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Cost and benefit analysis of smoking cessation in the workplace

Contents:	Summary 1. Introduction 2. Review of the literature 3. Survey of Worksites in Scotland 4. Focus groups and interviews with occupational health and personnel staff 5. The cost of employee smoking in Scotland 6. Conclusions and recommendations 7. References Appendices

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.