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Programs aimed at helping employees give up tobacco can pay off in lower health care costs.
Smoking is more than a health threat for the 45 million Americans who use tobacco. It’s also an employers’ problem because it raises health cost issues and productivity concerns.
Smoking and the illnesses that link to it, such as cancer and heart disease, account for annual medical costs of $150 billion or more, by some estimates. In turn, those costs affect the premiums for employer-sponsored health care. As employers try to exert control over their fast-rising health costs through wellness programs and other efforts to improve employees’ health, some are adopting smoking-cessation programs as one of their tools.
Smoking-cessation approaches range from reminding employees of the health effects of smoking, to offering them multifaceted assistance programs, to requiring them to quit smoking if they want to keep their jobs.
In that middle ground between encouragement and ultimatum reside a number of generally affordable programs that typically offer counseling—sometimes one-on-one—and various types of drugs formulated to help smokers quit. Health coverage companies, behavioral health organizations, stand-alone wellness companies, hospitals and others number among the providers.
As the availability of smoking-cessation programs increases and as new drugs arrive in the market, it’s important for benefits specialists to know how to choose a cessation approach that will work best for their employees, and where to turn when looking for a program.
The Will To Quit
Although about 47 million Americans say they have quit smoking, almost as many still smoke. About 70 percent of those who smoke say they want to quit, but only 5 percent succeed long term, the U.S. Centers for Disease Control and Prevention reports.
Indeed, quitting is difficult. Less than 7 percent of smokers who try to quit on their own abstain for longer than a year; most light up within a few days of attempting to quit, according to pharmaceutical manufacturer Pfizer Inc. It takes about 10 attempts, with or without treatment, before the average smoker kicks the habit for good, says Pfizer. The company recently introduced a smoking-cessation drug.
“Although we have made significant progress, tobacco use is still the leading cause of preventable illness and death,” says Susan Butterworth, director of Health Management Services within the School of Nursing at Oregon Health & Science University (OHSU), based in Portland. “Nicotine dependency is more than a lifestyle choice. It’s an addiction, and employees need assistance in addressing it,” she says.
How Programs Work
Butterworth and many other smoking-cessation experts recommend a strategic approach that includes “quit medications” and health counseling.
Medications available over the counter include nicotine patches and nicotine gum; prescription drugs include nasal sprays, inhalers and pills. An article on the U.S. Food and Drug Administration’s web site describes how these medications work: “Most medical aids to smoking cessation are nicotine replacement products. They deliver small, steady doses of nicotine into the body to relieve some of the withdrawal symptoms, without the ‘buzz’ that keeps smokers hooked. … Like cigarettes, the products deliver nicotine into the blood, but they don’t contain the tar and carbon monoxide that are largely responsible for cigarettes’ dangerous health consequences.”
Many programs that operate under an employer-sponsored wellness initiative include a personal health assessment that identifies smoking as a health risk. Follow-up efforts often involve counseling—increasingly delivered by the Internet with threaded discussion, chat or e-mail. The vast majority, Butterworth says, deliver counseling by phone, while others deliver it in person.
One of the largest cessation companies, Free & Clear Inc., a coaching-based provider in Seattle, has been named the official quit-smoking program for 16 states and more than 100 large employers and health plans. Last year, the company registered more than 115,000 people into tobacco-cessation programs and completed nearly 700,000 intervention calls, says Dr. Tim McAfee, senior vice president for clinical and behavioral sciences at Free & Clear.
The company offers a personal Internet application, called Web Coach, in its Quit For Life Program. It also offers Vital Signs, a real-time, online reporting tool for clients. OHSU’s Health Management Services competes in the field, offering smoking cessation as one of its healthcoaching services for outside clients.
Other major providers of smoking-cessation programs include QuitNet, WebMD and the Mayo Clinic.
Employers should avoid “going with a canned or low-cost program that doesn’t embrace best practice in nicotine dependence treatment,” says Butterworth, also an associate professor in OHSU’s School of Nursing. Look for programs that use best practices—a combination of quit medications and coaching—and that demonstrate measurable outcomes, she says.
Measurable outcomes are determined by quit rates at one year compared with the rates in a control group in a random controlled study, Butterworth says. When the quit rate significantly exceeds the rate in the control group, the treatment is considered effective.
The combined use of coaching and quit medications—she calls it “the gold standard”—seems to work equally well across demographic and cultural differences within workplaces, but she adds that it’s important for health coaches “to understand the culture, to be sensitive to employee norms, and to be acquainted with their benefits and other resources.”
Employees may prefer accessing information in different ways, for example. Office workers who have desktops may prefer Internet products, while those on a manufacturing line may do better with telephone coaching or printed handouts.
Costs and Savings
Employers can provide programs such as a telephone “quit line”—generally the lowest-price approach—for under 5 cents per employee per month, a figure based on the total population of employees and their covered dependents, not on the number of employees using the service. The figure is in the results of research commissioned by the American Legacy Foundation, a Washington, D.C., organization that focuses on smoking prevention and cessation, and carried out by Milliman, a global consulting organization based in Seattle.
The research report, Covering Smoking Cessation as a Health Benefit: A Case for Employers, released last December, found that more-comprehensive coverage that includes therapy and selected pharmaceuticals costs 28 cents to 45 cents per health plan member per month.
The annual savings for each smoker who quits, according to the report, is about $210 through reductions in costs for smoking-related conditions such as stroke, coronary heart disease, pneumonia, childhood respiratory disease and low birth weight. The dollar savings alone may not fully offset an employer’s annual cost for a cessation program, but they can make a difference over time, since they accrue each year the employee remains a nonsmoker.
In addition, smoking cessation reduces annual medical and life insurance costs almost immediately, says the study’s author, Bruce Pyenson, a principal and consulting actuary with Milliman in New York.
Among the approaches compared in the study, telephonic quit lines, with no face-to-face contact with employees, had quit rates of 4.5 percent, Pyenson says. Programs with more features, such as counseling and a range of medications, cost more but had higher quit rates, up to about 30 percent.
Noting that the costs of cessation programs vary according to the type of service provided and the vendor providing it, Butterworth says one-time fees for each health-coaching participant range from $100 to $250
Building the Base
Before settling on a particular program, benefits specialists should determine the incidence of smoking among the company’s employees, experts suggest, and start their searches by tapping their trusted sources of information, such as brokers and health plan providers.
Christopher J. Mathews, a Washington, D.C.-based senior health consultant and vice president of the Segal Co., a benefits consulting organization headquartered in New York, recommends working with your health plan or advisor to find out whether smoking is a real problem in your employee population. Employee surveys can be used to determine how many smokers you have and whether any are really interested in quitting.
If your organization’s smoker population is made up of those who have been smoking for 30 years, you might not get a lot of traction. “But if the smoker population is comprised of those who sincerely wish to quit, then the prospects for success are greatly improved,” Mathews explains.
Karen Roberts, a senior vice president in Aon Consulting’s Health and Benefits Practice in Las Vegas, recommends making sure that the program has support from the top. “If your CEO is a cigar smoker and there’s no way he’s going to quit, there’s a problem,” she says. “You really have to walk the talk with these programs.”
Take inventory of your physical premises to determine how committed you are to the cessation program. Are you going to push cessation but still have designated smoking areas on your property or allow smoking in company cars?
Also, take inventory of provisions in your health benefits plan to determine if there are barriers to a program’s success, such as lack of coverage for smoking-cessation drugs or for coaching or counseling, Mathews says. If such coverage isn’t provided, he says, and your plan, in effect, becomes “a barrier to providing the necessary support needed for smokers to quit, it will need to be modified.”
As sponsor of your health plan, you should decide how many attempts to quit smoking by an individual will be covered by your plan and whether there would be a maximum on the benefit per employee, Mathews says.
For OHSU’s own tobacco-cessation program, provided by Health Management Services, the university has structured its employee health plan so that over-the-counter quit medications such as patches and gum are free, and there are no co-payments for prescription-only quit medicines approved by the U.S. Food and Drug Administration. Employees who sign up also receive an individual quit plan.
Butterworth and her staff acknowledge that some smokers may want to try alternative cessation approaches such as acupuncture and hypnosis; they are not included in any OHSU plan, however.
Butterworth recommends motivational interviewing, an approach “used by many reputable vendors” to help tobacco users develop the self-confidence necessary to quit. It’s important, she says, to “engage smokers who aren’t ready to quit” to “help them consider their options, draw out their ambivalence and help them weigh the pros and cons of quitting.”
OHSU’s smoking-cessation campaign expands this month to its entire Portland campus—12,000 employees, thousands of patients and students. All smoking will be banned, even on streets and sidewalks.
Try a Little Tenderness
Roger Reed, a nurse practitioner and executive vice president of Gordian Health Solutions, a health management provider based in Franklin, Tenn., says a positive and benevolent approach can go a long way in a smoking-cessation initiative. “The biggest mistake,” he says, “is to start taking a list of smokers and singling them out with some kind of punitive action, such as saying you have 12 months to quit or you won’t work here anymore.”
Gordian provides one-on-one coaching, online information and health materials via mail to large employers, health plans and government entities. Last year, the company had 6,755 people enrolled in tobacco-cessation programs.
“Most people try to stop smoking multiple times, and it’s just that one time when they make that one more attempt that it actually works,” Reed says, adding, “You never know.” It could be that when their employer provides that extra opportunity, it just might be the employee’s time to quit for good.
Pamela Babcock is a freelance writer based in the New York City area.
Online sidebar: Tobacco Isn't Just for Smokers
Online sidebar: Among the Providers
SHRM article: Employers Want to Help Employees Quit Smoking, But How? (SHRM Online Compensation & Benefits Focus Area)
SHRM article: Smelling Smoke (HR Magazine)
SHRM article: Experts cite tobacco's drain on productivity (HR News)
SHRM article: Rhode Island: Employer health plans must cover smoking cessation treatment (SHRM Online Workplace Law Focus Area)
Booklet: Quitting Tobacco-The Next Step: Employer's Toolbox for Building a Cessation Program (Centers for Disease Control and Prevention)
Survey: Covering Smoking Cessation as a Health Benefit: A Case for Employers (American Legacy Foundation)
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