On the cover: The cover design includes a wispy background image intended to evoke the well-known health hazard of smoke associated with the use of combustible tobacco products, and the much less studied misty emissions associated with the use of electronic devices to "vape" liquids containing nicotine and other components. The full range of hazards associated with tobacco use extends well beyond such air contaminants, so the cover design also incorporates a text box to highlight the optimal "Tobacco-Free" (i.e., not just "Smoke-Free") status for both workplaces and workers. The text box also evokes the NIOSH Total Worker Health TM strategy. This strategy maintains a strong focus on protection of workers against occupational hazards, including exposure to secondhand tobacco smoke on the job, while additionally encompassing workplace health promotion to target lifestyle risk factors, including tobacco use by workers. Photo by Thinkstock.#
iii NIOSH CIB 67 - Workplace Tobacco Policies

# Foreword
Current Intelligence Bulletins (CIBs) are issued by the National Institute for Occupational Safety and Health (NIOSH) to disseminate new scientific information about occupational hazards. A CIB may draw attention to a formerly unrecognized hazard, report new data on a known hazard, or disseminate information about hazard control.
Public health efforts to prevent disease caused by tobacco use have been underway for the past half century, but more remains to be done to achieve a society free of tobaccorelated death and disease. The Centers for Disease Control and Prevention (CDC), of which NIOSH is a part, has recently proclaimed a "Winnable Battle" to reduce tobacco use. NIOSH marks a half century since the first Surgeon General's Report on the health consequences of smoking by disseminating this CIB 67, Promoting Health and Preventing Disease and Injury through Workplace Tobacco Policies.
Workers who use tobacco products, or who are employed in workplaces where smoking is allowed, are exposed to carcinogenic and other toxic components of tobacco and tobacco smoke. Cigarette smoking is becoming less frequent, and smoke-free and tobaccofree workplace policies are reducing exposure to secondhand smoke (SHS) and motivating smokers to quit-but millions of workers still smoke, and smoking is still permitted in many workplaces. Other forms of tobacco also represent a health hazard to workers who use them. In addition to direct adverse effects of tobacco on the health of workers who use tobacco products or are exposed to SHS, tobacco products used in the workplace-and away from work-can worsen the hazardous effects of other workplace exposures.
This CIB addresses the following aspects of tobacco use:
- Tobacco use among workers.
- Exposure to secondhand smoke in workplaces.
- Occupational health and safety concerns relating to tobacco use by workers.
- Existing occupational safety and health regulations and recommendations prohibiting or limiting tobacco use in the workplace.
- Hazards of worker exposure to SHS in the workplace.
- Interventions aimed at eliminating or reducing these hazards.
This CIB concludes with NIOSH recommendations on tobacco use in places of work and tobacco use by workers.
NIOSH urges all employers to embrace a goal that all their workplaces will ultimately be made and maintained tobacco-free. Initially, at a minimum, employers should take these actions:
- Establish their workplaces as smoke-free (encompassing all indoor areas without exceptions, areas immediately outside building entrances and air intakes, and all work vehicles).

# Introduction
Various NIOSH criteria documents on individual hazardous industrial agents, from asbestos  through hexavalent chromium , have included specific recommendations relating to tobacco use, along with other recommendations to eliminate or reduce occupational safety and health risks. In addition, NIOSH has published two Current Intelligence Bulletins focused entirely on the hazards of tobacco use. CIB 31, Adverse Health Effects of Smoking and the Occupational Environment, outlined how tobacco usemost commonly smoking-can increase risk, sometimes profoundly, of occupational disease and injury . In that CIB, NIOSH recommended that smoking be curtailed in workplaces where those other hazards are present and that worker exposure to those other occupational hazards be controlled. CIB 54, Environmental Tobacco Smoke in the Workplace: Lung Cancer and Other Health Effects, presented a determination by NIOSH that secondhand smoke (SHS) causes cancer and cardiovascular disease . In that CIB, NIOSH recommended that workplace exposures to SHS be reduced to the lowest feasible concentration, emphasizing that eliminating tobacco smoking from the workplace is the best way to achieve that. This current CIB 67, Promoting Health and Preventing Disease and Injury Through Workplace Tobacco Policies, augments those two earlier NIOSH CIBs. Consistent with the philosophy embodied in the NIOSH Total Worker HealthTM Program , this CIB is aimed not just at preventing occupational injury and illness related to tobacco use, but also at improving the general health and well-being of workers.

# Smoking and Other Tobacco Use by Workers-Exposure to Secondhand Smoke at Work
Millions of workers use tobacco products. Since publication of the first Surgeon General's Report on the health consequences of smoking, cigarette smoking prevalence in the United States has declined by more than 50% among all U.S. adults-from about 42% in 1965 to about 18% in . Overall, smoking among workers has similarly declined, but smoking rates among blue-collar workers have been shown to be consistently higher than among white-collar workers. Among blue-collar workers, those exposed to higher levels of workplace dust and chemical hazards are more likely to be smokers . Also, on average, blue-collar smokers smoke more heavily than white-collar smokers .
From 2004-2011, cigarette smoking prevalence varied widely by industry, ranging from about 10% in education services to more than 30% in construction, mining, and accommodation and food services. Smoking prevalence varies even more by occupation, ranging from 2% among religious workers to 50% among construction trades helpers . A recent survey of U.S. adults found that by 2013, approximately 1 in 3 current vi NIOSH CIB 67 - Workplace Tobacco Policies smokers reported ever having used e-cigarettes, a type of electronic nicotine delivery system (ENDS) . However, the prevalence of ENDS use by industry and occupation has not been studied. Overall, about 3% of all workers use smokeless tobacco in the form of chewing tobacco and snuff, but smokeless tobacco use exceeds 10% among workers in construction and extraction jobs and stands at nearly 20% among workers in the mining industry . The use of smokeless tobacco by persons who also smoke tobacco products-one form of what is known as "dual use"-is a way some workers maintain their nicotine habit in settings where smoking is prohibited (e.g., in an office where indoor smoking is prohibited or in coal mines where smoking can cause explosions). More than 4% of U.S. workers who smoke cigarettes also use smokeless tobacco .
The implementation of smoke-free policies has eliminated or substantially decreased exposure to SHS in many U.S. workplaces. But millions of nonsmoking workers not covered by these policies are still exposed to SHS in their workplace. A 2009-2010 survey found that 20.4% of nonsmoking U.S. workers experienced exposure to SHS at work on at least 1 day during the preceding week . Another survey conducted at about the same time estimated that 10.4% of nonsmoking adult U.S. workers experienced exposure to SHS at work on at least 2 days per week during the past year . Such exposure varied by industry (ranging from 4% for finance and insurance to nearly 28% for mining) and by occupation (ranging from 2% for education, training, and library occupations to nearly 29% for construction and extraction occupations). Inclusion of ENDS in smoke-free policies has increased over time. In the United States, the number of states and localities that explicitly prohibited use of e-cigarettes in public places where tobacco smoking was already prohibited totaled 3 states and more than 200 localities before the end of 2014 .

# Health and Safety Consequences of Tobacco Use
Since the first Surgeon General's report on smoking and health, many reports from the Surgeon General and other health authorities have documented serious health consequences of smoking tobacco, exposure to secondhand smoke (SHS), and use of smokeless tobacco.
Smoking is a known cause of the top fve health conditions impacting the U.S. population-heart disease, cancer, cerebrovascular disease, chronic lower respiratory disease, and unintentional injuries . The risk of most adverse health outcomes caused by smoking is related to the duration and intensity of tobacco smoking, but no level of tobacco smoking is risk free [DHHS 2010b[DHHS , 2014.
Likewise, there is no risk-free level of exposure to SHS . Among exposed adults, there is strong evidence of a causal relationship between exposure to SHS and a number of adverse health effects, including lung cancer, heart disease (including heart attacks), stroke, exacerbation of asthma, and reduced birth weight of offspring (due to SHS exposure of nonsmoking pregnant women) . In addition, there is suggestive evidence that exposure to SHS causes a range of other health effects among adults, including other cancers (breast cancer, nasal cancer), asthma, chronic obstructive pulmonary disease (COPD), and premature delivery of babies born to women exposed to SHS . vii NIOSH CIB 67 - Workplace Tobacco Policies
Because ENDS are relatively new products that vary widely and have not been well studied, limited data are available on potential hazardous effects of active and passive exposures to their emissions . A recent white paper from the American Industrial Hygiene Association thoroughly reviewed the ENDS issue and cautioned that "... the existing research does not appear to warrant the conclusion that e-cigarettes are "safe" in absolute terms ... e-cigarettes should be considered a source of volatile organic compounds (VOCs) and particulates in the indoor environment that have not been thoroughly characterized or evaluated for safety" .
Smokeless tobacco is known to cause several types of cancer, including oral, esophageal, and pancreatic cancers . Some newer smokeless tobacco products (e.g., snus) are processed in a way intended to substantially reduce toxicant and carcinogen content, though variable residual levels remain even in these newer products and represent potential risk to users . All smokeless tobacco products contain nicotine, a highly addictive substance which is plausibly responsible for high risks of adverse reproductive outcomes (e.g., low birth weight, pre-term delivery, and stillbirth) associated with maternal use of snus .

# Combining Tobacco Use and Occupational Hazards Enhances Risk
Many workers and their employers do not fully understand that tobacco use in their workplaces (most commonly smoking) can increase-sometimes profoundly-the likelihood and/or the severity of occupational disease and injury caused by other hazards present. This can occur in various ways. A toxic industrial chemical present in the workplace can also be present in tobacco products and/or tobacco smoke, so workers who smoke or are exposed to SHS are more highly exposed and placed at greater risk of the occupational disease associated with those chemicals.
Heat generated by smoking tobacco in the workplace can transform some workplace chemicals into more toxic chemicals, placing workers who smoke at greater risk of toxicity . Tobacco products can readily become contaminated by toxic workplace chemicals, through contact of the tobacco products with unwashed hands or contaminated surfaces and through deposition of airborne contaminants onto the tobacco products. Subsequent use of the contaminated tobacco products, whether at or away from the workplace, can facilitate entry of these toxic agents into the user's body .
Often, a health effect can be independently caused by tobacco use and by workplace exposure to a toxic agent. For example, tobacco smoking can reduce a worker's lung function, leaving that worker more vulnerable to the effect of any similar impairment of lung function caused by occupational exposure to dusts, gases, or fumes . For some occupational hazards, the combined impact of tobacco use and exposure to a toxic occupational agent can be synergistic (i.e., amounting to an effect profoundly greater than the sum of each independent effect). An example is the combined synergistic effect of tobacco smoking and asbestos exposure on lung cancer, which results in a profoundly increased risk of lung cancer among asbestos-exposed workers who smoke .
viii
NIOSH CIB 67 - Workplace Tobacco Policies
The risk of occupational injuries and traumatic fatalities can be greatly enhanced when tobacco use is combined with an occupational hazard. Obvious examples are explosions and fires when explosive or flammable materials in the workplace are ignited by sources associated with tobacco smoking . However, any form of tobacco use may result in traumatic injury if the worker operating a vehicle or industrial machinery is distracted by tobacco use (e.g., while opening, lighting, extinguishing, or disposing of a tobacco product) .

# Preventive Interventions
Both health and economic considerations can motivate people to quit tobacco use. Workers who smoke can protect their own health by quitting tobacco use and can protect their coworkers' health by not smoking in the workplace. Smokers who quit stand to benefit financially. Among other savings, they no longer incur direct costs associated with consumer purchases of tobacco products and related materials, and they generally pay lower life and health insurance premiums and lower out-of-pocket costs for health care.
Legally determined employer responsibilities set out in federal, state, and local laws and regulations, as well as health and economic considerations, can motivate employers to establish workplace policies that prohibit or restrict tobacco use. Even where smoke-free workplace policies are not explicitly mandated by state or local governments, the general duty of employers to provide safe work environments for their employees can motivate employers to prohibit smoking in their workplaces, thereby avoiding liability for exposing nonsmoking employees to SHS . Also, not only are nonsmoking workers generally healthier, but they are more productive and less costly for employers. Considering aggregate cost and productivity impacts, one recent study estimated that the annual cost to employ a smoker was, on average, nearly $6,000 greater than the cost to employ a nonsmoker . It follows that interventions that help smoking workers quit can benefit the bottom line of a business.
Several studies have shown that smoke-free workplace policies decrease exposure of nonsmoking employees to SHS at work, increase smoking cessation, and decrease smoking rates among employees . Less restrictive workplace smoking policies are associated with higher levels of sustained tobacco use among workers . In workplaces without a workplace rule that limits smoking, workers are significantly more likely to be smokers . Policies that make indoor workplaces smoke-free result in improved worker health . For example, smoke-free policies in the hospitality industry have been shown to improve health among bar workers, who are often heavily exposed to SHS in the absence of such policies . Smoke-free policies also reduce hospitalizations for heart attacks in the general population  and several recent studies suggest that these policies may also reduce hospitalizations and emergency department visits for asthma in the general population . The CDC-administered Task Force on Community Preventive Services recommends smoke-free workplace policies, not only to reduce exposure to SHS, but also to increase tobacco cessation, reduce tobacco use prevalence, and reduce tobacco-related morbidity and mortality .

# Workplace Tobacco Use Cessation Programs
Employees who smoke and want to quit can benefit from employer-provided resources and assistance. Various levels and types of cessation support can be provided to workers, though more intensive intervention has a greater effect .
Occupational health providers and worksite health promotion staff can increase quit rates simply by asking about a worker's tobacco use and offering brief counseling . Workers who smoke can be referred to publicly funded state quitlines, which have been shown to increase tobacco cessation success . Widespread availability, ease of accessibility, affordability, and potential reach to populations with higher levels of tobacco use make quitlines an important component of any cessation effort . However, many employers do not make their employees aware of them .
Mobile phone texting interventions and web-based interventions are also promising approaches to assist with tobacco cessation . The most comprehensive workplace cessation programs incorporate tobacco cessation support into programs that address the overall safety, health, and well-being of workers. A growing evidence base supports the enhanced effectiveness of workplace health promotion programs when they are combined with occupational health protection programs .

# Health Insurance and Smoking-Using Incentives and Disincentives to Modify Tobacco Use Behavior
Many workers are covered by employer-provided health insurance, which is increasingly being designed to encourage and help employees to adopt positive personal health-related behaviors, including smoking cessation for smokers. Health insurance coverage of evidence-based smoking cessation treatments is associated with increases in the number of smokers who attempt to quit, use proven treatments in these attempts, and succeed in quitting . Ideally, such coverage should provide access to all evidence-based cessation treatments, including individual, group, and telephone counseling, and all seven FDA-approved cessation medications, while eliminating or minimizing barriers such as cost-sharing and prior authorization .
The Affordable Care Act (ACA), Public Law 111-148, includes provisions pertinent to tobacco use and cessation . Some of these provisions are intended to help smokers quit by increasing their access to proven cessation treatments. Other ACA provisions are intended to encourage tobacco cessation by permitting small-group plans to charge tobacco users premiums that are up to 50% higher than those charged to nontobacco users, subject certain limitations .
x NIOSH CIB 67 - Workplace Tobacco Policies
The appropriate intent of incentives is to help employees who use tobacco quit, thus improving health and reducing health-care costs overall. The evidence for the effectiveness of imposing insurance premium surcharges on tobacco users is limited, and care is needed to ensure that incentive programs are designed to work as intended and to minimize the potential use of incentives in an unduly coercive or discriminatory manner .

# Conclusions
- Cigarette smoking by workers and SHS exposure in the workplace have both declined substantially over recent decades, but about 20% of all U.S. workers still smoke and about 20% of nonsmoking workers are still exposed to SHS at work.
- Smoking prevalence among workers varies widely by industry and occupation, approaching or exceeding 30% in construction, mining, and accommodation and food services workers.
- Prevalence of ENDS use by occupation and industry has not been studied, but ENDS has grown greatly, with about 1 in 3 current U.S. adult smokers reporting ever having used e-cigarettes by 2013.
- Smokeless tobacco is used by about 3% of U.S. workers overall, but smokeless tobacco is used by more than 10% workers in construction and extraction jobs and by nearly 20% of workers in the mining industry, which can be expected to result in disparities in tobacco-related morbidity and mortality.
- Tobacco use causes debilitating and fatal diseases, including cancer, respiratory diseases, and cardiovascular diseases. These diseases afflict mainly users, but they also occur in those exposed to SHS. Smoking is substantially more hazardous, but use of smokeless tobacco also causes adverse health effects. More than 16 million U.S. adults live with a disease caused by smoking, and each year nearly a half million die prematurely from smoking or exposure to SHS.
- Tobacco use is associated with increased risk of injury and property loss due to fire, explosion, and vehicular collisions.
- Tobacco use by workers can increase, sometimes profoundly, the likelihood and the severity of occupational disease and injury caused by other workplace hazards (e.g., lead, asbestos, and flammable materials).
- Restrictions on smoking and tobacco use in specific work areas where particular high-risk occupational hazards are present (e.g., explosives, highly flammable materials, or highly toxic materials that could be ingested via tobacco use) have long been used to protect workers.
- A risk-free level of exposure to SHS has not been established, and ventilation is insufficient to eliminate indoor exposure to SHS.
- Potential adverse health effects associated with using ENDS or secondhand exposure to particulate aerosols and gases emitted from ENDS remains to be fully characterized.
xi NIOSH CIB 67 - Workplace Tobacco Policies
- Policies that prohibit tobacco smoking throughout the workplace (i.e., smoke-free workplace policies) are now widely implemented, but they have not yet been universally adopted across the United States. These policies improve workplace air quality, reduce SHS exposure and related health effects among nonsmoking employees, increase the likelihood that workers who smoke will quit, decrease the amount of smoking during the working day by employees who continue to smoke, and have an overall impact of improving the health of workers (i.e., among both nonsmokers who are no longer exposed to SHS on the job and smokers who quit).
- Workplace-based efforts to help workers quit tobacco use can be easily integrated into existing occupational health and wellness programs. Even minimal counseling and/or simple referral to state quitlines, mobile phone texting interventions, and web-based intervention can be effective, and more comprehensive programs are even more effective.
- Integrating both occupational safety and health protection components into workplace health promotion programs (e.g., smoking cessation) can increase participation in tobacco cessation programs and successful cessation among blue-collar workers.
- Smokers, on average, are substantially more costly to employ than nonsmokers.
- Some employers have policies that prohibit employees from using tobacco when away from work or that bar the hiring of smokers or tobacco users. However, the ethics of these policies remain under debate, and they may be legally prohibited in some jurisdictions.

# Recommendations
NIOSH recommends that employers take the following actions related to employee tobacco use:
- At a minimum, establish and maintain smoke-free workplaces that protect those in workplaces from involuntary, secondhand exposures to tobacco smoke and airborne emissions from e-cigarettes and other electronic nicotine delivery systems. Ideally, smoke-free workplaces should be established in concert with tobacco cessation support programs. Smoke-free zones should encompass (1) all indoor areas without exceptions (i.e., no indoor smoking areas of any kind, even if separately enclosed and/ or ventilated), (2) all areas immediately outside building entrances and air intakes, and (3) all work vehicles. Additionally, ashtrays should be removed from these areas.
- Optimally, establish and maintain entirely tobacco-free workplaces, allowing no use of any tobacco products across the entire workplace campus (see model policy in Box 6-1).
- Comply with current OSHA and MSHA regulations that prohibit or limit smoking, smoking materials, and/or use of other tobacco products in work areas characterized by the presence of explosive or highly flammable materials or potential exposure to toxic materials (see Table A-3 in the Appendix). To the extent feasible, follow all similar NIOSH recommendations (see Table A-2 in the Appendix).
- Provide information on tobacco-related health risks and on benefits of quitting to all employees and other workers at the worksite (e.g., contractors and volunteers).
 Inform all workers about health risks of tobacco use.
 Inform all workers about health risks of exposure to SHS.
 Train workers who are exposed or potentially exposed to occupational hazards at work about increased health and/or injury risks of combining tobacco use with exposure to workplace hazards, about what the employer is doing to limit the risks, and about what the worker can do to limit his/her risks.
- Provide information on employer-provided and publicly available tobacco cessation services to all employees and other workers at the worksite (e.g., contractors and volunteers).
 At a minimum, include information on available quitlines, mobile phone texting interventions, and web-based cessation programs, self-help materials, and employer-provided cessation programs and tobacco-related health insurance benefits available to the worker.
 Ask about personal tobacco use as part of all occupational health and wellness program interactions with individual workers and promptly provide encouragement to quit and guidance on tobacco cessation to each worker identified as a tobacco user and to any other worker who requests tobacco cessation guidance.
- Offer and promote comprehensive tobacco cessation support to all tobacco-using workers and, where feasible, to their dependents.
 Provide employer-sponsored cessation programs at no cost or subsidize cessation programs for lower-wage workers to enhance the likelihood of their participation. If health insurance is provided for employees, the health plan should provide comprehensive cessation coverage, including all evidence-based cessation treatments, unimpeded by co-pays and other financial or administrative barriers.
 Include occupational health protection content specific to the individual workplace in employer-sponsored tobacco cessation programs offered to workers with jobs involving potential exposure to other occupational hazards.
- Become familiar with available guidance (e.g., CDC's "Implementing a Tobacco-Free Campus Initiative in Your Workplace") (see Box 6-2) and federal guidance on tobacco cessation insurance coverage under the ACA (e.g., ) before developing, implementing, or modifying tobacco-related policies, interventions, or controls.
- Develop, implement, and modify tobacco-related policies, interventions, and controls in a stepwise and participatory manner. Get input from employees, labor representatives, line management, occupational safety/health and wellness staff, and human resources professionals. Those providing input should include current and former tobacco users, as well as those who have never used tobacco. Seek voluntary input from employees with health conditions, such as heart disease and asthma, exacerbated by exposure to SHS.
- Make sure that any differential employment benefits policies that are based on tobacco use or participation in tobacco cessation programs are designed with a primary intent to improve worker health and comply with all applicable federal, state, and local laws and regulations. Even when permissible by law, these differential employment benefit policies-as well as differential hiring policies based on tobacco use-should be implemented only after seriously considering ethical concerns and possible
xiii NIOSH CIB 67 - Workplace Tobacco Policies unintended consequences. These consequences can include the potential for adverse impacts on individual employees (e.g., coercion, discrimination, and breach of privacy) and the workforce as a whole. Furthermore, the impact of any differential policies that are introduced should be monitored to determine whether they improve health and/or have unintended consequences.
NIOSH recommends that workers who smoke cigarettes or use other tobacco products take the following actions:
- Comply with all workplace tobacco policies.
- Ask about available employer-provided tobacco cessation programs and cessationrelated health insurance benefits.
- Quit using tobacco products. Know that quitting tobacco use is beneficial at any age, but the earlier one quits, the greater the benefits. Many people find various types of assistance to be very helpful in quitting, and evidence-based cessation treatments have been found to increase smokers' chances of quitting successfully.

# Background
The widespread recognition that tobacco use is the leading preventable cause of premature death and a major cause of preventable disease, injury, and disability in the United States is based on an extraordinarily strong scientific foundation. The first Surgeon General's report on smoking and health, issued a half century ago, concluded that cigarette smoke causes lung cancer and chronic bronchitis . Subsequent reports of the Surgeon General have determined that both active tobacco smoking and secondhand smoke (SHS) exposure are important causes of cancer, heart disease, and respiratory disease, and that smokeless tobacco use also causes serious disease, including oral, esophageal, and pancreatic cancer . Several reports of the Surgeon General have addressed benefits of effective smoking cessation programs and other means of reducing tobacco use [DHHS 1990[DHHS , 2000[DHHS , 2012[DHHS , 2014.
A Surgeon General's report also established the ongoing Healthy People strategy, aimed broadly at improving the nation's health . Currently, Healthy People 2020 includes a major goal of reducing "illness, disability, and death related to tobacco use and secondhand smoke exposure" along with several specific objectives that target eliminating tobacco smoking in workplaces . Later, when scientific evidence became clear that the health risk from inhaling tobacco smoke is not limited to smokers but also affects bystanders, NIOSH published another CIB focused solely on tobacco smoke-this one on SHS in the workplace . In that CIB, NIOSH presented its determination that SHS (referred to in that document as "environmental tobacco smoke") causes cancer and cardiovascular disease. In recommending that workplace exposures to SHS be reduced to the lowest feasible concentration using all available preventive measures, NIOSH emphasized that the best approach is to eliminate tobacco smoking in the workplace, and it endorsed employer-provided smoking cessation programs for employees who smoke  (see Appendix Table A-1).
In retrospect, the CIB on SHS in the workplace marked a watershed in the Institute's approach to occupational safety and health. Over time, NIOSH recommendations concerning specific industrial hazards-which earlier might have been relatively silent about what were then narrowly understood to be strictly personal health-related behaviors like smoking-have come to embrace a more comprehensive preventive approach. This evolution has been motivated by a better understanding of how tobacco use adversely impacts occupational diseases and injuries and-perhaps just as importantly-by a changing societal view of the health and economic consequences of tobacco use. By way of example, criteria documents produced in the past decade on two lung hazards-refractory ceramic fibers  and hexavalent chromium -have included entire sections on smoking cessation, something not seen in earlier criteria documents (see Appendix Table A-2). In a 2004 medical journal paper, the Director of NIOSH concluded that "Smoking is an occupational hazard, both for the worker who smokes and for the nonsmoker who is exposed to  in his or her workplace. " He also recommended that "Smoking as an occupational hazard should be completely eliminated for the sake of the health and safety of American workforce" . A 2010 post on the NIOSH Blog site pointed out that "Tobaccofree workplaces, on-site tobacco cessation services, and comprehensive, employer-sponsored healthcare benefits that provide multiple quit attempts, have all been shown to increase tobacco treatment success" .
Thus, instead of staying focused nearly exclusively on protecting workers from specific occupational hazards, NIOSH has progressively adopted a "strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance health and wellbeing" . This integrated approach, embodied by NIOSH in its Total Worker HealthTM Program  . The overall prevalence of current cigarette smoking among workers during the 2004-2010 period was 19.6%, very closely approximating the prevalence among all U.S. adults, which annually ranged from a high of 20.9% to a low of 19.3% during the period [CDC 2011a, 2013b.
During the past several decades, a number of studies have assessed smoking habits among U.S. workers. Consistently, these studies have shown substantially higher cigarette smoking prevalence among blue-collar workers compared with white-collar workers, particularly among males .
In addition, these studies provide evidence of higher intensity of smoking among blue-collar workers who smoke than white-collar workers who smoke . Among blue-collar workers, those with higher levels of exposure to dust and chemical hazards are more likely to be smokers .
NIOSH publishes recent data on cigarette smoking status by industry and occupation groupings in the Work-Related Lung Disease (WoRLD) Surveillance Report and corresponding online updates [NIOSH 2008a[NIOSH , 2014. The most recent tables, covering the period 2004-2011, show that smoking prevalence varies widely-nearly four-fold-by industry. Smoking prevalence at or below 10% was found among major industry sectors in education services (9.8%) and among minor industry sectors in religious, grantmaking, civic, labor, professional, and similar organizations (10.0%). Smoking prevalence exceeding 30% was found among three major industry sectors: construction (32.1%); accommodation and food services (32.1%); and mining (30.2%). Several minor sectors in other major industries also exceeded 30%: gasoline stations (37.6%); fishing, trapping, and hunting (34.3%); forestry and logging (32.9%); warehousing and storage (32.0%); rental and leasing services (31.3%); wood product manufacturing (30.7%); and nonmetallic mineral product manufacturing (30.4%).
Additional tables posted on that same NIOSH site show that cigarette smoking prevalence varies even more extremely-25-fold-by specific occupational group, from 2.0% for religious workers to 49.5% for construction trades helpers  (see Appendix Figures A-1a and A-1b).

# Smokeless Tobacco
Smokeless tobacco is not burned when used. Types of smokeless tobacco include chewing tobacco,
NIOSH CIB 67 - Workplace Tobacco Policies snuff, dip, snus, and dissolvable tobacco products.
As with smoking, NHIS data have been used to estimate smokeless tobacco use by workers NIOSH 2014]. During 2010, an estimated 3% of currently working adults used smokeless tobacco in the form of chewing tobacco or snuff. Smokeless tobacco use ranged up to 11% for those working in construction and extraction jobs and more than 18% for those working in the mining industry . (Appendix Figures A-2a and A-2b display prevalence of smokeless tobacco use for major industry and occupation categories.)

# Dual Use
Someone who smokes cigarettes and also uses smokeless tobacco engages in "dual use.

# Secondhand Smoke Exposures at Work
SHS is a mixture of the "sidestream smoke" emitted directly into the air by the burning tobacco product and the "mainstream smoke" exhaled by smokers while smoking. Workplace exposures to SHS have been demonstrated by using air monitoring and through the use of biological markers, such as cotinine, a metabolite of nicotine . By the late 1990s, studies that objectively measured markers of SHS found levels that varied substantially by workplace. Where smoking was allowed, offices and blue-collar workplaces had similar concentrations of nicotine in the air; higher nicotine concentrations were present in restaurants, and still higher concentrations (an order of magnitude higher than in offices) were measured in bars .
The 2009-2010 nationwide survey also found that 20.4% of nonsmoking employed adults reported SHS exposure in their indoor workplace on 1 or more days during the past 7 days .
An analysis of recent NHIS data that used a more restrictive definition of SHS exposure-exposure to SHS at work on 2 or more days per week during the past year-estimated that 10.0% of nonsmoking U.S. workers reported frequent exposure to SHS at work  ]. An even more recent survey involving all states found proportions of nonsmoking employed adults who reported SHS exposure on 1 or more days during the past 7 days in their indoor workplace ranging from 12.4% (Maine) to 30.8% (Nevada) .
Prevalences of SHS exposure at work on 1 or more days during the past 7 days were significantly higher among males (23.8%) than females (16.7%), among those without a high school diploma (31.9%) than those with a graduate school degree (11.9%), and among those with an annual household income less than $20,000 (24.2%) than those with  $100,000 income (14.8%). A recent study separated effects on workplace SHS exposure associated with education and income from effects associated with occupation . Even after statistically adjusting for the effects of education and income, blue-collar workers were more likely to report workplace SHS exposure than managers and professionals. That same study also found that bluecollar workers were also more likely to be smokers and more likely to be heavy smokers, suggesting that SHS exposures in the workplace could be intense for many blue-collar workers.

# Electronic Nicotine Delivery Systems
First introduced into the U.S. market in 2007 , electronic nicotine delivery systems (ENDS), which include electronic cigarettes, or e-cigarettes, are rapidly increasing in use . The ENDS marketplace has diversified in recent years and now includes multiple products, including electronic hookahs, vape pens, electronic cigars, and electronic pipes. Typically, an ENDS product has a cartridge containing a liquid consisting of varying amounts of nicotine, a propylene glycol and/or glycerin carrier, and flavorings. Inhalation draws the fluid to a heating element, creating vapor that subsequently condenses into an aerosol of minute droplets .
Available data suggest that e-cigarette use has increased greatly in the United States during the past several years. A mail survey of U.S. adults showed that the percentage who had ever used e-cigarette more than quadrupled from 0.6% in 2009 to 2.7% in 2010 

# Lung Disease
Cigarette smoking is estimated to cause more than 113,000 deaths among smokers each year in the

# Reproductive and Developmental Effects
Inhalation of tobacco smoke affects the reproductive system, with harmful effects related to fertility, fetal and child development, and pregnancy outcome. Smoking is estimated to cause more than 1,000 deaths from perinatal conditions each year in the United States . Exposure to the complex chemical mixture of combustion compounds in tobacco smoke-including carbon monoxide, which binds to hemoglobin and can deprive the fetus of oxygen-has been found to contribute to a wide range of reproductive effects in women. These effects include altered menstrual cycle and reduced fertility; placental abnormalities and preterm delivery; reduced birth weight, stillbirth, neonatal death, and sudden infant death syndrome (SIDS) in their offspring; earlier and more symptomatic menopause; and other effects [DHHS 2001[DHHS , 2004[DHHS , 2014

# Other Adverse Effects
Smoking is known to cause other health problems that contribute to the generally poorer health of smokers as a group. These include visual difficulties (due to cataracts and age-related macular degeneration), hip fractures (due to low bone density), peptic ulcer disease, diabetes, rheumatoid arthritis, and periodontitis  (Table 3-1). Smoking may also cause hearing loss in adults .
Inflammatory effects of tobacco smoke have been associated with many other health effects. For example, smoking has been found to delay wound healing after surgery and lead to wound complications . Also, tobacco smoking may increase the risk of hearing loss caused by occupational exposure to excessive noise . Research on other health effects associated with exposure to tobacco smoke will undoubtedly provide a more complete understanding of the adverse health effects of smoking.

# Secondhand Smoke
In the United States, SHS exposure causes more than 41,000 deaths among nonsmokers each year . There is strong evidence of a causal relationship between SHS of adults and adverse health effects, including lung cancer, heart disease, stroke, exacerbation of asthma, nasal irritation, and (due to maternal exposure) reduced birth weight of offspring (Table 3-2) . The evidence that exposure to SHS causes health effects among exposed infants and children is also strong (Table 3-2) .
There is also suggestive evidence that exposure to SHS causes a range of other health effects. These include respiratory diseases (asthma, COPD), breast cancer, and nasal cancer among nonsmoking adults, premature delivery of babies born to women exposed to SHS, and cancers (leukemia, lymphoma, brain cancer) among children exposed to SHS . SHS exposure may also be associated with hearing loss in adults .
Among nonsmoking adults, health risks of SHS exposure extend to workplace exposures. A metaanalysis of 11 pertinent studies provided quantitative estimates of lung cancer risk attributable to workplace exposure to SHS; lung cancer risk was increased by 24% overall among workers exposed to SHS in the workplace, and there was a doubling of lung cancer risk among workers categorized as highly exposed to SHS in the workplace . A dramatic example of an adverse effect of exposure to SHS in the workplace was an asthmatic worker's death (see Box 3-3).

# Smokeless Tobacco
Some forms of smokeless tobacco are well documented as causes of oral cancer, esophageal cancer,

# Box 3-2. Emphysema Risk in Coal Miners-Effects of Tobacco Smoking and Coal Mine Dust Exposure
A study  evaluated the effects of exposure to coal mine dust, cigarette smoking, and other factors on the severity of lung disease (emphysema) among more than 700 deceased persons, including more than 600 deceased coal miners. The study found that combined occupational exposure to coal mine dust and cigarette smoking had an additive effect on the severity of emphysema among the coal miners. Among smokers and never-smokers alike, emphysema was generally more severe among those who had higher levels of exposure to coal mine dust. However, at any given level of dust exposure, miners who had smoked generally had worse emphysema than miners who had not smoked.
NIOSH CIB 67 - Workplace Tobacco Policies Box 3-3. Asthma Death and Exposure to Secondhand Smoke-A Case Report
On May 1, 2004, a 19-year-old part-time waitress, who had a history of asthma since childhood, arrived at work. She spent 15 minutes chatting with a coworker in an otherwise unoccupied room adjacent to the bar and was reported to have no apparent breathing difficulty at that time. She then entered the bar, which was occupied by dozens of patrons, many of whom were smoking. Less than 5 minutes later she reported to the manager that she wished she had her inhaler with her, needed fresh air, and needed to get to the hospital. As she walked towards the door, she collapsed. An emergency medical crew attempted resuscitation and transported her to a hospital emergency room, where she was declared dead. "Status asthmaticus" and "asphyxia secondary to acute asthma attack'' were the causes of death recorded on the death certificate and autopsy report, respectively. The workplace was described by an investigator from a NIOSH-funded state program as a ''typical smoky bar. " Based on the nature and circumstances of the waitress's death, it was concluded by the principal investigator of the state's fatality investigation program and his colleagues that this waitress died from exposure to work-related SHS .  . Furthermore, beyond the concerns of nonuser exposure to nicotine and these other components, there is also potential for ENDS to be used to deliver psychoactive substances such THC, the active ingredient in marijuana .
A study funded by an organization that promotes consumer access to ENDS as a means of harm reduction for nicotine-addicted individuals, emphasizes that estimated exposure levels associated with the use of ENDS are generally much lower than occupational exposure limits (OELs) for toxic industrial hazards . In light of irritant compounds (e.g., formaldehyde, acetaldehyde, and acrolein) identified in emissions from ENDS, it has been recommended that research be done to evaluate possible adverse effects of exposure to these compounds among ENDS users and individuals exposed to secondhand ENDS aerosol . Indeed, findings relating to short-term adverse effects on ENDS users include preliminary reports of significantly increased airways resistance 

# Traumatic Injuries and Fatalities Caused by Tobacco Use
Tobacco use is also an important cause of traumatic death, injury, and property damage. In 2011, there were an estimated 90,000 fires related to lighted tobacco products in the United States, resulting in an estimated 540 deaths and 1,640 injuries among civilians, and more than $600 million in property damage. Of these fires, 1 in every 4 fatalities was a victim who was not the smoker whose cigarette or other combusting tobacco product caused the fire . Annual estimates have been declining over time, in part due to the decline in smoking . In addition to injuries caused by smoking-related fires, use of tobacco products is a recognized distracting factor while operating motor vehicles , and smoking while driving has been shown to increase the risk of being involved in a crash . Adverse smoking-associated physiological alterations in bone mineralization, blood vessels, and inflammatory response  may also contribute to higher risk of injuries, impaired recovery, and higher rates of associated disability among smokers .

# Tobacco Use and Increased Risk of Work-related Disease and Injury
In the general population, personal use of tobacco and exposure to SHS both cause debilitating and fatal health problems, as outlined above. What many workers and their employers often do not fully understand is that tobacco use can increase, sometimes profoundly, the likelihood and/or the severity of occupational disease and injury caused by other hazards present in their workplaces.  1991]. This section outlines some ways that tobacco use by workers and in the workplace can cause or worsen occupational risks (see Box 3-4). Readers are referred to other sources for more conceptual detail about how tobacco use can affect doses of hazardous industrial agents received by workers, metabolism of these agents by exposed workers, and pathogenesis and carcinogenesis of diseases caused by these agents, as well as how researchers assess complex causal relationships involving multiple causes .
Heat generated by smoking tobacco in the workplace can transform a workplace chemical to a more toxic chemical . Though smokers are most highly exposed to the transformed chemical, nonsmoking coworkers in the same work area may also be exposed. Examples of occupational agents that have the potential for conversion to highly toxic chemicals by smoking tobacco products include polytetrafluoroethylene (Teflon  ) and other chlorinated hydrocarbons (see Box 3-5).

# Box 3-4. Some Ways Tobacco Use by Workers or in the Workplace Can Cause or Worsen Occupational Safety and Health Risks
- Tobacco smoke/tobacco products can contain the same toxic agent that is released into the workplace from a work process, thus increasing the dose of that agent received by tobaccousing workers.
- A workplace chemical can be transformed into a more harmful agent by the heat involved in smoking.
- Tobacco products can become contaminated with industrial toxicants found in the workplace, thus facilitating entry of the agent into the body through inhalation, ingestion, and/or skin absorption.
- Smoking can contribute to an effect on the body comparable to that which can result from exposure to an industrial toxicant in the workplace, thus causing an additive combined effect.
- Smoking can act synergistically with industrial toxicants found in the workplace to cause a much more profound effect than anticipated based on the known individual effects of smoking and the occupational exposure.
- Tobacco use at work can contribute to work-related traumatic injuries and fatalities, either as an ignition source for explosive or flammable agents in the workplace, or through tobacco-related distraction while operating a vehicle or machinery at work.
- Smoking at work exposes nonsmoking coworkers to the hazards of secondhand smoke.
Adapted from NIOSH  Tobacco products can readily become contaminated by industrial toxicants in the workplace through contact of the tobacco products with unwashed hands or contaminated surfaces and through deposition of airborne contaminants onto the tobacco products. Subsequent use of the contaminated tobacco product, at or even away from the workplace, facilitates entry of these toxic agents into the user's body by inhalation, ingestion, and/or skin absorption . To protect workers from such exposure, occupational safety and health regulations for lead, cadmium, and many other specific toxic agents prohibit use of (and even carrying of) tobacco products in designated work areas (see Appendix Table A-2 and A-3).
Often, a particular health effect can be independently caused by tobacco use and workplace exposure to a toxic agent. Thus, even if tobacco is used only away from work, users will be more severely affected than non-users, typically in an additive manner. For example, tobacco smoking reduces a worker's lung function, leaving that worker more vulnerable to the effect of any similar lowering of lung function caused by occupational exposure to dusts, gases, or fumes. Occupational exposures that, like tobacco smoking, cause chronic airways diseases and lung function impairment, include cotton dust, coal mine dust, grain dust, silica dust, welding fumes, and others .
For some occupational hazards, the combined impact of tobacco use and exposure to the occupational agent can be synergistic (i.e., amounting to an effect much greater than the sum of each independent effect). Adverse biological effects of smoking on the respiratory tract can lead to higher effective doses of an industrial toxicant among smoking workers compared with nonsmoking workers. For example, deposition of hazardous occupational dusts can be increased in airways narrowed by smoking, and clearance of deposited dust can be slowed by smoking-induced impairment of both alveolar and mucociliary transport .
In addition, inflammatory cells recruited to the alveoli and airways by smoking can enhance lung injury from hazardous occupational agents, and tumor promoters in tobacco smoke can act on cells initiated by an occupational carcinogen, leading to an increased likelihood that cancer will develop from the occupational exposure among smokers .
An example of a synergistic effect is the combined effect of smoking and asbestos exposure on lung cancer (see Box 3-1). Smoking and asbestos exposure both independently cause lung cancer. Workers who both smoke and are exposed to asbestos at work face a much greater risk of dying from lung cancer than would be expected from the known independent risks of smoking by itself and asbestos exposure by itself [NIOSH 1979;DHEW 1979b;

# Box 3-5. Polymer Fume Fever in Smokers with Occupational Exposure to Tetrafluoroethylene
Soon after use of a new spray product containing tetrafluoroethylene (a fluorocarbon monomer) was introduced at a small industrial facility, workers began experiencing severe episodic "flu-like" symptoms. The symptoms-lower backache accompanied by fever, chills, and malaise, and a dry, nonproductive coughoccurred only on work days and usually subsided by the next morning. The spray was used in a stamp-making process, and only the employees making the stamps were affected. All the affected workers ate and smoked in their work area. After smoking was prohibited, no further symptoms occurred. Investigators concluded that workers had experienced polymer-fume fever due to contamination of cigarettes with the fluorocarbon (via the workplace air or direct contact with workers' hands) and subsequent inhalation of decomposition products created by the intense heat of the cigarettes as they smoked . IARC 2004;Frost et al. 2011;Markowitz et al. 2013]. Workers who only smoke outside of work remain vulnerable to the synergistic combined effect of smoking and asbestos exposure. Other sorts of synergistic effects may involve consideration of temporality of exposures and outcome. Workers who start smoking before they are occupationally exposed to radon may face a more-than-multiplicative risk of lung cancer that is much higher than the additive risk faced by radon-exposed workers who did not smoke until after their occupational exposure to radon  Tobacco use on the job can also cause occupational traumatic injuries and property loss unrelated to fires or explosions. Worker distraction by tobacco use (e.g., opening, preparing, lighting, extinguishing, or disposing of a tobacco product) or by a tobacco-caused coughing spell can result in traumatic injury or death when that worker is driving a work vehicle or operating other potentially hazardous machinery or equipment . Several studies have shown that smokers are more likely to be injured at work than nonsmokers .
As evident from the above discussion, both the type of tobacco/tobacco-related product used and where it is used can influence whether and how occupational safety and health risks are enhanced by tobacco use for users and for non-users. For example, tobacco smoking in a workplace will put nonsmoking workers in that workplace at increased risk due to their workplace exposure to SHS. In contrast, in workplaces free of other occupational chemical or physical hazards, use of smokeless tobacco would not be expected to result in any increased occupational risk for users or their coworkers. ENDS use in the workplace could, like use of any tobacco product, plausibly enhance a user's exposure to hazardous workplace toxicants present in the workplace, may serve as a potential ignition source in workplaces where explosive atmospheres are present, and can result in secondhand exposure of coworkers (see Electronic Nicotine Delivery Systems, above).
NIOSH CIB 67 - Workplace Tobacco Policies - Smoke-free or tobacco-free indoors or campuswide prohibitions.
- Other restrictions on tobacco use by employees.
- Tobacco vending machines removal and prohibiting other onsite sales of tobacco in workplaces.
- Provision of tobacco cessation programs.
- Employer-provided health insurance benefits designed to increase access and remove barriers to evidence-based cessation treatments and to provide incentives to quit tobacco use.
- Design of hiring policies based on smoking status.
Many preventive policies relating to smoking and the workplace are governed by local, state, or federal government laws and/or regulations. Others are independently implemented by employers as workplace requirements or conditions of employment. Employees and/or labor organizations can share in a sense of joint ownership if they meaningfully collaborate with the employer on policy language, approaches and timing, cessation supports, and compliance and consequence issues. Involving employees in the development, implementation, and evaluation of workplace programs is an effective strategy for changing employee culture and behavior .
Workplace tobacco policies are underpinned by several motivating interests (Boxes 4-1 and 4-2). First and foremost is an interest in protecting tobacco users' health, given that tobacco use causes Box 4-1. Some Reasons for Employers to Implement Workplace Tobacco Interventions
- Reducing occupational disease and injuries (and workers' compensation insurance costs).
- Lowering health insurance and life insurance costs and claims.
- Decreasing costs of training workers to replace those who become disabled or die prematurely.
- Increasing productivity through reduced absenteeism and reduced presenteeism.
- Reducing accidents and fires (and related insurance costs).
- Lessening property damage (and related insurance costs).
- Eliminating indoor air pollution (and related cleaning, maintenance, and ventilation costs).
- Limiting liability and legal costs for failing to provide a safe and healthful working environment.
- Enhancing worker morale and corporate image by showing concern for employees/customers. To improve one's own health - Reduce risk for lung, mouth, throat, and other types of cancer. For example, lung cancer risk drops by as much as 50% 10 years after quitting, and risks for cancers of the mouth and throat and bladder drop by 50% 5 years after quitting.
- Diminish risk for coronary heart disease, stroke, and peripheral vascular disease. For example, heart disease risk drops by as much as 50% 1 year after quitting. Stroke risk attributable to tobacco use may be eliminated 5 years after quitting.
- Ease symptoms such as coughing, wheezing, and shortness of breath within months of quitting and long-term risk for chronic obstructive pulmonary disease (COPD) and other respiratory diseases.
- Reduce risk of ulcer.
- Reduce risks of infertility (for women who stop smoking during their reproductive years).
To protect the health of others - Avoid exposing family, friends, coworkers, and others to the harmful effects of secondhand smoke (SHS).
- Lessen the risk of having a low-birth-weight baby (for women who stop smoking before becoming pregnant or during the first trimester of pregnancy).
- Increase the likelihood that one's young children will not use tobacco when they reach adolescence and adulthood.
To improve personal/family finances - Save money by not spending money on tobacco and other tobacco-related expenditures (e.g., higher insurance premiums).
- Reduce the risk of financial devastation resulting from income loss due to smoking-related disability or premature death, or from property loss due to a smoking-related home fire.

# To avoid personal inconvenience
- Avoid the need to go outside, sometimes in the rain and cold, when working in a tobacco-free workplace.
the top fve health conditions that impact the U.S. population . Protecting the health of nonsmoking workers is another important motivating interest. Although the health and safety consequences of tobacco use offer sufficient rationale for workplace tobacco policies, legal and economic considerations are also important. Government (i.e., taxpayers), employers, and employees all bear financial costs associated with adverse effects of tobacco use by workers and occupational exposure to SHS.  . Employees may bring claims under state workers' compensation laws for illness or injury attributable to SHS smoke exposure in the workplace, under federal or state disability law for failing to provide reasonable accommodations to alleviate an employee's exposure to SHS, and under the common law for failure to provide employees with a reasonably safe work environment free of SHS . Adopting an effective smokefree (or tobacco-free) workplace policy would protect an employer from such liability and provide employees with a safe workplace.
With respect to personal costs paid by individual smokers, there are obvious direct costs associated with consumer purchases of tobacco products and related materials. However, many smokers, especially those with the least discretionary income, are unaware of longer-term financial costs. One financial writer estimated in 2007 that a typical pack-aday smoker who is spending nearly $2,000 annually just to purchase cigarettes could instead amass more than $1 million by investing that amount each year from ages 18 to 65 in an individual retirement account invested with an emphasis on growth . That estimate did not encompass costs of smoking other than the purchase price of tobacco. Smokers may be charged higher premiums for health and life insurance and generally pay more out-of-pocket costs for health care. Families can experience substantial loss of income when their smoking breadwinner becomes disabled or dies prematurely from a smoking-related disease. Financial devastation can also result from smokingcaused residential fires through costly personal injury to the smoker and/or family members and through loss of residence and other personal property. In addition, smokers and their families may incur additional costs for more frequent cleaning, repairing, or replacement of clothing and other personal furnishings to remove smoke odors and tobacco-related stains.
With respect to employers' costs, a recent study estimated excess annual cost to U.S.-based private employers associated with employees who smoke cigarettes compared with those who do not. Considering aggregate cost and productivity impacts associated with smoking breaks, absenteeism, presenteeism, healthcare expenses, and pension benefits, the study estimated that the annual cost to employ a smoker was, on average, $5,816 greater than the cost to employ a nonsmoker . Interventions that help smoking workers quit can benefit a business' bottom line .

# Workplace Policies Prohibiting or Restricting Smoking
For safety reasons, smoking has long been prohibited in particular work settings where explosive or extremely flammable materials are present (see Appendix Tables A-2 and A-3). A century ago, such prohibitions may have been motivated more out of concern about property loss than concern for the well-being of workers. Subsequently, concern about worker health has motivated additional policies prohibiting the use of tobacco products in specific work sites where exposure to certain hazardous occupational agents can be increased as a result of tobacco use (see Appendix Tables A-1 and A-3). The need for such venue-specific prohibitions on tobacco use has been widely understood and accepted; however, compliance with these prohibitions has been imperfect , indicating a need for ongoing training and vigilance.
In the last decades of the past century, as the public became more aware of the hazards of exposure to SHS, government (at the local, state, and federal
NIOSH CIB 67 - Workplace Tobacco Policies levels) acted with the intent to reduce workplace exposures to SHS and subsequently to eliminate SHS from workplaces . The Surgeon General has concluded that there is no riskfree level of exposure to SHS .
Other measures, such as separating smokers from nonsmokers, cleaning the workplace air, and ventilating buildings, cannot eliminate exposures of nonsmokers to SHS . Thus, ventilation is not an acceptable alternative to making workplaces completely tobacco smoke-free.
Federal actions have been implemented to eliminate SHS from some workplaces. Actively supported by flight attendants and their union as a way to protect their health by eliminating SHS in their workplace, federal law has progressively prohibited smoking during commercial passenger flights, beginning in 1988 with shorter domestic flights and by 2000 encompassing all flights originating and/or terminating in the United States .
In 1990, the Interstate Commerce Commission acted to ban smoking on interstate buses . A 1997 Presidential Executive Order has prohibited tobacco smoking in all interior space owned, rented, or leased by the executive branch of the federal government, with limited exceptions (e.g., specially equipped designated smoking areas, certain residential settings, and space occupied by non-federal parties) . In 2009, this policy to prohibit smoking in all interior space owned, rented, or leased by the executive branch of the federal government was extended by action of the General Services Administration, eliminating remaining indoor designated smoking areas and additionally prohibiting smoking within 25 feet of doorways and air intakes and in courtyards where those outdoor spaces are under GSA jurisdiction . OSHA proposed a rule that would have more universally restricted smoking in the workplace , but later withdrew the proposed rule, noting that workplace regulation of SHS was being advanced by private employers and by state and local governments .
The first comprehensive local and state laws restricting smoking in private workplaces, restaurants, and bars went into effect in 1993 (Shasta County, California) and 2002 (Delaware), respectively .
There is no fundamental legal impediment to adoption of smoke-free workplace policies by private employers , and the private sector has taken independent actions to eliminate exposure to SHS in the workplace. In the early 1990s, new standards established by the Joint Commission on Accreditation of Hospitals spurred industry-wide adoption of workplace smoke-free policies by accredited hospitals, achieving a high level of compliance within just 2 years . In addition to its intended effect on exposure to SHS, this policy has been associated with additional beneficial impacts on workplace safety and property loss (see Box 4-3). Many other businesses also voluntarily implemented smoke-free policies in their workplaces and, by the late 1990s, nearly 70% of U.S. workers employed in non-residential indoor worksites were working in smoke-free workplaces .
A number of studies, including meta-analyses, have shown that smoke-free workplace policies decrease exposure of nonsmoking employees to SHS at work and increase cessation among employees who smoke . Although one review of the literature found
NIOSH CIB 67 - Workplace Tobacco Policies inconclusive evidence that smoke-free workplace policies cause smokers to quit altogether , there is strong evidence that such policies are associated with increased quit rates among smoking workers and with a reduction in the amount of smoking among those workers who continue to smoke . In contrast, less restrictive workplace smoking policies are associated with sustained tobacco use among workers . A nationally representative survey found that in workplaces without a workplace rule limiting smoking, workers were significantly more likely to be smokers .
There is clear evidence of improved health among workers as a result of policy interventions to make indoor spaces, including workplaces, smoke-free . This is especially true for workers in the hospitality industry (see Box 4-4). Smoke-free policies have been shown to improve indoor air quality, reduce SHS exposure, reduce sensory and respiratory symptoms, and improve lung function among bar workers . Implementation of smoke-free policies also has been shown in ecological studies to be associated with reduced hospitalizations for heart attacks in the general population . Results of similar studies suggest that such policies may also reduce hospitalizations and emergency department visits for asthma . Smoke-free policies in Coinciding with comprehensive smoke-free workplace policies being enacted across the U.S. health care industry, the number of smoking-ignited structure fires involving health-care facilities dropped from well over 3,000 per year in the early 1980s to only about 100 per year since the late 1990s. Notably, the percentage of all structural fires in health-care facilities determined to have been caused by smoking materials dropped from 30% to 5% over the same period .

# Box 4-4. Prohibiting Smoking in Bars Improves the Health of Bartenders
A state law that prohibited smoking in most California taverns and bars began on January 1, 1998. Bartenders were surveyed in the month before the law took effect and again about 1 month afterward. Self-reported exposure to SHS at work fell from a median of 28 hours per week before the law took effect to 2 hours per week afterward. Respiratory symptoms and eye, nose, and throat irritant symptoms were each reported by about 75% of bartenders before the law took effect. Of those with symptoms at baseline, 59% with respiratory symptoms and 78% with irritant symptoms experienced resolution of those symptoms after the law took effect (P < 0.001). On average, lung function measurements also improved. The authors of this study concluded that making taverns and bars smokefree resulted in a rapid improvement in the health of bartenders .
the hospitality industry have been found to receive high levels of public support and compliance, and they have not had a negative economic impact on the hospitality industry .
Acting on strong evidence of the effectiveness of smoke-free policies available by 2001, the Task Force on Community Preventive Services recommended workplace smoking bans and restrictions as effective means for reducing exposure to SHS . More recent evidence has led the Task Force to now recommend smoke-free workplace policies (i.e., total prohibition of smoking in the workplace), not only as a means to reduce exposure to SHS, but also as an effective means to increase tobacco cessation, reduce tobacco use prevalence, and reduce tobacco-related morbidity and mortality . To prevent SHS exposures, the recent Surgeon General's report urges that comprehensive smoke-free indoor protections be extended to the entire U.S. population .
World Health Organization reports have recommended that, in the absence of evidence that can assure authorities that use of ENDS does not expose bystanders to toxic emissions, ENDS should not be exempted from laws that restrict the places in which cigarette smoking is allowed . Similarly concerned about potentially hazardous secondhand exposure, the Federal German Institute for Risk Assessment has likewise recommended prohibiting use of ENDS wherever tobacco smoking is prohibited , and the American Heart Association has recommended including e-cigarettes in smokefree laws . The Forum of International Respiratory Societies has recommended that ENDS use be prohibited "in public places, workplaces, and on public transportation" . The American Industrial Hygiene Association similarly reviewed the issue of ENDS and concluded that "their use in the indoor environment should be restricted, consistent with current smoking bans, until and unless research documents that they will not significantly increase the risk of adverse health effects" to those exposed secondhand . In the United States, the number of states and localities that explicitly prohibit use of e-cigarettes in public places where tobacco smoking is already prohibited is increasing with time , totaling 3 states and more than 200 localities before the end of 2014 .
Employers are taking notice, and some are acting to prohibit ENDS use in their workplaces . Given the current unregulated nature of ENDS and the liquid concoctions used them, along with uncertainty about the impact of ENDS use in the workplace on the health of non-users, the simplest approach is for employers to simply add ENDS to the list of products covered by their tobacco-free (or smoke-free) workplace policy .

# Employer Prohibitions on Tobacco Use Extending Beyond the Workplace
Some employers have taken action to extend restrictions on tobacco use by their employees beyond the workplace. For example, in 2013, the U.S. Public Health Service Commissioned Corps became the first federal uniformed service to prohibit tobacco use by its officers whenever and wherever they are in uniform . More controversial are attempts of private employers to control the behavior of their employees outside of the workplace. For example, at a major medical center that had a smoke-free campus policy in place for years, the employer recently announced plans to prohibit smoking by workers during their workday breaks, including lunchtime, even when off campus  [Asch et al. 2013;.
Controversy surrounds many organizational policies that bar the hiring of smokers or prohibit tobacco use by employees during the workday when they are away from the worksite even on their own time. Proponents argue that a nonsmoking workforce serves as a positive role model for health, experiences better health status, incurs substantially lower health-care costs for employers and employees alike, and improves productivity . Opponents posit the addictive nature of tobacco and the fact that tobacco use usually begins in adolescence, note that tobacco use remains legal, and cite the disparate and potentially discriminatory effects such a policy might have on minority, lower-income, or less educated workers and job candidates-groups that tend to have higher levels of tobacco use. They also point out that employers who refuse to hire smokers typically do not similarly refuse to hire individuals with other personal health behaviors that, like tobacco use, have adverse health consequences. They add that more than half of states have laws in place prohibiting employers from refusing to hire individuals because they smoke .

# Workplace Tobacco Use Cessation Programs
Smoking employees who want to quit can benefit from employer-provided resources and assistance. In 2010, roughly 65% of employed smokers in the United States expressed an interest in quitting tobacco and about half reported having tried to quit in the previous year . Just as policies increasing tobacco taxes at the state and federal levels have led to increased calls to state telephone tobacco cessation quitlines , implementing tobacco-free workplace policies can be expected to increase worker interest in quitting and cessation support services. When a smoking cessation program is established in a workplace, smokers employed at that workplace are more likely to intend to quit in the next 6 months . Various levels and types of cessation support can be provided .
On a basic level, a health-care provider's inquiry about tobacco use and delivery of brief counseling advice to tobacco users has been shown to increase quit rates, with more intensive intervention having a greater effect . This basic approach can be readily 'piggy-backed' on occupational health services that already exist in many workplaces. For example, all workers enrolled in OSHA-mandated respiratory protection programs must be asked about tobacco use as part of their medical evaluation (see Appendix  Guideline 2008]. Similarly, the Community Preventive Services Task Force found that quitlines-especially proactive quitlines where the counselor initiates follow-up calls-increase tobacco cessation among callers who are interested in quitting and can help expand the use of evidence-based cessation services among smokers in populations that have limited access to cessation treatment . An updated Cochrane review has reaffirmed the effectiveness of proactive quitlines . Their widespread availability, ease of accessibility, affordability, and potential reach to populations with higher levels of tobacco use make quitlines an important component of any cessation effort . Yet many employers do not make their employees aware of them. For example, a 2008 Washington State survey of almost 700 employers with at least 50 employees found that only 6% mentioned the availability of the state quitline in their health promotion messages to workers .
The most comprehensive workplace cessation programs go well beyond minimal cessation counseling and referral to no-cost quitlines and web-based programs. Employers can enter into preferred relationships with state quitlines or contract quitline providers to establish employer-specific quitlines with special services . Webbased intervention to assist with tobacco cessation is a less studied but promising approach . One report described success achieved by a major corporation with a program offering employees webbased cessation intervention . Individualized counseling and support can often be provided by an existing employee assistance program. A systematic review of the literature found that workplace-based smoking cessation services such as individual and group counseling, pharmacological treatment, and social support are all effective in enhancing quit rates when compared with no interventions or minimal interventions . Optimal work-based tobacco cessation programs are designed to provide followup assistance and to support multiple quit attempts, because most smokers try to quit repeatedly before finally succeeding .
Ideally, employers should incorporate tobacco cessation support programs into a more comprehensive approach that addresses the overall safety, health, and well-being of workers. A growing evidence base supports the enhanced effectiveness of workplace programs that integrate health promotion efforts such as smoking cessation with more specific occupational health protection programs . Such integrated workplace tobacco cessation programs may be most usefully implemented among blue-collar workers, who generally have higher smoking (and lower quitting) rates than office workers and who generally face higher risks from industrial hazards.
A large randomized study involving 15 manufacturing sites showed that combining occupational health and safety messages with health promotion messages resulted in a doubling of smoking quit rates among hourly workers (from 5.9% to 11.8%; P = 0.04) compared with health promotion messages alone . Another demonstration study of an integrated program aimed at enhancing smoking cessation among blue collar workers targeted participants in a union apprenticeship program  (see Box 4-5).

# Health Insurance and Smoking Behavior
Another recent phenomenon is the increasing use of health insurance to encourage employees to adopt positive personal health-related behaviors (e.g., smoking cessation) through modification in the design of benefits and out-of-pocket cost for covered individuals. For example, it is known that quit rates are higher when health insurance covers the costs of evidence Apprentice ironworkers at a local union in Boston were studied before and after a 4-month smoking cessation demonstration program. With input from union leaders and members, the program was carried out in a local union hall, where posters promoting cessation and featuring photographs of ironworkers were displayed. Articles explaining and promoting the program were published in the union newsletter. Occupational health protection aspects of the program were featured in an educational module on "toxics and tobacco. " This module was taught by an industrial hygienist and covered separate and combined adverse health effects, including cancer, caused by smoking and workplace hazards (e.g., asbestos, welding fumes, and diesel exhaust) commonly encountered by ironworkers. Tobacco treatment specialists led weekly group sessions on tobacco cessation. Incentives to participate in the sessions included free lunches and, for those attending all sessions, a chance for a raffle prize. Self-help quit kits were provided to apprentices who chose not to attend the group sessions. Nicotine replacement therapy was available at no cost to participants. Of 337 participants, 139 (41.2%) were current smokers at the time the program started. One month after the program concluded, 27 (19.4%) of those smokers had quit-a rate much higher than the expected ~5% quit rate. Program participants were 3 times more likely to quit than nonparticipants .
NIOSH CIB 67 - Workplace Tobacco Policies Task Force assigned an "A" grade . Federal guidance clarifying this requirement states that health plans will be considered to be in compliance with this requirement if, for example, they cover ( 1 Insurers and employers who sponsor health insurance coverage for their employees will have expanded opportunities to design incentives for wellness programs, including interventions intended to enhance tobacco cessation (or, with some limitations, disincentives for continued tobacco use).
For example, in order to motivate employees to quit smoking, the ACA allows employer-sponsored health insurance issuers to charge tobacco users premiums that are up to 50% higher than premiums charged non-tobacco users . States have authority to limit the magnitude of such surcharges, and a number of states have done so .

# Using Incentives and Disincentives to Modify Tobacco Use Behavior
Increasingly, governmental and employer actions are removing barriers and offering incentives for employee quit attempts and success in quitting tobacco use. Likewise, such actions are increasingly discouraging tobacco use by workers covered by employer-sponsored health insurance programs (e.g., through increased premiums for smokers). For example, more than one-third of surveyed large employers who offer their employees smoking cessation programs incentivize participation in these programs. The number of large employers who are planning to reward or penalize smokers based on their smoking status is increasing-more than half of companies plan to do so by the end of 2013, up from less than 25% of employers who did so in 2010 .
A clear barrier that reduces use of evidence-based cessation treatments is out-of-pocket costs for cessation counseling and FDA-approved cessation medications. Because of strong evidence that the number of tobacco users who quit can be increased by reducing these out-of-pocket costs, the Community Preventive Services Task Force recommends reducing tobacco users' out-of-pocket costs for cessation treatments .
The Task Force had earlier examined the issue of providing incentives for tobacco cessation, finding insufficient evidence at that time that workplacebased incentives or competitions by themselves reduced tobacco use among employees . Even then, the Task Force went on to recommend worksite-based incentives and competitions when they are combined with other evidence-based interventions (e.g., education, group support, telephonic counseling, self-help materials, smoke-free workplace policies) as part of a comprehensive cessation program .
A subsequent systematic review of the literature identified a single well-designed study in which financial incentives integrated into a smoking cessation program produced a substantial and sustained beneficial impact .
Incentive payments for that randomized trial were structured as $100 for completion of the smokingcessation program; $250 for abstinence (confirmed biochemically) during the first 6 months after study enrollment; and $400 for abstinence (also confirmed biochemically) during the subsequent 6 months. Smokers offered the financial incentives were three times as likely to enroll in the program (15.4% vs. 5.4%, P < 0.001), four times as likely to complete the program (10.8% vs. 2.5%, P < 0.001), and three times as likely to remain abstinent more than a year later (14.7% vs. 5.0%, P < 0.001) . Notably, this study did not involve establishing a new smoking cessation program; rather, all participants were informed about existing smoking-cessation resources available in their community and about employer-provided health benefits related to smoking cessation.
A recent review explored ethical and legal issues relating to employer-provided incentives intended to change individual health behaviors, including tobacco use . The authors identified a number of specific issues that call for scrutiny, including the need to ensure that incentive programs are designed to work as intended, and the potential for incentives to be used in an unduly coercive or discriminatory manner. They emphasized that employers should play a collaborative, supportive role in advancing the health of workers, and they further suggested that, in order to limit the potential for discrimination, programs should be designed to minimize differences in individual employees' abilities to access incentives . It should be recognized that, while imposing insurance premium surcharges or other disincentives on smokers has the potential to motivate them to quit smoking, the evidence that they are effective in doing so is quite limited, and care is needed to avoid such practices having unintended consequences. For example, these practices could lead smokers to conceal their smoking (and thereby not benefit from cessation assistance), or even to forgo health insurance coverage or quit their jobs .
The appropriate intent of incentives is to improve health and reduce health-care costs overall, and not merely to shift health-care costs to high-risk individuals [Madison et al. 2011.
In summary, workplace policies are powerful tools that can benefit worker health. Well-designed policies protect workers from occupational risks, provide workplace-associated opportunities for enhancing worker health, and motivate workers to take beneficial actions to protect their well-being.
Although not a primary focus of this CIB, workplace policies that effectively sustain or improve worker health can also be cost-effective and benefit the employer's bottom line.
NIOSH CIB 67 - Workplace Tobacco Policies

# Conclusions
- Cigarette smoking by workers and SHS exposure in the workplace have both declined substantially over recent decades, but about 20% of all U.S. workers still smoke and about 20% of nonsmoking workers are still exposed to SHS at work.
- Smoking prevalence among workers varies widely by industry and occupation, approaching or exceeding 30% in construction, mining, and accommodation and food services workers.
- Prevalence of ENDS use by occupation and industry has not been studied, but ENDS has grown greatly, with about 1 in 3 current U.S. adult smokers reporting ever having used ecigarettes by 2013.
- Smokeless tobacco is used by about 3% of U.S. workers overall, but smokeless tobacco is used by more than 10% workers in construction and extraction jobs and by nearly 20% of workers in the mining industry, which can be expected to result in disparities in tobaccorelated morbidity and mortality.
- Tobacco use causes debilitating and fatal diseases, including cancer, respiratory diseases, and cardiovascular diseases. These diseases afflict mainly users, but they also occur in those exposed to SHS. Smoking is substantially more hazardous, but use of smokeless tobacco also causes adverse health effects. More than 16 million U.S. adults live with a disease caused by smoking, and each year nearly a half million die prematurely from smoking or exposure to SHS.
- Tobacco use is associated with increased risk of injury and property loss due to fire, explosion, and vehicular collisions.
- Tobacco use by workers can increase, sometimes profoundly, the likelihood and the severity of occupational disease and injury caused by other workplace hazards (e.g., lead, asbestos, and flammable materials).
- Restrictions on smoking and tobacco use in specific work areas where particular high-risk occupational hazards are present (e.g., explosives, highly flammable materials, or highly toxic materials that could be ingested via tobacco use) have long been used to protect workers.
- A risk-free level of exposure to SHS has not been established, and ventilation is insufficient to eliminate indoor exposure to SHS.
- The risk of adverse health effects associated with using ENDS or secondhand exposure to particulate aerosols and gases emitted from ENDS remains to be fully characterized.
- Policies that prohibit tobacco smoking throughout the workplace (i.e., smoke-free workplace policies) are now widely implemented, but they
have not yet been universally adopted across the United States. These policies improve workplace air quality, reduce SHS exposure and related health effects among nonsmoking employees, increase the likelihood that workers who smoke will quit, decrease the amount of smoking during the working day by employees who continue to smoke, and have an overall impact of improving the health of workers (i.e., among both nonsmokers who are no longer exposed to SHS on the job and smokers who quit).
- Workplace-based efforts to help workers quit tobacco use can be easily integrated into existing occupational health and wellness programs. Even minimal counseling and/or simple referral to state quitlines, mobile phone texting interventions, and web-based intervention can be effective, and more comprehensive programs are even more effective.
- Integrating both occupational safety and health protection components into workplace health promotion programs (e.g., smoking cessation) can increase participation in tobacco cessation programs and successful cessation among blue-collar workers.
- Smokers, on average, are substantially more costly to employ than nonsmokers.
- Some employers have policies that prohibit employees from using tobacco when away from work or that bar the hiring of smokers or tobacco users. However, the ethics of these policies remain under debate, and they may be legally prohibited in some jurisdictions.
NIOSH CIB 67 - Workplace Tobacco Policies

# Recommendations
The following recommendations relate specifically to the issues raised in this CIB. NIOSH recommends that employers take the following actions related to employee tobacco use:
- At a minimum, establish and maintain smokefree workplaces that protect those in workplaces from involuntary, secondhand exposures to tobacco smoke and airborne emissions from e-cigarettes and other electronic nicotine delivery systems. Ideally, smoke-free workplaces should be established in concert with tobacco cessation support programs. Smoke-free zones should encompass (1) all indoor areas without exceptions (i.e., no indoor smoking areas of any kind, even if separately enclosed and/or ventilated), (2) all areas immediately outside building entrances and air intakes, and (3) all work vehicles. Additionally, ashtrays should be removed from these areas.
- Optimally, establish and maintain entirely tobacco-free workplaces, allowing no use of any tobacco products across the entire workplace campus (see model policy in Box 6-1).
- Comply with current OSHA and MSHA regulations that prohibit or limit smoking, smoking materials, and/or use of other tobacco products in work areas characterized by the presence of explosive or highly flammable materials or potential exposure to toxic materials (see Table A-3 in the Appendix). To the extent feasible, follow all similar NIOSH recommendations (see Table A-2 in the Appendix).
- Provide information on tobacco-related health risks and on benefits of quitting to all employees and other workers at the worksite (e.g., contractors and volunteers).
 Inform all workers about health risks of tobacco use.
 Inform all workers about health risks of exposure to SHS.
 Train workers who are exposed or potentially exposed to occupational hazards at work about increased health and/or injury risks of combining tobacco use with exposure to workplace hazards, about what the employer is doing to limit the risks, and about what the worker can do to limit his/her risks.
- Provide information on employer-provided and publicly available tobacco cessation services to all employees and other workers at the worksite (e.g., contractors and volunteers).
 At a minimum, include information on available quitlines, mobile phone texting interventions, and web-based cessation programs, self-help materials, and employer-provided cessation programs and tobacco-related health insurance benefits available to the worker.
 Ask about personal tobacco use as part of all occupational health and wellness program interactions with individual workers and promptly provide encouragement to quit and guidance on tobacco cessation to each worker identified as a tobacco user and to any other worker who requests tobacco cessation guidance.
- Offer and promote comprehensive tobacco cessation support to all tobacco-using workers and, where feasible, to their dependents.
 Provide employer-sponsored cessation programs at no cost or subsidize 34 NIOSH CIB 67 - Workplace Tobacco Policies cessation programs for lower-wage workers to enhance the likelihood of their participation. If health insurance is provided for employees, the health plan should provide comprehensive cessation coverage, including all evidence-based cessation treatments, unimpeded by copays and other financial or administrative barriers.
 Include occupational health protection content specific to the individual workplace in employer-sponsored tobacco cessation programs offered to workers with jobs involving potential exposure to other occupational hazards.
- Become familiar with available guidance (e.g., CDC's "Implementing a Tobacco-Free Campus Initiative in Your Workplace") (see Box 6-2) and federal guidance on tobacco cessation insurance coverage under the ACA (e.g., . html) before developing, implementing, or modifying tobacco-related policies, interventions, or controls.
- Develop, implement, and modify tobaccorelated policies, interventions, and controls in a stepwise and participatory manner. Get input from employees, labor representatives, line management, occupational safety/health and wellness staff, and human resources professionals. Those providing input should include current and former tobacco users, as well as those who have never used tobacco.
Seek voluntary input from employees with health conditions, such as heart disease and asthma, exacerbated by exposure to SHS.
- Make sure that any differential employment benefits policies that are based on tobacco use or participation in tobacco cessation programs are designed with a primary intent to improve worker health and comply with all applicable federal, state, and local laws and regulations. Even when permissible by law, these differential employment benefit policies-as well as differential hiring policies based on tobacco use-should be implemented only after seriously considering ethical concerns and possible unintended consequences. These consequences can include the potential for adverse impacts on individual employees (e.g., coercion, discrimination, and breach of privacy) and the workforce as a whole. Furthermore, the impact of any differential policies that are introduced should be monitored to determine whether they improve health and/or have unintended consequences.
NIOSH recommends that workers who smoke cigarettes or use other tobacco products take the following actions:
- Comply with all workplace tobacco policies.
- Ask about available employer-provided tobacco cessation programs and cessation-related health insurance benefits.
- Quit using tobacco products. Know that quitting tobacco use is beneficial at any age, but the earlier one quits, the greater the benefits. Many people find various types of assistance to be very helpful in quitting, and evidencebased cessation treatments have been found to increase smokers' chances of quitting successfully. Workers can get help from  tobacco cessation programs, including web-based programs (e.g., . gov and ) and mobile phone texting services (e.g., the SmokefreeTXT program . gov/smokefreetxt);  state quitlines (phone: 1-800-QUIT-NOW , or 1-855-DEJELO-YA ); and/or  health-care providers.
In addition, individual workers who want to quit tobacco may find several of the websites listed in Box 6-2 helpful.
NIOSH recommends that all workers, including workers who use tobacco and nonsmokers exposed to SHS at their workplace:
- Know the occupational safety and health risks associated with their work, including those that can be made worse by personal tobacco use, and how to limit those risks; and
- Consider sharing a copy of this CIB with their employer.    To receive NIOSH documents or more information about occupational safety and health topics, contact NIOSH at