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 Health
On the cover: The cover design includes a wispy background image intended to evoke the well-known health 

hazard of smoke associated with the use of combustible tobacco products, and the much less studied misty 

emissions associated with the use of electronic devices to “vape” liquids containing nicotine and other components. The full range of hazards associated with tobacco use extends well beyond such air contaminants, so 

the cover design also incorporates a text box to highlight the optimal “Tobacco-Free” (i.e., not just “SmokeFree”) status for both workplaces and workers. The text box also evokes the NIOSH Total Worker HealthTM

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.
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

Robert M. Castellan, MD, MPH; L. Casey Chosewood, MD; Douglas Trout, MD; 

Gregory R. Wagner, MD; Claire C. Caruso, PhD, RN, FAAN; Jacek Mazurek, 

MD, MS, PhD; Susan H. McCrone, PhD, RN; David N. Weissman, MD
ii NIOSH CIB 67 • Workplace Tobacco Policies

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 Institute for Occupational Safety and Health (NIOSH). In addition, citations to websites 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 websites. All Web addresses referenced in this document were accessible as of the 

publication date.

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contact NIOSH at

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or visit the NIOSH website at www.cdc.gov/niosh.

For a monthly update on news at NIOSH, subscribe to NIOSH eNews by visiting www.cdc.

gov/niosh/eNews.

Suggested Citation

NIOSH [2015]. Current intelligence bulletin 67: promoting health and preventing disease 

and injury through workplace tobacco policies. By Castellan RM, Chosewood LC, Trout D, 

Wagner GR, Caruso CC, Mazurek J, McCrone SH, Weissman DN. Morgantown, WV: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 

2015-113, http://www.cdc.gov/niosh/docs/2015-113/.

DHHS (NIOSH) Publication No. 2015–113

April 2015

Safer • Healthier • PeopleTM
NIOSH CIB 67 iii • Workplace Tobacco Policies

Foreword

Current Intelligence Bulletins (CIBs) are issued by the National Institute for Occupational 

Safety and Health (NIOSH) to disseminate new scientific information about occupational 

hazards. A CIB may draw attention to a formerly unrecognized hazard, report new data on 

a known hazard, or disseminate information about hazard control.

Public health efforts to prevent disease caused by tobacco use have been underway for the 

past half century, but more remains to be done to achieve a society free of tobaccorelated death and disease. The Centers for Disease Control and Prevention (CDC), of which 

NIOSH is a part, has recently proclaimed a “Winnable Battle” to reduce tobacco use. NIOSH 

marks a half century since the first Surgeon General’s Report on the health consequences of 

smoking by disseminating this CIB 67, Promoting Health and Preventing Disease and Injury 

through Workplace Tobacco Policies.

Workers who use tobacco products, or who are employed in workplaces where smoking 

is allowed, are exposed to carcinogenic and other toxic components of tobacco and tobacco smoke. Cigarette smoking is becoming less frequent, and smoke-free and tobaccofree workplace policies are reducing exposure to secondhand smoke (SHS) and motivating 

smokers to quit—but millions of workers still smoke, and smoking is still permitted in 

many workplaces. Other forms of tobacco also represent a health hazard to workers who 

use them. In addition to direct adverse effects of tobacco on the health of workers who use 

tobacco products or are exposed to SHS, tobacco products used in the workplace—and 

away from work—can worsen the hazardous effects of other workplace exposures. 

This CIB addresses the following aspects of tobacco use:

• Tobacco use among workers.

• Exposure to secondhand smoke in workplaces.

• Occupational health and safety concerns relating to tobacco use by workers.

• Existing occupational safety and health regulations and recommendations prohibiting or limiting tobacco use in the workplace.

• Hazards of worker exposure to SHS in the workplace.

• Interventions aimed at eliminating or reducing these hazards. 

This CIB concludes with NIOSH recommendations on tobacco use in places of work and 

tobacco use by workers. 

NIOSH urges all employers to embrace a goal that all their workplaces will ultimately be made 

and maintained tobacco-free. Initially, at a minimum, employers should take these actions:

• Establish their workplaces as smoke-free (encompassing all indoor areas without exceptions, areas immediately outside building entrances and air intakes, and all work 

vehicles).
iv NIOSH CIB 67 • Workplace Tobacco Policies

• Assure compliance with OSHA and MSHA regulations that prohibit or otherwise restrict smoking, smoking materials, and/or use of other tobacco products in designated 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 workplaces, 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 
NIOSH CIB 67 • Workplace Tobacco Policies v

Executive Summary

Introduction

Various NIOSH criteria documents on individual hazardous industrial agents, from asbestos [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 Current Intelligence Bulletins focused entirely on the hazards of tobacco use. CIB 31, Adverse 

Health Effects of Smoking and the Occupational Environment, outlined how tobacco use—

most commonly smoking—can increase risk, sometimes profoundly, of occupational disease and injury [NIOSH 1979]. In that CIB, NIOSH recommended that smoking be curtailed in workplaces where those other hazards are present and that worker exposure to 

those other occupational hazards be controlled. CIB 54, Environmental Tobacco Smoke in 

the Workplace: Lung Cancer and Other Health Effects, presented a determination by NIOSH 

that secondhand smoke (SHS) causes cancer and cardiovascular disease [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 similarly declined, but smoking rates among blue-collar workers have been shown to be consistently higher than among white-collar workers. Among blue-collar workers, those exposed 

to higher levels of workplace dust and chemical hazards are more likely to be smokers [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 accommodation and food services. Smoking 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 NIOSH CIB 67 • Workplace Tobacco Policies

smokers reported ever having used e-cigarettes, a type of electronic nicotine delivery system (ENDS) [King et al. 2015]. However, the prevalence of ENDS use by industry and occupation has not been studied. Overall, about 3% of all workers use smokeless tobacco in the 

form of chewing tobacco and snuff, but smokeless tobacco use exceeds 10% among workers 

in construction and extraction jobs and stands at nearly 20% among workers in the mining 

industry [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 smoking is prohibited or in coal mines where smoking can cause explosions). More than 4% of 

U.S. workers who smoke cigarettes also use smokeless tobacco [CDC 2014b; NIOSH 2014]. 

The implementation of smoke-free policies has eliminated or substantially decreased exposure to SHS in many U.S. workplaces. But millions of nonsmoking workers not covered 

by these policies are still exposed to SHS in their workplace. A 2009–2010 survey found 

that 20.4% of nonsmoking U.S. workers experienced exposure to SHS at work on at least 1 day 

during the preceding week [King et al. 2014]. Another survey conducted at about the 

same time estimated that 10.0% 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 occupations to nearly 29% for construction and extraction occupations). Inclusion of ENDS 

in smoke-free policies has increased over time. In the United States, the number of states 

and localities that explicitly prohibited use of e-cigarettes in public places where tobacco 

smoking was already prohibited totaled 3 states and more than 200 localities before the 

end of 2014 [CDC 2014c].

Health and Safety Consequences of Tobacco Use

Since the first Surgeon General’s report on smoking and health, many reports from the Surgeon General and other health authorities have documented serious health consequences 

of smoking tobacco, exposure to secondhand smoke (SHS), and use of smokeless tobacco. 

Smoking is a known cause of the top fıve health conditions impacting the U.S. population—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 adverse health outcomes caused by smoking is related to the duration and intensity of tobacco 

smoking, but no level of tobacco smoking is risk free [DHHS 2010b, 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 premature delivery of babies born to women exposed to SHS [DHHS 2006, 2014; IARC 2009]. 
NIOSH CIB 67 vii • Workplace Tobacco Policies

Because ENDS are relatively new products that vary widely and have not been well studied, 

limited data are available on potential hazardous effects of active and passive exposures to 

their emissions [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 potential 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 reproductive 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 workplaces (most commonly smoking) can increase—sometimes profoundly—the likelihood 

and/or the severity of occupational disease and injury caused by other hazards present. This 

can occur in various ways. A toxic industrial chemical present in the workplace can also be 

present in tobacco products and/or tobacco smoke, so workers who smoke or are exposed 

to SHS are more highly exposed and placed at greater risk of the occupational disease associated with those chemicals.

Heat generated by smoking tobacco in the workplace can transform some workplace 

chemicals into more toxic chemicals, placing workers who smoke at greater risk of toxicity 

[NIOSH 1979; DHEW 1979b; DHHS 1985]. Tobacco products can readily become contaminated by toxic workplace chemicals, through contact of the tobacco products with unwashed hands or contaminated surfaces and through deposition of airborne contaminants 

onto the tobacco products. Subsequent use of the contaminated tobacco products, whether 

at or away from the workplace, can facilitate entry of these toxic agents into the user’s body 

[NIOSH 1979; DHEW 1979b]. 

Often, a health effect can be independently caused by tobacco use and by workplace exposure to a toxic agent. For example, tobacco smoking can reduce a worker’s lung function, leaving that worker more vulnerable to the effect of any similar impairment of lung 

function caused by occupational exposure to dusts, gases, or fumes [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 NIOSH CIB 67 • Workplace Tobacco Policies

The risk of occupational injuries and traumatic fatalities can be greatly enhanced when 

tobacco use is combined with an occupational hazard. Obvious examples are explosions 

and fires when explosive or flammable materials in the workplace are ignited by sources associated with tobacco smoking [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. Workers who smoke can protect their own health by quitting tobacco use and can protect their 

coworkers’ health by not smoking in the workplace. Smokers who quit stand to benefit financially. Among other savings, they no longer incur direct costs associated with consumer 

purchases of tobacco products and related materials, and they generally pay lower life and 

health insurance premiums and lower out-of-pocket costs for health care. 

Legally determined employer responsibilities set out in federal, state, and local laws and 

regulations, as well as health and economic considerations, can motivate employers to 

establish workplace policies that prohibit or restrict tobacco use. Even where smoke-free 

workplace policies are not explicitly mandated by state or local governments, the general 

duty of employers to provide safe work environments for their employees can motivate 

employers to prohibit smoking in their workplaces, thereby avoiding liability for exposing 

nonsmoking employees to SHS [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 nonsmoker [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 nonsmoking 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 general 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]. The CDC-administered Task Force on Community Preventive Services recommends smoke-free workplace policies, not only to reduce 

exposure to SHS, but also to increase tobacco cessation, reduce tobacco use prevalence, and 

reduce tobacco-related morbidity and mortality [Hopkins et al. 2010; Task Force on Community Preventive Services 2010; GCPS 2012a].
NIOSH CIB 67 • Workplace Tobacco Policies ix

Some employers have taken action to extend restrictions on tobacco use by their employees 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 policies 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, affordability, and potential reach to populations with higher levels of tobacco use make quitlines 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]. 

Mobile phone texting interventions and web-based interventions are also promising approaches 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 cessation programs incorporate tobacco cessation support into programs that address the overall 

safety, health, and well-being of workers. A growing evidence base supports the enhanced 

effectiveness of workplace health promotion programs when they are combined with occupational health protection programs [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 evidence-based smoking cessation treatments is associated with increases in the number of 

smokers who attempt to quit, use proven treatments in these attempts, and succeed in quitting [Clinical Practice Guideline 2008]. Ideally, such coverage should provide access to all 

evidence-based cessation treatments, including individual, group, and telephone counseling, and all seven FDA-approved cessation medications, while eliminating or minimizing 

barriers such as cost-sharing and prior authorization [Clinical Practice Guideline 2008; 

CDC 2014b]. 

The Affordable Care Act (ACA), Public Law 111-148, includes provisions pertinent to tobacco 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 plans 

to charge tobacco users premiums that are up to 50% higher than those charged to nontobacco users, subject certain limitations [78 Fed. Reg. 33158]. 
x NIOSH CIB 67 • Workplace Tobacco Policies

The appropriate intent of incentives is to help employees who use tobacco quit, thus improving health and reducing health-care costs overall. The evidence for the effectiveness 

of imposing insurance premium surcharges on tobacco users is limited, and care is needed to ensure that incentive programs are designed to work as intended and to minimize 

the potential use of incentives in an unduly coercive or discriminatory manner [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, approaching or exceeding 30% in construction, mining, and accommodation and food 

services workers.

• Prevalence of ENDS use by occupation and industry has not been studied, but ENDS 

has grown greatly, with about 1 in 3 current U.S. adult smokers reporting ever having 

used e-cigarettes by 2013.

• Smokeless tobacco is used by about 3% of U.S. workers overall, but smokeless tobacco 

is used by more than 10% workers in construction and extraction jobs and by nearly 

20% of workers in the mining industry, which can be expected to result in disparities 

in tobacco-related morbidity and mortality.

• Tobacco use causes debilitating and fatal diseases, including cancer, respiratory diseases, and cardiovascular diseases. These diseases afflict mainly users, but they also 

occur in those exposed to SHS. Smoking is substantially more hazardous, but use of 

smokeless tobacco also causes adverse health effects. More than 16 million U.S. adults 

live with a disease caused by smoking, and each year nearly a half million die prematurely from smoking or exposure to SHS.

• Tobacco use is associated with increased risk of injury and property loss due to fire, 

explosion, and vehicular collisions.

• Tobacco use by workers can increase, sometimes profoundly, the likelihood and the 

severity of occupational disease and injury caused by other workplace hazards (e.g., 

lead, asbestos, and flammable materials).

• Restrictions on smoking and tobacco use in specific work areas where particular 

high-risk occupational hazards are present (e.g., explosives, highly flammable materials, or highly toxic materials that could be ingested via tobacco use) have long been 

used to protect workers.

• A risk-free level of exposure to SHS has not been established, and ventilation is insufficient to eliminate indoor exposure to SHS. 

• Potential adverse health effects associated with using ENDS or secondhand exposure 

to particulate aerosols and gases emitted from ENDS remains to be fully characterized.
NIOSH CIB 67 xi • Workplace Tobacco Policies

• Policies that prohibit tobacco smoking throughout the workplace (i.e., smoke-free 

workplace policies) are now widely implemented, but they have not yet been universally adopted across the United States. These policies improve workplace air quality, reduce SHS exposure and related health effects among nonsmoking employees, 

increase the likelihood that workers who smoke will quit, decrease the amount of 

smoking during the working day by employees who continue to smoke, and have an 

overall impact of improving the health of workers (i.e., among both nonsmokers who 

are no longer exposed to SHS on the job and smokers who quit).

• Workplace-based efforts to help workers quit tobacco use can be easily integrated into 

existing occupational health and wellness programs. Even minimal counseling and/or 

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

intervention can be effective, and more comprehensive programs are even more effective.

• Integrating both occupational safety and health protection components into workplace health promotion programs (e.g., smoking cessation) can increase participation 

in tobacco cessation programs and successful cessation among blue-collar workers.

• Smokers, on average, are substantially more costly to employ than nonsmokers. 

• Some employers have policies that prohibit employees from using tobacco when away 

from work or that bar the hiring of smokers or tobacco users. However, the ethics 

of these policies remain under debate, and they may be legally prohibited in some 

jurisdictions.

Recommendations

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

• At a minimum, establish and maintain smoke-free workplaces that protect those in 

workplaces from involuntary, secondhand exposures to tobacco smoke and airborne 

emissions from e-cigarettes and other electronic nicotine delivery systems. Ideally, 

smoke-free workplaces should be established in concert with tobacco cessation support programs. Smoke-free zones should encompass (1) all indoor areas without exceptions (i.e., no indoor smoking areas of any kind, even if separately enclosed and/

or ventilated), (2) all areas immediately outside building entrances and air intakes, 

and (3) all work vehicles. Additionally, ashtrays should be removed from these areas.

• Optimally, establish and maintain entirely tobacco-free workplaces, allowing no use 

of any tobacco products across the entire workplace campus (see model policy in 

Box 6-1). 

• Comply with current OSHA and MSHA regulations that prohibit or limit smoking, 

smoking materials, and/or use of other tobacco products in work areas characterized 

by the presence of explosive or highly flammable materials or potential exposure to 

toxic materials (see Table A-3 in the Appendix). To the extent feasible, follow all similar NIOSH recommendations (see Table A-2 in the Appendix). 

• Provide information on tobacco-related health risks and on benefits of quitting to all 

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

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 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 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 representatives, line management, occupational safety/health and wellness staff, and human 

resources professionals. Those providing input should include current and former tobacco users, as well as those who have never used tobacco. Seek voluntary input from 

employees with health conditions, such as heart disease and asthma, exacerbated by 

exposure to SHS. 

• Make sure that any differential employment benefits policies that are based on tobacco use or participation in tobacco cessation programs are designed with a primary 

intent to improve worker health and comply with all applicable federal, state, and local laws and regulations. Even when permissible by law, these differential employment 

benefit policies—as well as differential hiring policies based on tobacco use—should 

be implemented only after seriously considering ethical concerns and possible 
NIOSH CIB 67 xiii • Workplace Tobacco Policies

unintended consequences. These consequences can include the potential for adverse 

impacts on individual employees (e.g., coercion, discrimination, and breach of privacy) and the workforce as a whole. Furthermore, the impact of any differential policies 

that are introduced should be monitored to determine whether they improve health 

and/or have unintended consequences. 

NIOSH recommends that workers who smoke cigarettes or use other tobacco products take 

the following actions:

• Comply with all workplace tobacco policies.

• Ask about available employer-provided tobacco cessation programs and cessationrelated health insurance benefits. 

• Quit using tobacco products. Know that quitting tobacco use is beneficial at any age, 

but the earlier one quits, the greater the benefits. Many people find various types 

of assistance to be very helpful in quitting, and evidence-based cessation treatments 

have been found to increase smokers’ chances of quitting successfully. 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, 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.
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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 NIOSH CIB 67 • Workplace Tobacco Policies

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
NIOSH CIB 67 xvii • Workplace Tobacco Policies

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 NIOSH CIB 67 • Workplace Tobacco Policies

Acknowledgments 

For contributions to the technical content and review of this document, the authors acknowledge 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 contributed 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 interested stakeholders and other members of the public. All comments were considered in 

preparing this final version of the document.
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NIOSH CIB 67 • Workplace Tobacco Policies 1

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 extraordinarily strong scientific foundation. The first 

Surgeon General’s report on smoking and health, 

issued a half century ago, concluded that cigarette 

smoke causes lung cancer and chronic bronchitis 

[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, esophageal, and pancreatic cancer [e.g., DHHS 1982; 

1983; 1984; 1986a,b; 2004; 2006; 2014]. One Surgeon 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]. Currently, Healthy People 2020 includes a major goal of 

reducing “illness, disability, and death related to tobacco use and secondhand smoke exposure” along 

with several specific objectives that target eliminating tobacco smoking in workplaces [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 Occupational 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 mentioned in a suggestion that the medical monitoring 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 substantially more research on asbestos had been published, 

NIOSH disseminated a document affirming synergistic (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 disease and injury [NIOSH 1979]. In that CIB, NIOSH 

recommended that smoking be curtailed in workplaces where those other hazards are present and 

that worker exposure to those other occupational 

hazards be controlled (see Appendix Table A-1). 
2 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 document as “environmental tobacco smoke”) causes 

cancer and cardiovascular disease. In recommending that workplace exposures to SHS be reduced to 

the lowest feasible concentration using all available 

preventive measures, NIOSH emphasized that the 

best approach is to eliminate tobacco smoking in 

the workplace, and it endorsed employer-provided 

smoking cessation programs for employees who 

smoke [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 comprehensive preventive approach. This evolution has 

been motivated by a better understanding of how 

tobacco use adversely impacts occupational diseases and injuries and—perhaps just as importantly—by a changing societal view of the health and 

economic consequences of tobacco use. By way of 

example, criteria documents produced in the past 

decade on two lung hazards—refractory ceramic 

fibers [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 hazard, 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 post 

on the NIOSH Blog site pointed out that “Tobaccofree workplaces, on-site tobacco cessation services, 

and comprehensive, employer-sponsored healthcare benefits that provide multiple quit attempts, 

have all been shown to increase tobacco treatment 

success” [Howard et al. 2010]. 

Thus, instead of staying focused nearly exclusively 

on protecting workers from specific occupational 

hazards, NIOSH has progressively adopted a “strategy integrating occupational safety and health protection with health promotion to prevent worker 

injury and illness and to advance health and wellbeing” [NIOSH 2013b]. This integrated approach, 

embodied by NIOSH in its Total Worker HealthTM 

Program [Schill and Chosewood 2013], has motivated NIOSH to produce this CIB, Promoting 

Health and Preventing Disease and Injury through 

Workplace Tobacco Policies. 
NIOSH CIB 67 • Workplace Tobacco Policies 3

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 substantially among U.S. adults, from 42.4% in 1965 to 

17.8% in 2013 [DHHS 2014; CDC 2014d]. Nationally representative studies on the smoking status of 

workers in the United States, most often based on 

one or more iterations of the National Health Interview Survey (NHIS), have demonstrated substantial declines in overall cigarette smoking, which are 

similar to the decrease in cigarette smoking among 

all U.S. adults [Sterling and Weinkam 1976; Nelson 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% during the 2004–2010 period [CDC 2011a, 2013b].

During the past several decades, a number of studies have assessed smoking habits among U.S. workers. Consistently, these studies have shown substantially higher cigarette smoking prevalence among 

blue-collar workers compared with white-collar 

workers, particularly among males [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 higher 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 smoking status by industry and occupation groupings 

in the Work-Related Lung Disease (WoRLD) Surveillance Report and corresponding online updates 

[NIOSH 2008a, 2014]. The most recent tables, 

covering the period 2004–2011, show that smoking prevalence varies widely—nearly four-fold—by 

industry. Smoking prevalence at or below 10% was 

found among major industry sectors in education 

services (9.8%) and among minor industry sectors in religious, grantmaking, civic, labor, professional, and similar organizations (10.0%). Smoking 

prevalence exceeding 30% was found among three 

major industry sectors: construction (32.1%); accommodation and food services (32.1%); and mining (30.2%). Several minor sectors in other major 

industries also exceeded 30%: gasoline stations 

(37.6%); fishing, trapping, and hunting (34.3%); 

forestry and logging (32.9%); warehousing and 

storage (32.0%); rental and leasing services (31.3%); 

wood product manufacturing (30.7%); and nonmetallic mineral product manufacturing (30.4%). 

Additional tables posted on that same NIOSH site 

show that cigarette smoking prevalence varies even 

more extremely—25-fold—by specific occupational group, from 2.0% for religious workers to 49.5% 

for construction trades helpers [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 NIOSH CIB 67 • Workplace Tobacco Policies 

snuff, dip, snus, and dissolvable tobacco products. 

As with smoking, NHIS data have been used to estimate smokeless tobacco use by workers [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 industry [CDC 2014a; NIOSH 2014]. (Appendix Figures A-2a and A-2b display prevalence of smokeless tobacco use for major industry and occupation 

categories.) 

Dual Use

Someone who smokes cigarettes and also uses 

smokeless tobacco engages in “dual use.” This is 

one way smokers can try to maintain their nicotine habit when and where smoking is prohibited. 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, including coal miners and others, employed in mines 

or factories where smoking poses risks for explosion and fire [Mejia and Ling 2010]. (Appendix Figures 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, respectively.) 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 Nicotine 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 cotinine, a metabolite of nicotine [Hammond et al. 

1995; Hammond 1999; Achutan et al. 2011; Pacheco et al. 2012]. By the late 1990s, studies that objectively measured markers of SHS found levels that 

varied substantially by workplace. Where smoking 

was allowed, offices and blue-collar workplaces had 

similar concentrations of nicotine in the air; higher 

nicotine concentrations were present in restaurants, and still higher concentrations (an order of 

magnitude higher than in offices) were measured 

in bars [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 documented 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 increasingly implemented over the past several decades in 

the United States and have been shown to be effective in reducing exposure to SHS [DHHS 2006, 

2014]. In a 1986 survey of the civilian U.S. population, 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 indoor workers who reported that they worked under 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; although 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 
NIOSH CIB 67 • Workplace Tobacco Policies 5

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 during the past year—estimated that 10.0% of nonsmoking U.S. workers reported frequent exposure 

to SHS at work [Calvert et al. 2013]. Prevalence 

of such frequent exposure by major industry sector ranged from 4.1% for finance and insurance to 

28.4% for mining, while prevalence by major occupation 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 conducted 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% (Nevada) to 85.8% (West Virginia), with a median of 

73.4% [CDC 2006]. Results from later surveys conducted 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% (Tennessee) 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 education and income from effects associated with occupation [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 professionals. That same study also found that bluecollar workers were also more likely to be smokers 

and more likely to be heavy smokers, suggesting 

that SHS exposures in the workplace could be intense for many blue-collar workers.

Electronic Nicotine Delivery Systems

First introduced into the U.S. market in 2007 [Regan et al. 2013], electronic nicotine delivery systems (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 consisting of varying amounts of nicotine, a propylene 

glycol and/or glycerin carrier, and flavorings. Inhalation draws the fluid to a heating element, creating 

vapor that subsequently condenses into an aerosol 

of minute droplets [Ingebrethsen et al. 2012]. 

Available data suggest that e-cigarette use has increased greatly in the United States during the past 

several years. A mail survey of U.S. adults showed 

that the percentage who had ever used e-cigarette 

more than quadrupled from 0.6% in 2009 to 2.7% 

in 2010 [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.
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NIOSH CIB 67 • Workplace Tobacco Policies 7

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 injuries [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 intensity of tobacco smoking, but no level of tobacco 

smoking is risk-free [DHHS 2010b, 2014]. Smoking 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
8 NIOSH CIB 67 • 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 cancer deaths among smokers each year in the United 

States [DHHS 2014]. Cancers caused by smoking include lung, mouth, throat, bladder, and other cancers 

(Table 3-1). Among the carcinogens present in cigarette 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 separately cause cancer, leading to effects on cancer causation greater than the effects of the two factors separately [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 responsible 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 smoking. Smoking also causes aortic aneurysms and peripheral 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 exposure to tobacco smoke—such as a smoking only 

a few cigarettes per day, occasional smoking, or exposure 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
NIOSH CIB 67 • Workplace Tobacco Policies 9

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 adverse effects of tobacco smoke. Chronic obstructive 

pulmonary disease (COPD), a broad designation 

encompassing bronchitis, emphysema, and airways 

obstruction, accounts for most smoking-caused respiratory deaths. As noted above, the effects of occupational 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 exposures 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 infectious pneumonias, and higher risk of tuberculosis [DHHS 2014]. 

Reproductive and Developmental Effects

Inhalation of tobacco smoke affects the reproductive system, with harmful effects related to fertility, fetal and child development, and pregnancy 

outcome. Smoking is estimated to cause more 

than 1,000 deaths from perinatal conditions each 

year in the United States [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, stillbirth, neonatal death, and sudden infant death syndrome (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 dysfunction [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 additive, 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, asbestos exposure. The insulators were divided into two subgroups—one with and the other without 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 substantially greater than what would be expected by adding the separate risks for smoking and asbestosis. 
10 NIOSH CIB 67 • Workplace Tobacco Policies 

Other Adverse Effects

Smoking is known to cause other health problems 

that contribute to the generally poorer health of 

smokers as a group. These include visual difficulties 

(due to cataracts and age-related macular degeneration), hip fractures (due to low bone density), 

peptic ulcer disease, diabetes, rheumatoid arthritis, 

and periodontitis [DHHS 2014] (Table 3-1). Smoking may also cause hearing loss in adults [Cruickshanks et al. 1998].

Inflammatory effects of tobacco smoke have 

been associated with many other health effects. For example, smoking has been found to 

delay wound healing after surgery and lead to 

wound complications [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 exposure to tobacco smoke will undoubtedly 

provide a more complete understanding of the 

adverse health effects of smoking.

Secondhand Smoke 

In the United States, SHS exposure causes more 

than 41,000 deaths among nonsmokers each year 

[DHHS 2014]. There is strong evidence of a causal 

relationship between SHS of adults and adverse 

health effects, including lung cancer, heart disease, stroke, exacerbation of asthma, nasal irritation, and (due to maternal exposure) reduced birth 

weight of offspring (Table 3-2) [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 nonsmoking 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 exposure may also be associated with hearing loss in 

adults [Fabry et al. 2011].

Among nonsmoking adults, health risks of SHS 

exposure extend to workplace exposures. A metaanalysis of 11  pertinent studies provided quantitative estimates of lung cancer risk attributable to 

workplace exposure to SHS; lung cancer risk was 

increased by 24% overall among workers exposed 

to SHS in the workplace, and there was a doubling 

of lung cancer risk among workers categorized as 

highly exposed to SHS in the workplace [Stayner et 

al. 2007]. A dramatic example of an adverse effect 

of exposure to SHS in the workplace was an asthmatic worker’s death (see Box 3-3).

Smokeless Tobacco

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

Box 3-2. Emphysema Risk in Coal Miners—Effects of Tobacco Smoking and Coal Mine Dust Exposure 

A study [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.
NIOSH CIB 67 • Workplace Tobacco Policies 11

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 generally lower risk levels than those associated with 

smoking [DHHS 2014]. The most harmful chemicals in smokeless tobacco are tobacco-specific 

nitrosamines, which are formed during the growing, curing, fermenting, and aging of tobacco. Other 

cancer-causing substances in smokeless tobacco include polonium-210 (a radioactive element found 
12 NIOSH CIB 67 • 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 products and represent potential 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 

reproductive outcomes (e.g., low birth weight, preterm delivery, and stillbirth) associated with maternal 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 impacts of ENDS use on individual and population 

level health. Contrary to some marketing messages, 

aerosol emitted from ENDS is not merely water vapor. Many of the hazardous components identified 

in tobacco smoke are present in ENDS emissions, 

though mostly at much lower levels. Liquids formulated for ENDS use commonly contain nicotine 

and flavorings in a propylene glycol and/or glycerin 

carrier, but exact formulations of these predominant constituents and other additives and contaminants 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 without 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, nausea, 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 effects on the developing fetus [DHHS 2014]. In addition, 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 harmful constituents [FDA 2009; McAuley et al. 2012; 

Schripp et al. 2013; Schober et al. 2014; Schaller et 

al. 2013; Bhatnagar et al. 2014; Cheng 2014; Goniewicz et al. 2014; Grana et al. 2014]. A recent review 

of the safety of ENDS use concluded that more research is warranted to determine the risk posed by 

various components of the liquids used in ENDS, 

including flavoring components in particular “because the effects of inhaling flavoring substances 

approved for food use are largely unknown” [Farsalinos 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]. Furthermore, beyond the concerns of nonuser exposure to nicotine and these other components, there 

is also potential for ENDS to be used to deliver psychoactive substances such THC, the active ingredient in marijuana [Welch 2014]. 

A study funded by an organization that promotes 

consumer access to ENDS as a means of harm reduction for nicotine-addicted individuals, emphasizes that estimated exposure levels associated with 

the use of ENDS are generally much lower than 

occupational exposure limits (OELs) for toxic industrial hazards [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). Finally, health-protective OELs have not been established for all chemicals capable of causing serious 

health impact on exposed workers [NIOSH 2004; 

CDC 2013c]. Thus, findings that exposures are below OELs should not lead directly to a conclusion 

that such exposures are entirely safe. Moreover, 
NIOSH CIB 67 • Workplace Tobacco Policies 13

another assessment concluded that current exposure 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 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 ... 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 contaminants were measured documented degradation of 

indoor air quality during ENDS use and found that 

air measurements of polycyclic aromatic hydrocarbons classified as probable carcinogens by IARC 

increased an average of 20% during ENDS use 

[Schober et al. 2014]. In light of irritant compounds 

(e.g., formaldehyde, acetaldehyde, and acrolein) 

identified in emissions from ENDS, it has been recommended that research be done to evaluate possible adverse effects of exposure to these compounds 

among ENDS users and individuals exposed to secondhand ENDS aerosol [Goniewicz et al. 2014]. Indeed, findings relating to short-term adverse effects 

on ENDS users include preliminary reports of significantly increased airways resistance [Gennimata 

et al. 2012] and respiratory irritation and cough, 

particularly among individuals with asthma [Tsikrika et al. 2014]. No studies to date have observed 

similar short-term effects due to secondhand exposure to ENDS aerosol, but one experimental study 

demonstrated that passive exposure of human volunteers 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 secondhand 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; Schraufnagel 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 declining over time, in part due to the decline in smoking [Hall 2013]. In addition to injuries caused by 

smoking-related fires, use of tobacco products is a 

recognized distracting factor while operating motor vehicles [NHTSA 2009], and smoking while 

driving has been shown to increase the risk of being involved in a crash [Young et al. 2003]. Adverse 

smoking-associated physiological alterations in 

bone mineralization, blood vessels, and inflammatory response [Leistikow 2000a] may also contribute to higher risk of injuries, impaired recovery, 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 fatal health problems, as outlined above. What many 

workers and their employers often do not fully understand is that tobacco use can increase, sometimes profoundly, the likelihood and/or the severity of occupational disease and injury caused by 

other hazards present in their workplaces. In addition, workplace exposure to SHS can cause serious 

health effects among nonsmoking workers [NIOSH 
14 NIOSH CIB 67 • 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 multiple 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 associated with them can be increased for workers who 

use tobacco or are exposed to SHS. These chemicals 

include acetone, acrolein, aldehydes (e.g., formaldehyde), arsenic, cadmium, carbon monoxide, hydrogen cyanide, hydrogen sulfide, ketones, lead, 

methyl nitrite, nicotine, nitrogen dioxide, phenol, 

and polycyclic aromatic compounds [NIOSH 1979]. 

Heat generated by smoking tobacco in the workplace can transform a workplace chemical to a 

more toxic chemical [NIOSH 1979; DHEW 1979b; 

DHHS 1985]. Though smokers are most highly exposed to the transformed chemical, nonsmoking 

coworkers in the same work area may also be exposed. Examples of occupational agents that have 

the potential for conversion to highly toxic chemicals by smoking tobacco products include polytetrafluoroethylene (Teflon®

) and other chlorinated 

hydrocarbons (see Box 3-5). 

Box 3-4. Some Ways Tobacco Use by Workers or in the Workplace Can Cause or 

Worsen Occupational Safety and Health Risks

• Tobacco smoke/tobacco products can contain the same toxic agent that is released into the 

workplace from a work process, thus increasing the dose of that agent received by tobaccousing workers.

• A workplace chemical can be transformed into a more harmful agent by the heat involved 

in smoking.

• Tobacco products can become contaminated with industrial toxicants found in the workplace, 

thus facilitating entry of the agent into the body through inhalation, ingestion, and/or skin 

absorption.

• Smoking can contribute to an effect on the body comparable to that which can result from 

exposure to an industrial toxicant in the workplace, thus causing an additive combined effect.

• Smoking can act synergistically with industrial toxicants found in the workplace to cause a 

much more profound effect than anticipated based on the known individual effects of smoking 

and the occupational exposure.

• Tobacco use at work can contribute to work-related traumatic injuries and fatalities, either as an 

ignition source for explosive or flammable agents in the workplace, or through tobacco-related 

distraction while operating a vehicle or machinery at work.

• Smoking at work exposes nonsmoking coworkers to the hazards of secondhand smoke.

Adapted from NIOSH [1979, 1991]
NIOSH CIB 67 • Workplace Tobacco Policies 15

Tobacco products can readily become contaminated by industrial toxicants in the workplace through 

contact of the tobacco products with unwashed 

hands or contaminated surfaces and through deposition of airborne contaminants onto the tobacco 

products. Subsequent use of the contaminated tobacco product, at or even away from the workplace, 

facilitates entry of these toxic agents into the user’s 

body by inhalation, ingestion, and/or skin absorption [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 independently caused by tobacco use and workplace exposure to a toxic agent. Thus, even if tobacco is used 

only away from work, users will be more severely 

affected than non-users, typically in an additive 

manner. For example, tobacco smoking reduces a 

worker’s lung function, leaving that worker more 

vulnerable to the effect of any similar lowering of 

lung function caused by occupational exposure 

to dusts, gases, or fumes. Occupational exposures 

that, like tobacco smoking, cause chronic airways 

diseases and lung function impairment, include 

cotton dust, coal mine dust, grain dust, silica dust, 

welding fumes, and others [NIOSH 1979; DHEW 

1979b; DHHS 1985]. 

For some occupational hazards, the combined impact of tobacco use and exposure to the occupational agent can be synergistic (i.e., amounting to 

an effect much greater than the sum of each independent effect). Adverse biological effects of smoking on the respiratory tract can lead to higher effective doses of an industrial toxicant among smoking 

workers compared with nonsmoking workers. For 

example, deposition of hazardous occupational 

dusts can be increased in airways narrowed by 

smoking, and clearance of deposited dust can be 

slowed by smoking-induced impairment of both 

alveolar and mucociliary transport [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 exposure both independently cause lung cancer. Workers who both smoke and are exposed to asbestos at 

work face a much greater risk of dying from lung 

cancer than would be expected from the known independent risks of smoking by itself and asbestos 

exposure by itself [NIOSH 1979; DHEW 1979b; 

Box 3-5. Polymer Fume Fever in Smokers with Occupational Exposure to Tetrafluoroethylene

Soon after use of a new spray product containing tetrafluoroethylene (a fluorocarbon monomer) was 

introduced at a small industrial facility, workers began experiencing severe episodic “flu-like” symptoms. The 

symptoms—lower backache accompanied by fever, chills, and malaise, and a dry, nonproductive 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].
16 NIOSH CIB 67 • 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 synergistic effects may involve consideration of temporality of exposures and outcome. Workers who start 

smoking before they are occupationally exposed to 

radon may face a more-than-multiplicative risk of 

lung cancer that is much higher than the additive 

risk faced by radon-exposed workers who did not 

smoke until after their occupational exposure to radon [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 hazards, 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 materials. Smoking has been implicated as the known or 

suspected cause of several major industrial disasters in the United States, including the infamous 

Triangle Shirtwaist Factory fire in 1911 [Leistikow 

et al. 2000b]. To help prevent occupational explosions 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 possession of smoking-related materials (e.g., cigarettes, 

cigars, pipes, lighters, matches) in designated hazardous work areas (see Appendix Table A-3). Despite existing regulations and widespread awareness 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 fatal 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 smoking 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, extinguishing, or disposing of a tobacco product) or by a 

tobacco-caused coughing spell can result in traumatic injury or death when that worker is driving a 

work vehicle or operating other potentially hazardous machinery or equipment [NIOSH 1979]. Several studies have shown that smokers are more likely 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].
NIOSH CIB 67 • Workplace Tobacco Policies 17

by tobacco use for users and for non-users. For 

example, tobacco smoking in a workplace will 

put nonsmoking workers in that workplace at increased risk due to their workplace exposure to 

SHS. In contrast, in workplaces free of other occupational chemical or physical hazards, use of 

smokeless tobacco would not be expected to result in any increased occupational risk for users 

or their coworkers. ENDS use in the workplace 

could, like use of any tobacco product, plausibly 

enhance a user’s exposure to hazardous workplace 

toxicants present in the workplace, may serve as a 

potential ignition source in workplaces where explosive atmospheres are present, and can result in 

secondhand exposure of coworkers (see Electronic 

Nicotine Delivery Systems, above).
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NIOSH CIB 67 • Workplace Tobacco Policies 19

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 workplaces 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 prohibiting other onsite sales of tobacco in workplaces. 

• Provision of tobacco cessation programs. 

• Employer-provided health insurance benefits 

designed to increase access and remove barriers to evidence-based cessation treatments 

and to provide incentives to quit tobacco use.

• Design of hiring policies based on smoking 

status. 

Many preventive policies relating to smoking and 

the workplace are governed by local, state, or federal government laws and/or regulations. Others 

are independently implemented by employers as 

workplace requirements or conditions of employment. Employees and/or labor organizations can 

share in a sense of joint ownership if they meaningfully collaborate with the employer on policy language, approaches and timing, cessation supports, 

and compliance and consequence issues. Involving 

employees in the development, implementation, 

and evaluation of workplace programs is an effective strategy for changing employee culture and behavior [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 tobacco users’ health, given that tobacco use causes 

Box 4-1. Some Reasons for Employers to Implement Workplace Tobacco Interventions

• Reducing occupational disease and injuries (and workers’ compensation insurance costs).

• Lowering health insurance and life insurance costs and claims.

• Decreasing costs of training workers to replace those who become disabled or die prematurely. 

• Increasing productivity through reduced absenteeism and reduced presenteeism. 

• Reducing accidents and fires (and related insurance costs).

• Lessening property damage (and related insurance costs).

• Eliminating indoor air pollution (and related cleaning, maintenance, and ventilation costs).

• Limiting liability and legal costs for failing to provide a safe and healthful working

environment.

• Enhancing worker morale and corporate image by showing concern for employees/customers.

Adapted from DHHS [1996]
20 NIOSH CIB 67 • 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 tobacco use may be eliminated 5 years after quitting. 

• Ease symptoms such as coughing, wheezing, and shortness of breath within months of quitting 

and long-term risk for chronic obstructive pulmonary disease (COPD) and other respiratory 

diseases. 

• Reduce risk of ulcer. 

• Reduce risks of infertility (for women who stop smoking during their reproductive years).

To protect the health of others 

• Avoid exposing family, friends, coworkers, and others to the harmful effects of secondhand 

smoke (SHS).

• Lessen the risk of having a low-birth-weight baby (for women who stop smoking before becoming pregnant or during the first trimester of pregnancy).

• Increase the likelihood that one’s young children will not use tobacco when they reach adolescence and adulthood.

To improve personal/family finances 

• Save money by not spending money on tobacco and other tobacco-related expenditures (e.g., 

higher insurance premiums).

• Reduce the risk of financial devastation resulting from income loss due to smoking-related disability or premature death, or from property loss due to a smoking-related home fire.

To avoid personal inconvenience

• Avoid the need to go outside, sometimes in the rain and cold, when working in a tobacco-free 

workplace.

the top fıve health conditions that impact the U.S. 

population [Task Force on Community Preventive Services 2010]. Protecting the health of nonsmoking workers is another important motivating 

interest. Although the health and safety consequences of tobacco use offer sufficient rationale 

for workplace tobacco policies, legal and economic considerations are also important. Government 

(i.e., taxpayers), employers, and employees all 

bear financial costs associated with adverse effects 

of tobacco use by workers and occupational exposure to SHS. 
NIOSH CIB 67 • Workplace Tobacco Policies 21

Legally determined employer responsibility to provide employees with a safe workplace can motivate 

action by employers. OSHA does not currently apply 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 exposure, but this is “a matter of prosecutorial discretion” [OSHA 2003]. Therefore, employers would do 

well not to ignore other legal implications of their 

duty to provide safe workplaces, including workplaces 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 workplace, under federal or state disability law for failing 

to provide reasonable accommodations to alleviate an employee’s exposure to SHS, and under the 

common law for failure to provide employees with 

a reasonably safe work environment free of SHS 

[Zellers et al 2007]. Adopting an effective smokefree (or tobacco-free) workplace policy would protect an employer from such liability and provide 

employees with a safe workplace. 

With respect to personal costs paid by individual 

smokers, there are obvious direct costs associated 

with consumer purchases of tobacco products and 

related materials. However, many smokers, especially those with the least discretionary income, are 

unaware of longer-term financial costs. One financial writer estimated in 2007 that a typical pack-aday smoker who is spending nearly $2,000 annually just to purchase cigarettes could instead amass 

more than $1 million by investing that amount 

each year from ages 18 to 65 in an individual retirement account invested with an emphasis on growth 

[Karp 2007]. That estimate did not encompass costs 

of smoking other than the purchase price of tobacco. Smokers may be charged higher premiums for 

health and life insurance and generally pay more 

out-of-pocket costs for health care. Families can 

experience substantial loss of income when their 

smoking breadwinner becomes disabled or dies 

prematurely from a smoking-related disease. Financial devastation can also result from smokingcaused residential fires through costly personal 

injury to the smoker and/or family members and 

through loss of residence and other personal property. In addition, smokers and their families may 

incur additional costs for more frequent cleaning, 

repairing, or replacement of clothing and other 

personal furnishings to remove smoke odors and 

tobacco-related stains. 

With respect to employers’ costs, a recent study estimated excess annual cost to U.S.-based private employers associated with employees who smoke cigarettes compared with those who do not. Considering 

aggregate cost and productivity impacts associated 

with smoking breaks, absenteeism, presenteeism, 

healthcare expenses, and pension benefits, the study 

estimated that the annual cost to employ a smoker 

was, on average, $5,816 greater than the cost to employ a nonsmoker [Berman et al. 2013]. Interventions 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 prohibited in particular work settings where explosive or extremely flammable materials are present 

(see Appendix Tables A-2 and A-3). A century ago, 

such prohibitions may have been motivated more 

out of concern about property loss than concern 

for the well-being of workers. Subsequently, concern about worker health has motivated additional 

policies prohibiting the use of tobacco products in 

specific work sites where exposure to certain hazardous occupational agents can be increased as a 

result of tobacco use (see Appendix Tables A-1 and 

A-3). The need for such venue-specific prohibitions 

on tobacco use has been widely understood and 

accepted; however, compliance with these prohibitions has been imperfect [MSHA 2000], indicating 

a need for ongoing training and vigilance. 

In the last decades of the past century, as the public became more aware of the hazards of exposure 

to SHS, government (at the local, state, and federal 
22 NIOSH CIB 67 • Workplace Tobacco Policies 

levels) acted with the intent to reduce workplace 

exposures to SHS and subsequently to eliminate 

SHS from workplaces [DHHS 2006]. The Surgeon General has concluded that there is no riskfree level of exposure to SHS [DHHS 2006, 2010b, 

2014]. Complete prohibitions on workplace smoking 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 ventilating 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 completely tobacco smoke-free.

Federal actions have been implemented to eliminate SHS from some workplaces. Actively supported by flight attendants and their union as a way 

to protect their health by eliminating SHS in their 

workplace, federal law has progressively prohibited 

smoking during commercial passenger flights, beginning in 1988 with shorter domestic flights and 

by 2000 encompassing all flights originating and/or 

terminating in the United States [Pan et al. 2005]. 

In 1990, the Interstate Commerce Commission acted 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 exceptions (e.g., specially equipped designated smoking 

areas, certain residential settings, and space occupied by non-federal parties)[Cook and Bero 2009]. 

In 2009, this policy to prohibit smoking in all interior space owned, rented, or leased by the executive 

branch of the federal government was extended 

by action of the General Services Administration, 

eliminating remaining indoor designated smoking 

areas and additionally prohibiting smoking within 

25 feet of doorways and air intakes and in courtyards where those outdoor spaces are under GSA 

jurisdiction [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 restricting smoking in private workplaces, restaurants, and 

bars went into effect in 1993 (Shasta County, California) and 2002 (Delaware), respectively [CDC 

2011b, 2012]. By the end of 2010, CDC reported 

that 26 states, the District of Columbia, and a majority of the 50 largest U.S. cities had enacted comprehensive 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 adoption 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 accredited hospitals, achieving a high level of compliance 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 beneficial impacts on workplace safety and property 

loss (see Box 4-3). Many other businesses also voluntarily implemented smoke-free policies in their 

workplaces and, by the late 1990s, nearly 70% of 

U.S. workers employed in non-residential indoor 

worksites were working in smoke-free workplaces 

[Shopland et al. 2004]. 

A number of studies, including meta-analyses, 

have shown that smoke-free workplace policies decrease exposure of nonsmoking employees to SHS 

at work and increase cessation among employees 

who smoke [DHHS 2006; IARC 2009; Hopkins et al. 

2010]. Although one review of the literature found 
NIOSH CIB 67 • Workplace Tobacco Policies 23

inconclusive evidence that smoke-free workplace 

policies cause smokers to quit altogether [Callinan 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; Hopkins et al. 2010]. In contrast, less restrictive workplace smoking policies are associated with sustained 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 ecological studies to be associated with reduced hospitalizations for heart attacks in the general population [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. Notably, the percentage of all structural fires in health-care facilities determined to have been caused by 

smoking materials dropped from 30% to 5% over the same period [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 afterward. Self-reported exposure to SHS at work fell from a median of 28 hours per week before the law 

took effect to 2 hours per week afterward. Respiratory symptoms and eye, nose, and throat irritant 

symptoms were each reported by about 75% of bartenders before the law took effect. Of those with 

symptoms at baseline, 59% with respiratory symptoms and 78% with irritant symptoms experienced 

resolution of those symptoms after the law took effect (P < 0.001). On average, lung function measurements also improved. The authors of this study concluded that making taverns and bars smokefree resulted in a rapid improvement in the health of bartenders [Eisner et al. 1998]. 
24 NIOSH CIB 67 • 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 recommended 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 smoking in the workplace), not only as a means to reduce 

exposure to SHS, but also as an effective means to 

increase tobacco cessation, reduce tobacco use 

prevalence, and reduce tobacco-related morbidity and mortality [Hopkins et al. 2010; Task Force 

on Community Preventive Services 2010; GCPS 

2012a]. To prevent SHS exposures, the recent Surgeon General’s report urges that comprehensive 

smoke-free indoor protections be extended to the 

entire U.S. population [DHHS 2014]. 

World Health Organization reports have recommended that, in the absence of evidence that can 

assure authorities that use of ENDS does not expose bystanders to toxic emissions, ENDS should 

not be exempted from laws that restrict the places 

in which cigarette smoking is allowed [WHO 2009, 

2014]. The British Medical Association has taken 

the position that use of e-cigarettes should be prohibited 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 has 

recommended including e-cigarettes in smokefree laws [Bhatnagar et al. 2014]. The Forum of 

International Respiratory Societies has recommended that ENDS use be prohibited “in public 

places, workplaces, and on public transportation” 

[Schraufnagel et al. 2014]. The American Industrial Hygiene Association similarly reviewed the 

issue of ENDS and concluded that “their use in the 

indoor environment should be restricted, consistent with current smoking bans, until and unless 

research documents that they will not significantly 

increase the risk of adverse health effects” to those 

exposed secondhand [AIHA 2014]. In the United 

States, the number of states and localities that explicitly prohibit use of e-cigarettes in public places 

where tobacco smoking is already prohibited is increasing with time [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 unregulated nature of ENDS and the liquid concoctions 

used them, along with uncertainty about the impact of ENDS use in the workplace on the health of 

non-users, the simplest approach is for employers 

to simply add ENDS to the list of products covered 

by their tobacco-free (or smoke-free) workplace 

policy [Phillips 2014].

Employer Prohibitions on 

Tobacco Use Extending Beyond

the Workplace

Some employers have taken action to extend restrictions on tobacco use by their employees beyond the workplace. For example, in 2013, the U.S. 

Public Health Service Commissioned Corps became the first federal uniformed service to prohibit 

tobacco use by its officers whenever and wherever 

they are in uniform [ACPM 2013]. More controversial are attempts of private employers to control the behavior of their employees outside of the 

workplace. For example, at a major medical center 

that had a smoke-free campus policy in place for 

years, the employer recently announced plans to 

prohibit smoking by workers during their workday 

breaks, including lunchtime, even when off campus 

[Toland 2013]. Several large employers and organizations (including the Cleveland Clinic, Union 
NIOSH CIB 67 • Workplace Tobacco Policies 25

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 policies that bar the hiring of smokers or prohibit tobacco use by employees during the workday when 

they are away from the worksite even on their own 

time. Proponents argue that a nonsmoking workforce serves as a positive role model for health, experiences better health status, incurs substantially 

lower health-care costs for employers and employees alike, and improves productivity [Asch et al. 

2013]. Opponents posit the addictive nature of tobacco and the fact that tobacco use usually begins 

in adolescence, note that tobacco use remains legal, 

and cite the disparate and potentially discriminatory effects such a policy might have on minority, 

lower-income, or less educated workers and job 

candidates—groups that tend to have higher levels 

of tobacco use. They also point out that employers 

who refuse to hire smokers typically do not similarly refuse to hire individuals with other personal 

health behaviors that, like tobacco use, have adverse 

health consequences. They add that more than half 

of states have laws in place prohibiting employers from refusing to hire individuals because they 

smoke [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 tobacco and about half reported having tried to quit 

in the previous year [Yong et al. 2014]. Just as policies 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 workplace policies can be expected to increase worker 

interest in quitting and cessation support services. 

When a smoking cessation program is established 

in a workplace, smokers employed at that workplace are more likely to intend to quit in the next 6 

months [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 readily ‘piggy-backed’ on occupational health services 

that already exist in many workplaces. For example, 

all workers enrolled in OSHA-mandated respiratory protection programs must be asked about tobacco use as part of their medical evaluation (see 

Appendix Table A-2 for applicable OSHA standard 

numbers). Other existing opportunities to ascertain 

individual smoking behavior include post-employment (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 Institute through http://smokefree.gov/smokefreetxt. 

State quitlines exist in all 50 states and the District of 

Columbia, are publicly funded, are typically available 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-language 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, especially proactive quitlines where the counselor 

initiates follow-up calls [GCPS 2012b; Clinical 
26 NIOSH CIB 67 • Workplace Tobacco Policies 

Practice Guideline 2008]. The Public Health Service 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—increase tobacco cessation among callers who are interested in quitting and can help expand the use of 

evidence-based cessation services among smokers 

in populations that have limited access to cessation 

treatment [GCPS 2012b]. An updated Cochrane 

review has reaffirmed the effectiveness of proactive 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 component 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% mentioned the availability of the state quitline in their 

health promotion messages to workers [Hughes et 

al. 2011]. 

The most comprehensive workplace cessation programs go well beyond minimal cessation counseling and referral to no-cost quitlines and web-based 

programs. Employers can enter into preferred relationships with state quitlines or contract quitline 

providers to establish employer-specific quitlines 

with special services [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 corporation 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 program. A systematic review of the literature found 

that workplace-based smoking cessation services 

such as individual and group counseling, pharmacological treatment, and social support are all effective in enhancing quit rates when compared with 

no interventions or minimal interventions [Cahill 

and Lancaster 2014]. Optimal work-based tobacco 

cessation programs are designed to provide followup assistance and to support multiple quit attempts, 

because most smokers try to quit repeatedly before 

finally succeeding [Clinical Practice Guideline 2008]. 

Ideally, employers should incorporate tobacco 

cessation support programs into a more comprehensive approach that addresses the overall safety, 

health, and well-being of workers. A growing evidence base supports the enhanced effectiveness of 

workplace programs that integrate health promotion efforts such as smoking cessation with more 

specific occupational health protection programs 

[Hymel et al. 2011; NIOSH 2013b]. Such integrated workplace tobacco cessation programs may 

be most usefully implemented among blue-collar 

workers, who generally have higher smoking (and 

lower quitting) rates than office workers and who 

generally face higher risks from industrial hazards. 

A large randomized study involving 15 manufacturing sites showed that combining occupational 

health and safety messages with health promotion 

messages resulted in a doubling of smoking quit 

rates among hourly workers (from 5.9% to 11.8%; 

P =  0.04) compared with health promotion messages alone [Sorensen et al. 2003]. Another demonstration study of an integrated program aimed 

at enhancing smoking cessation among blue collar 

workers targeted participants in a union apprenticeship 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 cessation treatments [Clinical Practice Guideline 2008]. 
NIOSH CIB 67 • Workplace Tobacco Policies 27

Ideally, such coverage should provide access to 

all evidence-based cessation treatments, including 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, premiums, 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. Insurance 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), Public 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 services 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 featuring photographs of ironworkers were displayed. Articles explaining and promoting the program 

were published in the union newsletter. Occupational health protection aspects of the program 

were featured in an educational module on “toxics and tobacco.” This module was taught by an 

industrial hygienist and covered separate and combined adverse health effects, including cancer, 

caused by smoking and workplace hazards (e.g., asbestos, welding fumes, and diesel exhaust) 

commonly encountered by ironworkers. Tobacco treatment specialists led weekly group sessions 

on tobacco cessation. Incentives to participate in the sessions included free lunches and, for those 

attending all sessions, a chance for a raffle prize. Self-help quit kits were provided to apprentices 

who chose not to attend the group sessions. Nicotine replacement therapy was available at no cost 

to participants. Of 337 participants, 139 (41.2%) were current smokers at the time the program 

started. One month after the program concluded, 27 (19.4%) of those smokers had quit—a rate 

much higher than the expected ~5% quit rate. Program participants were 3 times more likely to 

quit than nonparticipants [Barbeau et al. 2006].
28 NIOSH CIB 67 • 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 including four sessions of individual, group, and telephone 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 treatments 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 insurance coverage for their employees will have expanded opportunities to design incentives for wellness programs, including interventions intended 

to enhance tobacco cessation (or, with some limitations, disincentives for continued tobacco use). 

For example, in order to motivate employees to 

quit smoking, the ACA allows employer-sponsored 

health insurance issuers to charge tobacco users 

premiums that are up to 50% higher than premiums charged non-tobacco users [Kofman et al. 

2012; Madison et al. 2013]. However, issuers who 

impose these surcharges in the small-group market must provide tobacco users the opportunity to 

avoid them, for example by participating in a cessation program [78 Fed. Reg. 33158]. States have authority 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 tobacco use. Likewise, such actions are increasingly 

discouraging tobacco use by workers covered by 

employer-sponsored health insurance programs 

(e.g., through increased premiums for smokers). 

For example, more than one-third of surveyed large 

employers who offer their employees smoking cessation programs incentivize participation in these 

programs. The number of large employers who 

are planning to reward or penalize smokers based 

on their smoking status is increasing—more than 

half of companies plan to do so by the end of 2013, 

up from less than 25% of employers who did so in 

2010 [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 cessation medications. Because of strong evidence that 

the number of tobacco users who quit can be increased by reducing these out-of-pocket costs, the 

Community Preventive Services Task Force recommends reducing tobacco users’ out-of-pocket costs 

for cessation treatments [GCPS 2012c]. 

The Task Force had earlier examined the issue of 

providing incentives for tobacco cessation, finding 

insufficient evidence at that time that workplacebased incentives or competitions by themselves reduced tobacco use among employees [GCPS 2005]. 

Even then, the Task Force went on to recommend 

worksite-based incentives and competitions when 

they are combined with other evidence-based interventions (e.g., education, group support, telephonic counseling, self-help materials, smoke-free 

workplace policies) as part of a comprehensive cessation program [GCPS 2005]. 

A subsequent systematic review of the literature 

identified a single well-designed study in which 

financial incentives integrated into a smoking cessation program produced a substantial and sustained beneficial impact [Cahill and Perera 2011]. 

Incentive payments for that randomized trial were 

structured as $100 for completion of the smokingcessation program; $250 for abstinence (confirmed 

biochemically) during the first 6 months after study 
NIOSH CIB 67 • Workplace Tobacco Policies 29

enrollment; and $400 for abstinence (also confirmed biochemically) during the subsequent 6 

months. Smokers offered the financial incentives 

were three times as likely to enroll in the program 

(15.4% vs. 5.4%, P < 0.001), four times as likely to 

complete the program (10.8% vs. 2.5%, P < 0.001), 

and three times as likely to remain abstinent more 

than a year later (14.7% vs. 5.0%, P < 0.001) [Volpp 

et al. 2009]. Notably, this study did not involve 

establishing a new smoking cessation program; 

rather, all participants were informed about existing smoking-cessation resources available in their 

community and about employer-provided health 

benefits related to smoking cessation. 

A recent review explored ethical and legal issues 

relating to employer-provided incentives intended 

to change individual health behaviors, including 

tobacco use [Madison et al. 2011]. The authors 

identified a number of specific issues that call for 

scrutiny, including the need to ensure that incentive programs are designed to work as intended, 

and the potential for incentives to be used in an 

unduly coercive or discriminatory manner. They 

emphasized that employers should play a collaborative, supportive role in advancing the health of 

workers, and they further suggested that, in order 

to limit the potential for discrimination, programs 

should be designed to minimize differences in 

individual employees’ abilities to access incentives 

[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 unintended consequences. For example, these practices could lead smokers to conceal their smoking 

(and thereby not benefit from cessation assistance), 

or even to forgo health insurance coverage or quit 

their jobs [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 individuals [Madison et al. 2011, 2013]. 

In summary, workplace policies are powerful tools 

that can benefit worker health. Well-designed policies protect workers from occupational risks, provide workplace-associated opportunities for enhancing worker health, and motivate workers to 

take beneficial actions to protect their well-being. 

Although not a primary focus of this CIB, workplace policies that effectively sustain or improve 

worker health can also be cost-effective and benefit 

the employer’s bottom line. 
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NIOSH CIB 67 • Workplace Tobacco Policies 31

5 Conclusions

• Cigarette smoking by workers and SHS exposure in the workplace have both declined 

substantially over recent decades, but about 

20% of all U.S. workers still smoke and about 

20% of nonsmoking workers are still exposed 

to SHS at work.

• Smoking prevalence among workers varies widely by industry and occupation, approaching or exceeding 30% in construction, 

mining, and accommodation and food services workers.

• Prevalence of ENDS use by occupation and 

industry has not been studied, but ENDS has 

grown greatly, with about 1 in 3 current U.S. 

adult smokers reporting ever having used ecigarettes by 2013.

• Smokeless tobacco is used by about 3% of 

U.S. workers overall, but smokeless tobacco is 

used by more than 10% workers in construction and extraction jobs and by nearly 20% of 

workers in the mining industry, which can be 

expected to result in disparities in tobaccorelated morbidity and mortality.

• Tobacco use causes debilitating and fatal diseases, including cancer, respiratory diseases, 

and cardiovascular diseases. These diseases 

afflict mainly users, but they also occur in 

those exposed to SHS. Smoking is substantially more hazardous, but use of smokeless 

tobacco also causes adverse health effects. 

More than 16 million U.S. adults live with 

a disease caused by smoking, and each year 

nearly a half million die prematurely from 

smoking or exposure to SHS.

• Tobacco use is associated with increased risk 

of injury and property loss due to fire, explosion, and vehicular collisions.

• Tobacco use by workers can increase, sometimes profoundly, the likelihood and the 

severity of occupational disease and injury 

caused by other workplace hazards (e.g., lead, 

asbestos, and flammable materials).

• Restrictions on smoking and tobacco use in specific work areas where particular high-risk occupational hazards are present (e.g., explosives, 

highly flammable materials, or highly toxic materials that could be ingested via tobacco use) 

have long been used to protect workers.

• A risk-free level of exposure to SHS has not 

been established, and ventilation is insufficient to eliminate indoor exposure to SHS. 

• The risk of adverse health effects associated 

with using ENDS or secondhand exposure to 

particulate aerosols and gases emitted from 

ENDS remains to be fully characterized.

• Policies that prohibit tobacco smoking throughout the workplace (i.e., smoke-free workplace 

policies) are now widely implemented, but they 

have not yet been universally adopted across the 

United States. These policies improve workplace 

air quality, reduce SHS exposure and related 

health effects among nonsmoking employees, 

increase the likelihood that workers who smoke 

will quit, decrease the amount of smoking during the working day by employees who continue to smoke, and have an overall impact of 

improving the health of workers (i.e., among 

both nonsmokers who are no longer exposed 

to SHS on the job and smokers who quit).

• Workplace-based efforts to help workers quit 

tobacco use can be easily integrated into existing occupational health and wellness programs. Even minimal counseling and/or simple referral to state quitlines, mobile phone 

texting interventions, and web-based intervention can be effective, and more comprehensive programs are even more effective.

• Integrating both occupational safety and 

health protection components into workplace 

health promotion programs (e.g., smoking 
32 NIOSH CIB 67 • Workplace Tobacco Policies 

cessation) can increase participation in tobacco cessation programs and successful cessation among blue-collar workers.

• Smokers, on average, are substantially more 

costly to employ than nonsmokers. 

• Some employers have policies that prohibit 

employees from using tobacco when away 

from work or that bar the hiring of smokers 

or tobacco users. However, the ethics of these 

policies remain under debate, and they may 

be legally prohibited in some jurisdictions.
NIOSH CIB 67 • Workplace Tobacco Policies 33

6 Recommendations 

The following recommendations relate specifically 

to the issues raised in this CIB. NIOSH recommends that employers take the following actions 

related to employee tobacco use:

• At a minimum, establish and maintain smokefree workplaces that protect those in workplaces from involuntary, secondhand exposures to 

tobacco smoke and airborne emissions from 

e-cigarettes and other electronic nicotine delivery systems. Ideally, smoke-free workplaces 

should be established in concert with tobacco 

cessation support programs. Smoke-free zones 

should encompass (1) all indoor areas without 

exceptions (i.e., no indoor smoking areas of 

any kind, even if separately enclosed and/or 

ventilated), (2) all areas immediately outside 

building entrances and air intakes, and (3) all 

work vehicles. Additionally, ashtrays should be 

removed from these areas.

• Optimally, establish and maintain entirely tobacco-free workplaces, allowing no use of any 

tobacco products across the entire workplace 

campus (see model policy in Box 6-1). 

• Comply with current OSHA and MSHA 

regulations that prohibit or limit smoking, 

smoking materials, and/or use of other tobacco products in work areas characterized 

by the presence of explosive or highly flammable materials or potential exposure to 

toxic materials (see Table A-3 in the Appendix). To the extent feasible, follow all similar 

NIOSH recommendations (see Table A-2 in 

the Appendix). 

• Provide information on tobacco-related health 

risks and on benefits of quitting to all employees and other workers at the worksite (e.g., 

contractors and volunteers). 

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 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 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 
34 NIOSH CIB 67 • Workplace Tobacco Policies 

cessation programs for lower-wage 

workers to enhance the likelihood of 

their participation. If health insurance is 

provided for employees, the health plan 

should provide comprehensive cessation 

coverage, including all evidence-based 

cessation treatments, unimpeded by copays and other financial or administrative 

barriers.

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/faq-aca19.

html) before developing, implementing, or 

modifying tobacco-related policies, interventions, or controls. 

• Develop, implement, and modify tobaccorelated policies, interventions, and controls 

in a stepwise and participatory manner. Get 

input from employees, labor representatives, 

line management, occupational safety/health 

and wellness staff, and human resources professionals. Those providing input should include current and former tobacco users, as 

well as those who have never used tobacco. 

Seek voluntary input from employees with 

health conditions, such as heart disease and 

asthma, exacerbated by exposure to SHS. 

• Make sure that any differential employment 

benefits policies that are based on tobacco 

use or participation in tobacco cessation programs are designed with a primary intent 

to improve worker health and comply with 

all applicable federal, state, and local laws 

and regulations. Even when permissible by 

law, these differential employment benefit policies—as well as differential hiring 

policies based on tobacco use—should be 

implemented only after seriously considering 

ethical concerns and possible unintended consequences. These consequences can include 

the potential for adverse impacts on individual employees (e.g., coercion, discrimination, 

and breach of privacy) and the workforce as 

a whole. Furthermore, the impact of any differential policies that are introduced should be 

monitored to determine whether they improve 

health and/or have unintended consequences. 

NIOSH recommends that workers who smoke cigarettes or use other tobacco products take the following actions:

• Comply with all workplace tobacco policies.

• Ask about available employer-provided tobacco cessation programs and cessation-related health insurance benefits. 

• Quit using tobacco products. Know that quitting tobacco use is beneficial at any age, but 

the earlier one quits, the greater the benefits. 

Many people find various types of assistance 

to be very helpful in quitting, and evidencebased cessation treatments have been found 

to increase smokers’ chances of quitting successfully. Workers can get help from

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 CIB 67 • Workplace Tobacco Policies 35

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 NIOSH CIB 67 • 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 environment 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 applies 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. Additionally, 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 areas 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 implementation 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 department. [COMPANY] will not retaliate, discourage, or prohibit any employee, client or visitor 

from reporting violations of this policy. 
NIOSH CIB 67 • Workplace Tobacco Policies 37

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 WORKPLACE 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 Secondhand 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 NIOSH CIB 67 • 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/makingyourworkplacesmokefreegu.pdf
NIOSH CIB 67 • Workplace Tobacco Policies 39

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.pdf
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NIOSH CIB 67 • Workplace Tobacco Policies 41

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APPENDIX
58 NIOSH CIB 67 

• Workplace Tobacco Policies 

Table A-1. Previous NIOSH Current Intelligence Bulletins on Tobacco Use

Publication (year) Findings Recommendations

Current Intelligence Bulletin 31Smoking and the Occupational Environment (1979)

Smoking and/or tobacco products defined as cigarettes, cigars, pipe tobacco, chewing tobacco, and any by-products resulting from their burning and/or use.Identified six ways smoking and/or other tobacco use can interact with workplace exposures to worsen occupational disease and injury:

1. Certain toxic agents present in some workplaces may also 

be present in tobacco smoke, increasing exposure to those agents. 

2. Some workplace chemicals can be transformed into more 

harmful agents by smoking—specifically by the heat generated by burning tobacco. 

3. Tobacco products can become contaminated with toxic 

agents present in the workplace, thus facilitating entry of the agent into the body by inhalation, ingestion, and/or skin absorption. 

4. Smoking can cause adverse health effects comparable to 

those caused by exposure to toxic agents present in some workplaces, thus causing additive effects. 

5. Smoking can act synergistically with toxic agents present 

in some workplaces to cause a much more profound effect than anticipated simply from the separate influences of the occupational exposure and smoking. 

6. Smoking can contribute to accidents in the workplace.

Use of and/or carrying of tobacco products into the workplace should be curtailed in situations where employees may be exposed to physical or chemical substances that may interact with tobacco products. Curtailment of the use of tobacco products in the workplace should be accompanied by simultaneous control of worker exposure to hazardous physical and chemical agents.

See footnotes at end of table. (Continued)
NIOSH CIB 67 

• Workplace Tobacco Policies 59

Table A-1. Previous NIOSH Current Intelligence Bulletins on Tobacco Use (Continued)

Publication (year) Findings Recommendations

Current Intelligence Bulletin 54Environmental Tobacco Smoke in the Workplace: Lung Cancer and Other Effects* (1991)

Main conclusion: “NIOSH has determined that the collective weight of evidence ... is sufficient to conclude that [SHS]* poses an increased risk of lung cancer and possibly heart disease to occupationally exposed workers.”Conclusions and recommendations based on:

• Reports of Surgeon General on health effects of tobacco 

smoke.

• Comparison of chemical compositions of SHS and mainstream smoke.• Results from recent epidemiologic studies of nonsmokers 

exposedto SHS.

• Methods for controlling involuntary workplace exposures to 

ETS.*

Risk of developing cancer should be decreased by minimizing exposure to SHS.Workers should not be involuntarily exposed to tobacco smoke.Employers should ... assess conditions that may result in worker exposure to SHS and take steps to reduce exposures to the lowest feasible concentration.Best method for controlling worker exposure to SHS is to eliminate tobacco use from the workplace and begin a smoking cessation program.Management and labor should work together to develop nonsmoking policies:

• Prohibit smoking at the workplace; post signs at workplace 

entrances.

• Distribute information about health promotion and harmful effects 

of smoking. 

• Offer smoking-cessation classes to all workers. • Establish incentives to encourage workers to stop smoking.

Pending complete elimination of tobacco smoking in the workplace, smoking should be isolated to clearly posted, enclosed areas, with separate ventilation exhausted directly to the outside without recirculation. 

*The 1991 document used the term “environmental tobacco smoke” (ETS) to refer to what this CIB calls “secondhand smoke” (SHS).
60 NIOSH CIB 67 

• Workplace Tobacco Policies 

Table A-2. Other NIOSH Publications with Policy Recommendations Relating to Tobacco Use

Year Agent/Process Tobacco-related Recommendation(s) Selected Additional Content

Criteria Documents

1972 Asbestos Smoking cessation (as medical management for 

exposed workers who smoke).

1972 Carbon monoxide Medical exams, which could provide “opportunity 

to conduct anti-smoking programs for high-risk employees.” 

1973 Inorganic mercury No smoking in designated areas; wash before 

smoking.*

1975 Inorganic fluorides No smoking in designated areas; wash before 

smoking/chewing*; no carrying tobacco products in contaminated clothing.

1976 Boron trifluoride No smoking or uncovered smoking materials in 

designated areas.

1976 Cadmium No smoking or carrying uncovered tobacco 

products in designated areas.

1976 Carbaryl No smoking in designated areas; wash before 

smoking.*

1976 Formaldehyde No smoking in designated areas; wash before 

smoking.*

1976 Methyl parathion No smoking or carrying tobacco products in 

designated areas; wash before smoking*; post “No smoking” signs; provide area free of contamination for storing tobacco products.

1976 Organotin compounds No smoking in designated areas.1976 Parathion No smoking or carrying tobacco products in 

designated areas; wash before smoking*; post “No smoking” signs; provide area free of contamination for storing tobacco products.

See footnotes at end of table. (Continued)
NIOSH CIB 67 • Workplace Tobacco Policies 61 Year Agent/Process Tobacco-related Recommendation(s) Selected Additional Content 1978 Dinitro-ortho-cresol No smoking in designated areas. 1976 Carbon tetrachloride No smoking in designated areas; wash before smoking.* 1979 Chloroform No smoking in designated areas; wash before smoking.* 1988 Welding, brazing, and thermal cutting No use or storage of tobacco products in designated areas; wash before smoking*; counsel smokers about how smoking may enhance adverse effects of occupational hazards. 2006 Refractory ceramic fibers No smoking in workplace; collect smoking histories as part of the medical monitoring program; counsel workers who smoke tobacco products about increased risk of adverse respiratory effects induced by RCF; disseminate information about health promotion and the harmful effects of smoking; establish and offer smoking cessation programs to workers at no cost; all workers who smoke and are potentially exposed to RCFs should participate in smoking cessation program. Entire sections (1.13and 9.6) devoted to smoking cessation. NIOSH recognizes a synergistic effect of smoking and exposure to RCFs, increasing risk of adverse respiratory health effects induced by RCFs. Interactive effect of tobacco smoking and exposure to airborne fibers previously documented. RCF-associated decreases in pulmonary function limited to current and former smokers. Finding consistent with studies of workers exposed to airborne contaminants, in which combined smoking and exposures to various airborne dusts results on increased risk of occupational respiratory diseases, including chronic bronchitis, emphysema, and lung cancer. 2013 Hexavalent chromium Prohibit smoking in all areas of any workplaces in which workers are exposed to Cr(VI) compounds; as part of a comprehensive safety and health program, offer a no-cost smoking cessation program that informs workers about the hazards of cigarette smoking and provides assistance and encouragement for workers who want to quit smoking; all workers who smoke participate. Entire section (8.7) devoted to smoking cessation These elements, in combination with efforts to maintain airborne Cr(VI) concentrations below the REL and prevent dermal contact with Cr(VI) compounds, will further protect the health of workers. [A]ssociation of skin disease and/or smoking habit with elevated 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
62 NIOSH CIB 67 

• Workplace Tobacco Policies 

Year Agent/Process Tobacco-related Recommendation(s) Selected Additional Content

Current Intelligence Bulletins

1978 Tetrachloroethylene 

(perchloroethylene)

Workers who handle liquid tetrachloroethylene should wash hands thoroughly before smoking.

1986 Methylene chloride Smoking should not be permitted in areas where 

methylene chloride is manufactured, stored, or used.

1986 4,4’-methylenedianiline 

(MDA)

A smoking cessation program should be provided, because cigarette smoking is a well-established risk factor for bladder cancer

2013 Carbon nanotubes and 

nanofibers

Encourage workers to wash hands before eating, smoking. 

Alerts

1984 Carbon monoxide 

hazard in aircraft refueling operations

Workers engaged in fueling operations should be encouraged to refrain from smoking because smoking elevates blood levels of carbon monoxide enough to reduce margin of safety. 

1991 Lead poisoning in 

construction

No use or carrying of tobacco products in designated area(s); wash before smoking.*

1992 Silicosis from 

sandblasting

No use of tobacco products in blasting area; wash before smoking.*

1992 Silicosis in rock drillers No use of tobacco products in blasting area; wash 

before smoking.*

1996 Asthma from 

diisocyanate

Wash before smoking outside work area.

1996 Silicosis in construction No use of tobacco products in dusty areas; wash 

before smoking.*

See footnotes at end of table. (Continued)

Table A-2 (Continued). Other NIOSH Publications with Policy Recommendations Relating to Tobacco Use
NIOSH CIB 67 

• Workplace Tobacco Policies 63 See footnotes at end of table. (Continued)

Table A-2 (Continued). Other NIOSH Publications with Policy Recommendations Relating to Tobacco Use

Year Agent/Process Tobacco-related Recommendation(s) Selected Additional Content

1999 Phosphine poisoning 

and explosions during fumigation

Wash before smoking.*

2006 Asthma from MDI 

exposure during sprayon truck bed liner and related applications

Wash before smoking.*

2007 Explosions in industrial 

ethylene oxide sterilization facilities

No smoking where EtO is handled, used, or stored.

2007 Fire fighter fatalities 

due to heart attacks and other sudden cardiovascular events

Prohibit smoking in all fire stations and other fire department facilities; include a smoking cessation program in any wellness program. 

Because not all fire stations are smoke-free, involuntary exposure to tobacco smoke continues to present cardiovascular risks for fire fighters.Unrecognized sources of carbon monoxide exposure for fire fighters include environmental tobacco smoke; diesel exhaust in firehouse; diesel exhaust from fire engine operating at fire scene.

2011 Sensitization and 

disease from beryllium exposure

No storage or use of tobacco products in beryllium work areas.

Fact Sheets

2003 Asbestos associated 

with vermiculite from Libby, MT

Workers who have been exposed and currently smoke should quit smoking; employers can assist them by offering smoking cessation programs.

Workplace Solutions

2007 Handling Micotil 300® No smoking in designated area. 

Infosheets

2012 Cleaning chemicals Wash before smoking.*
64 NIOSH CIB 67 • Workplace Tobacco Policies 

Year Agent/Process Tobacco-related Recommendation(s) Selected Additional Content Updates 1993 Silicosis deaths No use of tobacco products in designated area; wash before smoking.* Proposed National Strategies 1989 Proposed National Strategy for the Prevention of Occupational Lung Diseases Management and labor should work together to develop smoking policies:

• Prohibit smoking at the workplace.• Distribute information about health promotion 

and harmful effects of smoking.

• Offer no-cost smoking-cessation classes to all 

workers. 

• Establish incentives to encourage workers to stop 

smoking.

• Post appropriate signs at workplace entrances.

Smoking is strongly associated with many lung diseases. Smoking has an additive effect on the risk of chronic bronchitis in workers exposed to coal mine and other dusts, and it acts synergistically with asbestos to increase the risk of lung cancer. Evidence indicates adverse effects on those who are exposed to the smoke of others. Because of the overwhelming evidence of the health consequences from smoking and the number of workers affected, a focus on smoking is an important component of an effective prevention strategy. Elimination of smoking in the workplace is an effective strategy. 

See footnotes at end of table. (Continued)

Table A-2 (Continued). Other NIOSH Publications With Policy Recommendations Relating to Tobacco Use
NIOSH CIB 67 

• Workplace Tobacco Policies 65

Year Agent/Process Tobacco-related Recommendation(s) Selected Additional Content

1989 Proposed National 

Strategy for the Prevention of Occupational Cardiovascular Diseases

Identify groups of workers at high risk of cardiovascular and other diseases based on exposure in the workplace and personal risk factors; to ensure that workers have full and effective access, implement programs for health promotion and disease prevention at the worksite whenever possible or practical; programs should include efforts to reduce personal, modifiable risk factors for cardiovascular disease, including smoking 

In an ideal situation, when occupational factors increase the risk of cardiovascular disease, both occupational and personal risks would be addressed at the workplace.Encouraging workers to quit smoking is particularly important because smoking contributes not only to several cardiovascular diseases but to other diseases as well. Increasing the availability of health promotion programs in the workplace requires the cooperation of industry, labor unions, community and voluntary groups, and the government.Most programs will be conducted in the private sector, but governmental agencies can play important roles in stimulating the 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 necessarily 

comprehensive. NOTE: Table does not include NIOSH recommendations focused solely on tobacco use (see Table A-1) or, for example, tobacco-related recommendations included in agent-specific guidance included in NIOSH/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
66 NIOSH CIB 67 • Workplace Tobacco Policies 

Table A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco Use Hazard Category and Provisions Agent/Process Industry Regulation CFR Fire/Explosion For designated area(s):

• Smoking prohibitions. 

and (in most listed regulations)

• ‘No-smoking’ placard requirements.

and (in some listed regulations)

• Program to assure that no smoking 

materials are carried. 

and (in some listed regulations)

• Smoking history required in 

medical surveillance.

HydrogenHydrogen or hydrogen sealing 

systems

General IndustryElectric Power Generation, Transmission, and Distribution

1910.1031910.269

Oxygen General Industry

Surface metal/nonmetal minesUnderground metal/nonmetal mines

1910.10456.780557.7805

Flammable liquids General Industry

ShipyardsMarine Terminals ConstructionConstructionSurface metal/nonmetal minesUnderground metal/nonmetal mines

1910.1061915.361917.1561926.15256.410056.410157.410057.4101

Spray finishing using flammable and combustible materials

General IndustryMarine Terminals

1910.1071917.153

Explosives and blasting agents General Industry

Surface metal/nonmetal minesUnderground metal/nonmetal minesUnderground coal mines

1910.1091926.9001926.9021926.90456.690457.690475.170275.1721

Storage and handling of liquefied petroleum gases

General Industry 1910.110

See footnotes at end of table. (Continued)
NIOSH CIB 67 

• Workplace Tobacco Policies 67See footnotes at end of table. (Continued)

Hazard Category and Provisions Agent/Process Industry Regulation CFR

Dipping and coating operations that use flammable liquids or liquids with flashpoints greater than 199.4   ̊F (93  ̊C)

General Industry 1910.125

Battery-charging/changing areas General Industry

Surface metal/nonmetal minesUnderground metal/nonmetal minesMarine TerminalsLongshoring

1910.17856.450257.45021917.1571918.1

Grain handling facilities General Industry 1910.272Permit-required Confined Spaces General Industry 1910.146Underground lines Power Transmission and Distribution 1926.956Benzene General Industry

ShipyardsConstruction

1910.10281915.10281926.1128

Acrylonitrile General Industry

Construction

1910.10451926.1145

Ethylene oxide General Industry

Construction

1910.10471926.1147

Formaldehyde General Industry

ShipyardsConstruction

1910.10481915.10481926.1148

Gassy operations Underground Construction Caissons, Cofferdams, 

and Compressed AirUnderground metal/nonmetal mines

1926.80057.2210257.22105

Table A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco Use (Continued)
68 NIOSH CIB 67 

• Workplace Tobacco Policies 

Hazard Category and Provisions Agent/Process Industry Regulation CFR

General Fire Prevention Construction

Underground metal/nonmetal minesUnderground coal mines

1926.15157.410057.410157.690457.780557.2210157.2210277.110277.1711

Record-keeping areas Underground metal/nonmetal mines 57.5041

Ingestion/absorption of toxic agentFor designated area(s):

• Prohibitions on smoking, storage of 

smoking materials, tobacco products (including chewing tobacco), and chewing of such products. 

and 

• Requirements for washing prior to 

smoking/eating.

and (in most listed regulations)

• Requirements to post 

“No-smoking” placards.

Asbestos General Industry

ShipyardsConstruction

1910.10011915.10011926.1101

13 specified carcinogens (4-Nitrobiphenyl, etc.)

General IndustryShipyardsConstruction

1910.10031915.10031926.1103

Inorganic arsenic General Industry

ShipyardsConstruction

1910.10181915.10181926.1118

Lead General Industry

ShipyardsConstruction

1910.10251915.10251926.62

Table A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco Use (Continued)See footnotes at end of table. (Continued)
NIOSH CIB 67 

• Workplace Tobacco Policies 69

Hazard Category and Provisions Agent/Process Industry Regulation CFR

Chromium (VI) General Industry

ShipyardsLongshoringConstruction

1910.10261915.10261918.11926.1126

Cadmium General Industry

ShipyardsConstructionAgriculture

1910.10271915.1027 1926.1127 1928.1027

Benzene General Industry

ShipyardsConstruction

1910.10281915.10281926.1128

Coke oven emissions General Industry

Construction

1910.10291926.1129

Bloodborne pathogens General Industry

Shipyards

1910.10301915.1030

1,2-dibromo-3-chloropropane General Industry

ShipyardsConstruction

1910.10441915.10441926.1144

Acrylonitrile General Industry

Construction

1910.10451926.1145

Ethylene oxide General Industry

Construction

1910.10471926.1147

Ethylene oxide General Industry

Shipyards

1910.10471915.1047

Formaldehyde General Industry

ShipyardsConstruction

1910.10481915.10481926.1148

Table A-3. OSHA and MSHA Regulations With Provisions Relating to Tobacco Use (Continued)See footnotes at end of table. (Continued)
70 NIOSH CIB 67 

• Workplace Tobacco Policies 

Hazard Category and Provisions Agent/Process Industry Regulation CFR

Methylenedianiline General Industry

ShipyardsConstruction

1910.10501915.10501926.60

1,3-Butadiene General Industry 1910.1051Methylene chloride General Industry

ShipyardsConstruction

1910.10521915.10521926.1152

Hazardous chemicals in laboratories

General IndustryShipyards

1910.14501915.1450

General/Field Sanitation Shipyards

Agriculture

1915.881928.110

Misc. 

• Personal Protective Equipment 

Standard: requires a 15-minute no-smoking period prior to Bitrex fit-testing of respirators. 

• Cotton Dust Standard: required 

medical questionnaire asks about smoking.

• Hazard Communication Standard: 

Appendices invoke smoking history in the assessment of evidence used to categorize substances as respiratory sensitizers, and detail requirements for “No smoking” warning labels.

Personal Protective Equipment General Industry

Shipyards Marine Terminals Longshoring Construction

1910.134 1915.154 1917.921918.102 1926.103

Cotton Dust General Industry 1910.1043Hazard Communication General Industry

ShipyardsConstruction

1910.12001915.12001926.59

Specific requirements of OSHA and MSHA regulations should be determined by directly consulting those regulations. Disclaimer: Table is not necessarily comprehensive 

and is not intended to be used for compliance purposes. NOTE: Table does not include OSHA regulations that require retention of Department of Transportation markings, placards, and labels relating to flammability/explosivity (e.g., 1910.1201, 1915.88, 1917.29, 1926.61). Nor does it include OSHA “model standards” for carcinogens (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)
NIOSH CIB 67 

• Workplace Tobacco Policies 71

Figure A-1a. Cigarette smoking among working adults, by industry—United States, 2004–2010
72 NIOSH CIB 67 

• Workplace Tobacco Policies 

Figure A-1b. Cigarette smoking among working adults, by occupation—United States, 2004–2010
NIOSH CIB 67 

• Workplace Tobacco Policies 73

Figure A-2a. Smokeless tobacco use among working adults, by industry—United States, 2010
74 NIOSH CIB 67 

• Workplace Tobacco Policies 

Figure A-2b. Smokeless tobacco use among working adults, by occupation—United States, 2010
NIOSH CIB 67 

• Workplace Tobacco Policies 75

Figure A-3a. Dual use of tobacco: Proportion of cigarette smokers who also use smokeless tobacco among working adults, by industry—United States, 2010
76 NIOSH CIB 67 

• Workplace Tobacco Policies 

Figure A-3b. Dual use of tobacco: Proportion of cigarette smokers who also use smokeless tobacco among working adults, by occupation—United States, 2010
NIOSH CIB 67 

• Workplace Tobacco Policies 77

Figure A-4a. Prevalence of frequent exposure to SHS at work among nonsmoking adults who worked in the past 12 months, by industry—United States, 2010
78 NIOSH CIB 67 

• Workplace Tobacco Policies

Figure A-4b. Prevalence of frequent exposure to SHS at work among nonsmoking adults who worked in the past 12 months, by occupation—United States, 2010
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