# Promoting Health and Preventing Disease and Injury Through Workplace Tobacco Policies CURRENT INTELLIGENCE BULLETIN 67

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Institute for Occupational Safety and HealthOn 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 com

ponents. The full range of hazards associated with tobacco use extends well beyond such air contaminants, sothe cover design also incorporates a text box to highlight the optimal “Tobacco-Free” (i.e., not just “SmokeFree”) 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

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# Current Intelligence Bulletin 67

Promoting Health and Preventing Disease and Injury Through Workplace Tobacco Policies

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Institute for Occupational Safety and Health

## ii This document is in the public domain and may be freely copied or reprinted.



## Disclaimer Mention of any company or product does not constitute endorsement by the National In

stitute for Occupational Safety and Health (NIOSH). In addition, citations to Web sites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these Web sites. All Web addresses referenced in this document were accessible as of the publication date. 

## Ordering Information To receive documents or other information about occupational safety and health topics, contact NIOSH at Telephone: 1–800–CDC–INFO (1–800–232–4636) TTY: 1–888–232–6348 E-mail: cdcinfo@cdc.gov or visit the NIOSH Web site at www.cdc.gov/niosh. For a monthly update on news at NIOSH, subscribe to 

### NIOSH eNews by visiting www.cdc. gov/niosh/eNews. DHHS (NIOSH) Publication No. 2015–113 April 2015



### Safer • Healthier • People TM 

### X

## iii 

# 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 thepast 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 to

bacco 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 prohibit

ing 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 ex

ceptions, areas immediately outside building entrances and air intakes, and all work vehicles).

## iv • Assure compliance with OSHA and MSHA regulations that prohibit or otherwise re

strict smoking, smoking materials, and/or use of other tobacco products in desig

nated hazardous work areas.

• Provide cessation support for their employees who continue to use tobacco products.

• Doing all this will help fulfill employers’ fundamental obligation to provide safe work

places, and these actions can improve the health and well-being of their workers.

John Howard, M.D. Director, National Institute for Occupational Safety and Health Centers for Disease Control and Prevention

## v 

# Executive Summary

Introduction Various NIOSH criteria documents on individual hazardous industrial agents, from asbes

tos [NIOSH 1972] through hexavalent chromium [NIOSH 2013a], 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 Cur

rent Intelligence Bulletins focused entirely on the hazards of tobacco use. CIB 31, Adverse Health Effects of Smoking and the Occupational Environment , outlined how tobacco use— most commonly smoking—can increase risk, sometimes profoundly, of occupational dis

ease and injury [NIOSH 1979]. In that CIB, NIOSH recommended that smoking be cur

tailed 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 [NIOSH 1991]. 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 [NIOSH 2013b], 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 2013 [DHHS 2014; CDC 2014d]. Overall, smoking among workers has simi

larly declined, but smoking rates among blue-collar workers have been shown to be consis

tently 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 [Chin et al. 2012]. Also, on average, blue-collar smokers smoke more heavily than white-collar smokers [Fujishiro et al. 2012]. 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 ac com

modation and food services. S moking prevalence varies even more by occupation, ranging from 2% among religious workers to 50% among construction trades helpers [NIOSH 2014]. A recent survey of U.S. adults found that by 2013, approximately 1 in 3 current

## vi smokers reported ever having used e-cigarettes, a type of electronic nicotine delivery sys

tem (ENDS) [King et al. 2015]. However, the prevalence of ENDS use by industry and occu

pation has not been studied. Overall, about 3% of all workers use s mokeless tobacco in the form of chewing tobacco and snuff, but s mokeless tobacco use exceeds 10% among workers in construction and extraction jobs and stands at nearly 20% among workers in the mining industry [NIOSH 2014]. 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 smok

ing 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 [CDC 2014b; NIOSH 2014]. The implementation of smoke-free policies has eliminated or substantially decreased ex

posure 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 [King et al. 2014]. 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 [Calvert et al. 2013]. 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 oc

cupations 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 [CDC 2014c]. 

## Health and Safety Consequences of Tobacco Use Since the first Surgeon General’s report on smoking and health, many reports from the Sur

geon 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 fıve health conditions impacting the U.S. popula

tion—heart disease, cancer, cerebrovascular disease, chronic lower respiratory disease, and unintentional injuries [DHHS 2004, 2014]. Smoking also causes a variety of other diseases, as well as adverse reproductive effects [ DHHS 2004, 2014] . Smoking is responsible for more than 480,000 premature deaths each year in the U.S. [DHHS 2014]. The risk of most ad

verse 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, 2014]. Likewise, there is no risk-free level of exposure to SHS [DHHS 2006, 2014]. SHS exposure causes more than 41,000 deaths each year among U.S. nonsmokers [DHHS 2014]. 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) [DHHS 2006, 2014; IARC 2009; IOM 2010; Henneberger et al. 2011]. 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 pre

mature delivery of babies born to women exposed to SHS [DHHS 2006, 2014; IARC 2009].

## vii 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 [Brown and Cheng 2014; Orr 2014; Bhatnagar et al. 2014]. 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” [AIHA 2014]. Smokeless tobacco is known to cause several types of cancer, including oral, esophageal, and pancreatic cancers [IARC 2012]. 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 poten

tial risk to users [Stepanov et al. 2008]. All smokeless tobacco products contain nicotine, a highly addictive substance which is plausibly responsible for high risks of adverse repro

ductive outcomes (e.g., low birth weight, pre-term delivery, and stillbirth) associated with maternal use of snus [DHHS 2014]

. 

## Combining Tobacco Use and Occupational Hazards Enhances Risk Many workers and their employers do not fully understand that tobacco use in their work

places (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 as

sociated 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 [NIOSH 1979; DHEW 1979b; DHHS 1985]. Tobacco products can readily become con

taminated by toxic workplace chemicals, through contact of the tobacco products with un

washed 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 [NIOSH 1979; DHEW 1979b]. Often, a health effect can be independently caused by tobacco use and by workplace ex

posure to a toxic agent. For example, tobacco smoking can reduce a worker’s lung func

tion, leaving that worker more vulnerable to the effect of any similar impairment of lung function caused by occupational exposure to dusts, gases, or fumes [NIOSH 1979; DHEW 1979b; DHHS 1985]. 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 [NIOSH 1979; DHEW 1979b; IARC 2004; Frost et al. 2011; Markowitz et al. 2013]

.

## viii 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 as

sociated with tobacco smoking [MSHA 2000; OSHA 2013a]. 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) [NIOSH 1979].


## Preventive Interventions Both health and economic considerations can motivate people to quit tobacco use. Work

ers 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 fi

nancially. 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 [Zellers et al. 2007]. 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 non

smoker [Berman et al. 2013]. 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 non

smoking employees to SHS at work, increase smoking cessation, and decrease smoking rates among employees [Fichtenberg and Glantz 2002; Bauer et al. 2005; DHHS 2006; IARC 2009; Hopkins et al. 2010]. Less restrictive workplace smoking policies are associated with higher levels of sustained tobacco use among workers [IARC 2009]. In workplaces without a workplace rule that limits smoking, workers are significantly more likely to be smokers [Ham et al. 2011]. Policies that make indoor workplaces smoke-free result in improved worker health [IARC 2009; Callinan et al. 2010]. 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 [Eisner et al. 1998; DHHS 2006; IARC 2009]. Smoke-free policies also reduce hospitalizations for heart attacks in the gen

eral population [IARC 2009; IOM 2010; Tan and Glantz 2012; DHHS 2014] and several recent studies suggest that these policies may also reduce hospitalizations and emergency department visits for asthma in the general population [Hahn 2010; Mackay et al. 2010; Tan and Glantz 2012; Herman and Walsh 2011]. Th e CDC-administered Task Force on Com

munity 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 [Hopkins et al. 2010; Task Force on Com

munity Preventive Services 2010; GCPS 2012a].

## ix Some employers have taken action to extend restrictions on tobacco use by their employ

ees beyond the workplace, for example by prohibiting smoking by workers during their workday breaks, when away from the workplace, including during lunchtime. Several large employers have gone further by barring the hiring of smokers. Such wide-ranging poli

cies generate substantial controversy and are illegal in some jurisdictions [Asch et al. 2013; Schmidt et al. 2013]. 

## 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 [Clinical Practice Guideline 2008]. 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 [O’Hara et al. 1993; Clinical Practice Guideline 2008]. Workers who smoke can be referred to publicly funded state quitlines, which have been shown to increase tobacco cessation success [ GCPS 2012b; Clinical Practice Guideline 2008]. Widespread availability, ease of accessibility, af

fordability, and potential reach to populations with higher levels of tobacco use make quit

lines an important component of any cessation effort [Clinical Practice Guideline 2008]. However, many employers do not make their employees aware of them [Hughes et al. 2011]. M obile phone texting interventions and web-based interventions are also promising ap

proaches to assist with tobacco cessation [Graham et al. 2007; Clinical Practice Guideline 2008; Whittaker et al. 2011; Civljak et al. 2013 ]. The most comprehensive workplace cessa

tion 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 oc

cupational health protection programs [Sorensen et al. 2003; Barbeau et al. 2006; Hymel et al. 2011; NIOSH 2013b]. 

## 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 evi

dence-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 quit

ting [Clinical Practice Guideline 2008]. Ideally, such coverage should provide access to all evidence-based cessation treatments, including individual, group, and telephone counsel

ing, and all seven FDA-approved cessation medications, while eliminating or minimizing barriers such as cost-sharing and prior authorization [Clinical Practice Guideline 2008; CDC 2014b]. The Affordable Care Act (ACA), Public Law 111-148, includes provisions pertinent to to

bacco use and cessation [McAfee et al. 2015] . 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 plansto charge tobacco users premiums that are up to 50% higher than those charged to nontobacco users, subject certain limitations [78 Fed. Reg. 33158]

.

## x The appropriate intent of incentives is to help employees who use tobacco quit, thus im

proving 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 need

ed 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 [Madison et al. 2011, 2013]. The Task Force on Community Preventive Services has recommended worksite-based incentives and competitions that 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 [GCPS 2005]

. 

## 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, ap

proaching 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 dis

eases, 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 prema

turely 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 materi

als, 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 insuf

ficient 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 • Policies that prohibit tobacco smoking throughout the workplace (i.e., smoke-free workplace policies) are now widely implemented, but they have not yet been univer

sally adopted across the United States. These policies improve workplace air qual

ity, 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 ef

fective.

• Integrating both occupational safety and health protection components into work

place 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 employ

ee 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 sup

port programs. Smoke-free zones should encompass (1) all indoor areas without ex

ceptions (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 simi

lar 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).

ȣ Inform all workers about health risks of tobacco use.ȣ Inform all workers about health risks of exposure to SHS.

ȣ 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 vol

unteers).

ȣ 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.

ȣ 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.

ȣ 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.

ȣ 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., http://www.dol.gov/ebsa/faqs/faqaca19.html ) 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 represen

tatives, line management, occupational safety/health and wellness staff, and human resources professionals. Those providing input should include current and former to

bacco 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 to

bacco 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 lo

cal 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 unintended consequences. These consequences can include the potential for adverse impacts on individual employees (e.g., coercion, discrimination, and breach of priva

cy) 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. Workers can get help from

ȣ tobacco cessation programs, including web-based programs (e.g., http://smokefree. gov and http://www.cdc.gov/tips ) and mobile phone texting services (e.g., the SmokefreeTXT program, http://smokefree.gov/smokefreetxt );

ȣ state quitlines (phone: 1-800-QUIT-NOW [1-800-784-8669], or 1-855-DEJELO-YA [1-855-335-3569 for Spanish-speaking callers]); and/or

ȣ 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, includ

ing 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.This page intentionally left blank.

# Contents

Foreword

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Executive Summary

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Introduction

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Smoking and Other Tobacco Use by Workers—Exposure to Secondhand Smoke at Work

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Health and Safety Consequences of Tobacco Use

. . . . . . . . . . . . . . . . . . . . . . . . . . . vi Combining Tobacco Use and Occupational Hazards Enhances Risk

. . . . . . . . . . vii Preventive Interventions

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Workplace Tobacco Use Cessation Programs

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Health Insurance and Smoking—Using Incentives and Disincentives to Modify Tobacco Use Behavior

. . . . . . . . . . . . . . . . . . . . . . ix Conclusions

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Recommendations

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Abbreviations

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Acknowledgments

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii 1 Background

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 Tobacco Use by Workers and Secondhand Smoke Exposures at Work

. . . . . . . . . . . . 3 Use of Conventional Tobacco Products by Workers

. . . . . . . . . . . . . . . . . . . . . . . . . 3 Tobacco Smoking

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Smokeless Tobacco

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Dual Use

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Secondhand Smoke Exposures at Work

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Electronic Nicotine Delivery Systems

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3 Health and Safety Consequences of Tobacco Use

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Health Problems Caused by Use of Tobacco Products

. . . . . . . . . . . . . . . . . . . . . . . 7 Tobacco Smoking

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Secondhand Smoke

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Smokeless Tobacco

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Electronic Nicotine Delivery Systems

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Traumatic Injuries and Fatalities Caused by Tobacco Use

. . . . . . . . . . . . . . . . 13 Tobacco Use and Increased Risk of Work-related Disease and Injury

. . . . . . . 13 4 Preventive Interventions

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Workplace Policies Prohibiting or Restricting Smoking

. . . . . . . . . . . . . . . . . . . . . 21 Employer Prohibitions on Tobacco Use Extending Beyond the Workplace

. . . . . 24 Workplace Tobacco Use Cessation Programs

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

## xvi Health Insurance and Smoking Behavior

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Using Incentives and Disincentives to Modify Tobacco Use Behavior

. . . . . . . . . 28 5 Conclusions

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 6 Recommendations

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 References

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Appendix

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

## xvii 

# Abbreviations

ACA Affordable Care Act
CDC Centers for Disease Control and Prevention
CIB Current Intelligence Bulletin
COPD chronic obstructive pulmonary disease
ENDS electronic nicotine delivery system
FDA Food and Drug Administration
MSHA Mine Safety and Health Administration
NHIS National Health Interview Survey
NIOSH National Institute for Occupational Safety and Health
OEL occupational exposure limit
OSHA Occupational Safety and Health Administration
SHS secondhand smoke
SIDS sudden infant death syndrome

## xviii 

# Acknowledgments
This Current Intelligence Bulletin (CIB) was developed by staff of the National Institute for Occupational Safety and Health (NIOSH). Robert M. Castellan, MD, MPH; L. Casey Chosewood, MD; Douglas Trout, MD; Gregory R. Wagner, MD; and David N Weissman, MD; were the principal authors. Other contributors were Claire C. Caruso, PhD, RN, FAAN; Jacek Mazurek, MD, MS, PhD; and Susan H. McCrone, PhD, RN. For contributions to the technical content and review of this document, the authors ac

knowledge the following NIOSH contributors: Toni Alterman, PhD; Richard J. Driscoll, PhD, MPH; Thomas R. Hales, MD, MPH; Candice Johnson, PhD ; and Anita L. Schill, PhD, MPH, MA. From the Office of Smoking and Health, CDC: Stephen Babb, MPH

. John Lechliter and Seleen Collins provided editorial support, and Vanessa Williams con

tributed to the design and layout of this document. The following external peer reviewers provided comments on a draft of this CIB: William S. Beckett, MD, MPH Associate Professor of Medicine Harvard Medical School Richard A. Daynard, JD, PhD University Distinguished Professor of Law Northeastern University School of Law James A. Merchant, MD, DrPH Professor of Occupational and Environmental Health University of Iowa College of Public Health Kristin M. Madison, JD, PhD Professor of Law and Health Sciences Northeastern University School of Law Jonathan M. Samet, MD, MS Distinguished Professor and Flora L. Thornton Chair Department of Preventive Medicine University of Southern California Keck School of Medicine Comments on a draft of this document were also submitted to the NIOSH docket by in

terested stakeholders and other members of the public. All comments were considered in preparing this final version of the document.This page intentionally left blank.This page intentionally left blank.

## 1 NIOSH CIB 67 

### • Workplace Tobacco Policies 

# 1 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 ex

traordinarily 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 [DHEW 1964]. 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, esoph

ageal, and pancreatic cancer [e.g., DHHS 1982; 1983; 1984; 1986a,b; 2004; 2006; 2014]. One Sur

geon General’s report focused entirely on smokingenhanced risks of cancer and chronic lung disease for workers exposed to hazardous industrial agents in the workplace [DHHS 1985]. Several reports of the Surgeon General have addressed benefits of effective smoking cessation programs and other means of reducing tobacco use [DHHS 1990, 2000, 2012, 2014]. A Surgeon General’s report also established the ongoing Healthy People strategy, aimed broadly at improving the nation’s health [DHEW 1979a]. Cur

rently, Healthy People 2020 includes a major goal of reducing “illness, disability, and death related to to

bacco use and secondhand smoke exposure” along with several specific objectives that target eliminat

ing tobacco smoking in workplaces [DHHS 2013]. The Centers for Disease Control and Prevention has declared reducing tobacco use a “Winnable Battle,” noting that tobacco use is one of several “public health priorities with large-scale impact on health and with known, effective strategies to address them” [CDC 2013a]. The U.S. Department of Health and Human Services has published a strategic plan for tobacco control that envisions “a society free of tobacco-related death and disease” [DHHS 2010a]. Over time, National Institute for Occupation

al Safety and Health (NIOSH) publications have evolved in how they have acknowledged and made recommendations about hazards associated with tobacco use by workers. The first criteria document published by NIOSH—on asbestos—only briefly mentioned smoking. Smoking was addressed in the context of a discussion of research findings that concluded that smoking alone could not explain the extremely high risk of lung cancer observed in asbestos-exposed workers. Smoking was also men

tioned in a suggestion that the medical monitor

ing recommended by NIOSH for asbestos-exposed workers would offer opportunity for various forms of individualized medical management, including smoking cessation [NIOSH 1972] (see Appendix Table A-2). Nearly a decade later, after substantial

ly more research on asbestos had been published, NIOSH disseminated a document affirming syn

ergistic (i.e., more than additive) effects on lung cancer risk of combined exposure to asbestos and smoking [NIOSH 1980]. In the late 1970s, NIOSH scientists authored a chapter on “The Interaction between Smoking and Occupational Exposure” in the 1979 Surgeon General’s Report on Smoking and Health [DHEW 1979b]. That work led directly to the first NIOSH publication focused solely on tobacco smoke, a Current Intelligence Bulletin (CIB) that outlined several ways in which tobacco use can increase, sometimes profoundly, the risk of occupational dis

ease and injury [NIOSH 1979]. In that CIB, NIOSH recommended that smoking be curtailed in work

places where those other hazards are present and that worker exposure to those other occupational hazards be controlled (see Appendix Table A-1).

## 2 3 NIOSH CIB 67 

### • Workplace Tobacco Policies NIOSH CIB 67 

### • Workplace Tobacco Policies 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 [NIOSH 1991]. In that CIB, NIOSH presented its determination that SHS (referred to in that docu

ment as “environmental tobacco smoke”) causes cancer and cardiovascular disease. In recommend

ing 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 [NIOSH 1991] (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 compre

hensive preventive approach. This evolution has been motivated by a better understanding of how tobacco use adversely impacts occupational dis

eases and injuries and—perhaps just as important

ly—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 [NIOSH 2006] and hexavalent chromium [NIOSH 2013a]—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 haz

ard, both for the worker who smokes and for the nonsmoker who is exposed to [SHS] 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” [Howard 2004]. A 2010 poston the NIOSH Blog site pointed out that “Tobaccofree workplaces, on-site tobacco cessation services, and comprehensive, employer-sponsored health

care benefits that provide multiple quit attempts, have all been shown to increase tobacco treatment success” [Howard et al. 2010]. Thus, instead of staying focused nearly exclusively on protecting workers from specific occupational hazards, NIOSH has progressively adopted a “strat

egy integrating occupational safety and health pro

tection with health promotion to prevent workerinjury and illness and to advance health and wellbeing” [NIOSH 2013b]. This integrated approach, embodied by NIOSH in its Total Worker HealthTM Program [Schill and Chosewood 2013], has mo

tivated NIOSH to produce this CIB, Promoting Health and Preventing Disease and Injury through Workplace Tobacco Policies

.

## 2 3 NIOSH CIB 67 

### • Workplace Tobacco Policies NIOSH CIB 67 

### • Workplace Tobacco Policies 

# 2 Tobacco Use by Workers and Secondhand Smoke Exposures at Work

Use of Conventional Tobacco Products by Workers Tobacco Smoking Since publication of the first Surgeon General’s report on the health consequences of smoking, cigarette smoking prevalence has decreased sub

stantially among U.S. adults, from 42.4% in 1965 to 17.8% in 2013 [DHHS 2014; CDC 2014d]. Nation

ally representative studies on the smoking status of workers in the United States, most often based on one or more iterations of the National Health Inter

view Survey (NHIS), have demonstrated substan

tial declines in overall cigarette smoking, which are similar to the decrease in cigarette smoking among all U.S. adults [Sterling and Weinkam 1976; Nel

son et al. 1994; Lee et al. 2004, 2007; Barbeau et al. 2004]. 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% dur

ing the 2004–2010 period [CDC 2011a, 2013b]. During the past several decades, a number of stud

ies have assessed smoking habits among U.S. work

ers. Consistently, these studies have shown substan

tially higher cigarette smoking prevalence among blue-collar workers compared with white-collar workers, particularly among males [Sterling and Weinkam 1976; DHHS 1985; Stellman et al. 1988; Brackbill et al. 1988; Covey et al. 1992; Nelson et al. 1994; Bang and Kim 2001; Barbeau et al. 2004; Lee et al. 2004, 2007; CDC 2011a; Calvert et al. 2013]. In addition, these studies provide evidence of high

er intensity of smoking among blue-collar workers who smoke than white-collar workers who smoke [Fujishiro et al. 2012]. Among blue-collar workers, those with higher levels of exposure to dust and chemical hazards are more likely to be smokers [Chin et al. 2012]. NIOSH publishes recent data on cigarette smok

ing status by industry and occupation groupings in the Work-Related Lung Disease (WoRLD) Sur

veillance Report and corresponding online updates [NIOSH 2008a, 2014]. The most recent tables, covering the period 2004–2011, show that smok

ing 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 sec

tors in religious, grantmaking, civic, labor, profes

sional, and similar organizations (10.0%). Smoking prevalence exceeding 30% was found among three major industry sectors: construction (32.1%); ac

commodation and food services (32.1%); and min

ing (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 non

metallic 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 occupation

al group, from 2.0% for religious workers to 49.5% for construction trades helpers [NIOSH 2014] (see Appendix Figures A-1a and A-1b).



## Smokeless Tobacco Smokeless tobacco is not burned when used. Types of smokeless tobacco include chewing tobacco,

## 4 5 NIOSH CIB 67 

### • Workplace Tobacco Policies NIOSH CIB 67 

### • Workplace Tobacco Policies snuff, dip, snus, and dissolvable tobacco products. As with smoking, NHIS data have been used to es

timate smokeless tobacco use by workers [Dietz et al. 2011; 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 in

dustry [CDC 2014a; NIOSH 2014]. (Appendix Fig

ures A-2a and A-2b display prevalence of smoke

less tobacco use for major industry and occupation categories.)



## Dual Use Someone who smokes cigarettes and also uses smokeless tobacco engages in “dual use.” This is one way smokers can try to maintain their nico

tine habit when and where smoking is prohib

ited. Based on 2010 NHIS data, more than 4% of U.S. adult workers who smoke cigarettes also use smokeless tobacco in the form of snuff or chewing tobacco [CDC 2014a; NIOSH 2014]. Dual use has traditionally been practiced by many workers, in

cluding coal miners and others, employed in mines or factories where smoking poses risks for explo

sion and fire [Mejia and Ling 2010]. (Appendix Fig

ures A-3a and A-3b display prevalence of dual use among U.S. adult workers who are current smokers for major industry and occupation categories, re

spectively.) Use of electronic cigarettes by persons who also smoke is another form of “dual use” that is becoming more prevalent as electronic cigarette use increases (see below, under “Electronic Nico

tine Delivery Systems”).


## 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 co

tinine, a metabolite of nicotine [Hammond et al. 1995; Hammond 1999; Achutan et al. 2011; Pache

co et al. 2012]. By the late 1990s, studies that objec

tively 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 restau

rants, and still higher concentrations (an order of magnitude higher than in offices) were measured in bars [Hammond 1999]. More recently, in studies involving nonsmoking card dealers at three casinos where smoking was prevalent, objective evidence of absorption of a cancer-causing component of SHS (a tobacco-specific nitrosamine) was docu

mented by showing significant increases in urine levels of a metabolite of that component over a work shift [Achutan et al. 2011]. A comprehensive review of research on SHS exposures in casinos has been published elsewhere [Babb et al. 2015]. Smoke-free workplace policies have been increas

ingly implemented over the past several decades in the United States and have been shown to be ef

fective in reducing exposure to SHS [DHHS 2006, 2014]. In a 1986 survey of the civilian U.S. popu

lation, only 3% of employed respondents reported working under a smoke-free workplace policy [CDC 1988]. Subsequent surveys carried out in the 1990s tracked an increasing proportion of in

door workers who reported that they worked un

der a smoke-free workplace policy—46.5% in 1993, 63.7% in 1996, and 69.3% by 1999 [Shopland et al. 2004]. The 1999 survey found wide disparities; al

though smoke-free workplace policies covered 90% of school teachers, they covered only 43% of food preparation and service workers, and only 13% of bartenders [Shopland et al. 2004]. Although establishment of smoke-free workplace policies continues to progress in the United States, these policies are not always 100% effective. A 2009–2010 nationwide survey found that, among employed nonsmoking adults in the United States whose workplaces were covered by an indoor smoke-free policy, 16.4% reported exposure to

## 4 5 NIOSH CIB 67 

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### • Workplace Tobacco Policies SHS at work 1 or more days during the past 7 days [King et al. 2014]. Still, this favorably compared with the much greater 51.3% of those not covered by smoke-free policies who reported such exposure to SHS at work [King et al. 2014]. 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 [King et al. 2014]. 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 dur

ing the past year—estimated that 10.0% of non

smoking U.S. workers reported frequent exposure to SHS at work [Calvert et al. 2013]. Prevalence of such frequent exposure by major industry sec

tor ranged from 4.1% for finance and insurance to 28.4% for mining, while prevalence by major oc

cupation ranged from 2.3% for education, training, and library occupations to 28.5% for “construction and extraction” occupations (See Appendix Figures A-4a and A-4b). Data from 14 state-based population surveys con

ducted in 2005 indicated that the majority of all indoor workers reported a completely smoke-free workplace policy at their place of employment. State-specific proportions ranged from 54.8% (Ne

vada) to 85.8% (West Virginia), with a median of 73.4% [CDC 2006]. Results from later surveys con

ducted by 13 states in 2008 found proportions of nonsmoking employed adults who reported SHS exposure on 2 or more days during the past 7 days in their indoor workplace ranging from 6.0% (Ten

nessee) to 15.8% (Mississippi), with a state-specific median of 8.6% [CDC 2009]. 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) [King et al. 2014]. 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 educa

tion and income from effects associated with occu

pation [Fujishiro et al. 2012]. 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 pro

fessionals. 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 in

tense for many blue-collar workers. 

## Electronic Nicotine Delivery Systems
F irst introduced into the U.S. market in 2007 [Re

gan et al. 2013], electronic nicotine delivery sys

tems (ENDS), which include electronic cigarettes, or e-cigarettes, are rapidly increasing in use [King et al. 2015]. 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 con

sisting of varying amounts of nicotine, a propylene glycol and/or glycerin carrier, and flavorings. Inha

lation draws the fluid to a heating element, creating vapor that subsequently condenses into an aerosol of minute droplets [Ingebrethsen et al. 2012]. Available data suggest that e-cigarette use has in

creased 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 [Regan et al. 2013]. A more recent survey of U.S. adults found that by 2013 approximately 1 in 3 current smokers reported ever having used e-cigarettes [King et al. 2015]. To date, there have been no nationally representative surveys of ENDS use specifically among workers or specifically in the workplace.This page intentionally left blank.

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# 3 Health and Safety Consequences of Tobacco Use
Health Problems Caused by Use of Tobacco Products Tobacco Smoking Smoking is a known cause of the top fıve health conditions impacting the U.S. population—heart disease, cancer, cerebrovascular disease, chronic lower respiratory disease, and unintentional inju

ries [DHHS 2004] (Table 3-1), and each of these is amenable to preventive intervention [Task Force on Community Preventive Services 2010]. The risk and severity of most adverse health outcomes caused by smoking are directly related to the duration and in

tensity of tobacco smoking, but no level of tobacco smoking is risk-free [DHHS 2010b, 2014]. Smok

ing is responsible for more than 480,000 deaths each year in the United States [DHHS 2014]. It is estimated that more than 16 million U.S. adults live with chronic obstructive pulmonary disease or other disease attributable to tobacco smoking [DHHS 2014]

. Table 3-1. Some health conditions caused by active tobacco smoking General disease category Site or specific health condition

Cancers Lung Bladder Esophageal Laryngeal Oral and throat Cervical Kidney Pancreatic Liver Stomach Colorectal Acute myeloid leukemia
Cardiovascular disease Atherosclerosis Coronary heart disease Cerebrovascular disease (stroke) Abdominal aortic aneurysm Lung disease Chronic obstructive pulmonary disease Acute respiratory infections, including pneumonia Asthma exacerbation Tuberculosis Asthmatic and other respiratory symptoms Accelerated lung function decline

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### • Workplace Tobacco Policies General disease category Site or specific health condition Reproductive effects Reduced fertility Placental abnormalities Ectopic pregnancy Impaired fetal development and congenital orofacial defects Premature delivery Low birth weight Sudden infant death syndrome (SIDS) Erectile dysfunction Other diseases or conditions Cataracts, macular degeneration, and blindness Low bone density and hip fractures Poor wound healing Peptic ulcer disease Periodontitis Diabetes Rheumatoid arthritis Impaired immune function General poor health Source: DHHS [2004, 2014]


### Cancer Smoking is estimated to cause nearly 164,000 can

cer deaths among smokers each year in the United States [DHHS 2014]. Cancers caused by smoking in

clude lung, mouth, throat, bladder, and other cancers (Table 3-1). Among the carcinogens present in ciga

rette smoke are polycyclic aromatic hydrocarbons; N-nitrosamines; aromatic amines; 1,3-butadiene; benzene; aldehydes; and ethylene oxide. In addition to directly causing cancer, smoking can synergistically interact with occupational exposures known to sepa

rately cause cancer, leading to effects on cancer cau

sation greater than the effects of the two factors sepa

rately [Wraith and Mengersen 2007; Frost et al. 2011; Markowitz et al. 2013] (see Box 3-1).



### Cardiovascular Disease Cigarette smoking is estimated to cause nearly 125,000 heart disease deaths among smokers each year in the United States [DHHS 2014]. The constituents of tobacco smoke believed to be re

sponsible for causing cardiovascular disease include oxidizing chemicals, nicotine, carbon monoxide, and particulate matter. Coronary heart disease (ischemic heart disease) makes up the majority of those heart disease deaths. Cerebrovascular disease (vascular disease in the brain), which can cause strokes, is also a major cause of death from smok

ing. Smoking also causes aortic aneurysms and pe

ripheral arterial disease. Smoking is estimated to cause nearly 27,000 cerebrovascular and peripheral vascular deaths among smokers each year in the United States [DHHS 2014]. Even low levels of ex

posure to tobacco smoke—such as a smoking only a few cigarettes per day, occasional smoking, or ex

posure to SHS—are enough to greatly increase risk of cardiovascular events [DHHS 2010b]. 

### Lung Disease Cigarette smoking is estimated to cause more than 113,000 deaths among smokers each year in the Table 3-1 (Continued). Some health conditions caused by active tobacco smoking

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### • Workplace Tobacco Policies United States from non-malignant lung diseases [DHHS 2014]. Some of the chemical pathways by which tobacco smoke produces lung damage have been well characterized. It is likely that familial or genetic factors influence susceptibility to the ad

verse effects of tobacco smoke. Chronic obstructive pulmonary disease (COPD), a broad designation encompassing bronchitis, emphysema, and airways obstruction, accounts for most smoking-caused re

spiratory deaths. As noted above, the effects of oc

cupational exposure to agents that are toxic to the lung can combine with the adverse health effects of tobacco smoke to cause lung disease of greater severity than that expected from either of the expo

sures alone (see Box 3-2). Although smoking is the single most common cause of COPD, occupational exposures—often combined with smoking—play a role in causing about 10% to 20% of all COPD cases [Balmes et al. 2003]. In addition, smoking causes exacerbation of asthma, greater susceptibility to in

fectious pneumonias, and higher risk of tuberculo

sis [DHHS 2014]. 

### Reproductive and Developmental Effects Inhalation of tobacco smoke affects the reproduc

tive system, with harmful effects related to fertil

ity, 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 [DHHS 2014]. 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, still

birth, neonatal death, and sudden infant death syn

drome (SIDS) in their offspring; earlier and more symptomatic menopause; and other effects [DHHS 2001, 2004, 2014; Soares and Melo 2008; Sadeu et al. 2010]. Smoking by men causes erectile dysfunc

tion [McVary et al. 2001; DHHS 2014], which can also impair reproduction. Box 3-1. Lung Cancer Risk in Insulators—Effects of Smoking, Asbestos Exposure, and Asbestosis Cigarette smoking and exposure to asbestos are each well-known causes of lung cancer. Many studies have assessed lung cancer risk among persons who have both smoking and asbestos exposure as risk factors. Frost et al. [2011] confirmed the long-standing view that cigarette smoking raises the risk of death from lung cancer among asbestos-exposed workers in a manner that is greater than addi

tive, if not multiplicative. Results of the study by Markowitz et al. [2013] illustrate effects of smoking combined not just with asbestos exposure, but also specifically with asbestosis (a fibrotic lung disease caused by asbestos). Markowitz et al. reported a long-term mortality study of 2,377 asbestos-exposed insulators identified in 1967 and 54,243 contemporaneous blue-collar workers with little, if any, as

bestos exposure. The insulators were divided into two subgroups—one with and the other with

out radiographic evidence of asbestosis—with roughly equivalent asbestos exposure. Separate lung cancer risks were 10.3-fold for smoking (without asbestos exposure), 3.6-fold for asbestos exposure (without smoking), and 7.4-fold for asbestosis (without smoking). Combined lung cancer risks were 14.4-fold for smoking combined with asbestos exposure and 36.5-fold for smoking combined with asbestosis. The former illustrates an apparent additive effect, because the combined effect was about what would be expected by adding the separate risks for smoking and asbestos exposure. The latter illustrates an apparent supra-additive (i.e., synergistic) effect, because the combined effect is substan

tially greater than what would be expected by adding the separate risks for smoking and asbestosis.

## 10 11 NIOSH CIB 67 

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### 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 degen

eration), hip fractures (due to low bone density), peptic ulcer disease, diabetes, rheumatoid arthritis, and periodontitis [DHHS 2014] (Table 3-1). Smok

ing may also cause hearing loss in adults [Cruick

shanks et al. 1998]. 

### Inflammatory effects of tobacco smoke have been associated with many other health ef

fects. For example, smoking has been found to delay wound healing after surgery and lead to wound complications [Sorensen 2012]. Also, tobacco smoking may increase the risk of hearing loss caused by occupational exposure to excessive noise [Tao et al. 2013]. Research on other health effects associated with ex

posure 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 [DHHS 2014]. There is strong evidence of a causal relationship between SHS of adults and adverse health effects, including lung cancer, heart dis

ease, stroke, exacerbation of asthma, nasal irrita

tion, and (due to maternal exposure) reduced birth weight of offspring (Table 3-2) [DHHS 2006, 2014; IARC 2009; Henneberger et al. 2011]. The evidence that exposure to SHS causes health effects among exposed infants and children is also strong (Table 3-2)[DHHS 2006, 2014; IARC 2009]. 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 nonsmok

ing adults, premature delivery of babies born to women exposed to SHS, and cancers (leukemia, lymphoma, brain cancer) among children exposed to SHS [DHHS 2006, 2014; IARC 2009]. SHS ex

posure may also be associated with hearing loss in adults [Fabry et al. 2011]. Among nonsmoking adults, health risks of SHSexposure extend to workplace exposures. A metaanalysis of 11  pertinent studies provided quanti

tative 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 [Stayner et al. 2007]. A dramatic example of an adverse effect of exposure to SHS in the workplace was an asth

matic worker’s death (see Box 3-3). 

## Smokeless Tobacco Some forms of smokeless tobacco are well docu

mented 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 [Kuempel et al. 2009] 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.

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### • Workplace Tobacco Policies 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 [MIFACE 2006; Stanbury et al. 2008]. Table 3-2. Health Conditions Caused by Exposure to Secondhand Smoke Affected population Adverse health effect Effects on nonsmoking adults Premature death and disease Lung cancer Coronary artery disease Stroke Asthma exacerbation Nasal Irritation

Effects on infants/children Premature death and disease Reduced birth weight (due to maternal SHS exposure) Sudden infant death syndrome (SIDS) Slow lung growth and reduced lung function Lower respiratory illnesses More severe asthma Wheeze illnesses Respiratory symptoms (cough, phlegm, wheeze, breathlessness) Middle ear disease Source: DHHS [2006, 2014]; IARC [2009]; Henneberger et al. [2011]

and pancreatic cancer [IARC 2012], though at gen

erally lower risk levels than those associated with smoking [DHHS 2014]. The most harmful chemi

cals in smokeless tobacco are tobacco-specific nitrosamines, which are formed during the grow

ing, curing, fermenting, and aging of tobacco. Other cancer-causing substances in smokeless tobacco in

clude polonium-210 (a radioactive element found

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### • Workplace Tobacco Policies in tobacco fertilizer and soil) and polynuclear aromatic hydrocarbons (also known as polycyclic aromatic hydrocarbons) [DHHS 1986a]. 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 prod

ucts and represent potential risk to users [Stepanov et al. 2008]. All smokeless tobacco products con

tain nicotine, a highly addictive substance which is plausibly responsible for high risks of adversereproductive outcomes (e.g., low birth weight, preterm delivery, and stillbirth) associated with mater

nal use of snus [DHHS 2014]. 

## Electronic Nicotine Delivery Systems 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 [Brown and Cheng 2014; Orr 2014; Bhatnagar et al. 2014]. Questions remain regarding potential im

pacts of ENDS use on individual and population level health. Contrary to some marketing messages, aerosol emitted from ENDS is not merely water va

por. Many of the hazardous components identified in tobacco smoke are present in ENDS emissions, though mostly at much lower levels. Liquids for

mulated for ENDS use commonly contain nicotine and flavorings in a propylene glycol and/or glycerin carrier, but exact formulations of these predomi

nant constituents and other additives and contami

nants vary widely and are not well standardized [Cheng 2014]. In sum, aerosol generated by ENDS use is not as safe as clean air [CDC 2014c]. Secondhand exposure to nicotine is not with

out potential risk for bystanders in the vicinity ENDS use. Nicotine is addictive and is associated with various systemic toxicities at sufficient doses [NIOSH 2012] and adverse vascular effects at low doses [DHHS 2010b]. For non-smokers, nicotine is an acute irritant, capable of causing headache, nau

sea, and discomfort; for former smokers, nicotine exposure can trigger cravings jeopardizing their abstinence [DHHS 2014]. In pregnant women, nicotine can be transferred to and have toxic ef

fects on the developing fetus [DHHS 2014]. In ad

dition, other substances that have been detected or can be reasonably anticipated in aerosol produced by ENDS include known carcinogens, respiratory irritants, and other harmful and potentially harm

ful constituents [FDA 2009; McAuley et al. 2012; Schripp et al. 2013; Schober et al. 2013; Schaller et al. 2013; Bhatnagar et al. 2014; Cheng 2014; Gonie

wicz et al. 2014; Grana et al. 2014]. A recent review of the safety of ENDS use concluded that more re

search is warranted to determine the risk posed by various components of the liquids used in ENDS, including flavoring components in particular “be

cause the effects of inhaling flavoring substances approved for food use are largely unknown” [Far

salinos and Polosa 2014]. Some flavorings intended for ingestion have been shown to cause serious lung disease when inhaled at high concentrations in other contexts [NIOSH 2004; CDC 2013c]. Fur

thermore, beyond the concerns of nonuser expo

sure to nicotine and these other components, there is also potential for ENDS to be used to deliver psy

choactive substances such THC, the active ingredi

ent in marijuana [Welch 2014]. A study funded by an organization that promotes consumer access to ENDS as a means of harm re

duction for nicotine-addicted individuals, empha

sizes that estimated exposure levels associated with the use of ENDS are generally much lower than occupational exposure limits (OELs) for toxic in

dustrial hazards [Burstyn 2014]. However, this sort of comparison should be interpreted with caution because OELs are typically set to reduce, rather than totally prevent, adverse effects among exposed workers. Furthermore, OELs are not set to protect persons with particular vulnerabilities (e.g., asthma, cardiac or circulatory conditions, pregnancy). Fi

nally, health-protective OELs have not been estab

lished for all chemicals capable of causing serious health impact on exposed workers [NIOSH 2004; CDC 2013c]. Thus, findings that exposures are be

low OELs should not lead directly to a conclusion that such exposures are entirely safe. Moreover,

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### • Workplace Tobacco Policies another assessment concluded that current expo

sure guidelines for some components of ENDS emissions may in fact be exceeded during ENDS use, even for those exposed secondhand [Offerman 2014]. A recent white paper from the American In

dustrial Hygiene Association thoroughly reviewed the ENDS issue and cautioned that “... the existing research does not appear to warrant the conclusionthat e-cigarettes are “safe” in absolute terms ... ecigarettes 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” [AIHA 2014]. Although much remains to be done, evaluation of ENDS exposures and short-term health effects has been a rapidly developing area of research. An experimental chamber study in which air contami

nants were measured documented degradation of indoor air quality during ENDS use and found that air measurements of polycyclic aromatic hydrocar

bons classified as probable carcinogens by IARC increased an average of 20% during ENDS use [Schober et al. 2013]. In light of irritant compounds (e.g., formaldehyde, acetaldehyde, and acrolein) identified in emissions from ENDS, it has been rec

ommended that research be done to evaluate possi

ble adverse effects of exposure to these compounds among ENDS users and individuals exposed to sec

ondhand ENDS aerosol [Goniewicz et al. 2014]. In

deed, findings relating to short-term adverse effects on ENDS users include preliminary reports of sig

nificantly increased airways resistance [Gennimata et al. 2012] and respiratory irritation and cough, particularly among individuals with asthma [Tsi

krika et al. 2014]. No studies to date have observed similar short-term effects due to secondhand expo

sure to ENDS aerosol, but one experimental study demonstrated that passive exposure of human vol

unteers to ENDS emissions did cause measurable changes in serum levels of cotinine, a metabolite of nicotine [Flouris et al. 2013]. It is plausible that personal use of ENDS and even sec

ondhand exposure to ENDS aerosol will also lead to adverse long-term health effects, but current data are insufficient to quantify the risks [Wagener et al. 2012; BMA 2013; Kamerow 2013; AIHA 2014; Bhatnagar et al. 2014; Drummond and Upson 2014; Schrauf

nagel et al. 2014]. Evaluating potential long-term health effects of ENDS use is an important research priority [Andrade and Hastings 2013; AIHA 2014]. 

## 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 [Hall 2013]. Annual estimates have been declin

ing over time, in part due to the decline in smok

ing [Hall 2013]. In addition to injuries caused by smoking-related fires, use of tobacco products is a recognized distracting factor while operating mo

tor vehicles [NHTSA 2009], and smoking while driving has been shown to increase the risk of be

ing involved in a crash [Young et al. 2003]. Adverse smoking-associated physiological alterations in bone mineralization, blood vessels, and inflam

matory response [Leistikow 2000a] may also con

tribute to higher risk of injuries, impaired recov

ery, and higher rates of associated disability among smokers [Lincoln et al. 2003].


## 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 fa

tal health problems, as outlined above. What many workers and their employers often do not fully un

derstand is that tobacco use can increase, some

times profoundly, the likelihood and/or the sever

ity of occupational disease and injury caused by other hazards present in their workplaces. In addi

tion, workplace exposure to SHS can cause serious health effects among nonsmoking workers [NIOSH

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### • Workplace Tobacco Policies 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 mul

tiple causes [NIOSH 1979; DHEW 1979b; DHHS 1985; IARC 2004. In some workplaces, an industrial toxicant released from work processes is also present in tobacco products and/or tobacco smoke. Thus, exposures to these toxicants and the risks of disease associ

ated with them can be increased for workers who use tobacco or are exposed to SHS. These chemicals include acetone, acrolein, aldehydes (e.g., formal

dehyde), arsenic, cadmium, carbon monoxide, hy

drogen cyanide, hydrogen sulfide, ketones, lead, methyl nitrite, nicotine, nitrogen dioxide, phenol, and polycyclic aromatic compounds [NIOSH 1979]. Heat generated by smoking tobacco in the work

place can transform a workplace chemical to a more toxic chemical [NIOSH 1979; DHEW 1979b; DHHS 1985]. Though smokers are most highly ex

posed to the transformed chemical, nonsmoking coworkers in the same work area may also be ex

posed. Examples of occupational agents that have the potential for conversion to highly toxic chemi

cals by smoking tobacco products include polytet

rafluoroethylene (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 theworkplace 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 [1979, 1991]

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### • Workplace Tobacco Policies Tobacco products can readily become contaminat

ed by industrial toxicants in the workplace through contact of the tobacco products with unwashed hands or contaminated surfaces and through de

position of airborne contaminants onto the tobacco products. Subsequent use of the contaminated to

bacco 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 absorp

tion [NIOSH 1979; DHEW 1979b]. 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 indepen

dently caused by tobacco use and workplace expo

sure 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 [NIOSH 1979; DHEW 1979b; DHHS 1985]. For some occupational hazards, the combined im

pact of tobacco use and exposure to the occupa

tional agent can be synergistic (i.e., amounting to an effect much greater than the sum of each inde

pendent effect). Adverse biological effects of smok

ing on the respiratory tract can lead to higher effec

tive 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 [DHHS 1985]. 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 [DHHS 1985; IARC 2004]. 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 expo

sure both independently cause lung cancer. Work

ers 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 in

dependent 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 cough— occurred 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 [CDC 1987].

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### • Workplace Tobacco Policies 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 syn

ergistic effects may involve consideration of tempo

rality 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 ra

don [Thomas et al. 1994; IARC 2004]. With regard to temporality of outcome, radiation-induced lung cancer among radon exposed workers may occur earlier (i.e., with shorted latency) in workers who smoke than in nonsmoking workers [DHHS 1985]. When combined with certain occupational haz

ards, tobacco use can also enhance the risk of occupational traumatic injuries, fatalities, and property loss. First, smoking in the workplace can ignite explosive and other flammable materi

als. Smoking has been implicated as the known or suspected cause of several major industrial disas

ters in the United States, including the infamous Triangle Shirtwaist Factory fire in 1911 [Leistikow et al. 2000b]. To help prevent occupational explo

sions and fires, the Occupational Safety and Health Administration (OSHA) and the Mine Safety and Health Administration (MSHA) have established a number of regulations prohibiting use and posses

sion of smoking-related materials (e.g., cigarettes, cigars, pipes, lighters, matches) in designated haz

ardous work areas (see Appendix Table A-3). De

spite existing regulations and widespread aware

ness of the risk, occupational injuries and fatalities caused by smoking have continued to occur in the United States. Though prohibited in underground coal mines, smoking materials ignited three fa

tal coal mine explosions between 1990 and 2000 [MSHA 2000]. OSHA records for 2000 through 2012 include documentation of 13 work-related fires or explosions—five of them fatal and all of them involving employee injuries—where smok

ing materials were implicated as the ignition source [OSHA 2013a] (see Box 3-6). 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, extinguish

ing, or disposing of a tobacco product) or by a tobacco-caused coughing spell can result in trau

matic injury or death when that worker is driving a work vehicle or operating other potentially hazard

ous machinery or equipment [NIOSH 1979]. Sev

eral studies have shown that smokers are more like

ly to be injured at work than nonsmokers [Ryan et al. 1992; Sacks and Nelson 1994; Craig et al. 2006]. 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

Box 3-6. Smoking-ignited Fire Engulfs a Painting Crew—Two Dead and 11 Others Hospitalized On July 29, 2003, two painting crews were working in a new residential subdivision when one of their two box trucks broke down near the end of the day. The company had the driver of the other truck pick up the stranded crew. That put 13 employees in the back of the truck and four in the cab. The truck was loaded with paints, lacquer thinner, stains, and acrylics, among other paint chemicals. A can of lacquer thinner spilled while employees were smoking in the truck. A lighted cigarette or a spark from a lighter ignited the lacquer thinner vapors. The truck was engulfed immediately. All 13 employees in the back of the truck were hospitalized for severe burns, and two of them died as a result of their injuries [OSHA 2013b].

## 16 17 NIOSH CIB 67 

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### • Workplace Tobacco Policies by tobacco use for users and for non-users. For example, tobacco smoking in a workplace will put nonsmoking workers in that workplace at in

creased risk due to their workplace exposure to SHS. In contrast, in workplaces free of other oc

cupational chemical or physical hazards, use of smokeless tobacco would not be expected to re

sult 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 ex

plosive atmospheres are present, and can result in secondhand exposure of coworkers (see Electronic Nicotine Delivery Systems, above).This page intentionally left blank.

## 19 NIOSH CIB 67 

### • Workplace Tobacco Policies 

# 4 Preventive Interventions

A range of efforts has been undertaken to decrease tobacco use in the workplace and by workers. Most of these interventions focus on smoking, which is the most prevalent form of tobacco use (see Part I, above). Policies related to tobacco use in work

places originally focused on prohibiting smoking in industrial work areas where explosion hazards were present. Currently, workplace tobacco policies increasingly center on the following:

• Smoke-free or tobacco-free indoors or campuswide prohibitions.

• Other restrictions on tobacco use by employees.

• Tobacco vending machines removal and pro

hibiting other onsite sales of tobacco in work

places.

• Provision of tobacco cessation programs.

• Employer-provided health insurance benefits designed to increase access and remove bar

riers 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 fed

eral government laws and/or regulations. Others are independently implemented by employers as workplace requirements or conditions of employ

ment. Employees and/or labor organizations can share in a sense of joint ownership if they meaning

fully collaborate with the employer on policy lan

guage, approaches and timing, cessation supports, and compliance and consequence issues. Involving employees in the development, implementation, and evaluation of workplace programs is an effec

tive strategy for changing employee culture and be

havior [NIOSH 2008b]. Workplace tobacco policies are underpinned by several motivating interests (Boxes 4-1 and 4-2). First and foremost is an interest in protecting to

bacco 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.
Adapted from DHHS [1996]

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### • Workplace Tobacco Policies Box 4-2. Some Reasons for Employees to Quit Tobacco Use
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 to

bacco 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 becom

ing pregnant or during the first trimester of pregnancy).

• Increase the likelihood that one’s young children will not use tobacco when they reach adoles

cence 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 dis

ability 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 f ıve health conditions that impact the U.S. population [Task Force on Community Preven

tive Services 2010]. Protecting the health of non

smoking workers is another important motivating interest. Although the health and safety conse

quences of tobacco use offer sufficient rationale for workplace tobacco policies, legal and econom

ic 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 expo

sure to SHS.

## 20 21 NIOSH CIB 67 

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### • Workplace Tobacco Policies Legally determined employer responsibility to pro

vide employees with a safe workplace can motivate action by employers. OSHA does not currently ap

ply the “general duty clause” [29 USC § 654; Section 5(a)1] of the Occupational Safety and Health Act of 1970 (OSH Act), Public Law 91-596, to SHS expo

sure, but this is “a matter of prosecutorial discre

tion” [OSHA 2003]. Therefore, employers would do well not to ignore other legal implications of their duty to provide safe workplaces, including work

places that are free from SHS exposure [Zellers et al. 2007]. Employees may bring claims under state workers’ compensation laws for illness or injury attributable to SHS smoke exposure in the work

place, under federal or state disability law for failing to provide reasonable accommodations to allevi

ate 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[Zellers et al 2007]. Adopting an effective smokefree (or tobacco-free) workplace policy would pro

tect 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, espe

cially those with the least discretionary income, are unaware of longer-term financial costs. One finan

cial writer estimated in 2007 that a typical pack-aday smoker who is spending nearly $2,000 annu

ally 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 retire

ment account invested with an emphasis on growth [Karp 2007]. That estimate did not encompass costs of smoking other than the purchase price of tobac

co. 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. Fi

nancial 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 prop

erty. 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 esti

mated excess annual cost to U.S.-based private em

ployers associated with employees who smoke ciga

rettes 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 em

ploy a nonsmoker [Berman et al. 2013]. Interven

tions that help smoking workers quit can benefit a business’ bottom line [NBGH 2013]. 

## Workplace Policies Prohibiting or Restricting Smoking For safety reasons, smoking has long been pro

hibited in particular work settings where explo

sive 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, con

cern about worker health has motivated additional policies prohibiting the use of tobacco products in specific work sites where exposure to certain haz

ardous 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 prohibi

tions has been imperfect [MSHA 2000], indicating a need for ongoing training and vigilance. In the last decades of the past century, as the pub

lic became more aware of the hazards of exposure to SHS, government (at the local, state, and federal

## 22 23 NIOSH CIB 67 

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### • Workplace Tobacco Policies levels) acted with the intent to reduce workplace exposures to SHS and subsequently to eliminate SHS from workplaces [DHHS 2006]. The Sur

geon General has concluded that there is no riskfree level of exposure to SHS [DHHS 2006, 2010b, 2014]. Complete prohibitions on workplace smok

ing have been shown to be effective in essentially eliminating SHS in workplaces [Hammond 1999]. Other measures, such as separating smokers from nonsmokers, cleaning the workplace air, and ven

tilating buildings, cannot eliminate exposures of nonsmokers to SHS [NIOSH 1991; DHHS 2006, 2014; ASHRAE 2013]. Thus, ventilation is not an acceptable alternative to making workplaces com

pletely tobacco smoke-free. Federal actions have been implemented to elimi

nate SHS from some workplaces. Actively sup

ported 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, be

ginning in 1988 with shorter domestic flights and by 2000 encompassing all flights originating and/or terminating in the United States [Pan et al. 2005]. In 1990, the Interstate Commerce Commission act

ed to ban smoking on interstate buses [49 CFR Part 374.201]. 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 excep

tions (e.g., specially equipped designated smoking areas, certain residential settings, and space occu

pied by non-federal parties)[Cook and Bero 2009]. In 2009, this policy to prohibit smoking in all inte

rior 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 court

yards where those outdoor spaces are under GSA jurisdiction [73 Fed. Reg. 77517]. OSHA proposed a rule that would have more universally restricted smoking in the workplace [OSHA 1994], but later withdrew the proposed rule, noting that workplace regulation of SHS was being advanced by private employers and by state and local governments [OSHA 2001]. The first comprehensive local and state laws restrict

ing smoking in private workplaces, restaurants, and bars went into effect in 1993 (Shasta County, Cali

fornia) and 2002 (Delaware), respectively [CDC 2011b, 2012]. By the end of 2010, CDC reported that 26 states, the District of Columbia, and a ma

jority of the 50 largest U.S. cities had enacted com

prehensive smoke-free laws prohibiting, with no exceptions, smoking in all indoor areas of private workplaces, restaurants, and bars [CDC 2011b, 2012]. Additionally, there has been a decline from 12/31/04 to 12/31/09 in the number of states with laws preempting the regulation by local authorities of smoking in government workplaces (from 16 to 9 states), private workplaces (from 15 to 9 states), and restaurants (from 18 to 12 states) [CDC 2010]. There is no fundamental legal impediment to adop

tion of smoke-free workplace policies by private employers [Graff 2008], 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 ac

credited hospitals, achieving a high level of com

pliance within just 2 years [Longo et al. 1995]. In addition to its intended effect on exposure to SHS, this policy has been associated with additional ben

eficial impacts on workplace safety and property loss (see Box 4-3). Many other businesses also vol

untarily 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 [Shopland et al. 2004]. A number of studies, including meta-analyses, have shown that smoke-free workplace policies de

crease exposure of nonsmoking employees to SHS at work and increase cessation among employees who smoke [DHHS 2006; IARC 2009; Hopkins et al. 2010]. Although one review of the literature found

## 22 23 NIOSH CIB 67 

### • Workplace Tobacco Policies NIOSH CIB 67 

### • Workplace Tobacco Policies inconclusive evidence that smoke-free workplace policies cause smokers to quit altogether [Call

inan et al. 2010], 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 [Fichtenberg and Glantz 2002; Bauer et al. 2005; DHHS 2006; IARC 2009; Hop

kins et al. 2010]. In contrast, less restrictive work

place smoking policies are associated with sus

tained tobacco use among workers [DHHS 2006; IARC 2009]. A nationally representative survey found that in workplaces without a workplace rule limiting smoking, workers were significantly more likely to be smokers [Ham et al. 2011]. There is clear evidence of improved health among workers as a result of policy interventions to make indoor spaces, including workplaces, smoke-free [Callinan et al. 2010]. 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 [DHHS 2006; IARC 2009; DHHS 2014]. Implementation of smoke-free policies also has been shown in eco

logical studies to be associated with reduced hospi

talizations for heart attacks in the general popula

tion [IARC 2009; IOM 2010; Tan and Glantz 2012; DHHS 2014]. Results of similar studies suggest that such policies may also reduce hospitalizations and emergency department visits for asthma [Hahn 2010; Mackay et al. 2010; Tan and Glantz 2012; Herman and Walsh 2011]. Smoke-free policies in Box 4-3. Smoke-free Policies and Reduction in Structural Fires in Health-Care Facilities 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. No

tably, 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 [Arhens 2010].

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 after

ward. 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 mea

surements also improved. The authors of this study concluded that making taverns and bars smokefree resulted in a rapid improvement in the health of bartenders [Eisner et al. 1998].

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### • Workplace Tobacco Policies 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 [DHHS 2006; IARC 2009]. Acting on strong evidence of the effectiveness of smoke-free policies available by 2001, the Task Force on Community Preventive Services recom

mended workplace smoking bans and restrictions as effective means for reducing exposure to SHS [Hopkins et al. 2010]. More recent evidence has led the Task Force to now recommend smoke-free workplace policies (i.e., total prohibition of smok

ing 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 morbid

ity and mortality [Hopkins et al. 2010; Task Force on Community Preventive Services 2010; GCPS 2012a]. To prevent SHS exposures, the recent Sur

geon General’s report urges that comprehensive smoke-free indoor protections be extended to the entire U.S. population [DHHS 2014]. World Health Organization reports have recom

mended that, in the absence of evidence that can assure authorities that use of ENDS does not ex

pose bystanders to toxic emissions, ENDS should not be exempted from laws that restrict the places in which cigarette smoking is allowed [WHO 2009, 2014]. The British Medical Association has taken the position that use of e-cigarettes should be pro

hibited in workplaces and public places, not only to limit potentially harmful effects of secondhand exposures, but also to ensure that their use does not undermine smoking prevention and cessation efforts [BMA 2013]. 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 [FGIRA 2012], and the American Heart Association hasrecommended including e-cigarettes in smokefree laws [Bhatnagar et al. 2014]. The Forum of International Respiratory Societies has recom

mended that ENDS use be prohibited “in public places, workplaces, and on public transportation” [Schraufnagel et al. 2014]. The American Indus

trial Hygiene Association similarly reviewed the issue of ENDS and concluded that “their use in the indoor environment should be restricted, consis

tent 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 [AIHA 2014]. In the United States, the number of states and localities that ex

plicitly prohibit use of e-cigarettes in public places where tobacco smoking is already prohibited is in

creasing with time [ANRF 2014], totaling 3 states and more than 200 localities before the end of 2014 [CDC 2014c]. Employers are taking notice, and some are acting to prohibit ENDS use in their workplaces [Slavit 2011; Gay 2013; Moore 2014]. Given the current unregu

lated nature of ENDS and the liquid concoctions used them, along with uncertainty about the im

pact 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 [Phillips 2014]. 

## Employer Prohibitions on Tobacco Use Extending Beyond the Workplace Some employers have taken action to extend re

strictions on tobacco use by their employees be

yond the workplace. For example, in 2013, the U.S. Public Health Service Commissioned Corps be

came the first federal uniformed service to prohibit tobacco use by its officers whenever and wherever they are in uniform [ACPM 2013]. More contro

versial are attempts of private employers to con

trol 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 [Toland 2013]. Several large employers and orga

nizations (including the Cleveland Clinic, Union

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### • Workplace Tobacco Policies Pacific Railroad, the World Health Organization, and several others) have gone further by barring the hiring of smokers [Asch et al. 2013; Schmidt et al. 2013]. Controversy surrounds many organizational poli

cies that bar the hiring of smokers or prohibit to

bacco use by employees during the workday when they are away from the worksite even on their own time. Proponents argue that a nonsmoking work

force serves as a positive role model for health, ex

periences better health status, incurs substantially lower health-care costs for employers and employ

ees alike, and improves productivity [Asch et al. 2013]. Opponents posit the addictive nature of to

bacco and the fact that tobacco use usually begins in adolescence, note that tobacco use remains legal, and cite the disparate and potentially discrimina

tory 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 simi

larly 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 employ

ers from refusing to hire individuals because they smoke [Schmidt et al. 2013]. 

## 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 to

bacco and about half reported having tried to quit in the previous year [Yong et al. 2014]. Just as poli

cies increasing tobacco taxes at the state and federal levels have led to increased calls to state telephone tobacco cessation quitlines [McGoldrick and Boonn 2010], implementing tobacco-free work

place 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 work

place are more likely to intend to quit in the next 6 months [Ham et al. 2011]. Various levels and types of cessation support can be provided [DHHS 1996]. 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 [O’Hara et al. 1993; Clinical Practice Guideline 2008]. This basic approach can be read

ily ‘piggy-backed’ on occupational health services that already exist in many workplaces. For example, all workers enrolled in OSHA-mandated respira

tory protection programs must be asked about to

bacco use as part of their medical evaluation (see Appendix Table A-2 for applicable OSHA standard numbers ) . Other existing opportunities to ascertain individual smoking behavior include post-employ

ment (pre-placement) examinations, fitness-forduty evaluations, and other health examinations already provided by employers. Whenever workers who smoke are identified, they can be counseled and offered cessation assistance. Occupational health providers and workplace health promotion staff can offer basic cessation assistance by encouraging workers to use tobacco cessation telephone quitlines, web-based cessation services, and cessation text-messaging programs, such as those offered by the National Cancer In

stitute through http://smokefree.gov/smokefreetxt

. State quitlines exist in all 50 states and the District of Columbia, are publicly funded, are typically avail

able at no cost to smokers, and often provide free or discounted FDA-approved cessation medications. Callers can access their state quitline by dialing 1-800-QUIT-NOW (1-800-784-8669). Similarly, Spanish-speaking callers can access Spanish-lan

guage services from their state quitline by calling 1-855-DEJELO-YA (1-855-335-3569). Because of strong evidence that quitlines increase quit rates, the 2008 Public Health Service Clinical Practice Guideline and the Community Preventive Services Task Force recommend quitline interventions, es

pecially proactive quitlines where the counselor initiates follow-up calls [GCPS 2012b; Clinical

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### • Workplace Tobacco Policies Practice Guideline 2008]. The Public Health Ser

vice Guideline further concludes that quitlines are effective with diverse populations and have broad reach [Clinical Practice Guideline 2008]. Similarly, the Community Preventive Services Task Force found that quitlines—especially proactive quitlines where the counselor initiates follow-up calls—in

crease tobacco cessation among callers who are in

terested in quitting and can help expand the use of evidence-based cessation services among smokers in populations that have limited access to cessation treatment [GCPS 2012b]. An updated Cochrane review has reaffirmed the effectiveness of proac

tive quitlines [Stead et al. 2013]. Their widespread availability, ease of accessibility, affordability, and potential reach to populations with higher levels of tobacco use make quitlines an important com

ponent of any cessation effort [Clinical Practice Guideline 2008]. 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% men

tioned the availability of the state quitline in their health promotion messages to workers [Hughes et al. 2011]. The most comprehensive workplace cessation pro

grams go well beyond minimal cessation counsel

ing and referral to no-cost quitlines and web-based programs. Employers can enter into preferred re

lationships with state quitlines or contract quitline providers to establish employer-specific quitlineswith special services [Lichtenstein et al. 2010]. Webbased intervention to assist with tobacco cessation is a less studied but promising approach [Clinical Practice Guideline 2008; Civljak et al. 2013]. One report described success achieved by a major cor

poration with a program offering employees webbased cessation intervention [Graham et al. 2007]. Individualized counseling and support can often be provided by an existing employee assistance pro

gram. A systematic review of the literature found that workplace-based smoking cessation services such as individual and group counseling, pharma

cological treatment, and social support are all effec

tive in enhancing quit rates when compared with no interventions or minimal interventions [Cahill and Lancaster 2014]. Optimal work-based tobaccocessation programs are designed to provide followup assistance and to support multiple quit attempts, because most smokers try to quit repeatedly before finally succeeding [Clinical Practice Guideline 2008]. Ideally, employers should incorporate tobacco cessation support programs into a more compre

hensive approach that addresses the overall safety, health, and well-being of workers. A growing evi

dence base supports the enhanced effectiveness of workplace programs that integrate health promo

tion efforts such as smoking cessation with more specific occupational health protection programs [Hymel et al. 2011; NIOSH 2013b]. Such inte

grated 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 manufac

turing 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 mes

sages alone [Sorensen et al. 2003]. Another dem

onstration study of an integrated program aimed at enhancing smoking cessation among blue collar workers targeted participants in a union appren

ticeship program [Barbeau et al. 2006] (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-based smoking cessa

tion treatments [Clinical Practice Guideline 2008].

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### • Workplace Tobacco Policies Ideally, such coverage should provide access to all evidence-based cessation treatments, includ

ing individual, group, telephone counseling, and all seven FDA-approved cessation medications [Clinical Practice Guideline 2008; CDC 2014c]. This coverage should have minimal barriers (such as cost-sharing and prior authorization) or no barriers [Clinical Practice Guideline 2008; CDC 2014b]. The coverage should also be promoted to tobacco users and health-care providers to ensure that they are aware of it and to that the covered treatments are used [Clinical Practice Guideline 2008; CDC 2014b]. Many workers are covered by employer-provided health insurance, and the employer can negotiate with the insurance company to set benefits, pre

miums, and cost shares for covered workers. For multi-employer health insurance programs that cover millions of union workers, representatives of the union also have a voice in the process. Insur

ance companies and human resources managers responsible for designing and negotiating health insurance plans need to be aware of various laws at the state and federal levels that limit what can be negotiated. Applicable federal laws include the Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191, and the Patient Protection and Affordable Care Act (ACA), Pub

lic Law 111-148, which is now being implemented [Madison et al. 2013]. The ACA includes provisions pertinent to tobacco use and cessation [McAfee et al. 2015]. For the many workers covered by group and individual private health insurance plans, including both fully insured and self-insured employer coverage, the ACA requires non-grandfathered private plans to cover—without cost sharing—all preventive ser

vices judged by the U.S. Preventive Services Task Force to provide a high certainty of substantial (grade A) or a moderate-to-substantial (grade B) net benefit. This includes tobacco use counseling and tobacco cessation interventions, to which the Box 4-5. Demonstration of a Smoking Cessation Program for Blue-Collar Workers 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 featur

ing 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 [Barbeau et al. 2006].

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### • Workplace Tobacco Policies Task Force assigned an “A” grade [Kofman et al. 2012]. 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) screening for tobacco use; (2) at least two quit attempts a year, with each quit attempt in

cluding four sessions of individual, group, and tele

phone counseling of at least ten minutes each and all seven FDA-approved cessation medications for a 90-day course [USDOL 2014 McAfee et al. 2015]. The guidance further states that none of these treat

ments should be subject to cost-sharing or prior authorization [USDOL 2014; McAfee et al. 2015]. If fully implemented by health insurers, this level of coverage, which is closely based on the 2008 U.S. Public Health Service Clinical Practice Guideline, would be expected to increase smokers’ access to proven cessation treatments and to help thousands of smokers quit [McAfee et al. 2015]. Insurers and employers who sponsor health insur

ance coverage for their employees will have ex

panded opportunities to design incentives for well

ness programs, including interventions intended to enhance tobacco cessation (or, with some limi

tations, 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 premi

ums charged non-tobacco users [Kofman et al. 2012; Madison et al. 2013]. However, issuers who impose these surcharges in the small-group mar

ket must provide tobacco users the opportunity to avoid them, for example by participating in a cessa

tion program [78 Fed. Reg. 33158]. States have au

thority to limit the magnitude of such surcharges, and a number of states have done so [CMS 2014]. 

## 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 to

bacco 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 ces

sation 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 [Towers Watson 2011].
A clear barrier that reduces use of evidence-based cessation treatments is out-of-pocket costs for cessation counseling and FDA-approved cessa

tion medications. Because of strong evidence that the number of tobacco users who quit can be in

creased by reducing these out-of-pocket costs, the Community Preventive Services Task Force recom

mends reducing tobacco users’ out-of-pocket costs for cessation treatments [GCPS 2012c].
The Task Force had earlier examined the issue of providing incentives for tobacco cessation, findinginsufficient evidence at that time that workplacebased incentives or competitions by themselves re

duced tobacco use among employees [GCPS 2005]. Even then, the Task Force went on to recommend worksite-based incentives and competitions when they are combined with other evidence-based in

terventions (e.g., education, group support, tele

phonic counseling, self-help materials, smoke-free workplace policies) as part of a comprehensive ces

sation program [GCPS 2005]. A subsequent systematic review of the literature identified a single well-designed study in which financial incentives integrated into a smoking ces

sation program produced a substantial and sus

tained beneficial impact [Cahill and Perera 2011]. Incentive payments for that randomized trial werestructured as $100 for completion of the smokingcessation program; $250 for abstinence (confirmed biochemically) during the first 6 months after study

## 28 29 NIOSH CIB 67 

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### • Workplace Tobacco Policies enrollment; and $400 for abstinence (also con

firmed 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) [Volpp et al. 2009]. Notably, this study did not involve establishing a new smoking cessation program; rather, all participants were informed about exist

ing 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 [Madison et al. 2011]. The authors identified a number of specific issues that call for scrutiny, including the need to ensure that incen

tive 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 collab

orative, 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 [Madison et al. 2011]. 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 un

intended consequences. For example, these prac

tices 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 [Madison et al. 2011; McAfee et al. 2015]. 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 indi

viduals [Madison et al. 2011, 2013]. In summary, workplace policies are powerful tools that can benefit worker health. Well-designed poli

cies protect workers from occupational risks, pro

vide workplace-associated opportunities for en

hancing worker health, and motivate workers to take beneficial actions to protect their well-being. Although not a primary focus of this CIB, work

place policies that effectively sustain or improve worker health can also be cost-effective and benefit the employer’s bottom line.This page intentionally left blank.

## 31 NIOSH CIB 67 

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# 5 Conclusions

• Cigarette smoking by workers and SHS ex

posure 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 var

ies widely by industry and occupation, ap

proaching or exceeding 30% in construction, mining, and accommodation and food ser

vices 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 construc

tion and extraction jobs and by nearly 20% of workers in the mining industry, which can beexpected to result in disparities in tobaccorelated morbidity and mortality.

• Tobacco use causes debilitating and fatal dis

eases, including cancer, respiratory diseases, and cardiovascular diseases. These diseases afflict mainly users, but they also occur in those exposed to SHS. Smoking is substan

tially 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, explo

sion, and vehicular collisions.

• Tobacco use by workers can increase, some

times 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 spe

cific work areas where particular high-risk oc

cupational hazards are present (e.g., explosives, highly flammable materials, or highly toxic ma

terials 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 insuffi

cient 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 through

out 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 dur

ing the working day by employees who con

tinue 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 ex

isting occupational health and wellness pro

grams. Even minimal counseling and/or sim

ple referral to state quitlines, mobile phone texting interventions, and web-based inter

vention can be effective, and more compre

hensive programs are even more effective.

• Integrating both occupational safety and health protection components into workplace health promotion programs (e.g., smoking

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### • Workplace Tobacco Policies cessation) can increase participation in to

bacco cessation programs and successful ces

sation 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.

## 32 33 NIOSH CIB 67 

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### • Workplace Tobacco Policies 

# 6 Recommendations

The following recommendations relate specifically to the issues raised in this CIB. NIOSH recom

mends that employers take the following actions related to employee tobacco use:

• At a minimum, establish and maintain smokefree workplaces that protect those in workplac

es from involuntary, secondhand exposures to tobacco smoke and airborne emissions from e-cigarettes and other electronic nicotine de

livery 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 to

bacco-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 to

bacco products in work areas characterized by the presence of explosive or highly flam

mable materials or potential exposure to toxic materials (see Table A-3 in the Appen

dix). 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 employ

ees and other workers at the worksite (e.g., contractors and volunteers). ȣ Inform all workers about health risks of tobacco use.

ȣ Inform all workers about health risks of exposure to SHS.

ȣ 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 ser

vices to all employees and other workers at the worksite (e.g., contractors and volunteers).

ȣ 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.

ȣ Ask about personal tobacco use as part of all occupational health and wellness program interactions with individualworkers 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 work

ers and, where feasible, to their dependents.

ȣ Provide employer-sponsored cessation programs at no cost or subsidize

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### • 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-basedcessation treatments, unimpeded by copays and other financial or administrative barriers.

ȣ 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 Cam

pus Initiative in Your Workplace”) (see Box 6-2) and federal guidance on tobacco cessa

tion insurance coverage under the ACA (e.g., http://www.dol.gov/ebsa/faqs/faq-aca19. html ) before developing, implementing, or modifying tobacco-related policies, interven

tions, 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 pro

fessionals. Those providing input should in

clude 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 pro

grams 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 ben

efit policies—as well as differential hiring policies based on tobacco use—should be implemented only after seriously considering ethical concerns and possible unintended con

sequences. These consequences can include the potential for adverse impacts on individ

ual employees (e.g., coercion, discrimination, and breach of privacy) and the workforce as a whole. Furthermore, the impact of any dif

ferential policies that are introduced should be monitored to determine whether they improve health and/or have unintended consequences. NIOSH recommends that workers who smoke cig

arettes or use other tobacco products take the fol

lowing actions:

• Comply with all workplace tobacco policies.

• Ask about available employer-provided to

bacco cessation programs and cessation-re

lated health insurance benefits.

• Quit using tobacco products. Know that quit

ting tobacco use is beneficial at any age, but the earlier one quits, the greater the benefits. Many people find various types of assistanceto be very helpful in quitting, and evidencebased cessation treatments have been found to increase smokers’ chances of quitting suc

cessfully. Workers can get help from

ȣ tobacco cessation programs, including web-based programs (e.g., http://smokefree. gov and http://www.cdc.gov/tips ) and mobile phone texting services (e.g., the SmokefreeTXT program http://smokefree. gov/smokefreetxt );

ȣ state quitlines (phone: 1-800-QUIT-NOW [1-800-784-8669], or 1-855-DEJELO-YA [1-855-335-3569 for Spanish-speaking callers]); and/or

ȣ health-care providers. In addition, individual workers who want to quit tobacco may find several of the websites listed in Box 6-2 helpful.

## 34 35 NIOSH CIB 67 

### • Workplace Tobacco Policies NIOSH CIB 67 

### • Workplace Tobacco Policies 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.

## 36 37 NIOSH CIB 67 

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### • Workplace Tobacco Policies Box 6-1: A Model Policy for a Tobacco-Free Workplace



## [COMPANY]’s TOBACCO-FREE POLICY
I. PURPOSE [COMPANY] is dedicated to providing a healthy, comfortable, and productive work environ

ment for all of our employees and clients. The goal of this policy is two-fold. First, this policy aims to promote a safe work environment for everyone who works on or visits [COMPANY]’s campus. Second, this policy is designed to improve the health of [COMPANY]’s employees by promoting tobacco use cessation.

II. POLICY Effective [DATE], [COMPANY] is implementing a campus-wide tobacco-free policy that ap

plies to all employees, clients, and visitors. This policy prohibits the use of any tobacco products, including but not limited to smokeless tobacco, cigarettes, cigars, and electronic smoking/vaping devices. This policy is in effect at all times, including during and after regular business hours. Smoking or use of tobacco products will not be permitted in any indoor or outdoor space owned, leased, or used by the company or within 25 feet of any door, window, or ventilation system. Ad

ditionally, tobacco use will not be permitted in company-owned parking lots or vehicles. This policy also applies to any work function where two or more employees are present, regardless of where the event is held. Employees who choose to use tobacco products may do so during their regularly scheduled breaks off company property. Ashtrays will not be provided or permitted in any company area. Smoking areas may be designated at the discretion of management. Any designated smoking ar

eas must be accompanied by proper signage, and they must be located at least 25 feet away from any door, window, or ventilation system. This policy also prohibits the sale on company property of any tobacco products, including but not limited to cigarettes, cigars, pipe tobacco, smokeless tobacco, and electronic smoking/vaping devices and materials.

III. PROCEDURE Copies of this policy shall be distributed to all current employees in advance of the implementa

tion date. All future employees will be provided a copy of this policy during the hiring process and a copy will be available for review from [COMPANY]’s human resources department at any time. Signs stating that this is a “Tobacco-Free Campus” will be posted. Compliance with this policy is mandatory and violations will be subject to disciplinary action in accordance with other relevant company policy. Repeated violations may result in more serious disciplinary action, to be handled by supervisors in conjunction with the human resources de

partment. [COMPANY] will not retaliate, discourage, or prohibit any employee, client or visitor from reporting violatio ns of this policy.

## 36 37 NIOSH CIB 67 

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### • Workplace Tobacco Policies Box 6-1: A Model Policy for a Tobacco-Free Workplace (Continued)

IV. TOBACCO CESSATION OPPORTUNITIES [COMPANY] encourages all employees who currently use tobacco products to quit by taking advantage of cessation programs available through the company. More information about these offerings can be obtained by contacting [APPROPRIATE WORKPLACE CONTACT] or human
resources.
V. QUESTIONS Any questions regarding this policy should be directed to [NAME OF APPROPRIATE WORK

PLACE CONTACT] at [NUMBER]. Thank you for your cooperation. Adapted from CDC [2005], ANR [2014], and the University of Maryland Francis King Carey School of Law Legal Resource Center [2014].

Box 6-2. Selected Web Resources



### Government U.S. Department of Health And Human Services

• Smokefree.gov http://www.Smokefree.gov

• BeTobaccoFree.gov http://betobaccofree.hhs.gov/index.html

• The Guide to Community Preventive Services: Reducing Tobacco Use and Second

hand Smoke Exposure http://www.thecommunityguide.org/tobacco/index.html
CDC

• Office on Smoking and Health http://www.cdc.gov/tobacco/quit_smoking/index.htm

• Tobacco Use Cessation http://www.cdc.gov/workplacehealthpromotion/implementation/topics/tobacco-use.html

## 38 39 NIOSH CIB 67 

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### • Workplace Tobacco Policies Box 6-2. Selected Web Resources (Continued)

CDC (Continued)

• Tips from Former Smokers http://www.cdc.gov/tips/

• Implementing a Tobacco-Free Campus Initiative in Your Workplace http://www.cdc.gov/nccdphp/dnpao/hwi/toolkits/tobacco/index.htm

• “Save Lives, Save Money: Make Your Business Smoke-Free” http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/guides/business/pdfs/ save_lives_save_money.pdf

• A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment http://www.cdc.gov/tobacco/quit_smoking/cessation/practical_guide/pdfs/practical_guide.pdf

• Total Worker HealthTM http://www.cdc.gov/niosh/twh/ http://www.cdc.gov/niosh/twh/essentials.html

• Tobacco Smoke in the Workplace http://www.cdc.gov/niosh/topics/tobacco/
Other North American Quitline Consortium (NAQC)

• Quitline Map http://map.naquitline.org/ American Lung Association

• Stop Smoking http://www.lung.org/stop-smoking/

• Workplace Wellness http://www.lung.org/stop-smoking/workplace-wellness/ American Cancer Society

• Great American Smokeout http://www.cancer.org/healthy/stayawayfromtobacco/greatamericansmokeout/index

• “Strategies for Promoting a Smoke-free Workplace Policy” http://www.cancer.org/downloads/gahc/hp_strategies_for_promoting_and_implementing_ smokefree_workplace.pdf

• Making Your Workplace Smokefree: A Decision Maker’s Guide http://www.cancer.org/acs/groups/content/@highplains/documents/document/makingyour

workplacesmokefreegu.pdf

## 38 39 NIOSH CIB 67 

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### • Workplace Tobacco Policies Box 6-2. Selected Web Resources (Continued)

American Heart Association

• Quit Smoking http://www.heart.org/HEARTORG/GettingHealthy/QuitSmoking/Quit-Smoking_ UCM_001085_SubHomePage.jsp American Legacy Foundation

• EX: A New Way to Think About Quitting Smoking http://www.becomeanex.org National Business Group on Health

• Tobacco: The Business of Quitting—An Employer’s Website for Tobacco Cessation http://www.businessgrouphealth.org/tobacco/benefits PACT (Professional Assisted Cessation Therapy)

• Employers’ Tobacco Cessation Guide: Practical Approaches to a Costly Workplace Problem http://www.elginhealth.on.ca/downloads/RIYSEQXL.pdfThis page intentionally left blank.

## 41 NIOSH CIB 67 

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# APPENDIX

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### • Workplace Tobacco PoliciesTable A-1. Previous NIOSH Current Intelligence Bulletins on Tobacco UsePublication (year)FindingsRecommendationsCurrent IntelligenceBulletin 31Smoking and theOccupationalEnvironment (1979)Smoking and/or tobacco products defined as cigarettes, cigars,pipe tobacco, chewing tobacco, and any by-products resultingfrom their burning and/or use.Identified six ways smoking and/or other tobacco use caninteract with workplace exposures to worsen occupationaldisease and injury:1.Certain toxic agents present in some workplaces may alsobe present in tobacco smoke, increasing exposure tothose agents.2.Some workplace chemicals can be transformed into moreharmful agents by smoking—specifically by the heatgenerated by burning tobacco.3.Tobacco products can become contaminated with toxicagents present in the workplace, thus facilitating entry ofthe agent into the body by inhalation, ingestion, and/orskin absorption.4.Smoking can cause adverse health effects comparable tothose caused by exposure to toxic agents present in someworkplaces, thus causing additive effects.5.Smoking can act synergistically with toxic agents presentin some workplaces to cause a much more profound effectthan anticipated simply from the separate influences of theoccupational exposure and smoking.6.Smoking can contribute to accidents in the workplace.Use of and/or carrying of tobacco products into theworkplace should be curtailed in situations where employeesmay be exposed to physical or chemical substances that mayinteract with tobacco products.Curtailment of the use of tobacco products in the workplaceshould be accompanied by simultaneous control of workerexposure to hazardous physical and chemical agents.See footnotes at end of table.(Continued)

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### • Workplace Tobacco PoliciesTable A-1. Previous NIOSH Current Intelligence Bulletins on Tobacco Use (Continued)Publication (year)FindingsRecommendationsCurrent IntelligenceBulletin 54EnvironmentalTobacco Smoke inthe Workplace: LungCancer and OtherEffects* (1991)Main conclusion: “NIOSH has determined that the collectiveweight of evidence ... is sufficient to conclude that [SHS]* posesan increased risk of lung cancer and possibly heart disease tooccupationally exposed workers.”Conclusions and recommendations based on:•Reports of Surgeon General on health effects of tobaccosmoke.•Comparison of chemical compositions of SHS and mainstream smoke.•Results from recent epidemiologic studies of nonsmokersexposedto SHS.•Methods for controlling involuntary workplace exposures toETS.*Risk of developing cancer should be decreased byminimizing exposure to SHS.Workers should not be involuntarily exposed to tobaccosmoke.Employers should ... assess conditions that may result inworker exposure to SHS and take steps to reduce exposuresto the lowest feasible concentration.Best method for controlling worker exposure to SHS isto eliminate tobacco use from the workplace and begin asmoking cessation program.Management and labor should work together to developnonsmoking policies:•Prohibit smoking at the workplace; post signs at workplaceentrances.•Distribute information about health promotion and harmful effectsof smoking.•Offer smoking-cessation classes to all workers.•Establish incentives to encourage workers to stop smoking.Pending complete elimination of tobacco smoking in theworkplace, smoking should be isolated to clearly posted,enclosed areas, with separate ventilation exhausted directlyto the outside without recirculation.*The 1991 document used the term “environmental tobacco smoke” (ETS) to refer to what this CIB calls “secondhand smoke” (SHS).

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### • Workplace Tobacco PoliciesTable A-2. Other NIOSH Publications with Policy Recommendations Relating to Tobacco UseYearAgent/ProcessTobacco-related Recommendation(s)Selected Additional ContentCriteria Documents1972AsbestosSmoking cessation (as medical management forexposed workers who smoke).1972Carbon monoxideMedical exams, which could provide “opportunityto conduct anti-smoking programs for high-riskemployees.”1973Inorganic mercuryNo smoking in designated areas; wash beforesmoking.*1975Inorganic fluoridesNo smoking in designated areas; wash beforesmoking/chewing*; no carrying tobacco products incontaminated clothing.1976Boron trifluorideNo smoking or uncovered smoking materials indesignated areas.1976CadmiumNo smoking or carrying uncovered tobaccoproducts in designated areas.1976CarbarylNo smoking in designated areas; wash beforesmoking.*1976FormaldehydeNo smoking in designated areas; wash beforesmoking.*1976Methyl parathionNo smoking or carrying tobacco products indesignated areas; wash before smoking*; post “Nosmoking” signs; provide area free of contaminationfor storing tobacco products.1976Organotin compoundsNo smoking in designated areas.1976ParathionNo smoking or carrying tobacco products indesignated areas; wash before smoking*; post “Nosmoking” signs; provide area free of contaminationfor storing tobacco products.See footnotes at end of table.(Continued)

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### • Workplace Tobacco PoliciesYearAgent/ProcessTobacco-related Recommendation(s)Selected Additional Content1978Dinitro-ortho-cresolNo smoking in designated areas.1976Carbon tetrachlorideNo smoking in designated areas; wash beforesmoking.*1979ChloroformNo smoking in designated areas; wash beforesmoking.*1988Welding, brazing, andthermal cuttingNo use or storage of tobacco products in designatedareas; wash before smoking*; counsel smokersabout how smoking may enhance adverse effects ofoccupational hazards.2006Refractory ceramicfibersNo smoking in workplace; collect smoking historiesas part of the medical monitoring program; counselworkers who smoke tobacco products aboutincreased risk of adverse respiratory effects inducedby RCF; disseminate information about healthpromotion and the harmful effects of smoking;establish and offer smoking cessation programs toworkers at no cost; all workers who smoke and arepotentially exposed to RCFs should participate insmoking cessation program.Entire sections (1.13and 9.6) devoted to smoking cessation.NIOSH recognizes a synergistic effect of smoking andexposure to RCFs, increasing risk of adverse respiratory healtheffects induced by RCFs. Interactive effect of tobacco smokingand exposure to airborne fibers previously documented.RCF-associated decreases in pulmonary function limited tocurrent and former smokers.Finding consistent with studies of workers exposed to airbornecontaminants, in which combined smoking and exposures tovarious airborne dusts results on increased risk of occupationalrespiratory diseases, including chronic bronchitis, emphysema,and lung cancer.2013Hexavalent chromiumProhibit smoking in all areas of any workplaces inwhich workers are exposed to Cr(VI) compounds;as part of a comprehensive safety and healthprogram, offer a no-cost smoking cessationprogram that informs workers about the hazardsof cigarette smoking and provides assistance andencouragement for workers who want to quitsmoking; all workers who smoke participate.Entire section (8.7) devoted to smoking cessationThese elements, in combination with efforts to maintainairborne Cr(VI) concentrations below the REL and preventdermal contact with Cr(VI) compounds, will further protectthe health of workers.[A]ssociation of skin disease and/or smoking habit withelevated urinary Cr levels in cement workers.See footnotes at end of table.(Continued)Table A-2 (Continued). Other NIOSH Publications with Policy Recommendations Relating to Tobacco Use

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### • Workplace Tobacco PoliciesYearAgent/ProcessTobacco-related Recommendation(s)Selected Additional ContentCurrent Intelligence Bulletins1978Tetrachloroethylene(perchloroethylene)Workers who handle liquid tetrachloroethyleneshould wash hands thoroughly before smoking.1986Methylene chlorideSmoking should not be permitted in areas wheremethylene chloride is manufactured, stored, orused.19864,4’-methylenedianiline(MDA)A smoking cessation program should be provided,because cigarette smoking is a well-established riskfactor for bladder cancer2013Carbon nanotubes andnanofibersEncourage workers to wash hands before eating,smoking.Alerts1984Carbon monoxidehazard in aircraftrefueling operationsWorkers engaged in fueling operations shouldbe encouraged to refrain from smoking becausesmoking elevates blood levels of carbon monoxideenough to reduce margin of safety.1991Lead poisoning inconstructionNo use or carrying of tobacco products indesignated area(s); wash before smoking.*1992Silicosis fromsandblastingNo use of tobacco products in blasting area; washbefore smoking.*1992Silicosis in rock drillersNo use of tobacco products in blasting area; washbefore smoking.*1996Asthma fromdiisocyanateWash before smoking outside work area.1996Silicosis in constructionNo use of tobacco products in dusty areas; washbefore smoking.*See footnotes at end of table.(Continued)Table A-2 (Continued). Other NIOSH Publications with Policy Recommendations Relating to Tobacco Use

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### • Workplace Tobacco PoliciesSee footnotes at end of table.(Continued)Table A-2 (Continued). Other NIOSH Publications with Policy Recommendations Relating to Tobacco UseYearAgent/ProcessTobacco-related Recommendation(s)Selected Additional Content1999Phosphine poisoningand explosions duringfumigationWash before smoking.*2006Asthma from MDIexposure during sprayon truck bed liner andrelated applicationsWash before smoking.*2007Explosions in industrialethylene oxidesterilization facilitiesNo smoking where EtO is handled, used, or stored.2007Fire fighter fatalitiesdue to heart attacksand other suddencardiovascular eventsProhibit smoking in all fire stations and other firedepartment facilities; include a smoking cessationprogram in any wellness program.Because not all fire stations are smoke-free, involuntaryexposure to tobacco smoke continues to present cardiovascularrisks for fire fighters.Unrecognized sources of carbon monoxide exposure for firefighters include environmental tobacco smoke; diesel exhaust infirehouse; diesel exhaust from fire engine operating at fire scene.2011Sensitization anddisease from berylliumexposureNo storage or use of tobacco products in berylliumwork areas.Fact Sheets2003Asbestos associatedwith vermiculite fromLibby, MTWorkers who have been exposed and currentlysmoke should quit smoking; employers can assistthem by offering smoking cessation programs.Workplace Solutions2007Handling Micotil 300®No smoking in designated area.Infosheets2012Cleaning chemicalsWash before smoking.*

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### • Workplace Tobacco PoliciesYearAgent/ProcessTobacco-related Recommendation(s)Selected Additional ContentUpdates1993Silicosis deathsNo use of tobacco products in designated area; washbefore smoking.*Proposed National Strategies1989Proposed NationalStrategy for thePrevention ofOccupational LungDiseasesManagement and labor should work together todevelop smoking policies:•Prohibit smoking at the workplace.•Distribute information about health promotionand harmful effects of smoking.•Offer no-cost smoking-cessation classes to allworkers.•Establish incentives to encourage workers to stopsmoking.•Post appropriate signs at workplace entrances.Smoking is strongly associated with many lung diseases.Smoking has an additive effect on the risk of chronic bronchitisin workers exposed to coal mine and other dusts, and it actssynergistically with asbestos to increase the risk of lung cancer.Evidence indicates adverse effects on those who are exposed tothe smoke of others.Because of the overwhelming evidence of the healthconsequences from smoking and the number of workersaffected, a focus on smoking is an important component of aneffective prevention strategy.Elimination of smoking in the workplace is an effectivestrategy.See footnotes at end of table.(Continued)Table A-2 (Continued). Other NIOSH Publications With Policy Recommendations Relating to Tobacco Use

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### • Workplace Tobacco PoliciesYearAgent/ProcessTobacco-related Recommendation(s)Selected Additional Content1989Proposed NationalStrategy for thePrevention ofOccupationalCardiovascular DiseasesIdentify groups of workers at high risk ofcardiovascular and other diseases based onexposure in the workplace and personal risk factors;to ensure that workers have full and effectiveaccess, implement programs for health promotionand disease prevention at the worksite wheneverpossible or practical; programs should includeefforts to reduce personal, modifiable risk factorsfor cardiovascular disease, including smokingIn an ideal situation, when occupational factors increase therisk of cardiovascular disease, both occupational and personalrisks would be addressed at the workplace.Encouraging workers to quit smoking is particularly importantbecause smoking contributes not only to several cardiovasculardiseases but to other diseases as well.Increasing the availability of health promotion programs in theworkplace requires the cooperation of industry, labor unions,community and voluntary groups, and the government.Most programs will be conducted in the private sector, butgovernmental agencies can play important roles in stimulatingthe development of effective programs and in evaluating them.*“Wash” in this context means wash hands and face.To access individual documents, see NIOSH Publications and Products website,http://www.cdc.gov/niosh/pubs/default.html.Disclaimer: Table is not necessarilycomprehensive. NOTE: Table does not include NIOSH recommendations focused solely on tobacco use (see Table A-1) or, for example, tobacco-relatedrecommendations included in agent-specific guidance included inNIOSH/OSHA Occupational Health Guidelines for Chemical Hazards(DHHS NIOSH Publication No.81-123).Table A-2 (Continued). Other NIOSH Publications With Policy Recommendations Relating to Tobacco Use

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### • Workplace Tobacco PoliciesTable A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco UseHazard Category and ProvisionsAgent/ProcessIndustryRegulation CFRFire/ExplosionFor designated area(s):•Smoking prohibitions.and (in most listed regulations)•‘No-smoking’ placard requirements.and (in some listed regulations)•Program to assure that no smokingmaterials are carried.and (in some listed regulations)•Smoking history required inmedical surveillance.HydrogenHydrogen or hydrogen sealingsystemsGeneral IndustryElectric Power Generation, Transmission,and Distribution1910.1031910.269OxygenGeneral IndustrySurface metal/nonmetal minesUnderground metal/nonmetal mines1910.10456.780557.7805Flammable liquidsGeneral IndustryShipyardsMarine Terminals ConstructionConstructionSurface metal/nonmetal minesUnderground metal/nonmetal mines1910.1061915.361917.1561926.15256.410056.410157.410057.4101Spray finishing using flammableand combustible materialsGeneral IndustryMarine Terminals1910.1071917.153Explosives and blasting agentsGeneral IndustrySurface metal/nonmetal minesUnderground metal/nonmetal minesUnderground coal mines1910.1091926.9001926.9021926.90456.690457.690475.170275.1721Storage and handling of liquefiedpetroleum gasesGeneral Industry1910.110See footnotes at end of table.(Continued)

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### • Workplace Tobacco PoliciesSee footnotes at end of table.(Continued)Hazard Category and ProvisionsAgent/ProcessIndustryRegulation CFRDipping and coating operationsthat use flammable liquids orliquids with flashpoints greaterthan 199.4 ̊F (93 ̊C)General Industry1910.125Battery-charging/changing areasGeneral IndustrySurface metal/nonmetal minesUnderground metal/nonmetal minesMarine TerminalsLongshoring1910.17856.450257.45021917.1571918.1Grain handling facilitiesGeneral Industry1910.272Permit-required Confined SpacesGeneral Industry1910.146Underground linesPower Transmission and Distribution1926.956BenzeneGeneral IndustryShipyardsConstruction1910.10281915.10281926.1128AcrylonitrileGeneral IndustryConstruction1910.10451926.1145Ethylene oxideGeneral IndustryConstruction1910.10471926.1147FormaldehydeGeneral IndustryShipyardsConstruction1910.10481915.10481926.1148Gassy operationsUnderground Construction Caissons, Cofferdams,and Compressed AirUnderground metal/nonmetal mines1926.80057.2210257.22105Table A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco Use (Continued)

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### • Workplace Tobacco PoliciesHazard Category and ProvisionsAgent/ProcessIndustryRegulation CFRGeneral Fire PreventionConstructionUnderground metal/nonmetal minesUnderground coal mines1926.15157.410057.410157.690457.780557.2210157.2210277.110277.1711Record-keeping areasUnderground metal/nonmetal mines57.5041Ingestion/absorption of toxic agentFor designated area(s):•Prohibitions on smoking, storage ofsmoking materials, tobacco products (including chewing tobacco),and chewing of such products.and•Requirements for washing prior tosmoking/eating.and (in most listed regulations)•Requirements to post“No-smoking” placards.AsbestosGeneral IndustryShipyardsConstruction1910.10011915.10011926.110113 specified carcinogens(4-Nitrobiphenyl, etc.)General IndustryShipyardsConstruction1910.10031915.10031926.1103Inorganic arsenicGeneral IndustryShipyardsConstruction1910.10181915.10181926.1118LeadGeneral IndustryShipyardsConstruction1910.10251915.10251926.62Table A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco Use (Continued)See footnotes at end of table.(Continued)

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### • Workplace Tobacco PoliciesHazard Category and ProvisionsAgent/ProcessIndustryRegulation CFRChromium (VI)General IndustryShipyardsLongshoringConstruction1910.10261915.10261918.11926.1126CadmiumGeneral IndustryShipyardsConstructionAgriculture1910.10271915.10271926.11271928.1027BenzeneGeneral IndustryShipyardsConstruction1910.10281915.10281926.1128Coke oven emissionsGeneral IndustryConstruction1910.10291926.1129Bloodborne pathogensGeneral IndustryShipyards1910.10301915.10301,2-dibromo-3-chloropropaneGeneral IndustryShipyardsConstruction1910.10441915.10441926.1144AcrylonitrileGeneral IndustryConstruction1910.10451926.1145Ethylene oxideGeneral IndustryConstruction1910.10471926.1147Ethylene oxideGeneral IndustryShipyards1910.10471915.1047FormaldehydeGeneral IndustryShipyardsConstruction1910.10481915.10481926.1148Table A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco Use (Continued)See footnotes at end of table.(Continued)

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### • Workplace Tobacco PoliciesHazard Category and ProvisionsAgent/ProcessIndustryRegulation CFRMethylenedianilineGeneral IndustryShipyardsConstruction1910.10501915.10501926.601,3-ButadieneGeneral Industry1910.1051Methylene chlorideGeneral IndustryShipyardsConstruction1910.10521915.10521926.1152Hazardous chemicals inlaboratoriesGeneral IndustryShipyards1910.14501915.1450General/Field SanitationShipyardsAgriculture1915.881928.110Misc.•Personal Protective EquipmentStandard: requires a 15-minuteno-smoking period prior to Bitrexfit-testing of respirators.•Cotton Dust Standard: requiredmedical questionnaire asks aboutsmoking.•Hazard Communication Standard:Appendices invoke smoking historyin the assessment of evidence usedto categorize substances as respiratory sensitizers, and detail requirements for “No smoking” warninglabels.Personal Protective EquipmentGeneral IndustryShipyardsMarine TerminalsLongshoringConstruction1910.1341915.1541917.921918.1021926.103Cotton DustGeneral Industry1910.1043Hazard CommunicationGeneral IndustryShipyardsConstruction1910.12001915.12001926.59Specific requirements of OSHA and MSHA regulations should be determined by directly consulting those regulations. Disclaimer: Table is not necessarily comprehensiveand is not intended to be used for compliance purposes. NOTE: Table does not include OSHA regulations that require retention of Department of Transportationmarkings, placards, and labels relating to flammability/explosivity (e.g., 1910.1201, 1915.88, 1917.29, 1926.61). Nor does it include OSHA “model standards” forcarcinogens (1990.151; 1990.152), which include a provision prohibiting smoking/chewing/tobacco.Table A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco Use (Continued)

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### • Workplace Tobacco PoliciesFigure A-1a.Cigarette smoking among working adults, by industry—United States, 2004–2010

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### • Workplace Tobacco PoliciesFigure A-1b.Cigarette smoking among working adults, by occupation—United States, 2004–2010

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### • Workplace Tobacco PoliciesFigure A-2a.Smokeless tobacco use among working adults, by industry—United States, 2010

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### • Workplace Tobacco PoliciesFigure A-2b.Smokeless tobacco use among working adults, by occupation—United States, 2010

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### • Workplace Tobacco PoliciesFigure A-3a.Dual use of tobacco: Proportion of cigarette smokers who also use smokeless tobaccoamong working adults, by industry—United States, 2010

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### • Workplace Tobacco PoliciesFigure A-3b.Dual use of tobacco: Proportion of cigarette smokers who also use smokeless tobaccoamong working adults, by occupation—United States, 2010

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### • Workplace Tobacco PoliciesFigure A-4a.Prevalence of frequent exposure to SHS at work among nonsmoking adultswho worked in the past 12 months, by industry—United States, 2010

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### • Workplace Tobacco PoliciesFigure A-4b.Prevalence of frequent exposure to SHS at work among nonsmoking adultswho worked in the past 12 months, by occupation—United States, 2010This page intentionally left blank.

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DHHS (NIOSH) Publication No. 2015–113



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