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Cost and benefit analysis of smoking cessation in the workplace

Summary

• Smoking in the workplace imposes a number of costs on both employers and employees.
• The purpose of this research was to examine the costs of smoking in the workplace in Scotland and the potential for encouraging smoking cessation policies.
• The four major parts of the research are: i) a literature review of the costs of workplace smoking. ii) a telephone survey of Scottish employers, iii) focus group work with six Scottish employers, iv) estimates of the cost of employee smoking in Scottish workplaces.
• The literature review identified six major categories of costs resulting from employee smoking in the workplace. i)Employees who smoke are absent from work more often than non-smokers resulting in reduced output. ii) Smokers place greater demands on health care services which results in higher insurance premiums. Insurance costs are also increased as a result of industrial fires which may result from smokers’ materials. iii) Productivity is affected by workers taking ‘smoke breaks’ or smoking ‘on the job’. iv) Passive smoking has an adverse effect on the health of non -smoking colleagues. v) In some occupations synergistic effects occur through the interaction of cigarette smoke and certain industrial chemicals. This can increase the risk of exposure to harmful materials and lead to claims for compensation for damages caused to workers’ health. vi) Cigarette smoke can also have a harmful effect on plant and machinery. Damage to wallcoverings and floors impose costs on employers, and sensitive machinery can also be seriously damaged. In addition there are costs involved when cigarette ends, ash and matches must be cleaned up.
• Estimates of the total cost of employee smoking are largely based upon studies from the USA, and these figures range from £300 to £4,500 per employee per month, depending upon the assumptions made.
• Smoking cessation policies in the workplace can help to reduce costs borne by employers. Workplace based cessation help is estimated to be 20-30% successful in stopping employees smoking which is consistent with clinic based help.
• A phone survey of 200 Scottish employers, based upon a stratified random sample, was conducted in January and February 1996 to investigate the types of smoking policy in operation.
• 26% of employers were experiencing problems with their smoking policy, including smoking in toilets and the negative corporate image portrayed when employees congregate outside the entrance to smoke.
• 29% of the firms offered cessation help to their employees, but many firms only offered cessation help for a short time, usually while introducing smoking restrictions.
• The primary reason for introducing cessation help was a concern for employees health. Employers were generally unaware, and unconcerned about, of the potential cost savings to the business.
• The cost of workplace smoking in Scotland in terms of lost productivity was estimated at approximately £293 million, with an additional £33 million from excess absence from work amongst smokers, and £81 million due to fire damage.
• The report outlines a methodology that can be applied to a business to estimate the costs of employee smoking in terms of productivity and absence from work. This methodology is then used to illustrate the cost to a hypothetical Scottish firm with 200 employees. The results show a total cost of £66,920 per annum. A smoking cessation policy with a 25% success rate could save the business a total of £16,730 per annum.
• Smoking restrictions are generally well accepted by staff, although in some companies employees did express resentment at dictatorial behaviour by management.
• Most companies were found to have little information on what cessation methods are effective or where to obtain such information. There is need for clear guidance on choosing cessation help.
• The report recommends that:

»The Health Education Board for Scotland produces guidance for companies and workplaces on the design of workplace policies.

»The Health Education Board for Scotland produces guidance for companies on how to choose and find effective cessation help. This should also highlight the potential problems which may result from each policy.

»Employers are made aware of potential savings which can result from smoking cessation programmes beyond the immediate health benefits to employees.

1. Introduction

The issue of employee smoking in the workplace has become increasingly important in recent years. Awareness of the dangers of passive smoking has led to concerns about the health of employees and the need for protection from environmental tobacco smoke. Furthermore, as a result of EU legislation and recent legal cases, the responsibility for the protection of employees from such dangers clearly lies with the employer, making it necessary for firms to pay close attention to the problem.

In addition to the health issue, employee smoking imposes considerable costs on employers. Evidence shows that workers who smoke are absent from work more often than their non-smoking colleagues which results in a loss of output. Time is also lost as workers take ‘smoke breaks’ or, if permitted, smoke ‘on the job’. Insurance premiums may be higher as a result of previous claims for fire damage due to smokers’ materials and tobacco smoke may also result in damage to plant and machinery.

Smoking also imposes costs on the individual and society. Costs to the individual are evident through an increased risk of developing diseases such as lung cancer. Costs to society are those which extend beyond the individual smoker and have an impact on society as a whole. These include the harmful effects imposed on non-smokers through passive smoking, and the costs borne by National Health Service as individuals receive treatment for smoking induced diseases. These costs are borne by society as resources are diverted away from other demands.

A workplace smoking cessation policy can help to reduce some of the costs attributable to employee smoking, such as saving time spent taking smoke breaks and reducing employee absence due to smoking related disease. If cost savings are a major reason for introducing a policy, the type of policy adopted by an employer is likely to depend upon the areas in which savings are perceived. A total ban on workplace smoking will help to reduce the amount of environmental tobacco smoke inhaled by co-workers and will also protect machinery and products from potential damage. However, if the target of the policy is to improve the health of smoking employees and reduce absence from work, the employer should aim at a smoking cessation intervention.

The benefits of a workplace smoking cessation policy extend beyond cost savings to the employer. The workplace setting provides a valuable opportunity to provide cessation help to a large population. A successful policy which reduces the number of workers smoking would then create benefits to society as a whole including savings to the NHS and a reduction in exposure to environmental tobacco smoke.

The purpose of this research was to identify the major costs borne by employers as a result of smoking in the workplace and to estimate how these costs may affect Scottish employers. A secondary aim was to investigate the economic aspects for Scottish employers introducing smoking cessation programmes for their workers. The report is structured as follows.

In Section One the literature to date is reviewed and the major costs of smoking in the workplace and the benefits to employers and society which result from the introduction of smoking cessation policies are identified. In Section Two the results from a survey of employers in Scotland, which aimed to provide details of the smoking policies and the cessation help offered by these employers, are presented. The results from the focus group work conducted with six Scottish employers are presented in Section Three. The survey results and data from the literature review are combined in Section Four in an attempt to provide a framework for estimating the costs of smoking for Scottish employers. The work investigated details of the company’s smoking policy and their experiences with the policy. The attitudes of company employees towards different types of policy are also detailed, together with recommendations as to how firms employers should be assisted in the introduction of cessation help in the workplace.

2. Review of the literature

The literature review was undertaken in order to identify the costs of workplace smoking and benefits of introducing a restrictive smoking policy or cessation help. Identification of the key costs and benefits is vital so that they can be measured and then costed, hence the review forms the basis of the estimates presented in Section 4. A summary of a selection of studies investigating different smoking cessation interventions is presented to provide an indication of the effectiveness of different programmes.

2.1 Introduction to the literature

There is a fairly large body of literature exploring the costs of smoking in the workplace. This chapter will review some of the studies which have investigated the costs of smoking to employers, together with a brief review of the effectiveness of different worksite smoking programmes and cessation help interventions. However, the vast majority of the work has been undertaken in the United States and its applicability to the UK is therefore limited. Studies made in a single workplace or geographical area are not generalisable to other populations as the characteristics of subjects will be specific to the study. Problems for interpretation include different rates of smoking prevalence between geographical areas and workforces, different attitudes to smoking, and different characteristics of workers, all of which will obviously affect the cost-effectiveness of any intervention to reduce workplace smoking or to help employees to stop smoking.

Articles included in this review were identified from searches of Medline (1976-1995) and the BIDS Social Science Index databases (1983-1995). The search was based on terms such as “workplace”, “worksite”, “smoking”, “health policy”, “benefits” and “cost benefit analysis”. Copies of the search strategies are presented in Appendix One. In addition, the Applied Social Sciences Index and Abstracts (1988-1995) were searched by hand. This strategy has the advantage of identifying most of the studies published in academic journals but is less helpful in identifying unpublished material. It is recognised that these studies, especially those conducted within workplaces, may be under-represented in this review. However, the resource constraints of the project did not allow a more extensive search strategy to be adopted.

A total of 267 articles were identified from the search strategy (see Appendix). Articles concerned with the clinical aspects of drug testing and articles based on non-specific employee assistance programmes were rejected from the literature identified. The articles selected for this review were those based on the costs and benefits of smoking cessation and the effectiveness of smoking cessation policies. A total of 52 articles were used in the review.

Section One will be structured as follows. In Section 2.2 the major cost categories which result from employee smoking are identified and estimates of the magnitude of the costs identified in the section are presented. In Section 2.3 the estimates of the total cost of employee smoking are outlined, whilst the effectiveness of workplace smoking cessation interventions is presented in Section 2.4.

Cost estimates in U.S. dollars were converted to current UK costs by firstly inflating to 1995 equivalent costs using U.S. inflation rate, and then converting to U.K. pounds by applying the dollar-sterling exchange rate which prevailed at the time of the study.

2.2 The costs of employee smoking

The costs of employee smoking will depend upon the perspective from which the study is undertaken. A societal perspective would include all costs and benefits to society. Such a study would include the value of NHS resources used to treat smoking induced disease and the impacts of passive smoking outside of the work place. This report however focuses on the perspective of the costs and benefits to the employer. The costs of employee smoking are divided into six major categories: absence from work; insurance costs; productivity costs; passive smoking; occupational health; and damage to plant and machinery.

2.2.1 Absence from Work

There is a relatively large body of literature examining the relationship between smoking and workplace absenteeism. However, any cause-effect relationship which may exist between smoking and absence from work is difficult to evaluate because of the numerous potential confounding factors. Determination of a cause-effect relationship would require a random allocation of workers to a smoking (intervention) and non-smoking (control) group. Unfortunately the ‘gold standard’ of a randomised experiment is not ethically feasible, although it is possible to allow for the effects of potential confounders by using statistical techniques such as regression analysis. The studies identified in the literature search have used observational data in order to investigate associations between the levels of smoking and sickness absence. The following section presents a summary of the evidence to date, together with a discussion of their limitations.

Lowe (1963) investigated the link between emergency room visits, absenteeism and smoking amongst 3,341 male workers at the GEC plant in Birmingham, UK between 1956 and 1957. When age standardised, Lowe’s results showed an increase in the number of days absent from work as the number of cigarettes smoked per day increased. This relationship was more pronounced amongst older workers, which is what would be expected given the known relationship between smoking and disease. Frequency of emergency room attendance also increased with number of cigarettes smoked, with a stronger relationship amongst younger workers. Holcomb and Meigs (1972) examined medical absenteeism amongst 226 workers in a US manufacturing plant and also found a positive relationship between the length of time that an individual had smoked and the annual levels of absenteeism. They found more absences with higher daily consumption, with lower absence rates amongst those who had never smoked or had stopped smoking. The relationship between the number of cigarettes smoked and absence rates showed higher rates of absence amongst non-smokers than those who had smoked cigarettes for under 15 years, although the highest rates were amongst smokers who had smoked for over 15 years. The results must however be treated with caution, as they cannot prove a cause effect relationship as confounding factors are not fully explored, and associations were primarily assessed by the use of correlation coefficients. In addition, lower levels of absenteeism were found amongst cigar and pipe smokers.

Van Tuinen and Land (1986) studied 406 employees from the Missouri Department of Health over a 20 month period. The results showed that the 97 smokers in the Department took an average sick leave of 5.3 hours per month in comparison to the 4.3 hours taken by non-smokers. The result was statistically significant at a 95% confidence level. Using the average departmental salary this was translated to an annual excess cost of $11,931, equivalent to £14,821 at 1995 prices (see Section 2.1 for details of conversion procedure). However, the study failed to identify the amount that each individual smoked or the reasons for taking sick leave. Using the conservative estimate of the total cost to the employer of $601 (£572) per smoker per year (Kristein 1983), the total cost to the Department becomes $73,497 in 1984 dollars (£91,299 at 1995 prices). Kristein’s estimates are based on results of the National Center for Health Statistics’ Health Interview Survey aggregate epidemiological data and population averages, and the estimates for each cost category are presented in the sections below. Van Tuinen and Land also use the estimates of Weis (1981) and conclude that the total cost could be as high as $510,802 (£500,310).

The DuPont study (Bertera, 1991) investigated the impact of six behavioural factors on absenteeism and health care costs amongst 45,976 employees at the DuPont Company in the US. The results showed that smokers had an excess absenteeism of 0.90 days per year (p<0.001) as compared to non-smokers. After controlling for six other risk factors (excess alcohol intake, obesity, elevated cholesterol, high blood pressure, inadequate seatbelt use and lack of exercise) current smokers were found to incur excess illness costs of $960.04 per person (p<0.001) in comparison to non-smokers (£602.27 at UK 1995 prices). The total cost to the company based on the total DuPont US workforce of 96,000 was estimated at $26,174,530 per annum as a result of employee smoking (£16,420,409 at UK 1995 prices).

The Whitehall II Study (North et al., 1993) was based on a population of 6,281 male and 1,434 female non-industrial civil servants in London, with the aim of explaining the differences in rates of sickness absence among workers. The results showed male smokers to have a 46% higher rate of short term absence (periods of seven days or less) and a 81% higher rate of long term absence (periods of greater than seven days). For women the rates were 9% and 37% respectively. However, the lack of baseline data meant the results were difficult to interpret. Wooden and Bush (1995), in a study of the Australian National Health Service, found the probability of absence to be higher amongst ex-smokers and to fall with the number of years since smoking cessation. For example, an individual who ceased smoking 20 years ago would be expected to be 4.5 times less likely to be absent from work than someone who stopped smoking last year. However, a problem with these studies is that the baseline absence rate used in the analysis was not stated. This makes it difficult to apply the findings to other scenarios since the actual time spent absent cannot be determined, as the actual percentage cannot be translated into number of days absent from work.

Jeffery et al. (1993) report on the Healthy Worker Project, a randomized trial in Minnesota, which involved assigning 32 workplaces to either a smoking cessation and obesity reduction programme or a control group. When the results were restricted to the 271 employees who were smokers at the baseline assessment, the reduction in absenteeism was found to be significant. The authors estimated the cost of each sick day saved was $2.60 (£1.71 at 1995 prices) which, if realistic, suggests that work-site smoking cessation programmes offer the possibility of immediate cost savings in terms of absenteeism, besides the other savings such as insurance and long term disability. However, a particular weakness of the study is that absenteeism was based wholly on self report data with no attempt to validate the evidence.

Jackson et al. (1989) attempted to investigate the excess absence between smokers and ex-smokers using a time series control design to investigate patterns of absenteeism. The study population was drawn from the employees of a North Carolina pharmaceutical company. Fifty smokers were matched to the experimental group of 50 ex-smokers, and absences from work for each individual were examined retrospectively. Examination of the data for ex-smokers showed a statistically significant decrease in absences following cessation. A statistically significant difference was also evident between smokers’ and ex-smokers’ absenteeism rates. The study also suggests that absence amongst smokers falls as time since smoking cessation, but fails to detect any relationship between absence and the number of cigarettes smoked. A notable feature of this study is that ex-smokers’ absences tended to decrease before stopping smoking, suggesting that there may be other causes of reduced absenteeism (confounding factors) besides smoking cessation. The issue is complicated by the complex interrelationships between smoking, stressful lifestyles, physical symptoms and upper respiratory tract infections.

An estimate of the impact of absence as a consequence of employee smoking on the U.S. economy as a whole quoted by Serxner et al. (1993) shows the effects to be considerable, with an estimated loss of 81 million working days. These figures are derived from a Surgeon General’s report which stated that smokers tend to be absent from work 33% to 45% more than non-smokers (Royal College of Physicians, 1993).

Studies have provided a range of estimates of absenteeism costs which result from employee smoking. The studies in the review were based on different employment situations, which may explain part of the differences in their findings. It would be expected that costs will vary depending upon employee characteristics, the nature of the workplace, the geographical area and population in question. For example, different levels of smoking prevalence and attitudes to smoking which vary between populations will affect the results of these studies. Each study outlined above will therefore provide estimates specific to the workplace in question, and therefore extreme caution should be exercised when attempting to put such estimates into contexts outside that of the particular study.

2.2.2 The Insurance Costs of Smoking

Many large companies offer health insurance to their employees. If a company pays premiums which are experience rated then its premiums will in part depend on the level of claims in the previous period. With such schemes, therefore, a firm which has made large claims in the past will face high insurance premiums.

Evidence indicates that smokers do tend to use more medical services than non-smokers. Fielding (1986) estimated the average smoker’s utilisation to be up to 50% higher than a non-smoker. Therefore, if insurance premiums are experience rated then premiums will be higher for businesses with a large proportion of smokers. This is supported by Dawley et al. (1991) who argue that much of the incentive for businesses to reduce employee smoking in the United States has come from massive increases in health care costs.

Kristein (1983) reports health care insurance excess costs of between $105 and $204 per annum (£100-£194 at 1995 prices) for the average adult smoker. The estimate is based on the annual excess-illness cost (direct excess medical-care spending due to smoking) divided by the number of estimated number of smokers in the United States.

Although a significant cost category in American research, excess health insurance costs are only relevant to companies which provide health insurance to employees. This is widespread in the USA, but tends to be limited to only the largest employers in the UK. However, any savings in health care resources in the UK as a result of employer smoking policies would enter the cost benefit equation as a benefit of society as a whole.

Historically, a large number of industrial fires have resulted from employee smoking, which increases the risk of accidents due to fire. Luce and Schweitzer (1978) estimated $5 (£7.72 at 1995 prices) per smoking employee per year for non residential fire losses. Smokers have also been shown to have twice the accident rate of non-smokers (Yusta and De Guevara, 1973 (in Kristein, 1983) and this may be due in part to loss of attention, smoking hand being occupied, eye irritation and cough.

Smokers can raise life assurance costs due to the early disability and early retirement costs imposed on businesses. For example, earlier retirements and disability claims will increase the premiums which must be paid. Therefore, large firms either self insuring or with experience rated employee insurance premiums have a potential to offset part of the cost of their smoking cessation programme through reduced premiums.

2.2.3 Productivity

Employee smoking results in direct productivity costs. Such costs include time taken by ‘smoking rituals’, inefficiency and errors due to excess carbon monoxide levels in employees and eye irritation (Kristein, 1983). Workers dexterity may also be affected if their smoking hand is occupied. Kristein’s 1983 estimate was a productivity loss of $80 per year per smoker (£92 at 1995 prices). However, Walsh and McDougall (1988) argue that the productivity argument may be incorrect if cigarette smoking helps addicted workers to concentrate, although there is no direct evidence to support this view. Hocking et al. (1991) also reported that productivity losses could be incurred due to time losses as smokers must leave work to go outside to smoke. Under these assumptions, studies attempting to evaluate productivity gains may be questionable if these negative effects are excluded. Smoking bans may also reduce the morale of smokers.

A further cost in this category is productivity losses due to smoking related deaths and retirements. High unemployment may mean that the employer can replace workers but training costs will be incurred (Nelson, 1986). The actual training cost will depend upon the type of labour used.

2.2.4 Involuntary Smoking

The dangers of ‘passive smoking’ have long been known. Non-smoking employees suffer both physical and psychological damage from the tobacco smoke produced by their smoking colleagues. The psychological effect can be to reduce work effort. In 1988 some 28.5 million non-smoking workers in the U.S. were employed in workplaces with few or no smoking restrictions (Repace et al., 1993). Studies have shown (White and Froeb, 1980) that passive smoking can have the same impact upon a non-smoker’s health as light smoking (1-10 cigarettes per day). By applying the risk of cancer for light smokers to non-smokers Kristein estimated that passive smoking cost the average business between $53 and $105 (1980 dollars) in terms of insurance (£50-£100 at 1995 prices). In terms of absenteeism, accidents and productivity costs this was $27 to $56 (£26-£53 at 1995 prices).

Improved ventilation has been one means used to remove tobacco smoke from some workplaces. However, such ventilation systems are extremely expensive to install. In addition, the fresh air which replaces the smoky air must be heated which adds to the firm’s heating bill (Nelson, 1986).

2.2.5 Occupational Health

In certain occupations tobacco smoke can have the effect of making workplace agents more harmful to employee health (Coultas et al., 1992; Strasser, 1991). Such an interaction can occur between tobacco smoke and substances such as cyanide, acetone and lead (Kristein, 1983), nickel (Magnus et al., 1982) and chloromethyl ethers (Weiss et al., 1979). Although the evidence is limited, a synergism has been shown to exist between cigarette smoke and asbestos (Saracci, 1987). This factor is made more significant by the fact that the workers most likely to smoke are also those with the highest risk of exposure to such harmful industrial agents (Walsh et al., 1988). Exposure to the synergistic effects of multiple agents can cause employee disability and consequently claims for large amounts of compensation, which can be averted by preventing workplace smoking. Industries in which smoking has been shown to raise occupational health risks are uranium mining, gold mining, asbestos and rubber production.

2.2.6 Damage to Plant and Machinery

Smokers impose clean up costs upon employers, such as clearing away ash, cigarette butts and matches. Damage to equipment, for example cigarette burns and falling ash, can also impose significant costs on employers. Tobacco smoke can cause particular damage to sensitive machinery, including computers, telephone switchboard equipment and fine measuring equipment (Nelson, 1986). Redecoration costs will also be higher in workplaces permitting smoking, as environmental tobacco smoke damages surfaces and wall-coverings.

2.3 Total cost of employee smoking estimates

The total cost of employee smoking estimates are derived by combining the above categories to produce a single figure. If both costs and benefits are included in the analysis this figure will show whether the effect is an overall net cost or net benefit. A number of studies have attempted to provide a total cost figure.

Weis (1981) attempted to calculate the total cost of smoking in the workplace. The estimated costs were $220 (£215 at 1995 prices) as a result of excess absenteeism, $230 (£225) medical care costs, $765 (£749) due to lost earnings, $90 (£88) for inflated insurance premiums, $1,820 (£1,782) due to time lost on the job, $500 (£490) for property damage and depreciation, $500 (£490) for maintenance and $486 (£476) for the effects of involuntary smoking. This gave a total cost of $4,611 (£4,515) per smoking employee per month.

A more conservative estimate of between $336 and $601 at 1980 prices (£320-£572 at 1995 prices) per smoking employee per month was made by Kristein (1983). The estimate was low because the costs of property maintenance and depreciation were excluded and used lower estimates for the costs of involuntary smoking and time lost on the job.

Kristein’s estimates were inflated to 1986 prices and used as the cost per employee in the computer simulation set up by Swank et al. (1988). The model was based on introducing a smoking cessation programme in a population of hospital nurses, an occupational group which tends to have a high prevalence of smoking. Six scenarios are presented with different programme success rates and proportions of incoming smokers. The net economic impact of the programme ranges from -$284,000 to $684,000 (-£293,099 to +£705,914 at 1995 prices) with the largest economic gain in the scenario with the lowest incoming staff smoking rate. The paper demonstrates how the proportion of incoming staff who are smokers and the turnover rate are important in the determination of the economic impact of a smoking cessation programme, and therefore a programme which yields economic benefits in one workplace need not have the same effect in another workplace with different characteristics. Swank et al. also note that whilst some economic benefits can be gained from simply banning smoking in the workplace, which is the least expensive policy, this should only be part of the employer’s approach. In order to reduce the costs of ill health and associated absenteeism, it is necessary to eliminate smoking both on and off the job.

Nelson (1986) attempted to calculate the economic costs of smoking to employers in Northern Ireland. Absenteeism as a result of smoking related illness is estimated to cost employers an annual loss of almost £40 million at 1984 prices (£66.5 million at 1995 prices). This is supplemented by a loss of £10 million (£16.6 million) due to smoking related deaths and retirements. In organisations where smokers can smoke in designated areas, the ‘smoking ritual’ is estimated to take 30 minutes per day, which would cost employers over £84 million (£139.6 million). An estimate of five minutes daily is estimated for workplaces where employees can smoke ‘on the job’. The cost estimate here is approximately £13.5 million (£22.4 million). Damage to plant and machinery must also be added to these costs, including fire damage attributable to smoking of almost £2 million. The overall cost of employee smoking to employees in Northern Ireland was estimated to be £100,704,000 (£167.4 million).

A pilot study of a smoking cessation programme at the Hawaii Telephone Company in 1990 (Serxner et al., 1993) estimated that the intervention paid for itself in one year and saved an additional $350 (£230 at 1995 prices) per year for each individual remaining smoke free after the study period. This figure excludes productivity and morale benefits. However, the sample size of 12 is extremely small and these are likely to be the more motivated workforce members due to their self selection into the study.

2.4 Effectiveness of smoking cessation programmes in the workplace

The following provides a review of studies which are concerned with the ‘effectiveness’ of different worksite smoking policies. The review includes only specific studies of smoking cessation interventions in the workplace. Attempts were made to identify studies which included evidence of the cost effectiveness of the intervention.

2.4.1 Cessation Help in the Workplace

Smoking cessation programmes have incorporated several different strategies. These have included self-help manuals, support groups, media coverage and incentives such as lotteries or weekly bonuses.

A cost-effectiveness analysis of the smoking cessation programme at the DuPont Company, Wilmington, Delaware is reported by Bertera et al. (1990). Approximately 1,400 employees in a large office complex were given the opportunity to attend stop smoking group meetings. Of the 110 employees which attended, 90 employees filled out cards showing interest in one of the two cessation methods. Twenty-seven employees received either a self-help kit containing a manual containing a quit manual, a maintenance manual and an audio cassette. The remaining 43 employees signed up for the clinic based approach to quitting. The 70 employees provided baseline and 18 month follow up data by self report. After 18 months, 3 of the 27 (11%) participants in the self help group were abstinent compared to 9 of the 43 (21%) in the clinic based group. However, the results were not statistically significant. A cost analysis was attempted by the authors. The total cost of the self help programme was estimated at $448.50 (£294.66), whilst the clinic intervention was costed at $1,385 (£909.94). The cost per successful quit in the self help group was therefore $149.50 (£98.22) in comparison to the $153.89 (£101.10) in the clinic group. The authors also attempted to attach costs to the number of employees who managed to reduce their cigarette consumption by at least 33%. Cost per person was estimated at $44.85 (£29.47) in the self help group and $197.86 (£129.99) at the clinic.

The authors draw two major conclusions. Firstly, in the light of the similar costs of the programmes, employees should be offered the choice of the two programmes in order that the largest number of potential participants is reached. Secondly, basing the cost of employee smoking on the estimates of Kristein (1983), if the programme costs per quitter are $150 as the study suggests, a smoking cessation programme offers a return of $4 for every $1 invested. Therefore smoking cessation policies appear to offer a cost-beneficial investment for employers.

It should, however, be noted that this study has serious limitations. Firstly, employees are not assigned to the groups randomly, raising the question of biases in the estimates of effectiveness. Secondly, the method of attributing costs to the programmes is not presented. Thirdly, data are based on self report with no attempt to validate the results, which as the authors concede may lead to employees giving what they believe to be socially desirable responses. Fourthly, the cost-benefit ratio of 4:1 is based on the assumption of constant returns to scale, in that there is the implicit assumption that it costs the same amount to help every smoker stop smoking. In reality it is likely that such a programme would exhibit diminishing returns so that the 4:1 return is not attainable as the policy is expanded. This would be the case where it is easier to help the first few smokers to stop smoking, whereas a considerably higher amount of resources would be needed to help the more dependent smoker. Finally, the differences in quit rates between the groups were not statistically significant, which should be one of the first requirements of such a study. Hence it must be noted that this study should be interpreted with caution.

A study of 400 smokers at the Dow Chemical Company was undertaken by Danaher (1980), where ex-smokers received a $1 (£0.95 at 1995 prices) bonus for abstinence and chances to win a quarterly $50 (£47.55) bonus and a boat. The results reported showed 76% of the study population remaining abstinent, although no validation of the self report data was provided. Klesges et al. (1986) found evidence of higher cessation rates in cessation programmes with competition for monetary prizes. The study included one US loan institution and four banks. The banks were awarded monetary prizes for the highest take up of cessation help and the highest level of cessation. No competition was included for the loan institution. Results showed higher levels of abstinence in the competitive environment (16% abstinence at six month follow up) in comparison to the non-competitive scenario (7% abstinence). Klesges, Cigrang and Glasgow (1987) review seven incentive/competition programmes and find the average post-test cessation rate to be 44.8% with 26% at follow up (in Jason et al., 1989). The authors suggest that programmes including incentive components may motivate smokers and achieve higher outcome rates.

Worksite support groups provide a useful addition to workplace smoking cessation programmes. Jason et al. (1987) analysed a programme using self help manuals in combination with television broadcasts and smoker support groups. The comparison group received just the manuals and television schedules. At the end of the programme 41% of smokers receiving the full package were abstinent, compared to 21% without the worksite support group. Unfortunately the abstinence rates in the two groups were not statistically significant at 12 month follow up. The effectiveness of group meetings and incentives were also investigated by Jason et al. (1989). The twice weekly 1-hour group meetings and incentive package of a $50 (£39 at 1995 prices) lottery at each group meeting were provided as a supplement to a core programme of self-help manuals, television and support groups. Thirty-eight corporations were randomly assigned to one group or the other. The results showed that 42% of smokers provided with incentives and group meetings were abstinent post-treatment in comparison to just 15% in the core group. The figures were 26% and 16% respectively at 12 month follow up. However, the authors do state that the results should be treated with caution until a longer follow up evaluation can be made.

Li (1984) randomly assigned 576 employees at a naval shipyard to groups with either a simple warning not to smoke or brief behavioural counselling. Results showed the counselling to produce a statistically significant reduction in smoking, with 8% abstinent in the counselling group after 11 months compared to 4% in the group that had received a warning only. Self report data was validated by measuring expired air carbon monoxide.

A videotape was employed as the treatment intervention by Sutton et al. (1984) as 61 employees were randomly assigned to either a treatment group receiving a videotape on smoking or a control group receiving a tape on seatbelts. The results were 14% abstinence in the smoking group and 0% abstinence in the seatbelt group after a 3 month follow up. Sutton (1988) extended the 1984 study by offering nicotine gum to a randomly chosen 50% of the group who had seen the smoking videotape but were still smoking at the 3 month follow up. At 12 month follow up, 22% of the 32 individuals using the gum were abstinent compared to 2% abstinence in the control group who were not offered gum.

Hymowitz et al. (1991) investigated the effect of offering an ‘enriched milieu’ of health education and promotion activities as well as worksite smoking policies would increase the long term effectiveness of a smoking cessation programme. The comparison group was offered only a group quit-smoking programme. The sustained abstinence for the full programme was 50% as compared to 44% for the group only programme. However, the results failed to achieve statistical significance and hence although in the expected direction, could not support the study hypothesis.

Windsor et al. (1988) used a 2x2 factorial design to evaluate the effectiveness of self-help smoking cessation methods. All 378 individuals in the study received either a self-help manual or cessation skills training/social support. Within each group subjects were then randomly assigned to receive a monetary incentive of $25 ($19 at 1995 prices) after 6 weeks abstinence with a further $25 after 6 months or no monetary incentive, hence creating a factorial study design. The manual only was therefore the basic intervention, to be compared to the manual plus monetary incentive, social support and social support plus monetary incentive. The results showed that the skills training/social support was significantly more successful than the manual only programme regardless of the monetary incentive suggesting that the monetary incentives were not effective. At the one year follow-up none of the participants cited the monetary incentive as the main reason for quitting. However, this may be due to the arbitrary nature of the amount as different amounts of recompense were not evaluated. It should also be noted that monetary incentives are likely to have different impacts depending upon whether they are offered as a recruitment aid or as a reward for abstinence. This is because a recruitment incentive is likely to attract smokers most committed to abstinence and hence would appear to exaggerate the effect of treatment.

Three different smoking cessation interventions were compared by Omenn et al. (1988) at the U.S. Department of Energy in Hansford, Washington. The Multiple Component Program combined behavioural skills training and stress management in an intensive three week intervention. Relapse Prevention was an eight week interactive programme focusing on the relapse period. The third intervention was a seven day self-help Minimal Treatment Program. Employees were randomised to the three programs in either group or self help format depending upon their preferred format. Results from the study showed quit rates at the end of the program for the MCP (60.8%) to exceed the RPP (36.8%), which in turn was greater than the MTP (11.8%). However, after a twelve month follow up there were no significant differences between programs. Quit rates showed the same rankings in the self help format, although the rates were consistently lower than the group format. Self report results were corroborated by cotinine saliva samples, but this was of limited value due to missing samples.

It should be noted that although smoking cessation policies may be successful in reducing the number of smokers at a worksite, the effects are not necessarily translated immediately into cost savings for the employer. In a recently published study, Wooden and Bush (1995) investigated the relationship between absence and the time since smoking cessation in a sample of 4,821 ex-smokers as part of the 1989-90 Australian Health survey. The results showed that ex-smokers were more likely to be absent from work in the first year following cessation and that the probability of absence declined with the amount of time since stopping smoking. A positive relationship between smoking cessation and work attendance was discovered, but the effects are only fully realised after a significant time period. For example, an individual who ceased smoking 20 years ago would be expected to be 4.5 times less likely to be absent from work than someone who stopped last year.

The effects of a smoking ban and employee smoking cessation programmes at the John Hopkins Hospital were investigated by Waranch et al. (1993). The hospital had 8,742 full-time employees, of which an estimated 2,000 were smokers. The four cessation programmes offered were a multi-component group, a one hour clinic, brief individual counselling and an American Lung Association manual. From a total of 262 employees participating in one of the programmes it was possible to contact 186 for the one-year follow-up (71%), of which 26 reported that they had not smoked for a year. The results were verified by CO measures for 22 of these, indicating a one year cessation rate of 8.4%. At the follow-up there was a significant decrease in the number of cigarettes smoked. The one hour clinic and the multi component groups had the highest number of quitters (21.7% and 12.5% of participants respectively). However, it is very difficult to draw firm conclusions from the results as the programmes attracted employees with significantly different characteristics (mean number of cigarettes smoked, mean number of quit attempts, mean Fagerström score and mean CO level (ppm)). Since these characteristics are likely to affect the effectiveness of the programme, this would introduce considerable biases into the results. Furthermore, the interventions are non-comparable due to the different strategies used to recruit participants, although these differences are not explained. The authors did note that the three self/minimal-help programmes required the least staff-time input but did not present a cost analysis of the interventions.

2.4.2 Other Worksite Smoking Policies

The relationship between workplace smoking policies and cigarette consumption was investigated by the California Tobacco Survey (Woodruff et al., 1990). The results found the prevalence of regular smokers to be lower in workplaces with restrictive smoking policies. Regular smokers in smoke free workplaces consumed less cigarettes than those workers in workplaces with no restrictions. This was supported by Wakefield et al. (1992) in a comparison of cigarette consumption on work and leisure days for employees at workplaces with and without smoking policies. Findings showed that employees subject to workplace smoking restrictions smoked fewer cigarettes on workdays compared to leisure days. The comparison group of employees without workplace smoking restrictions was found to have no difference between work and leisure day consumption.

Sorensen et al. (1991) investigated the effect of a non-smoking policy at the New England Telephone Company in 1986. The results showed that 21% of the 375 respondents who were smokers had stopped smoking after a period of 20 months. Eighteen per cent said they had not smoked for at least three months. Of the 375 smokers, 32 cited the policy as the reason for abstinence. The study does show that a worksite no-smoking policy can be effective in helping smokers to stop smoking, but is limited due to the lack of a comparison group.

The Group Health Cooperative, Puget Sound, was the focus of a study by Rosenstock et al. (1986). In 1986 the GHC introduced a three stage policy to prohibit smoking from its 35 facilities. The programme impact was assessed by a mail survey of a representative sample of 687 company employees. Amongst the 447 respondents, three reported having stopped smoking during or soon after the programme and 67 smokers indicated a desire to stop smoking, 61% of these reporting smoking fewer cigarettes since implementation of the smoke-free policy. Twenty-nine per cent of current smokers reported they were now smoking less and attributed the reduction to the policy. The average reduction in cigarettes smoked was two per day (p<.003). The results support the reductions in the consumption of cigarettes identified in other studies following a restrictive worksite smoking policy, but must be treated with caution for three major reasons. Firstly the study is based upon self report data which is uncorroborated. Secondly, the survey response rate of 65% may introduce some bias to the results, and thirdly there is no control group against which to compare the results. However, the authors provide some useful recommendations for the introduction of restrictive smoking policies. For a policy to be successful they suggest that:-

the new policies are introduced gradually.

provisions are made to offer opportunities for dissidents to express their feelings.

the limitations of employee influence are clearly communicated.

Borland et al. (1990) found evidence of a reduction in cigarette consumption following a worksite no-smoking policy in the Australian Public Service. The study used the 391 respondents reporting being smokers both before the policy was introduced and 5 to 6 months after its inception. Average cigarette consumption fell by 7.0 cigarettes per day, which was only partly compensated by a 0.7 increase outside working hours. Furthermore, no evidence of higher compensation amongst heavier smokers was found. The authors conclude that the heaviest smokers are those who are most likely to benefit from a worksite smoking ban as they are the ones which find cessation most difficult, and a worksite smoking ban provides a means by which cigarette consumption can be reduced. The results are also supported by Brenner and Fleischle (1994) who observed a lower average number of cigarettes smoked per day amongst employees at worksites with smoking restrictions in a cross sectional study of 931 employees in Southern Germany.

A study of the impact of a ban on smoking at the John Hopkins Children’s Center in Baltimore in 1987 was undertaken by Becker et al. (1989). The Center was a 200 bed acute care hospital with 951 full-and part-time staff. Surveys of self reported smoking behaviour, numbers of staff smoking in the visitors lounge, the numbers of cigarette butts in ashtrays inside the Center and environmental nicotine vapour concentrations were made before and after the ban. Six months after the ban was imposed the number of smokers smoking at work had decreased from 82% to 43%. The number of visitors and staff smoking in public areas which was observed to be 53% one month before the ban had decreased to 0% six months after the ban. Counts of cigarette butts dropped from an average 940 per day pre-ban to 19 per day six months post-ban. Environmental nicotine vapour also declined from 13 µg/m3 one month pre-ban to 0.51 µg/m3 six months post ban in nine of the lobby lounges, although no statistically significant change was found in the restrooms and the outpatient clinics. There was no statistically significant decline in the prevalence of smoking or the average number of cigarettes smoked per day.

Waranch at al (1993) in their study of the smoking ban and cessation help at the John Hopkins Hospital (see above) undertook a before and after survey of the smoking behaviour of the whole workforce. A questionnaire was sent to all 8,742 full time workers of which 2,877 returned a usable questionnaire both at the six month pre-ban and six month post-ban mailings. The mean number of cigarettes smoked per day decreased from 16.4 to 13.1 (p<0.0001) and the mean number smoked at work fell from 7.8 to 3.1 (p<0.0001). The results should be treated with caution as data are based on self-report with no validation. Furthermore, no attempt was made to collect information on those not responding to the questionnaire, which reduces the generalisability of the findings.

It should be noted that whilst restrictive workplace smoking policies may be successful in reducing environmental tobacco smoke at the workplace, such policies may not succeed in improving employee health as smoking outside the workplace may be unaffected or even increase (Gottlieb, 1990).

Reference	Cessation Policy	Results
Sutton et al (1984)	Random assignment to: (1) Videotape onseatbelts (control) (n=33) and (2) Videotape on smoking (n=28).	Group (1), abstinence 14% and Group (2)abstinence=0%.
Li (1984)	US Naval shipyard: Group 1, warning not tosmoke. Group (2), warning and counselling	Group 1, abstinent 4% at 11 months. Group(2), abstinent 8% at 11 months. Validated by exhaled CO.
Klesges et al (1986)	5 US worksites; One loan company and fourbanks. Loan Co. received basic programme. The four banks entered intocompetition, with monetary prizes for (1) Greatest uptake and (2) Greatestabstinence rate.	Six month follow up showed 16% had stoppedsmoking in the competitive worksites, comapred to 7% in the non-competitivesite.
Jason et al. (1987)	43 corporations assigned to either (1) TV andself help or (2) TV, self help and support group.	After programme 41% abstinent in (2) and 21%in (1): After 18 months, abstinence
Windsor (1988)	University of Alabama, Birmingham, U.S. 2x2factorial design: Self help or cessation training, then randomly assigned toreceive monetary incentive or not.	At 1 year follow up, monetery reward cited asthe main reason for quitting. However, incentive may also affect recruitmentand bias the study.
Sutton (1988)	Extended 1984 study by offering nicotine gumto randomly chosen 50% of the group who had seen the smoking videotape (n=79).No offer of gum to the control group (n=82).	Those using gum achieved 22% abstinence at 12month follow up, compared to 2% abstinence in the control group.
Omenn et al (1988)	US Department of Energy, Washington 402 smokers allocated to either: (1) Multiple component programme, (2)Relapse prevention or (3) Minimal Treatment Programme. Programmes available ineither group or self help format	Quit rates after the programme were Group(1), 60.8%; Group (2), 36.8%; Group (3), 11.8%. At 12 month follow up thedifferences between programmes failed to achieve levels of statisticalsignificance.
Jason et al. (1989)	38 workplaces assigned to either (1) Selfhelp, TV, support or (2) Self help, TV, support and incentives.	Post treatment 42% abstinent in (2) and 15%abstinent in (1). At 12 month follow up, 26% in (1) and 16% in (2).
Bertera et al. (1990)	DuPont, Delaware: 27 in self help, 43 in clinic based approach	After 18 months 3/27 had stopped smoking inself help, 9/43 had stopped in clinic group.
Hymowitz et al. (1991)	Six US white collar work sites randomlyassigned to either: (1) Full program of cessation help (n=131) or (2) Grouphelp only (n=121)	Group (1), 50% abstinence, Group (2) 44%abstinence. Results failed to reach statistical significance.
Waranch et al (1993)	Johns Hopkins Hospital, Baltimore. 262 smokers participated in either (1) Multicomponent programme (n=88); (2)American Lung Association manual (n=59) or Lifesign (n=59); (3) One hourclinics (n=23); (4) Brief individual counselling (n=33).	186 were contacted at one year follow up.Highest quit rates were in Group (3), abstinence=21.7% and Group (1),abstinence=12.5%. Problem with the study is that the groups werenon-comparable, hence confounding factors may influence the results.

2.5 Implications for Scotland

The categories of costs incurred by employers as a result of employee smoking may depend upon the characteristics of the workplace and workforce in question and the type of smoking policy to be introduced. The magnitude of the benefits yielded by a workplace smoking policy will also depend upon the prevalence of smoking in the particular workplace. For example, a policy is likely to produce larger benefits in a workplace with a higher smoking prevalence as opposed to one with low prevalence where the potential for benefits is limited. The prevalence of cigarette smoking is high in Scotland in comparison to the rest of Great Britain. The 1992 General Household Survey (HMSO, 1994) showed 34% of Scottish men and women to be smokers, this being the highest rate for the regions of Great Britain (see Table 1.1). The smoking prevalence in Scotland is considerably higher than the 26.5%(1) in the U.S., where most of the evaluation studies have been conducted. This suggests that there is are greater potential benefits to be gained from smoking policies in Scotland.

The major costs of employee smoking are summarised in Table 1.2, along with an assessment of the relevance of different items to Scottish workplaces. The impact of employee smoking upon absenteeism, the health of non-smoking colleagues and occupational health issues will be common to both U.S. and Scottish workplace smoking policies. The health insurance category is less applicable to Scotland as it will only be relevant to employers which offer their workforce health insurance packages. Higher insurance premiums for fire are more likely to be applicable if the premium is related to whether the employer has a restrictive smoking policy. The productivity category is ambiguous, as in the U.S. scenario. If workers have to stop work to smoke elsewhere then productivity may be adversely affected. Conversely, if smoking helps worker concentration then productivity may be aided, although against this must be offset possible negative effects on non-smoking workers.

Table 1.1: Prevalence of smoking by sex and standard region

Smoking prevalence (% smoking cigarettes)

Region	All persons	Men	Women
England Wales Scotland Great Britain	28 32 34 28	29 32 34 29	27 33 34 28

Source: General Household Survey 1992. HMSO 1994.

Population base: persons aged 16 and over

Table 1.2: Costs of employee smoking in the workplace

Cost category	Relevance to Scotland	Comments
Absenteeism Insurance costs: Health Insurance costs: Fire Productivity Passive Smoking Occupational health Damage to plant and machinery	Yes Yes Yes Yes Yes Yes	If employer pays experience rated health insurance premiums If employer pays fire damage insurance premium related to workplace smoking policy. Effect may be positive or negative

(1) US Department of Health and Human Services (1990) Healthy People 2000. The 1987 smoking prevalence has been adjusted to 1992 by the average decrease in smoking prevalence of 0.5% per annum.

2.6 Conclusions

Research shows that smokers impose significant costs on employers through higher rates of absenteeism, inflated insurance premiums, reduced productivity and higher maintenance costs. Costs are also imposed on non-smoking colleagues through the inhalation of environmental tobacco smoke.

The effectiveness of workplace smoking cessation policies has been estimated at 20-30% (Katz et al., 1990), although this will depend upon many variables such as the population being targeted, the smoking prevalence amongst this population and the particular policy in question. Studies also tend to show that workplace smoking restrictions reduce the consumption of cigarettes and policies involving competition and monetary rewards also appear to perform well.

The vast majority of the literature is from the United States, and hence the applicability to the United Kingdom is unknown. Whilst the major categories of economic costs of employee smoking are likely to be similar, their magnitude will certainly differ. The different specifications of the smoking restrictions and smoking cessation policies which have been evaluated also make it very difficult to provide meaningful comparisons of results. Caution must therefore be taken when interpreting these studies and especially when attempting to apply results to countries outside the United States.

3. Survey of Worksites in Scotland

3.2 Methodology

A stratified random sample was drawn based upon the number of workers in Scotland employed in the different SIC categories. Employment in the 10 SIC sectors in Scotland is shown in Table 2.1.

A list of Scottish companies was compiled from local authority business directories, the Scottish section of the business directory Kompass and lists of local authorities and Health Boards. The study did not exclusively use Kompass as a source of company information as has been done in several previous surveys since this directory is limited to industrial suppliers and excludes firms in the consumer good industries and also most public sector organisations. Only companies with over 50 employees were included. Fifty was chosen because of the difficulties in compiling a stratified sample of firms with 100 or more employees.

Table 2.1: Employment in Scotland 1994

	SIC code	Group	Scotland Employment	%
	0	Agriculture, forestry and fishing	25,000	1.28
	1	Energy and water supply	50,000	2.57
	2	Metal manufacturing and chemicals	36,000	1.85
	3	Metal goods, engineering and vehicles	148,000	7.60
	4	Other manufacturing	166,000	8.52
	5	Construction	102,000	5.24
	6	Wholesale distribution, hotels and catering	406,000	20.84
	7	Transport and communication	109,000	5.60
	8	Banking, insurance and finance	202,000	10.37
	9	Education, health services and other	704,000	36.14
		Total	1,948,000	100

Source: Employment Gazette

The directories used to draw the sample did not all use the same industrial classifications, hence firms were allocated to the closest SIC code. Furthermore, many firms are involved in activities which overlapped several different SIC codes. The number of firms in each sector to be contacted for the telephone survey were drawn from the SIC categories according to the proportion of the Scottish workforce employed in that sector. However, due to the distribution of Scottish employment across the 10 SIC sectors, some of the sectors were too small to provide meaningful results when presented in SIC codes. In order to present the results disaggregated by broad industrial groups, the results were therefore presented by combining SIC codes. The groups used for this study are shown in Table 2.2. The ‘manufacturing’ group comprises of firms engaged in manufacturing activities, together with energy and water supply industries. The second group comprises a non-office based service sector. The third group includes office based services and public sector organisations. The aim of this aggregation was to group together industries producing similar outputs whilst preserving the basic SIC groupings by which employment statistics are published.

Table 2.2: Industrial groups used for the study

Manufacturing	Energy & water supply, manufacturing, engineering & vehicles
Non- office services	Construction, distribution, hotel & catering, transport & communication
Office and public sector	Banking, insurance, finance, education, health services & other services

Interviews were conducted over the telephone and were based on a questionnaire. A 30 item questionnaire was piloted with 6 employers before the survey was undertaken. However, after the pilot phase it was decided to use a shortened 18 item version (see Appendix 3) as the original questionnaire was time consuming, therefore making it unpopular with respondents. Appendix 3 also presents the full results from the survey.

The revised questionnaire collected basic information about the firm including number of employees and the industrial activities of the firm. Information was then collected about the type of smoking policy in operation at the firm. If smoking cessation help was offered the details of the programme were compiled. Finally the employer was asked about their perceptions of the costs and benefits of restricting smoking at the workplace and offering cessation help.

A total of 200 firms were contacted. If it was not possible to contact the appropriate person in the company after three attempts, the inquiry was pursued no further. There were three refusals to participate in the survey. In the remaining firms it was either not possible to make contact with the person responsible for the policy (22 firms) or the firm had ceased trading or it was not possible to contact the firm (eight firms). This procedure produced 167 completed questionnaires.

3.3 Results

The number of successful interviews completed in the three employment categories are shown in Table 2.3, together with the numbers of firms with a restrictive workplace smoking policy and the proportions of these policies which are written.

Table 2.3: Smoking policies in worksites in Scotland

	Interviews completed	Firms with a smoking policy		Written smoking policies
	n	n	%	n	%
Manufacturing	41	35	85%	32	91%
Non office services	49	44	90%	31	70%
Office & public sector	77	77	100%	70	91%
Full sample	167	156	93%	133	85%

Table 2.4 shows the types of smoking restrictions which were in place in the firms sampled. Of the 156 firms in the sample, 57% restricted smoking to a ‘smoke room’. This was the most common policy across all three industrial groups. A smoke free building policy was operated by 37% of employers. Three employers placed restrictions upon the times at which employees are allowed to smoke. Seven employers stated that the decision over whether to allow smoking in an office was based upon individuals’ preferences.

Table 2.4: Types of smoking policies in sample of Scottish firms

Policy

Group

Smoke free building

Smoking allowed in ‘smoke room’ only

Smoking allowed at certain times only

Other

Total

	n	%	n	%	n	%	n	%	n
Manufacturing	9	26%	25	71%	-	-	1	3%	35
Non office services	18	41%	21	48%	-	-	5	9%	44
Office & public sector	30	39%	43	56%	3	4%	1	1%	77
Full sample	57	37%	89	57%	3	2%	7	4%	156

A total of 41 firms of the 156 with a smoking policy (26.3%) indicated having experienced problems with the policy. The problems identified are shown in Table 2.5.

Table 2.5: Problems experienced with smoking policies

Problem

Responses *

Smoke breaks - productivity loss and non-smokers perceived unfairness	17
Complaints from smokers	16
‘Fly-smoking’ in toilets	6
Senior staff ignoring ban	3
Staff congregating at entrance; litter and negative image	4

* Figures do not add to 41 due to multiple responses

Forty-nine of the 167 firms surveyed offered cessation help to employees wishing to stop smoking. The proportions of firms offering cessation help to employees wishing to stop smoking by industrial group are shown in Table 2.6. Cessation help had been offered by 21 employers temporarily whilst a no-smoking policy was introduced but indicated that there had been a very disappointing uptake and the decision was taken not to provide help as an on-going policy.

Table 2.6: Firms offering cessation help as an on-going policy

Firms offering cessation help

	Group	%	n
	Manufacturing	34%	14
	Non office services	16%	8
	Office & public sector	35%	27
	Full sample	29%	49

Table 2.7 shows who undertakes the cessation help in those workplaces providing help to smokers. It can be seen from the table that over half of the firms in the survey undertook the work ‘in house’ by using their own occupational health staff.

Table 2.7: Who undertakes cessation help†

	Occupational Health Staff		Outside Consultants		Other *		Unknown**
	%	n	%	n	%	n	%	n
Full sample	57%	28	20%	10	8%	4	14%	7

Figures show who provides cessation help in firms who have indicated that they offer such help to employees. The individual results were too small to report by group.

Notes

†	figures may not add due to rounding
*	includes help for workers to buy their own help and employers providing leaflets
**	“unknown” includes firms who do not have an on-going programme but would provide help if approached by an employee. In this case the provider of the help would be decided upon when help is requested.

The questionnaire included detailed questions about the smoking cessation element of the policy that firms were offering. None of the firms surveyed had undertaken any evaluation of the programme and there was little interest in obtaining such information. Knowledge of the smoking status of employees was not widespread and only nine firms claimed to know the prevalence of smoking amongst their employees, these estimates ranging from 17% to 80%. Very little interest was also shown in sources of help concerning smoking cessation programmes except for the three companies which requested ‘Smokeline’ information and two which requested the address of the local Health Board.

Employers perceptions of the major benefits from introducing worksite smoking restrictions are shown in Table 2.8.

Table 2.8: Employers’ perceived benefits of worksite smoking restrictions

	Reductions in Absenteeism	Cost savings	Health benefits	Hygiene benefits	Legal issues	Morale benefits	Safety issues
Full sample	2	19	130	30	9	9	40

Note:

Figures show number of firms Figures do not add due to multiple responses

As regards the major costs of worksite smoking restrictions, reduced productivity was cited by 17 employers. This was a concern about smokers leaving their tasks to smoke in permitted areas, such as a smoke room or outside the building. Nine employers believed there was a cost involved when introducing a restrictive smoking policy because of the equipment needed. These costs included having to release productive work space in order to provide a smoke room, and also the equipment such as extractor fans needed for such a facility.

3.4 Discussion

The vast majority of Scottish employers now restrict smoking in the workplace: 93% of employers in the telephone survey had in place some form of restrictive smoking policy. The results from a stratified random sample of 200 employers across Scotland, indicated that 93% of the 167 employers completing the questionnaire operated some form of restriction on employee smoking. The most common policy was to confine smoking to designated areas of the building(s) only, (operated by 53% of the 167 survey respondents). Total smoking bans (no smoking is allowed anywhere in the building) was operated by over a third of firms taking part in the survey. Many of the employers believed restrictions on smoking to be the norm and that the freedom to smoke at work was the exception.

Problems associated with the worksite smoking policy were experienced by 26% of firms in the survey. The most common problems identified were productivity losses when smokers leave their tasks in order to smoke (cited by 17 employers) which had been noticed to create workplace tensions as non-smokers were aggrieved at the longer breaks enjoyed by smoking colleagues. Attempts to resolve the problem included one employer’s requirement that workers ‘clock out’ for smoke breaks, whilst another employer required that workers wishing to take a smoke break must work an extra half hour each day. Nine employers currently operating a complete worksite smoking ban stated that employees congregating at the entrance to the building and creating an undesirable corporate image and large amounts of litter was presenting a problem.

The results did show an awareness amongst employers of the health benefits of a restrictive smoking policy with 84% of employers in the survey citing ‘benefits to health’ as a major benefit of a restrictive smoking policy. The other key benefits identified by firms were safety, hygiene and cost-savings (including savings in damage to plant and machinery and reduced insurance costs). A significant reduction in computer failures and consequently repair costs had been noticed by one firm following the institution of a no-smoking policy. Three employers stated that a written policy was beneficial as it made clear the position of employers and employees as regards the policy towards smoking.

There does appear to be a lack of knowledge surrounding the wider cost-saving benefits of policies aimed to help employees stop smoking. Reducing absence from work was only identified as a benefit by two of the 167 employers interviewed despite the evidence from the studies outlined above (see Section 2.2.1).

Several external influences were noted to have brought about the introduction of no-smoking policies such as health and safety regulations for companies in the food and drink industry, trade union pressure and landlord’s regulations for firms occupying rented accommodation. Insurance companies also dictated a no-smoking policy in three warehouse based organisations. However, one firm indicated that insurance costs may actually be higher in premises with a total smoking ban and no ‘smoking room’ since it was feared that employees may smoke in areas of the building where they are unlikely to be detected, and where the absence of proper disposal facilities can lead to fire hazards.

Two carefully planned approaches to the introduction of a worksite smoking ban were noted to have been successful. A phasing-in of the policy whereby smoking is initially restricted to certain areas of the premises, then to smoke rooms which are then removed after a period of time was thought to have helped the employees in one organisation to accept the policy without the opposition which is often experienced. Two other employers reported setting up working groups including both smoking and non-smoking employees, trade unions and employers representatives, therefore allowing conflicting views to be raised. These approaches follow the recommendations for the introduction of a restrictive smoking policy put forward by Rosenstock et al. (1986) as outlined above in Section 2.4.2.

Amongst the firms with no policy, four stated that this was the case because senior staff from who the policy decision would be forthcoming were themselves smokers and were not prepared to initiate a restrictive policy. Three firms with policies also reported senior staff ignoring the ban.

3.5 Conclusions

The telephone survey showed that employers were willing to be interviewed but only with a limited questionnaire. Employers were generally interested in the issues of restrictive smoking policies as shown by there being only three refusals to participate. A difficulty involved in the survey was in constructing an adequate sampling frame, as there are a large number of small employers in Scotland. The list was compiled from a variety of sources, such as local authorities’ business directories, and lists of local authorities and health boards. This was time consuming but avoided the problems of bias which would result from using a directory such as Kompass.

The survey results showed that most firms across Scotland do have some kind of smoking restrictions, although there are several different types of policy in operation. The majority of employers were aware of the health benefits of introducing a restrictive smoking policy, although knowledge of other benefits was limited.

Twenty nine percent of the full sample offered cessation help to employees wanting to stop smoking, although employers appeared not to be aware of the wider benefits such as the potential reductions in absenteeism identified in the literature. The lack of knowledge surrounding the costs and benefits of such policies was a consistent finding throughout the survey. Cessation help had been offered by 21 of the employers whilst instituting the restrictive smoking policy, but this had been discontinued due to poor take up, a problem also noted in the focus group work in Section 4.

3.1 Introduction

This chapter outlines the methodology and results of a survey of workplaces in Scotland which was undertaken in January and February 1996 to collect information about smoking policies and help offered to employees wishing to stop smoking.

The survey of Scottish employers was undertaken in order to investigate the various smoking policies currently in place and the attitudes of employers to such policies. The survey population was a random sample of Scottish employers. A random sample was used in order to remove any potential biases which might be evident if the sample was drawn by a non-random method.

The survey asked whether the employer had a policy restricting smoking at the workplace, what the characteristics of that policy were, whether any problems had been experienced and whether the firm offered cessation help to its employees. The employer was then asked their views on the costs and benefits of worksite smoking policies.

4. Focus groups and interviews with occupational health and personnel staff

4.2 The companies

This section provides summary information for the six companies involved in the focus group work.

Company: Company 1

Activity: Bakery

Number of smokers:	Informal estimate of 75% smokers, 90% of whom want to stop.
Smoking Policy:	Total smoking ban by law (food factory). Smoking allowed in canteen during breaks.
Is the policy written down?	Policy currently being written down.
Problems?	Serious problems with compliance (smoking in toilets).
Does employer offer cessation help?	Yes, cessation help is ongoing.
What help is offered?	Nicotine patches, laser therapy.
Would more guidance be helpful?	Yes.

Company: Company 2

Activity: Headquarters office building

Number of smokers:	Approx. 450 employees in HQ building, 6% (27) smokers.
Smoking Policy:	Total smoking ban in building, no smoking room.
Is the policy written down?	Not as yet.
Problems?	Not with compliance, but cigarette butts strewn around the building.
Does employer offer cessation help?	Yes; all smokers offered help when policy introduced; 11 expressed interest, 7 took up offer.
What help is offered?	Groups run by company nurse, patches at cost price.
Would more guidance be helpful?	Possibly, although they are happy with their current approach.

Company: Company 3

Activity: Office and factory

Number of smokers:	Approx. 500 staff, 120 smokers (24%).
Smoking Policy:	Smoking allowed in smoking rooms only, at certain times e.g. breaks; surveyed attitudes during introduction; originally proposed total ban but backed off because of opposition.
Is the policy written down?	Yes.
Does employer offer cessation help?	Yes.
What help is offered?	Before policy introduced in January 1995, offered laser therapy; 40 tried it; problems with patches because of dispensing; now an open offer of help, no takers.
Would more guidance be helpful?	Very much so, including a guidance document on how to set up and run groups. Interested in idea of cessation counselling training for staff.

Company: Company 4.

Activity:Factory

Number of smokers:	Approx. 250 people, 70 smokers (28%).
Smoking Policy:	Smoking only allowed in one smoking area.
Is the policy written down?	Yes.
Does employer offer cessation help?	Yes.
What help is offered?	Organised (but did not pay for) hypnosis, acupuncture, reflexology, laser therapy, nicotine patch; poor uptake.
Would more guidance be helpful?	Yes.

Company: Company 5

Activity: Factories and office buildings

Number of smokers:	1,500 employees, 520 smokers (35%), 330 interested in stopping (mostly early 20s), 110 returned slip requesting help, 35 actually took up offer of help, don’t know exact success rate but less than 10.
Smoking Policy:	Smoking only in smoking room (during breaks).
Is the policy written down?	Yes, includes a guidance booklet for employees.
Does employer offer cessation help?	Yes, company paid, but in own time.
What help is offered?	Local health authority came in and ran groups (for nominal fee).
Would more guidance on methods be helpful?	Yes, but they were very happy with the support they got from the health promotion department.

Company: Company 6

Activity: UK headquarters, includes offices and factory

Number of smokers:	Approx. 950 employees of which 300 are smokers.
Smoking Policy:	Smoking permitted in designated areas during break times only.
Is the policy written down?	Yes.
Does employer offer cessation help?	Yes, in staff's own time.
What help is offered?	Health visitors came in and ran groups; very poor uptake.
Would more guidance be helpful?	Yes.

4.3 The focus group discussions

4.3.1 General views on smoking policies

Surprisingly few employees, including smokers, objected to the introduction of smoking policies in principle. The predominant view was that the world has changed in this respect over the last ten or so years, and that especially with the evidence now on the health risks of passive smoking, it is no longer acceptable to smoke where and when you like. This view was expressed by even some hardened lifelong smokers. In fact some support for smokers came from some non-smokers in the groups, who thought that smokers should not be victimised and that smoking areas should be provided.

However, considerable resentment was expressed about the way policies were introduced - they were often perceived as having been brought in a dictatorial way - and about the type of policy. Many employees were also cynical about the motives of employers in bringing in smoking policies, assuming that it must in some way save the company money. It did not occur to them that it might actually cost the company money and that the company might actually believe in health and safety at work.

4.3.2 Total bans or the provision of smoking areas

Total bans (with no smoking room(s) provided) did not go down well with employees and seem to generate serious compliance and enforcement problems. There was virtually a consensus on this. Resentment was expressed that such policies were not consistently enforced, and that this was not fair on compliers. Two of the companies visited had originally intended total bans but softened this to include smoking rooms as a result of consultation, and the employees clearly appreciated the consultation.

4.3.3 Practical aspects of cessation help

The employees at Company 1 had rather negative views about the nicotine patch but rated laser therapy highly. Employees at another company also rated the laser therapy but commented that they didn't think the treatment itself mattered; it just provided a focus for their efforts. Several people praised the personality and commitment of the laser therapist. The nicotine patch generally came out of the focus groups discussions rather poorly and one reason may simply be, as was highlighted at Company 4, that whilst the laser therapy included a lot of support, the patches usually came with none.

Shift patterns create real problems for cessation groups run in-house. One late shift worker would not have been able to attend the treatment sessions anyway, and felt it may have been better if the company had provided the money and allowed employees to make their own arrangements. The employees at Company 2 (daytime headquarters office staff) appeared satisfied with the treatment which they had been offered. This treatment had taken the form of in-house groups run by the nurse, including nicotine patches at cost price and no glamorous unvalidated treatments like laser therapy.

Great concern was expressed about weight gain by a predominantly female workforce in one company, who said that they wanted a treatment approach which dealt specifically with this. They had not heard of the Quit booklet on the subject.

4.3.4 Payment for cessation help

The majority of people felt that the company should pay for cessation help, although some felt less strongly about this. For example, Company 3 shared the costs 50:50 with employees who on the whole felt this fair and generous. Schemes whereby employees’ payments are taken from their pay packets in instalments were widely appreciated. This meant they could afford some treatments (laser therapy, for example, at £70), when they would not otherwise have been able to do so without such a scheme. However the issue of payment is not simple. Non-smokers at one company (which does not contribute to the cost of cessation help) would have resented it if smokers had been allowed work time for stopping smoking, and management were very conscious of this aspect of fairness.

4.4 Discussion

The introduction of policies does appear to encourage smokers to stop, and it is clear from talking to management that legislation has had a key role in leading the move towards workplace policies. All companies acknowledged that the issue cannot just be ignored. Encouraging for the companies was the widespread acknowledgement, even amongst smokers, that it is reasonable to restrict smoking these days. However, resentment about perceived management style when introducing policies, and the practicality and fairness of the policy itself, needs to be addressed by, among other measures, improved consultation and communication.

4.4.1 Total bans

Total bans appealed to management on the grounds of completeness and simplicity but on the basis of this research such bans do not really appear to work. Total bans on smoking tend to create resentment as well as practical difficulties, including compliance and policing problems, and litter. They also appear unsuccessful in stopping employees from smoking, and one company commented that they had been advised against a total ban by its insurance company. The concern was that a total ban would force smoking underground, thereby creating fire risk. This concern was also noted by a different employer in the telephone survey.

Two of the companies visited had originally intended to implement total bans but had softened their stance to provide smoking rooms as a result of consultation. One company acknowledged that the vigorous debate sparked by the proposed total ban was extremely valuable; "You must have that debate." At Company 2, the effect of the total ban is that cigarette butts can be seen strewn around the outside of the building, and at Company 1 employees still get caught, and dismissed, for smoking in the toilets. The issue of litter and cigarette butts outside the building, together with the adverse image presented to the public, was also voiced by employers in the telephone survey.

4.4.2 What treatment?

Generally occupational health and personnel staff knew very little about which cessation programmes work and which provide good value for money. Most companies had no idea whatsoever. One employer stated that they would never use an unproven method. However, the laser therapist, for example, claims an 80% success rate, and most companies simply did not know how to evaluate such a claim. Companies clearly need help in assessing what works and what may be value for money. Guidance is needed also on how to set up and run groups. Few knew the success rates of the courses they had offered.

If there was a model approach among the companies visited it was Company 2, who offer groups run in-house by a highly trained and committed nurse. The company used the nicotine patches and eschewed unvalidated methods.

4.4.3 Uptake of help

In general the uptake of cessation help is low, and there are inherent problems involved with running in-house courses when employees work in shifts.

At Company 2, approximately 450 staff at their headquarters building were surveyed. Of the 27 (6%) smokers, 11 (41%) expressed an interest in cessation help, but only about 7 (26%) actually took up the offer of help. Even lower figures were reported at Company 5 where 330 of the 520 smokers (63%) expressed interest but only 35 (7%) actually accepted help.

There are many possible reasons for these findings: difficulties with shift patterns; difficulties getting enough people on one site with multi-site companies; there simply being not enough smokers strongly motivated to stop, who need help (this phenomenon is not limited to companies); inadequate information about what is on offer and why it should work. Guidance is needed on the pros and cons of the company paying for help, and offering it in company time. Most companies did not want to do everything for the smokers. They felt it important the smokers made their contribution, partly to demonstrate their genuine desire to stop, and also because of concern about resentment from the non-smokers.

4.4.4 Payment

Companies vary on whether they contribute nothing or something (money, time) to cessation help, but one way they can and do help is by paying for the treatment up front and then deducting it from pay packets gradually. Otherwise laser therapy at £70 would not be affordable. Some companies were ambivalent about whether to offer help at all, and whether to contribute.

4.5 Summary and conclusions

In the very short time available to set up the focus groups a company without a smoking policy was not found. The most recently introduced policy (February 1996) was prompted partly by the occupational health department talking to colleagues in other companies and discovering they were lagging far behind.

Two principle forces were cited as driving the introduction of workplace smoking policies - legislation (both from the EU and interpretation of existing legislation, for example the Veronica Bland settlement), and their responsibility as employers for the health and safety of their employees. Not only were potential financial benefits not mentioned, but some companies knew the financial cost of introducing the policy (for example £5,000 excluding staff time) and still rated it as good value and worth doing. When questioned about the potential longer term benefits (like less sickness absence) they felt these were too far ahead to be worth trying to take account of, and unquantifiable.

Policies restricting workplace smoking were widely accepted by staff, but in some companies resentment was expressed at dictatorial behaviour by management and cynicism about the reasons for such policies. Resentment was also expressed that policies were not enforced fairly and consistently. The message that comes over is that companies should consult properly when introducing a new smoking policy, and take the trouble to explain it, and the reasons for it. The policy should also be clear, fair, and as simple - and simply enforceable - as possible.

As far as type of policy goes, policies banning all smoking within buildings or sites (i.e. no smoking rooms) did not go down well with employees, seem to cause serious policing problems, and can even push up insurance costs. There was a strong consensus among employees that such policies are unfair and that smoking rooms or areas should be provided. They can also lead to litter problems and, because the cigarette ends are sometimes dropped outside the front of the building, image problems. Total bans do not appear to work.

As regards cessation help, most companies have little information on what works or know where to get it. Availability of such knowledge in local health education departments is patchy, and it would probably be an exceptional department that was up to date with the latest cessation research. There is a clear need for guidance on choosing cessation help. Our recommended approach would be to either train staff to offer help in-house, or provide time and/or money for employees to make their own arrangements (because of the difficulties of running courses with shift systems). The problem then would be offering guidance on what treatments are worthwhile.

4.1 Introduction

The companies involved in the focus groups were drawn from a list of companies actively involved in workplace health promotion, which was supplied by HEBS. The companies were selected simply going down the list in order until six had agreed to participate. Each company was visited for around two to three hours. An in-depth discussion was held with occupational health/personnel staff about smoking policies, including not only practical details, but their perceived costs and benefits. Focus groups were then run, lasting around an hour, and with from five to ten employees present. Management were sometimes present but willing to leave on request if the researcher believed their presence to inhibit the discussion.

5. The cost of employee smoking in Scotland

5.2 Employment and earnings in Scotland

This section will attempt to provide estimates of the costs to employers which result from employee smoking. In order to estimate these costs it is firstly necessary to calculate the number of Scottish employees who are smokers and the level of earnings at which to cost the time lost as a result of employee smoking. This requires information on smoking prevalence, employment and earnings as presented in the following sections.

5.2.1 Employment in Scotland

The total number of persons in full-time and part-time employment in Scotland is shown in Table 4.1.

Table 4.1: Employment in Scotland, September 1995

	Male		Female
	Full Time	Part Time	Full Time	Part Time
Employees	895,000	97,000	526,000	431,000
Estimated smokers	297,140	32,204	190,412	143,092

Source: Labour Market Trends, February 1996.

Table 4.1 also shows the estimated number of smokers in employment in Scotland. The prevalence of smoking is applied to the employed population to provide an estimate the total number of Scottish employees who smoke. The prevalence of smoking amongst the employed population of Scotland is estimated at 33.2% for males and 36.2% for females (General Household Survey, 1994).

5.2.2 Earnings

Hourly earnings for the UK are shown in Table 4.2, both as an average wage for the UK and by separate SIC classifications.

Table 4.2: Average earnings in the UK

SIC	Description of SIC	Average Male wage	Average Female wage
SIC 0	Agriculture, forestry and fishing	£5.57	£4.80
SIC 1	Energy and water supply	£10.43	-
SIC 2	Metal manufacturing and chemicals	£7.43	£5.34
SIC 3	Metal goods, engineering and vehicles	£7.02	£4.90
SIC 4	Other manufacturing	£6.91	£4.76
SIC 5	Construction	£6.11	-
SIC 6	Wholesale distribution, hotels and catering	£5.56	£4.17
SIC 7	Transport and communication	£6.36	£5.84
SIC 8	Banking, insurance and finance	£5.79	£5.12
SIC 9	Education, health services and other	£5.96	£4.67
All sectors		£8.86	£7.09

Source: Labour Market Trends, February 1996

5.3 The cost of employee smoking

5.3.1 Absence due to Smoking Related Disease

The costs of employee absence from work are one of the most frequently cited effects of employee smoking. Section 2.2.1 outlines several studies which have attempted to estimate the effects of absence as a result of employee smoking.

Two key studies were found which provided baseline data. The first was based on the Missouri Department of Health (Van Tuinen and Land, 1986) and found an excess absence amongst smokers of one hour a month. An average of 5.3 hours a month sick leave amongst 97 smokers, compared to 4.3 hours amongst 309 non-smokers. The study therefore estimates absence to be 23.2% higher amongst smokers. This result is lower than the estimates for male civil servants in the Whitehall study (46% higher for short absences and 81% higher for long absences), although it is similar to the estimates for female workers (9% and 37% respectively).

The estimates presented below are based on the results of the DuPont study (Bertera, 1991). This study was selected because of its use of a large population (n=45,976) consisting of a diversified workforce. The results were presented as excess days absence per employee which provides the information required to transform the estimates to other scenarios. The DuPont study estimates an excess absence from work amongst smokers of 0.90 days per year (7.2 hours per year), a result which is significant at a 99% confidence level. The estimated excess absence (which translates to 32.2% amongst smokers) is of a similar magnitude to the Van Tuinen and Land and the Bertera studies. The estimated cost of this excess absence for Scottish employers are presented in Table 4.3.

Table 4.3: Estimated cost of absenteeism due to smoking: Scotland 1995

	Smoking employees	Excess sickness absence per annum (hours)	Wage per hour	Cost of absenteeism
Male workers	313,242*	2,255,342	£8.86	£19,982,330
Female workers	261,958*	1,886,098	£7.09	£13,372,435
				£33,354,765

* Part time workers included as half a full time worker

Using the estimates of Bertera et al. (1991), the total cost of employee smoking in terms of excess absenteeism is therefore estimated to be approximately £33 million per annum. This may be interpreted as a ‘low’ estimate of the cost. However, it should be noted that the cost of absenteeism will depend upon a number of factors. Firstly, the estimated excess absence amongst smokers, which will in turn depend upon the study population, and factors such as the level of sickness benefits. If the estimates are drawn from other studies the estimated cost will be different. For example, if the excess absence estimates from the Van Tuinen and Land study are used, the cost to Scottish employers of absenteeism as a result of employee smoking would be £55 million per annum. This may be interpreted as a ‘high’ estimate. Figure 4.1 shows the results of a sensitivity analysis in which the excess absence from work is varied along the x-axis, to show the difference in the cost of smoking related absence from work along the y-axis. The figure shows how the cost to employers increases as the excess absence from work amongst smokers increases.

Figure 4.1. The relationship between the cost of employee smoking and the excess absence from work amongst smokers: sensitivity analysis.

A second factor affecting the estimate is the prevalence of smoking. A lower prevalence should mean that the costs of absence are lower. Figure 4.2 shows the relationship between smoking prevalence and the cost of smoking induced absence from work, using an excess absence of 7.2 hours per annum as estimated by Bertera (1991).

Figure 4.2: Relationship between smoking prevalence and the cost of absence as a result of employee smoking

Thirdly, the wage rate will be an important factor determining the cost of absenteeism. As can be seen from Table 4.3, the estimated costs as a result of smoking by male employees exceed the costs of female employees partly as a result of the higher wages earned by men. The accuracy of this estimate rests upon the assumption that wages reflect the productivity of labour. This assumption is frequently made in economics, but is often violated, for example in cases where labour is supplied by a monopoly supplier (trade union) or hired by a monopsonistic employer. In these cases wages can be maintained artificially above or below the wage rate which would prevail in a free market.

It should be noted that these absenteeism estimates are those which result only from the absence of the individual worker. Bensinger (1985) outlined problems such as the interruption of production schedules, requirement for overtime, the imposition of production quotas on fewer workers and the impaired safety and questionable quality which result when employees are absent from work. Hence, dependent upon the specific scenario, costs may be significantly higher.

5.3.2 Productivity losses due to employee smoking

Productivity losses are highly dependent upon the type of smoking policy which is operated by an employer. A policy permitting smokers to smoke in a designated area at any time is likely to result in the largest productivity losses as smoke breaks can be taken in addition to the breaks allowed to other workers. Productivity losses can be reduced by either requiring that workers ‘clock out’ when they take smoke breaks or restricting the times at which smoking is allowed to the breaks allowed to all workers. However, restrictions on times when smokers can smoke has been found to result in workers smoking secretively in certain areas of the premises, creating a fire risk as proper disposal facilities for matches and cigarette butts are not provided, and also leaving tobacco smoke in the air in toilets and other communal facilities.

The different types of policy identified by the telephone survey are shown in Table 3.4. Following Nelson (1986), a moderate estimate of 5 cigarettes per day at an average of 6 minutes per cigarette represents a time loss of 30 minutes per day due to smoking. These times would appear to be relevant to worksites with a ‘smoke room’ where employees are allowed to smoke at any time of the day. For worksites with no restrictions, Nelson used an estimate of 5 minutes per day representing time spent lighting cigarettes, drawing on the cigarette, flicking the ash and extinguishing the butt.

Table 4.4: Estimated time as a result of employee smoking

	Percentage of firms	Estimated time loss due to smoking (mins)
Smoke room	53.3%	30
Smoke Free Building	34.1%	0
No policy	6.6%	5
Other	6.0%	0

In order to calculate the productivity loss due to smoking, the time spent on smoking is valued at the average wage rate. The estimated cost of the productivity loss to Scottish employers is shown in Tables 4.5 and 4.6. Part time workers are assumed to work for half of the hours worked by full time workers.

Table 4.5: Productivity loss due to employee smoking: Male workers

	Proportion of sites	Employees	Time lost (min)	Wage £	Cost of time £	Total Cost/Day £
Smoke room	0.533	166,958	30	8.86	4.43	739,624
Smoke free	0.341	106,816	0	8.86	0	0
No policy	0.066	20,674	5	8.86	0.73833	15,264
						754,888

Table 4.6: Productivity loss due to employee smoking: Female workers

	Proportion of sites	Employees	Time lost (min)	Wage £	Cost of time £	Total Cost/Day £
Smoke room	0.533	143,069	30	7.09	3.545	507,181
Smoke free	0.341	91,532	0	7.09	0	0
No policy	0.066	17,716	5	7.09	0.59083	10,467
						517,648

By summing the above totals, the total productivity loss is therefore estimated at £1,272,536 per day, or £292,683,406 per annum.

It is possible that productivity losses are also evident at smoke free worksites if employees are permitted to take smoke breaks but have to leave the building. Table 4.7 shows how the cost of smoking which would be affected by different lengths of time spent on smoke breaks in ‘smoke free’ buildings. This however excludes the ‘cost’ of the adverse image created if smokers congregate outside the entrances to the building.

Table 4.7. The costs of employee smoking: Sensitivity to duration of breaks in smoke free buildings

Time spent smoking per smoker per day (mins)

Smoke free building	Smoke room	No policy	Total cost per day
0	30	5	£1,272,536
10	30	5	£1,538,428
20	30	5	£1,804,320
30	30	5	£2,070,211

A plausible assumption, given the absence of accurate data, may be that smokers can take unrestricted smoke breaks in 50% of smoke free buildings and 50% of buildings with smoke rooms, and that smoke breaks in these workplaces last for 30 minutes. Table 4.8 shows the cost of productivity losses with these assumptions.

Table 4.8 Productivity costs per day, assuming 50% of employees in smoke free buildings and premises with smoke rooms can take unrestricted smoke breaks

Male

Female

Productivity cost in premises with smoke room	£369,812	£253,591
Productivity cost in smoke free buildings	£236,596	£162,241

Assuming employees work 46 weeks year, of 5 days a week, the costs in Table 4.8 translate to an annual productivity loss of £235,115,200.

5.3.3 Fire damage to business premises

Fire damage to business premises as a result of employee smoking is another cost which must be taken into consideration. Although firms are often insured against fire damage, ultimately businesses will share the cost through higher insurance premiums.

However, discounts for firms with no-smoking policies were not available at several insurance companies contacted, indicating that employee smoking is not considered to be a significant risk factor.

The total insurance claims for fire damage to commercial premises in the UK for 1993 was £425,000,000 (Association of British Insurers, 1995). Allocated in proportion to the number of non-residential premises in Scotland this gives £46,854,870. Using the estimates of Nelson (1986), the proportions attributable to smokers materials (cigarettes and ash) for the UK is 9.5%, matches 8.7% and unknowns 4.6%. These proportions may also be used to estimate the proportions of unknowns attributable to smokers materials and matches. The estimated cost of fire damage attributable to smoking is shown in Table 4.9. The cost of fire damage to business premises in Scotland would therefore be £80,750,000. Inflated to 1995 prices this becomes £85,749,232.

Table 4.9: Cost of fire damage attributable to smoking: Scotland, 1993.

Source of ignition	Proportion attributable †	Total cost of fire damage (1993)
Smokers materials §	0.095	£40,375,000
Matches	0.087	£36,975,000
Unknowns- Smokers materials*	0.004	£1,700,000
- Matches*	0.004	£1,700,000
		£80,750,000

* Unknowns are allocated to smokers’ materials and matches according to the proportion of other fires resulting from these sources.

§ Smokers materials = Cigarettes, discarded cigarette butts, ash, cigars etc.

† Source of attributable risks: Nelson (1986)

5.3.4 Deaths due to smoking

Employee deaths and retirements due to smoking related diseases also impose costs on employers. The cost will depend upon several factors such as how easily the labour can be replaced and the prevailing level of unemployment. In an economy with a high level of unemployment, costs will tend to be lower since there is a pool of replacement labour available. However, for specialist labour in short supply the costs to an employer may be significant. This would be the case for example if an employer employed labour which needed a lengthy training period. Hence the costs are very specific to each particular scenario.

5.3.5 Other costs

In addition to the above costs of employee smoking, there are numerous other costs which must be taken into account. This category will include clean-up costs, redecoration costs, and potential damage to equipment such as computers and buildings, walls and floor coverings. These costs are specific to each particular employment situation and are extremely difficult to generalise.

5.4 Simulations

The cost of employee smoking to an employer will depend on several variables, such as the type of smoking policy in operation, the prevalence of smoking amongst employees and whether employees are allowed to take smoke breaks in addition to other breaks.

Table 4.10 provides a summary of how the costs of employee smoking may be estimated. Firstly, the number of male and female smokers should be calculated, either by direct observation or by applying prevalence rates to the workforce as a whole. The time spent by each smoker taking smoke breaks should then be estimated. If smoking is permitted in the workplace this time will be the time spent by employees lighting, drawing on, extinguishing and disposing of cigarettes. If there is a smoke room facility then this will include time spent taking breaks. The time per person should then be multiplied by the number of smokers to give a total time spent smoking per day. The time in hours is multiplied by the average wage rate to give an estimate of the cost of this time.

An estimate of the excess absence from work can be derived by multiplying the number of smokers by the estimated excess absence from work. The cost of absence from work can then be derived by multiplying the wage rate by the total excess hours absent from work. An example is shown in Section 4.5. Insurance costs do not enter the equation for a single firm, as premiums will only be reduced if there is a reduction in the prevalence of smoking across all employers and therefore claims as a result of fire damage are reduced.

Table 4.10: Estimating the cost of productivity losses and absence from work

1. Determine/estimate the number of male and female smokers in the firm. 2. Calculate the hours spent taking smoke breaks or lighting and smoking cigarettes for male and female workers that smoke. 3. Multiply the total number of hours for male and female workers by the relevant wage rates to estimate the cost of productivity losses. 4. Calculate the total time absent from work as a result of smoking induced disease for male and female workers that smoke. 5. Multiply the number of hours by the relevant wage rates for males and females to give the cost of absence. 6. Adding together the totals (3+5) provides an estimate of the cost of employee smoking to the firm in terms of productivity losses and absence costs.

An estimate of the net benefits to the employer of a smoking cessation programme can be made by following the methodology summarised in Table 4.11. The method estimates the costs of productivity losses and absence losses as in Table 4.10, then multiplies the total cost by the success rate of the policy to derive the benefits of the programme. The net benefits of a smoking cessation programme are estimated by deducting the cost of the programme from the cost of the time saved and the reductions in absence from work that are achieved. However, it must be emphasised that all benefits are not immediately realised (see Section 1.4.1) and there may be a considerable time lag of several years before reductions in absence from work are achieved. Furthermore, the benefits will be dependent upon the staff turnover rates as a stream of benefits will only be realised if staff remain in employment with the firm.

Table 4.11: Estimating the net benefits of a smoking cessation programme

1. Determine / Estimate the number of male and female smokers in the firm. 2. Calculate the hours spent taking smoke breaks or lighting and smoking cigarettes for male and female workers that smoke. 3. Multiply the number of hours by the wage rate. 4. Calculate the total time absent from work as a result of smoking induced disease for male and female workers that smoke. 5. Multiply the number of hours by the wage rate. 6. Add together the totals (3+5). 7. Multiply this total by the success rate of the policy. 8. Deduct from this total the cost of the programme to give an estimate of the net benefits to the employer of the programme.

5.5 Example of the costs and benefits to an employer

This section provides an example of how the net benefits of a smoking cessation programme may be estimated. Consider a hypothetical firm with 200 employees of which half are male. Applying the prevalence figures from the General Household Survey (1994) 33 of the male workers and 36 of the female workers would therefore be expected to smoke (see Section 4.2.1). Suppose that the firm has a smoke room where employees are allowed to smoke for 15 minutes morning and afternoon in addition to normal breaks taken by all workers. Costing the lost time at the average wage rate, the productivity loss from male workers smoking is therefore estimated to be £33,624 per annum and for female workers £29,353 per annum.

Using the estimated excess absence of 0.9 days per year (7.2 hours) amongst smokers (Bertera 1991) the firm would expect the 33 male smokers to take an annual additional 237.6 hours absence at a cost of £2,105 and the 36 female smokers to take 259.2 hours costing £1,838.

A worksite smoking cessation programme is introduced, with a success rate of 25% (Katz et al, 1990). There would now be 25 male and 27 female smokers in the firm. During the next year the firm would experience cost savings in terms of male absence of £526 and female absence £459. A productivity gain of £8,406 would also be expected for male workers and £7,338 for female workers. The total gains for the first year are therefore estimated to be £16,730 in terms of reductions in productivity losses and absenteeism. This suggests that if the policy costs less than £16,730 then the employer may expect positive cost savings to in year one. However, it should be noted that these gains in the first year after cessation are not certain and there is often a time lag before gains are achieved once a smoker has stopped smoking. It should also be noted that these calculations will vary according to assumptions about the employer in question, such as the length of smoke breaks, the provisions for smokers and the relationship between the wage level and productivity. In addition, the estimates of absence from work amongst smokers will affect the savings when a cessation programme is introduced.

Tables 4.12 - 4.14 summarise the results from three simulations of the cost of employee smoking and benefits of a cessation programme. The calculations behind the results are provided in Appendix 2. The attached disk provides Microsoft Excel files that can produce estimates of the cost of employee smoking and the benefits of a cessation programme for any rates of smoking prevalence, programme success rate, wage level, employed population, excess sickness absence amongst smokers and duration of smoke breaks.

Table 4.12. Simulation 1. SIC4 company: No smoking allowed, no smoke breaks

SIC 4 Manufacturing

Employees:	Male: 250	Female: 150

	Time spent smoking per person per day	0
	Estimated productivity loss	0
	Estimated cost of absence	£5,955.23
	Cessation policy success rate	25%
	Estimated savings to employer	£1,488.81

Table 4.13. Simulation 2. SIC3 company: No restrictions on smoking

SIC 3 Metal goods engineering and vehicles

Employees:	Male: 250	Female: 150

	Time spent smoking per person per day	5 mins
	Estimated productivity loss	£16,171.88
	Estimated cost of absence	£6,075.00
	Cessation policy success rate	25%
	Estimated savings to employer	£5,561.72

Table 4.14. Simulation 3. SIC9: Smoke room, smokers can take un-restricted breaks

SIC 9 Education, health services and others

Employees:	Male: 500	Female: 500

	Time spent smoking per person per day	50 mins
	Estimated productivity loss	£349,600.00
	Estimated cost of absence	£13,132.80
	Cessation policy success rate	25%
	Estimated savings to employer	£90,683.20

The above examples show the kind of simulations that can be produced by changing the key variables. This is, however, a simplistic model which cannot take into account all of the variables which may affect the cost of employee smoking. A diagrammatic representation of these issues is presented in Appendix 4. The diagram shows how the costs and benefits will be affected by different types of policy and the specific aspects of the policy. An important point to note is that if employees are permitted to smoke in a restricted area then it should be determined whether there are restrictions on the amount of time that workers can take smoke breaks (as seen in the lower section of the diagram). If time is not strictly limited then information on the number of breaks taken and distance to the smoking facility is needed. These costs will be a function of building size and the number of areas in which smoking is permitted. Workplace specific variables may also result from the activities of the firm, for example in certain workplaces, safety regulations may mean that smokers can only smoke away from certain industrial materials. Therefore, in order to make accurate estimates of the cost of employee smoking, it is necessary to obtain precise workplace data.

5.6 Conclusions

The costs imposed on employers by employees who smoke are significant. The above estimates show that the annual cost of employee smoking in Scotland may be in the region of £293 million as a result of lost productivity, £33 million from higher rates of absenteeism among smokers and £81 million as a result of fire damage. However, this estimate of the productivity loss is highly dependent on the assumptions made. Using a different set of assumptions, namely that 50% of smoke free buildings and 50% of premises with a smoke room to allow unlimited smoke breaks, the estimated productivity loss is an annual £235 million. It should also be noted that the cost of absenteeism is highly dependent upon the estimate of excess absence from work by smokers. These cost estimates also exclude other possible costs such as cleaning, redecoration and repairs to machinery. Furthermore, employers may face legal costs if they are found guilty of failing to protect non-smokers at work.

Estimating the costs which smokers impose on their employers is dependent upon many specific details of the actual employment scenario. The actual costs will depend upon many variables such as the type of labour employed and how easily labour is replaced, whether smoke breaks are permitted or not, how many cigarettes employees smoke (heavy versus light smokers) and the physical characteristics of the working environment.

However, from the estimates presented it should be noted that employees who smoke do impose considerable costs on their employers. Cessation programmes to assist smokers to stop smoking do offer a significant potential for cost savings in the workplace.

5.1 Introduction

Knowledge of the cost of smoking in a particular workplace could be useful in helping promote interest in workplace smoking policies. Such figures may also provide a starting point for a fuller evaluation of the introduction of smoking cessation programmes as a part of workplace policies. The aim of this section is to provide a template which can be applied to different types of workplaces in Scotland.

The estimates are divided into the major cost categories outlined above and are based on published data sources (see Section 2), previous studies and the results of the survey of Scottish employers (see Section 3).

6. Conclusions and recommendations

6.2 Recommendations

• HEBS produces a document offering guidance on the design and implementation of workplace policies. This would draw on the results of this report, in particular highlighting the advantages and disadvantages of different policies in terms of the costs and benefits which might result from these policies, and the potential problems that may be experienced.
• HEBS produces guidance on how to choose effective cessation help. Employers need to be made aware of the approaches which are supported by scientific evidence, and those for which there is no evidence but which may be useful. Employers also need guidelines on how to assess value for money. The costs and benefits which may result from implementation of a cessation policy should be highlighted. Employers should be made aware of the benefits beyond the health of their employees.
• Such a document may provide a simple model by which employers may calculate the costs which employee smoking imposes upon their business. The employer may then assess the net costs or benefits which may be expected if cessation help is offered to employees. This may follow the simple model provided with the report, which would allow an employer to assess such a programme by entering specific information for his or her workplace.

6.1 Conclusions

Employee smoking imposes considerable costs on employers. The literature review identified several major costs of employee smoking: absence from work; lost productivity; increased insurance premiums; costs due to passive smoking; occupational health costs; and costs of damage to plant and machinery. Costs in terms of productivity losses and absence as a result of smoking related disease can be estimated, but the impact upon a particular employer will depend on a wide range of employer specific factors.

The telephone survey and the focus group work showed that most Scottish employers have restrictive smoking policies. The two major driving forces behind the widespread implementation of restrictive smoking policies over recent years have been legislation (both from the EU and interpretation of existing legislation) and concerns for employee health and safety. The other benefits of a restrictive smoking policy were rarely considered. Both the survey and the focus group work showed that employees did not expect to be able to smoke freely at work, although a total ban on smoking without any provisions for smokers was generally found to be unacceptable to smokers. Besides being unpopular with smokers, total smoking bans may actually increase insurance premiums. Forcing smokers outside also causes problems such as litter and cigarette butts strewn outside buildings, together with the adverse impact on the firm’s image which this creates.

Cessation help was offered by 29% of firms in the telephone survey. However, none of the firms had undertaken any evaluation of how effective the policy had been. Most companies had no idea of which programmes were successful or what provided value for money. Furthermore, the focus group work highlighted low take up rates when help was actually offered. Employers were found to be unaware of the potential benefits of a smoking cessation policy. Cost savings to the firm were not thought important, or had not been considered, despite evidence in the literature pointing to the potential savings to businesses.

The simulations presented indicate that the cost to employers in Scotland may be in the region of £293 million per annum in terms of lost productivity, although estimates are very sensitive to the assumptions made. Costs in terms of excess absence were estimated at £33 million per annum, with fire damage in the region of £81 million as a result of smoking. There are other potential costs such as damage to plant and machinery and the effects of passive smoking for which generalisable values cannot be made, since the effects will depend upon variables of which no information is as yet available. Employers may also face legal costs if found guilty of failing to protect employees from the dangers of tobacco smoke.

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Appendices

Appendix 2. Questionnaire results

Details of Sample

Total sample size:	200
Total successful responses:	167
Refusal to participate:	3

Could not contact person responsible for policy:

22

Firm could not be contacted / ceased trading:	8

Section 1: Smoking policy

Q1. Does your company have any sort of smoking policy?

YES	156	Go to Q2	1
			SMKPOLCY
NO	11	Go to Q3	2

Q2. Is the policy written down?

YES	133	Go to Q4	1
			WRITTEN
NO	23	Go to Q4	2

Q3. Are you planning or developing a smoking policy at the moment?

YES	1*	Go to Q4 THEN Q15	1
			PLANDVLP
NO	11	Go to Q15	2

* employer re-designing smoking policy; current policy is used for the purpose of this analysis

Q4. What are the key elements of your policy?

Help to employees to stop smoking	49	1
Total smoking ban	57	2

Partial ban

				FEATURE
	smoking only allowed in some places (smoke room)	89	3
	smoking only allowed at some times	3	4
	non-smoker protection from passive smoking at all times		5
	more complex (ask for details)	7*	6

* smoking allowed if agreed by all persons sharing an office, and also permitted for sole occupants of an office.

Q5. Have any problems been encountered introducing the policy?

YES	41	Please detail	1
			PROBLEMS
NO	115	Go to Q6	2

productivity losses due to smoke breaks; non-smoking staff aggrieved at smokers having longer breaks (17) smokers congregating at entrance to building creating a negative corporate image and large amount of litter (9) enforcement I; ‘fly-smoking’ in toilets and out of sight areas (6) enforcement II; senior staff ignoring ban (3) complaints from smokers (16) * figures do not add to 41 due to multiple responses

Q6. Has your company evaluated the smoking policy?

YES

0

Please give details

Go to Q7

1

				EVLUATE1
NO	156	Go to Q7		2

Q7. Does the policy offer help to employees who want to stop smoking?

YES	49	Go to Q8	1
			STOPHELP
NO	107	Go to Q15	2

Section 2: Help to Employees Wanting to Stop Smoking

Q8. Who will offer help to employees who want to stop smoking? WHOHELP

Occupational health staff	28		1
Outside consultants	10		2
Telephone helpline	-		3
Money to staff to buy own help	3		4
Other (please give details)	8*		5

* ‘Other’ included 1 employer providing leaflets and contact and 7 employers who stated that they would offer help if approached by employees but as yet the nature of the help is unknown.

Q9. How did you choose the type of help you are offering?

Don’t know (26) Local Health Board (7) From consultations with employees (2) Directive from company HQ (12)

Q10. Have any problems have been encountered with this element of the policy?

YES	2	Please detail then go to Q11	1
			STOPPROB
NO	47	Go to Q11	2

- low take up (2)

Q11. Are smokers generally satisfied with the help being offered?

YES	11	Go to Q12	1
			STSFIED
NO	3	Go to Q12	2

* don’t know (35)

Q12. Has your company evaluated the help element of the policy?

YES

-

Please give details

Go to Q14

1

				EVLUATE2
NO	49	Go to Q13		2

Q13. Would you be interested in details of the cost effectiveness of the programme?

YES	1	Go to Q14	1
			WANTINFO
NO	48	Go to Q14	2

Q14. Would more guidance on the kinds of help available and how to find this help be useful to you?

YES	5	Go to Q15	1
			MOREHELP
NO	44	Go to Q15	2

Section 3: Costs and Benefits

Q15. Do you know how many smokers work in your company?

Number

Range; 17-80%

PREV

(estimates provided by 9 employers)

Q16. What do you think are the main benefits of implementing a workplace smoking policy?

¯ absenteeism (2) cost savings (19) health (130) hygeine (30)

legal considerations (9) employee morale (9) safety (40)

Q17. What do think are the benefits to be gained from helping employees to stop smoking?

health benefits (42) promotes the ‘caring’ image of the firm to employees (1)

Q18. Do you think there are any costs involved when implementing a workplace smoking policy or a programme to help smokers stop smoking?

reduced productivity as smokers take smoke breaks (17) equipment and space needed (smoke room, extractor fans etc)(9)

Appendix 3. Simulations

Simulation 1

SIC CODE 4

EMPLOYMENT: Male: 250 Female: 150

SMOKING RESTRICTIONS: No smoking, no extra smoke breaks allowed

Applying prevalence of smoking:

Male	0.33	x 250	= 82.5	smokers
Female	0.36	x 150	= 54	smokers

Time spent smoking per day per worker: 0 mins

Cost of time per annum:

M	0 mins	x 82.5	x £6.91	= £0	x 230 days	= £0
F	0 mins	x 54	x £4.76	= £0	x 230 days	= £0
						£0

Time absent from work:

M	7.2 hrs	x 82.5	x £6.91	= £4104.54
F	7.2 hrs	x 54	x £4.76	= £1850.69
				£5955.23

Smoking cessation policy: Success rate = 25%

Productivity gain:

M	0.25	x 0	= £0
F	0.25	x 0	= £0
			£0

Reduction in cost of absence

M	0.25	x 4104.54	= £1026.135
F	0.25	x 1850.69	= £462.672
			£1488.807

Total savings = £1488.807

Simulation 2

SIC CODE 3

EMPLOYMENT: Male: 250 Female: 150

SMOKING RESTRICTIONS: Nil

Applying prevalence of smoking:

Male	0.33	x 250	= 82.5	smokers
Female	0.36	x 150	= 54	smokers

Time spent smoking per day per worker: 5 mins

Cost of time per annum:

M	5 mins	x 82.5	x £7.02	= £48.2625	x 230 days	= £11100.375
F	5 mins	x 54	x £4.90	= £22.05	x 230 days	= £5071.5
						£16171.875

Time absent from work:

M	7.2 hrs	x 82.5	x £7.02	= £4169.88
F	7.2 hrs	x 54	x £4.90	= £1905.12
				£6075

Smoking cessation policy: Success rate = 25%

Productivity gain:

M	0.25	x 11100.375	= £2275.09375
F	0.25	x 5071.5	= £1267.875
			£4042.96875

Reduction in cost of absence

M	0.25	x 4169.88	= £1042.47
F	0.25	x 1905.12	= £476.28
			£1518.75

Total savings = £5561.71875

Simulation 3

SIC CODE 9

EMPLOYMENT: Male: 500 Female: 500

SMOKING RESTRICTIONS: Smokers take 25 mins morning & afternoon

Applying prevalence of smoking:

Male	0.33	x 500	= 165	smokers
Female	0.36	x 500	= 180	smokers

Time spent smoking per day per worker: 50 mins

Cost of time per annum:

M	50 mins	x 165	x £5.96	= £0	x 230 days	= £188485
F	50 mins	x 180	x £4.67	= £0	x 230 days	= £161115
						£349600

Time absent from work:

M	7.2 hrs	x 165	x £5.96	= £7080.48
F	7.2 hrs	x 180	x £4.67	= £6052.32
				£13132.8

Smoking cessation policy: Success rate = 25%

Productivity gain:

M	0.25	x 188485	= £47121.25
F	0.25	x 161115	= £40278.75
			£87400

Reduction in cost of absence

M	0.25	x 7080.48	= £1770.12
F	0.25	x 6052.32	= £1513.08
			£3283.20

Total savings = £90,683.20

Appendix 4. Identifying the productivity costs of employee smoking

Notes

1.	Benefits: better health of workers asresult of lower cigarette consumption, no productivity losses due to breaks,lower insurance, no damage to premises. Costs: smokers aggrieved at not being able to smoke.
2.	Benefits: freedom of smokers Costs: passive smoking risks, productivity losses due to lighting,drawing etc, damage to workplace if indoors, insurance and fire risks.
3.	Benefits: protects non smokers,productivity losses limited to permitted breaks, passive smoking problemsavoided, avoids higher insurance and reduces fire risks. Costs: provision of smoke room.
4.	As (3) except potentially larger productivitylosses. Costs may depend upon the distance to the smoke room.
5.	As (3) except smoke room costs avoided. Extracost may be adverse corporate image if smokers congregate in areas such ascompany doorways.
6.	As (5) except productivity losses may begreater if smokers have to travel a long distance to areas where smoking ispermitted.

Appendix 5. Costs of employee smoking to an employer and benefits of smoking cessation help: productivity and absence

COSTS OFEMPLOYEE SMOKING TO AN EMPLOYER AND BENEFITS OF SMOKING CESSATION HELP:PRODCTIVITY AND ABSENCE
	PRODUCTIVITY
	Prevalence	No. of Workers	No. Smokers		Time smoke/day (mins)	Totl. Time	Wage Rate	Total Cost	Total cost per annum
Male	0.33	1000	330		5	27.5	£ 7.02	£ 193.05	£ 44,401.50
Female	0.36	875	315		5	26.25	£ 4.90	£ 128.63	£ 29,583.75
									£ 73,985.25
	TIMEABSENT
	Smokers	Excess/Smkr(hrs/yr)	Total loss		Total cost
Male	330	7.2	2376		£ 16,679.52
Female	315	7.2	2268		£ 11,113.20
					£ 27,792.72
					Total Prody loss	£ 73,985.25
					Total Absence	£ 27,792.72
					Total cost	£ 101,777.97
					Productivity Gain
	Smoking cessationSuccess Rate			M	£ 13,320.45
		0.3		F	£ 8,875.13
				Total	£ 22,195.58
					Absence gain
				M	£ 5,003.86
				F	£ 3,333.96
				Total	£ 8,337.82
					Total saving
					£ 30,533.39
		Cost of cessationpolicy			£ 1,000.00
		Net benefits			£ 29,533.39

Appendix 6. Estimating the cost of employee smoking in Scotland: productivity and absence costs

ESTMATINGTHE COST OF EMPLOYEE SMOKING IN SCOTLAND: Productivity and AbsenceCosts
	PRODUCTIVITYCOSTS OF EMPLOYEE SMOKING
	Male	Male full time	Male part time	Smoking prev.
		895,000	97,000	0.332
		Proportion of sites	Employees	Time lost (min)	Wage	Cost of time/day	Total Cost/Day
	Smoke room	0.533	166,958	30	£ 8.86	£ 4.43	£ 739,623.88
	Smoke free	0.341	106,816	10	£ 8.86	£ 1.48	£ 157,730.92
	No policy	0.066	20,674	5	£ 8.86	£ 0.74	£ 15,264.28
£ 912,619.08
				Cost per annum(male)=		£ 209,902,388.74
	Female	Female full time	Female part time	Smoking prev.
		526,000	431,000	0.362
		Proportion of sites	Employees	Time lost (min)	Wage	Cost of time/day	Total Cost/Day
	Smoke room	0.533	143,069	30	£ 7.09	£ 3.55	£ 507,181.23
	Smoke free	0.341	91,532	10	£ 7.09	£ 1.18	£ 108,160.60
	No policy	0.066	17,716	5	£ 7.09	£ 0.59	£ 10,467.15
							£ 625,808.99
				Cost per annum(female)=		£ 143,936,067.13
		Total cost perday=	£ 1,538,428.07		Total cost perannum=		£ 353,838,455.87
		ABSENCE COSTS AS A RESULT OFEMPLOYEE SMOKING
			Excess absence / year(hours)	Cost
	Male		7.2	£ 10,650,583.84
	Female		7.2	£ 7,303,409.74
			Cost of absence perannum=	£ 17,953,993.59
			Total cost of employeesmoking per annum=	£ 371,792,449

Appendix 1. Literature search

Medline 1991 - Dec 1995

	Search terms	Results
1	(wellness adj program$).tw.	35
2	(continuing adj medical adj program$).tw.	0
3	(preventive adj pulmonary adj practice).tw.	0
4	(individual adj counseling adj practice$).tw.	1
5	(health adj promotion adj program$).tw.	190
6	(employee adj assistance adj program$).tw.	34
7	(holistic adj health).tw.	30
8	(health adj promotion).tw.	1467
9	(better adj health).tw.	177
10	(social adj control adj work).tw.	1
11	(medical adj surveillance adj program$).tw.	20
12	or/1-11	1738
13	(preventive adj pulmonary adj practice$).tw.	1
14	or/1-2,4-11,13	1738
15	workplace.tw.	1580
16	worksite.tw.	212
17	(worksite adj environment).tw.	1
18	factory.tw.	625
19	office.tw.	3513
20	(health adj care adj environment).tw.	164
21	15 or 16 or 17 or 18 or 19 or 20	5962
22	16 or 17	212
23	smoking.tw.	11437
24	(smoking adj polic$).tw.	75
25	(smoking adj ban).tw.	24
26	-	-
27	23 or 24 or 25	11437
28	(smoke adj free adj environment).tw.	12
29	27 or 28	11443
30	effectiv$.tw.	87052
31	benefit$.tw	21287
32	30 or 31	104700
33	cost$.tw.	21183
34	cost-effectiv$.tw.	4328
35	cost$ adj benefit$).tw.	949
36	33 or 34 or 35	21183
37	14 or 27	12993
38	21 and 37	464
39	32 or 36	117644
40	38 and 39	92
41	14 or 29	12999
42	21 and 41	464
43	39 and 42	92
44	40 or 43	92
45	smoking/	10129	*
46	smoking/pc [prevention and control]	1287	*
47	workplace/	438	†
48	smoking cessation/mt [methods]	394	*
49	smoking cessation/	1507	*
50	attitude to health/	5402	*
51	health behaviour/	2261	*
52	health promotion/	3916	*
53	occupational health services/	810	*
54	program evaluation/	2629	*
55	occupational health/	1722	*
56	occupational exposure/pc [prevention and control]	226	*
57	organizational policy/	1214	*
58	tobacco smoke pollution/pc [prevention & control]	135	*
59	health care costs/	2303	**
60	preventive health services/ec [economics]	121	*
61	preventive health services/og [organization & administration]	174	*
62	employer health costs/	63	**
63	cost-benefit analysis	4481	**
64	health education/	4293	*
65	health policy/	4914	*
66	health benefit plans, employee/	393	*
67	health benefit plans, employee/ec [economics]	154	**
68	or/45-46, 48-53, 55-58, 60-61, 64-66	31890	*
69	54 or 59 or 62 or 63 or 67	9190	**
70	68 and 69	1420
71	47 and 70	15
72	40 or 71	104
73	71 not 40	12

Notes

*	smoking/smoking policy and wellness programmes
**	cost-benefit analysis and evaluation
†	workplace

Medline (1984 - 1990)

	Search terms	Results
1	(wellness adj program$).tw.	50
2	(continuing adj medical adj program$).tw.	0
3	(preventive adj pulmonary adj practice).tw.	0
4	(individual adj counseling adj practice$).tw.	0
5	(health adj promotion adj program$).tw.	181
6	employee assistance program$.tw.	45
7	holistic health.tw.	46
8	(health adj promotion).tw.	1195
9	(better adj health).tw.	160
10	(social adj control adj work).tw.	0
11	(medical adj surveillance adj program$).tw.	17
12	or/1-11	1481
13	workplace.tw.	1443
14	worksite.tw.	243
15	(worksite adj environment).tw.	1
16	factory.tw.	771
17	office.tw.	3837
18	(health adj care adj environment).tw.	103
19	(workplace adj environment).tw.	27
20	13 or 14 or 15 or 16 or 17 or 18 or 19	6320
21	smoking.tw.	11666
22	(smoking adj polic$).tw.	56
23	(smoking adj ban).tw.	9
24	(smoke adj free adj environment).tw.	12
25	21 or 22 or 23 or 24	11672
26	effectiv$.tw.	94784
27	benefit$.tw	17831
28	cost$.tw.	18754
29	cost-effectiv$.tw.	3361
30	(cost$ adj benefit$).tw.	843
31	26 or 27 or 28 or 29 or 30	122206
32	12 or 25	13034
33	20 and 32	493
34	31 and 33	111
35	smoking/	13436
36	smoking/pc [prevention and control]	1955
37	smoking cessation/mt [methods]	7
38	smoking cessation/	18
39	attitude to health/	6007
40	health behaviour/	917
41	health promotion/	3695
42	occupational health services/	1764
43	occupational health/	131
44	occupational exposure/pc [prevention and control]	18
45	organizational policy/	73
46	tobacco smoke pollution/pc [prevention & control]	126
47	preventive health services/ec [economics]	93
48	preventive health services/og [organization & administration]	254
49	health education/	6862
50	health policy/	3951
51	health benefit plans, employee/	358
52	health benefit plans, employee/ec [economics]	114
53	or/35-52	33466
54	programme evaluation/	1114
55	health care costs/	6
56	employer health costs/	1
57	cost-benefit analysis	3436
58	health benefit plans, employee/ec [economics]	114
59	54 or 55 or 56 or 57 or 58	4615
60	employment/	2841
61	53 and 59	670
62	60 and 61	4
63	62 not 34	4
64	34 or 63	115

Medline 1976 - 1983

	Search terms	Results
1	(wellness adj program$).tw.	3
2	(continuing adj medical adj program$).tw.	0
3	(preventive adj pulmonary adj practice).tw.	0
4	(individual adj counseling adj practice$).tw.	0
5	(health adj promotion adj program$).tw.	21
6	employee assistance program$.tw.	16
7	holistic health.tw.	46
8	(health adj promotion).tw.	250
9	(better adj health).tw.	55
10	(social adj control adj work).tw.	0
11	(medical adj surveillance adj program$).tw.	8
12	or/1-11	365
13	workplace.tw.	375
14	worksite.tw.	41
15	(worksite adj environment).tw.	0
16	factory.tw.	720
17	office.tw.	2519
18	(health adj care adj environment).tw.	14
19	(workplace adj environment).tw.	13
20	13 or 14 or 15 or 16 or 17 or 18 or 19	3631
21	smoking.tw.	5870
22	(smoking adj polic$).tw.	7
23	(smoking adj ban).tw.	1
24	(smoke adj free adj environment).tw.	1
25	21 or 22 or 23 or 24	5871
26	effectiv$.tw.	54776
27	benefit$.tw	8753
28	cost$.tw.	10432
29	cost-effectiv$.tw.	1125
30	(cost$ adj benefit$).tw.	557
31	26 or 27 or 28 or 29 or 30	70094
32	12 or 25	6228
33	20 and 32	108
34	31 and 33	11
35	smoking/	9995
36	smoking/pc [prevention and control]	1090
37	smoking cessation/mt [methods]	0
38	smoking cessation/	0
39	attitude to health/	4484
40	health behaviour/	8
41	health promotion/	907
42	occupational health services/	1403
43	occupational health/	1
44	occupational exposure/pc [prevention and control]	1
45	organizational policy/	0
46	tobacco smoke pollution/pc [prevention & control]	24
47	preventive health services/ec [economics]	69
48	preventive health services/og [organization & administration]	182
49	health education/	6000
50	health policy/	1262
51	health benefit plans, employee/	257
52	health benefit plans, employee/ec [economics]	68
53	or/35-52	22775
54	programme evaluation/	7
55	health care costs/	2
56	employer health costs/	0
57	cost-benefit analysis	2700
58	health benefit plans, employee/ec [economics]	68
59	54 or 55 or 56 or 57 or 58	2769
60	employment/	2822
61	53 and 59	262
62	60 and 61	3
63	62 not 34	3
64	34 or 63	14

B.I.D.S. 1983 - 1995

Search Strategy:

(wellness + program*), (smok*) + (workplace, worksite, factory, office) + (effectiv*, benefit*, cost*, cost-effectiv*)

Hits = 99.