Good for Health,Good for Business: The Business Case for Reducing Tobacco Use

Despite substantial progress in reducing rates of cigarette smoking in the United States, about 34 million US adults smoke, with devastating consequences for their health. Each year, nearly 500 000 persons in the United States die of diseases directly linked to smoking and exposure to secondhand smoke. ¹ In addition to its grievous effect on health, smoking affects the economy: it costs the United States more than $300 billion each year, ^2,3 including nearly $170 billion in medical care and more than $150 billion in lost productivity. ⁴

Jerome M. Adams, MD, MPH

Vice Admiral, US Public Health Service

US Surgeon General

As Surgeon General, I believe no other health goal that businesses can pursue with their employees and communities would yield economic and health benefits as great as those produced by reducing tobacco use and exposure to secondhand smoke. Evidence shows that helping employees quit smoking and making worksites smoke-free improve employee health, reduce employer costs, and increase productivity. ⁵ Reduced employee smoking pays large dividends and is feasible. A sizable portion of the health and productivity costs of smoking can be averted by implementing evidence-based interventions at worksites. Here, I summarize the evidence for the business case to reduce tobacco use among US workers.

Smoking Is Common in the US Workforce

Millions of adult workers in the United States smoke. In 2014, 21.7% of US adult workers, representing more than 32 million persons, reported currently using a tobacco product, and more than 22 million workers reported currently smoking cigarettes. ⁶ Rates of smoking vary by occupation. For example, smoking rates among persons in blue-collar occupations (eg, construction, transportation) are higher than among persons in white-collar occupations (eg, management, sales). A 2011 study found that a higher percentage of blue-collar workers than white-collar workers initiated smoking (46% vs 33%). Furthermore, among those who reported ever smoking, more blue-collar workers than white-collar workers continued as daily smokers (52% vs 35%). ⁷ Military veterans, especially veterans aged 18-25, also have elevated rates of smoking. A 2018 study estimated that 57% of military veterans used tobacco products. ⁸

The Cost of Smoking to Business

Tobacco use substantially reduces employee productivity in several ways, including by increasing absenteeism. A meta-analysis of 17 studies ⁹ found that, compared with nonsmoking employees, employees who currently smoked were 33% more likely to miss work and were absent from the workplace for an average of 2.7 more days per year. ⁹ Absenteeism decreases when smokers quit, even among those who have recently quit. ¹⁰ Smokers are also more likely than nonsmokers to take unsanctioned breaks. These breaks are “the largest single cost from a smoking employee” ¹¹ and result in 8 to 30 minutes per day per employee in lost work time. In terms of overall economic impact, the annual additional cost of an employee who smokes cigarettes is approximately $5816, which includes $2056 in added health care costs and $3760 in lost productivity costs. ¹¹ On average, employers pay an additional $659 per year in medical and pharmacy costs for each employee who smokes. ¹² Across US states, 6%-18% of total health care expenditures are attributed to smoking-related illnesses. ¹³

Tobacco use is also associated with increased risk of injury and property loss due to fire, explosions, and vehicular collisions. ¹⁴ The National Fire Protection Association found that in 2011, smoking caused 1960 fires in nonresidential structures, resulting in direct property damage of $39 million. ¹⁴ Fire insurance costs are typically reduced by 25% to 30% when businesses go smoke-free. ¹⁵ Workplace smoking interventions may also reduce costs: employers save $150 to $540 annually for each smoker who quits, depending on quit rates and cessation drug costs and including both health care costs and non–health care costs, such as lost earnings and absenteeism. ¹³

The Cost of Smoking to Employee Health

Cigarette smoking is a major cause of cardiovascular disease, pulmonary disease, peripheral vascular disease, infections, cancer, and premature death among employees who smoke. ¹⁶ When smokers and their family members successfully quit smoking, the benefits to their health begin to accrue immediately and continue for the rest of their lives. ³ Exposure to secondhand smoke is also a substantial health risk. Findings from a 2007 study found that exposure to environmental tobacco smoke in the workplace was related to an increased risk of lung cancer. ¹⁶ Among nonsmokers, exposure to secondhand smoke also increases the risk of heart disease by 25%-30% and stroke by 20%-30%. ¹⁷ Research shows that young and middle-aged adults working in smoke-free workplaces have a lower risk of cardiovascular events, such as myocardial infarction, heart failure, and stroke, than their peers who work in an environment that allows smoking. ¹⁸ Finally, smoking results in immediate detrimental effects on health and functioning, including decreased efficiency, errors at work, eye irritation, and reduced attentiveness, all of which can affect productivity. ¹⁹

Providing Benefits for Smoking Cessation Pays Off

Businesses that provide a smoking cessation benefit to their employees reap substantial rewards; their employees are more likely to quit smoking, resulting in improved employee health, increased productivity, and reduced costs. The benefits provided to employees may include health insurance coverage for cessation treatments, financial or other incentives for quitting, and/or cessation treatment provided at the worksite. For example, providing a workplace smoking cessation benefit is estimated to result in substantial health and economic benefits, with economic savings exceeding the cost of the benefit within 4 years. ²⁰ Financial incentives also promote cessation. In a study of CVS Caremark employees and their relatives and friends, modest payments given to persons who quit smoking boosted both participation in cessation treatment and rates of cessation. ²¹

What Can Businesses Do?

The following strategies can help businesses encourage employees to quit smoking and create smoke-free worksites:

Review employee health insurance coverage provisions to ensure that evidence-based smoking cessation counseling and medications are fully covered benefits without barriers to access, consistent with federal guidelines for such coverage as outlined in the US Department of Health and Human Services, US Department of Labor, and US Department of Treasury frequently asked questions. ²²

Promote cessation benefits to employees and health care providers to increase awareness and use of covered cessation treatments.

Implement a tobacco-free worksite policy. Precede the implementation of the tobacco-free policy with employee communications that highlight tobacco cessation health insurance coverage and other resources for quitting. Consider providing free, convenient access to cessation counseling and medication at the worksite and/or financial incentives to employees who quit and abstain from smoking for at least 6 months.

Review fire policies and other insurance policies after implementing a tobacco-free or smoke-free environmental policy to take advantage of the expected cost savings, including savings for health care, facility maintenance, and increased employee productivity.

In employee communications, provide a clear rationale for any new policies and resources aimed at reducing employee smoking, noting the substantial benefits of quitting for the business, the employee, and the employees’ family, friends, and coworkers.

Partner with public health stakeholders to implement evidence-based population-level strategies to reduce tobacco use, such as smoke-free policies, in local communities.

The evidence is clear: reducing tobacco use improves employee health, increases worker productivity, and reduces costs. As Surgeon General, I call on US employers and businesses to adopt these proven strategies to help improve our nation’s health and economic prosperity.