SMOKE-FREE WORKPLACES: WHAT’S THE IMPACT ON SMOKING AND HEALTH?

On July 4, 2005, the Cleveland Clinic declared its campuses smoke-free. Smoking is prohibited indoors and outdoors at all of 11 hospitals and 15 clinics. This is a rather ambitious policy considering the Clinic has 34,000 employees, more than 2,700,000 patient visits per year, and some expansive campuses, including a main urban campus of 15 blocks by 3 blocks that is bordered and transected by major arteries. The inspiration for this policy came from the Clinic’s surgeon CEO, Dr. Toby Cosgrove, who told me that after seeing the charred lungs and damaged hearts of thousands of smokers over the span of three decades, he just couldn’t stand to watch patients and families coming to the hospital seeking care only to be exposed to other people’s smoke. He also hoped the policy would motivate employees, patients, and visitors to quit smoking, and inspire other hospitals and employers to declare their campuses smoke-free. The impact of this policy will be discovered in the coming years. Until then, it is instructive to review what the literature tells us about passive smoking and the impact of smoke-free workplaces.

Smoking and Health
Even though direct smoking produces a dose 100 times greater than passive smoking, the cardiovascular system is exquisitely sensitive to the interactions of the toxins in passive smoke.¹ A 20-year prospective study, using cotinine as a measure of exposure, found that nonsmokers exposed to secondhand smoke had a relative risk of 1.45–1.57 for developing coronary heart disease compared to 1.78 for smokers.²  More than 50 studies have shown consistent findings that secondhand smoke increases the risk of lung cancer by 20% to 30% at home and 12% to 19% at work, and there is some evidence that it increases chronic respiratory symptoms and lung function distress. Finally, maternal smoking reduces the birth weight of infants, which is a leading cause of premature births.³ An estimated 53,000 people die from passive smoking in the United States each year.⁴ To put this in perspective, this is more than are killed each year from car crashes, or from suicide and homicide combined,⁵ or from drowning, plane crashes, terrorism, war, blizzards, heat waves, lightning, snake, bear, dog and shark attacks, earthquakes, tornados and hurricanes, avalanche, hyperthermia, floods, and fires combined.

Impact of Smoking Policy
A meta-analysis of 26 studies found that smoke-free workplaces reduced the number of smokers by 3.8%, and consumption among continuing smokers by 3.1%, collectively producing a 29% net reduction in cigarettes smoked.⁶  Barnoya and Glanz calculated that there would be 950 million fewer packs of cigarettes smoked and 1500 fewer heart attacks in the United States every year if all workplaces were smoke-free.¹ Furthermore, smoke-free workplace policies are estimated to be 9 times more cost effective than free nicotine replacement therapy in quality adjusted life years (QALY’s) saved.⁷ How much more effective is a smoke-free campus than a smoke-free building policy? We don’t really know. In the case of the Cleveland Clinic, it means that frail patients no longer need to pass through a cloudy gauntlet of smoking health care professionals as they enter our doors. It also means that an employee who wants a smoke must walk half a mile and go off campus to do so . . . which is prohibited during work hours. We do have some data on the impact of policies that restrict smoking to designated areas versus policies that prohibit smoking. Averaging the results of three population level studies showed that smoke-free policies reduced consumption 77% more and number of smokers 100% more than restricted policies.^8-10

Prevalence of Policies
The good news is that smoke free workplaces have become the norm in the United States. Between 1993 and 2001, the percent of smoke free workplaces increased from 27% to 76%, restricted policies dropped from 54% to 19% and only 5% do not restrict smoking compared to 19% in 1993.¹¹ Furthermore, an estimated 6000 employers do not hire smokers,¹² including the American Cancer Society and the World Health Organization, and a handful of companies are starting to fire smokers.¹³

Smoking remains the number one preventable cause of death in the United States; smoke free workplace policies may be the most effective method to improve employee health.

References

1. Barnoya J, Glantz S. Cardiovascular effects of secondhand smoke: nearly as large as smoking. Circulation. 2005;111:2684–2698.
    
2. Wincup PH, Gilg JA, Emberson JR, Jarvis MJ, Feyerabend C, Bryant A, Walker M, Cook DG. Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement. BMJ. 2004;329:200–205.
    
3. World Health Organization International Agency for Research on Cancer (IARC). Monographs on the Evaluation of Carcinogenic Risks to Humans. Tobacco Smoke and Involuntary Smoking. Summary of Data Report and Evaluation. Vol 83. Available at: http://www-cie.iarc.fr/htdocs-indexes/vol83index.html. Accessed January 21, 2006
    
4. Glantz SA, Parmley WW. Passive smoking and heart disease. Epidemiology, physiology, and biochemistry. Circulation. 1991;83:1–12.
    
5. Centers for Disease Control and Prevention. WISQARS Leading Causes of Death Reports, 1999–2002,. Available at: http://webapp.cdc.gov/sasweb/ncipc/leadcaus10.
   html. Accessed January 14, 2006.
    
6.  Fichtenberg CM, Glanz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ. 2002;325:188.
    
7.  Ong M, Glanz SA. Free nicotine replacement therapy programs vs implementing smoke-free workplaces: a cost-effectiveness comparison. Am J Public Health, 2005;95:969–975.
    
8. Farrelly MC, Evans WN, Sfekas AES. The impact of smoking bans: results from a national survey. Tob Control. 1999;8:272–277.
    
9. Glasgow RE, Cummings KM, Hyland A. Relationship of worksite smoking policies to changes in employee tobacco use: findings from COMMIT. Tob Control. 1997;6(suppl 2):S44–S48.
    
10. Woodruff TJ, Rosbrook B, Peirce J, Glantz SA. Lower levels of cigarette consumption found in smoke-free workplaces in California. Arch Intern Med. 1993;153:1485–1493.
     
11. Bauer JE, Hyland A, Li Q, Steger C, Cummings KM. Am J Public Health. 2005;95:1024–1029.
     
12.  Ozols JB. A job or a cigarette? Newsweek. 24 February 2005. Available at: http://msnbc.msn.com/id/7019590/site/newsweek. Accessed 14, January 2006.
     
13. Ilan Brat. A company's threat: quit smoking or leave, Scotts Miracle-Gro joins ranks of employers trying to cut costs by targeting smokers. Wall Street Journal. December 20, 2005:D1.
    
    

    Michael P. O'Donnell, PhD, MBA, MPH
    Editor in Chief, American Journal of Health Promotion