription. Some smokers also can benefit from the anti-depressant drugs Zyban® or Welbutrin®, which require a prescription. NRT and other drugs should always be used in combination with a quit program. Some Health and Welfare Trust Funds offer coverage for nicotine replacement products. If the products are not covered by the Fund, employers may provide NRT directly as a self-funded benefit, or may reimburse employees who use the products as part of an effort to quit smoking.
Incentives	Special incentives can be very effective in increasing employee interest in quitting. They give employees a positive focus, reinforcing motivation and encouraging participation in cessation programs. Even small rewards or recognition, such as in a company newsletter, can help smokers succeed.
Alternative Approaches	These include hypnosis, acupuncture, and herbal supplements. There are no studies documenting the success of these methods.

A successful cessation program provides many different approaches to quitting. At a minimum, a successful cessation program will offer these three elements:

1. Access to information and educational materials
2. Access to Nicotine Replacement Therapy (NRT)
3. Counseling, either individual or group, in person or by telephone.

The most effective programs have two additional features:

1. No limits on the number of times a smoker can try to quit. We want to encourage smokers to try over and over. The more times they try, the more likely they are to quit!
2. No deductibles or co-payments. Such costs can give smokers an excuse not to try. Even very small co-payments lead to much lower participation rates.

Employer Programs That Work

Offering tobacco cessation to employees is neither new nor revolutionary. Many companies are currently offering comprehensive programs. BUILT does not endorse any specific program, but highlights some successful worksite programs as examples of different approaches.

Northwest Carpenters Trust Fund	This cessation program, developed jointly by labor and management, received the 2002 National Achievement Award of the American Association of Health Plans. The Fund is a union-employer Taft Hartley health and welfare fund that covers 10,000 union workers and many employers. To date it offers the only cessation program designed for a multi-employer group. The Fund’s plan offers an unlimited smoking cessation benefit covering telephone counseling provided by Free & ClearSM and smoking cessation medications, including NRT and Zyban®. The Free & ClearSM Program is delivered over the course of one year. It provides each participant with educational materials, self-help materials, continuing telephone interventions with a personal cessation specialist, access to a toll-free Quitline, and access to the tobacco cessation website https://smokefree.gov/tools-tips/get-extra-help/free-resources. This website gives participants tips and support to reinforce the information they get from the telephone counseling sessions. Recommendations for Nicotine Replacement Therapy are provided when appropriate. Evaluation of this program shows that it is effective for building trades workers. The program had a 12-month quit rate of 27.5% at a cost of one-half cent per hour contribution to the trust fund. Most importantly, 95% of participants say they recommend the program to friends and co-workers.
Union Pacific Railroad	This large national company has chosen to develop its own in-house program. The BOB (Butt Out and Breathe) program was awarded the C. Everett Koop Health Award in 2001. Smoking among Union Pacific employees dropped from 40% to 26% in eight years. Each Union Pacific employee can use BOB twice in a lifetime. To start, employees complete a “readiness to quit” questionnaire. BOB then provides them with a 90-day prescription for Zyban®. Nicotine Replacement Therapy (patch, gum, inhaler) is also available for a five dollar co-pay. The program provides follow-up for six months, and an incentive program that includes a drawing. The program has “health coaches” who offer personal telephone follow-up, a website, reminder notes every two weeks, and literature on quitting smoking or chew. BOB is run by a third-party medical provider to ensure confidentiality. Since BOB is part of Union Pacific’s larger health education program, employees are able to go to health clubs for free with the company’s membership plan.
Bath Iron Works	This Maine shipyard is a single-site company with 6,500 workers represented by four different unions. The smoking rate among workers is more than 10% higher than the state’s average. The company’s program combines in-house efforts with outside resources. Union representatives and company management have crafted a health education program called “Building Healthy Ways” which includes tobacco education and cessation. Currently employees are eligible for reimbursement through their health plan for prescription NRT (patch, inhaler, nasal spray) as well as Welbutrin® and Zyban®. They can also be reimbursed for participating in a tobacco cessation program offered by local hospitals. Bath Iron Works is also adopting a version of Quit and Win, a World Health Organization-endorsed incentive program. The goal of Quit and Win is to encourage employees and family members to quit using tobacco products by leveraging community resources. The program awards a prize to those employees and adult family members who participate in one of the reimbursable cessation programs, and who attend a follow-up counseling session or use the Maine Tobacco Hotline.
Johnson & Johnson	One of the world’s largest health products companies, Johnson & Johnson has a very active health promotion program for its employees that includes many different tobacco cessation plans. Several Johnson & Johnson facilities make available the Smoke Stoppers® cessation program. This is a 21-day program with userfriendly materials that give information, techniques, and strategies to stop smoking in a day-by-day format. Participants also designate a personal “Smoke Stoppers Coach” who can be a family member, friend, or co-worker they work with as they go through the quitting process. The coach is provided a guidebook. Smoke Stoppers® also recommends the use of Nicotine Replacement Therapy and/or nonnicotine medication (Zyban® or Welbutrin®). A study of blue-collar Johnson & Johnson union workers in Chicago showed 40% of smokers enrolled in this program were able to quit. Another effort, at a Johnson & Johnson manufacturing plant in Florida, uses two programs. The American Cancer Society’s Fresh Start® is a group program. It consists of four sessions held during a two-week period. Employees participate in activities that introduce the most effective elements for success. The plant also uses Health Enhancement Systems’ Tobacco-Free Wellstage Program, which provides information and cessation activities based upon a theory of stages of change. 70% of smokers at the plant attended at least one class in this program. 45% completed the program and 22% are still tobacco-free.

Options for Your Worksite

Once you have decided to provide cessation services, there are a number of other decisions to make.

First ask these questions	How active do you want to be? How many employees do you have? Do you have personnel to give support (perhaps company medical professionals or health and safety specialists)? What does the employees’ health plan cover? How much money do you want to spend? Can you allow workers to attend sessions at work? After work?

Here are a few options

Referral Free to low cost	Provide employees with information on community smoking cessation programs. Promote the California Smokers Helpline (1-800-NO-BUTTS), a free and confidential service of the California Department of Health Services. The Helpline has posters and other materials informing workers about the free service available. Insert “check stuffers” produced by BUILT that promote the California Smokers Helpline. Communicate with all employees about changes in smoking policies and support to be offered.
Facilitation Low to moderate cost	Provide all the services described in the Referral section above. Work with outside health care providers to offer smoking cessation to employees. Provide self-help cessation materials. Ensure that your company health and safety personnel have enough information to refer employees to resources such as cessation groups at local hospitals, the American Lung Association’s Freedom From Smoking™ program, American Cancer Society’s Fresh Start, or Nicotine Anonymous™.
Comprehensive Higher cost	Provide all the services described in the Referral and Facilitation sections above. Develop and maintain an in-house tobacco education and cessation program or hire an outside third-party company to provide this service. You can also encourage the labor-management health and welfare funds in which you participate to offer this benefit. Offer a range of incentives, such as recognition letters, awards, mention in company newsletters, and special events.

EVALUATING OUTSIDE PROVIDERS

Consider these questions before you contract with an outside organization:

1. How long has the organization been in existence? How long has it been providing smoking cessation programs?
2. How many people have gone through the program?
3. Will the approach be appropriate for your employees?
   1. What methods are used to help smokers quit?
   2. How is maintaining abstinence from smoking addressed?
   3. What resources will be provided to help promote the program to your employees and stimulate participation?
4. Have others been satisfied with the program?
1. Will the program provide a list of clients?
2. Will the program provide references?
5. What are the qualifications of the instructors? What training have they received? What is their cessation counseling experience?
6. Are printed materials appropriate for the educational level of your employees? Are they attractive and motivational?
7. Will the structure of the program accommodate the needs of your employees? Can the provider:
1. accommodate all shifts?
2. provide on-site and off-site programs?
3. structure flexible program formats?
4. provide audio or visual materials and equipment?
8. Is the program provider willing to offer ongoing assistance and follow-up once the formal program ends?
9. Does the program use the participants’ existing support systems, such as peers and family members?
10. Does the program offer any form of guarantee? For example, can employees repeat the program for free or at a lower cost if they don’t quit the first time, or have a relapse?
11. How does the program plan to establish eligibility so you only pay for your workers and not others?
12. Will the program supply you with monthly data reports so that you can evaluate how well it is doing and whether it needs to be changed?
13. Can the provider supply evidence of six-month and one-year success rates among previous clients with a background similar to your employees? A range of 20-30% success rate is realistic. Remember: if it sounds too good to be true, it probably is.
14. How much does the program cost per employee? Are group discounts available?

Summing Up

Whatever services you are able to offer your workers, remember:

Smoke-free worksites encourage cessation.

Tobacco cessation is the most cost effective health program available.



Providing a smoke-free worksite along with tobacco cessation services will be enormously beneficial to your employees and to your business.


Resources

American Cancer Society: Fresh Start
1-800-ACS-2345 or call your local American Cancer Society office.
www.cancer.org
Group cessation program.
Cost: Call local ACS office.

American Lung Association:
Freedom From Smoking™
1-800-586-4872
https://www.kintera.org/site/apps/kb/home/login.asp?c=dvLUK9O0E&b=38973&
kntaw1360=E918DB881C99417A9DB35743E474CC1F&membershipreq=83912
&targetURL=http%3A%2F%2Fwww%2Elungusa%2Eorg%2Fsite%2Fpp%2Easpx%
3Fc%3DdvLUK9O0E%26b%3D22933
Self-help manual and cessation clinics, audiotapes, 7 Steps to a Smoke Free Life book, online step-by-step
program.
Cost: Online program free, book $14.95, or contact your local ALA office for other information.

California Smokers Helpline
1-800-NO BUTTS (1-800-662-8887)
www.californiasmokershelpline.org
Telephone counseling, educational materials.
Cost: Free.

Free and ClearSM
1-800-292-2336
www.freeandclear.org
Self-help materials, telephone counseling, pharmaceuticals.
Cost: $195/participant.

Nicotine Anonymous™
www.nicotine-anonymous.org
12 step program for tobacco cessation. Group support and recovery.
Cost: Group attendance: Free.
Books and pamphlets at nominal

Northwest Carpenters Trust Fund
1-206-444-9811
Comprehensive program with telephone-based counseling and NRT/Zyban™ for construction
union health and welfare fund.
Cost: 0.5 cents per hour of contribution (roughly $12 per FTE).

Quit and Win
www.quitandwin.org
Sponsored by the World Health Organization, this international tobacco cessation contest provides
prizes for quitting. Go to website for prize information.

Smoke Stoppers™
1-800-697-7221
www.smokestoppers.com
Internet self-help, telephone counseling, 21-day QuitKit program, business programs.
Cost: $39 for the internet program, or contact group for information about other programs.

Wellstage
1-800-326-2317
www.hesonline.com
This self-help quit program offers brochures in a“stages of readiness” format.
Cost: Varies depending on brochure and quantity. See website.


916-443-3302 • www.sbctc.org/built

Can provide information on tobacco for tailgate safety meetings, “check stuffers” to promote the California Smokers Helpline, and signs in different languages to communicate your worksite’s tobacco policies.


Internet-based Programs and Resources


Quit.com
www.quit.com
Individual self-help internet program.
Cost: Free.
This website is created by GlaxoSmithKline, the maker of Nicorette® and NicoDerm®.

WhyQuit.com
www.whyquit.com
Individual self-help internet program.
A combination of cessation sites,WhyQuit emphasizes “cold turkey” and discourages NRT.
Cost: Free.

Trytostop.org
www.trytostop.org
Individual self-help internet program.
Sponsored by the Massachusetts Department of Public Health.
Cost: Free.

A Spit Tobacco Cessation Website
www.trytostop.org
A self-help internet program for spit tobacco users.
Cost: Free.

PACT (Professional Assisted Cessation
Therapy)
www.endsmoking.org
PACT is a consortium of smoking cessation professionals. This website includes an Employers’ Smoking Cessation Guide in pdf, and a wealth of other information.
Cost: Free.

CDC – National Center for Chronic Disease
Prevention and Health Promotion
www.cdc.gov/tobacco
The CDC has tobacco facts, the Surgeon General’s Reports, research and data, and educational materials. Be sure to read Making Your Workplace Smoke-Free – A Decision Makers’ Guide.
Cost: Free.

Local Programs
Many other cessation services may be available in your community. Find out about other local resources by contacting your local Public Health Department and/or hospitals.



Building Trades Unions Ignite Less Tobacco

BUILT is a statewide program sponsored by the State Building and Construction Trades Council of California. Funded by the California Department of Health Services, BUILT strives to promote smoking cessation and prevention among construction workers and create smoke-free work environments.

BUILT reaches union members through:

• Local Unions, who distribute educational materials to their members
• Health and Welfare Trust Funds, who provide information about tobacco and the benefits of quitting smoking
• Joint Apprenticeship Training Committees, who include information about tobacco and toxic hazards in their health and safety training for apprentices
• Labor-Management Committees, who develop worksite tobacco policies.

For information about BUILT and our other programs:
916-443-3302
www.sbctc.org/built


PROJECT DEVELOPMENT TEAM

Wayne Hagen
Debra Chaplan
Cathy Leonard
Knut Ringen

Editor:
Gene Darling

Designed by:
Barbara Nishi

This guide was made possible by funds received from the Tobacco Tax Health Protection Act of 1988-Proposition 99, under Grant Number 99-85070 with the California Department of Health Services, Tobacco Control Section.

Produced by BUILT, State Building and Construction Trades Council of California
in collaboration with the Labor Occupational Health Program, UC Berkeley