DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

Summary

Worksite health promotion programs designed to improve worker health, such as those that help 

workers stop or reduce tobacco use, 

have traditionally focused on individual factors and not taken workrelated exposures and hazards into 

account. Through its Total Worker 

HealthTM Program, the National Institute for Occupational Safety and 

Health (NIOSH) recommends an 

integrated approach to addressing 

personal as well as workplace safety and health factors. 

Using Total Worker HealthTM 

Concepts to Enhance Workplace 

Tobacco Prevention and Control

Description of 

Exposure

Tobacco use is associated with cardiovascular diseases, various types of cancer, respiratory diseases, and reproductive disorders [DHHS 2014]. An 

estimated 19.6% of workers smoke cigarettes regularly [CDC 2011], and an 

estimated 17.8% of U.S. adults were 

cigarette smokers in 2013 [CDC 2014]. 

Smoking cigarettes can be as addictive 

as heroin or cocaine [CDC 2008, 2013]. 

Smokeless tobacco also poses health 

risks; it increases the risk of oral cavity, esophageal, and pancreatic cancers [DHHS 2014]. Nonsmoking workers who are exposed to secondhand 

smoke* may be at risk of lung cancer, 

heart disease, stroke, and respiratory 

illnesses.

Current Standards

In addition to Federal prohibitions on 

tobacco smoking in commercial flights, 

interstate buses, Federal office buildings, and facilities where federally 

funded educational services are provided to children, smoke-free policies in 

private-sector workplaces, restaurants, 

and bars have been enacted by individual States [CDC 2015b]. Hundreds 

of local jurisdictions have also enacted 

smoke-free laws. These regulations are 

generally meant to eliminate exposure 

to secondhand smoke in these environments. According to a report by the 

*Secondhand smoke is smoke from burning tobacco products, or smoke that has been exhaled by the person smoking [CDC 2015a]

Surgeon General [DHHS 2014], there 

is no established safe level of exposure 

to cigarette smoke. OSHA does not regulate workplace tobacco use, but notes 

that poor indoor air quality can affect 

worker health [OSHA 2013]. 

Total Worker HealthTM: 

an Integrated 

Approach

Successful worksite tobacco control 

initiatives can help improve health outcomes by promoting cessation among 

tobacco users and reducing exposure 

to secondhand smoke for nonsmoking 

employees and other nonsmokers present in the workplace [CDC 2013]. Successful programs can result in workers 

using fewer health care services if they 

quit smoking, and improved absenteeism rates and productivity [Task Force 

2010; Goetzel and Pronk 2010; Leif Associates 2012]. The effects of serious 

diseases associated with smoking cigarettes (such as cancer and heart and respiratory conditions) can be reduced 

through intervention efforts that help 

workers quit smoking.
The workplace offers an ideal setting for such programs: a 

stable population frequently interacting with one another 

over extended periods allows for peer influences and support 

networks to develop. This support, combined with smokefree policies and provision and promotion of services that 

support cessation, can increase the chances that a worker 

will quit tobacco use. As noted by Goetzel et al. [2014], any 

workplace prevention program must have clear goals, be integrated into the workplace structure, and promote a culture 

of health. 

Worksite health promotion programs typically focus on promoting positive lifestyle factors (such as tobacco prevention 

and control) without addressing organizational, social, and 

environmental risk factors that also may be harmful to the 

worker’s overall health and may contribute to tobacco use. 

Worksite safety and health protection programs focus on reducing exposures to harmful substances while on the job. 

Health promotion and health protection have often been 

considered separately and may even compete for limited resources [Sorensen 2001]. However, Baron et al. [2014] show 

that a worker’s safety and health are often affected by workplace exposures, lifestyle, and community factors. Their research includes examples of increasing employee input and 

employer support that make workplace health programs 

more successful [see Baron et al. 2014]. Programs aimed at 

improving safety and promoting health may be more effective when employers consider implementing them together.

Workplace Tobacco Use and Secondhand 

Smoke Exposure

Low income, blue collar, and service workers are more likely to hold jobs that expose them to hazardous substances, 

including secondhand smoke. They are also more likely to 

smoke, be employed in places that allow smoking, and live in 

communities with high levels of outdoor air pollution. Research shows that persons who face more hazards on the job 

are more likely to smoke [Baron et al. 2014; Sorensen 2001]. 

Interventions that focus solely on tobacco cessation without 

accounting for job hazards may be less successful at improving health. 

Some chemical exposures in the workplace may increase the 

likelihood that smokers will develop cancer. For example, 

tobacco smokers who have been exposed to asbestos have 

a “far greater-than-additive” risk for lung cancer compared 

with smokers who have not been exposed to asbestos or nonsmokers who have been exposed to asbestos. Nonsmokers 

exposed to asbestos have a 5 times greater risk of developing lung cancer than nonexposed nonsmokers [Alberg and 

Samet 2003]. Smoking alone (with no asbestos exposure) 

increases the risk of lung cancer by approximately 25 times 

[DHHS 2014]. But when a cigarette smoker is exposed to 

asbestos, his/her risk of lung cancer increases by 50 to 84 

times [ATSDR 2006, 2008]. 

Making sure that workplaces are safe may increase employee 

buy-in for health promotion efforts. In the absence of workplace safety initiatives, workers may feel that workplace hazards are not being addressed, that employee smoking should 

not be a concern of the employer, and that smoking cigarettes is a minor risk compared with job hazards [Sorensen 

et al. 2004]. Following the hierarchy of controls can help reduce employee exposure to hazards and is a foundation of Total Worker HealthTM principles. (According to the hierarchy 

of controls, eliminating or controlling a hazard at its source 

is the best way to reduce worker exposure and takes precedence over personal protective equipment) [NIOSH 2011, 

2013]. Programs that address both employee and management concerns are therefore necessary for successful adoption of healthful lifestyle choices. Management is responsible 

for reducing harmful exposures on the job, but they can also 

support employee participation in health promotion activities [Sorensen 2001]. Addressing both worker safety on the 

job as well as healthful lifestyle choices can benefit the overall health of the worker. Smokefree policies can bridge both 

of these approaches, since they protect workers from an occupational hazard (secondhand smoke) while also helping 

employees who want to quit smoking. 

Factors Affecting the Success of Tobacco 

Prevention and Control Initiatives

Any health protection or promotion program must account 

for influences and factors from all aspects of workers’ lives in 

order to be more successful. 

Job-related factors that may limit the success of workplace 

health programs (such as tobacco prevention and control) 

include job stress, high job demands [Radi et al. 2007], and 

characteristics of low income work such as repetitiveness, 

exposure to hazards that may exacerbate respiratory conditions, and lack of control over work and work schedules [Sorensen et al. 2004]. Low income workers are also less likely to 

have tobacco cessation or other health promotion programs 

offered to them at work. 

Yong et al. [2014] found that smokers exposed to respiratory 

hazards on the job were more likely to be interested in quitting smoking, but this did not translate into a higher success 

rate for quitting. 

Personal factors that may limit the success of tobacco prevention and control initiatives include time constraints; 

workers’ having other unmet needs such as insufficient food 

and medical care; and lack of affordable child care, access to 

healthcare services, or transportation [Baron et al. 2014]. All 

of these factors may be reasons that workers with lower in-
comes have less success with quitting tobacco use [Sorensen 

et al. 2004]. Tobacco prevention and control initiatives 

should also consider the highly addictive nature of tobacco 

and incorporate clinical recommendations for tobacco dependence and treatment [DHHS 2008]. Another important 

factor in successful tobacco cessation is the worker’s “perceived self efficacy” or confidence that he or she can be successful at quitting [Bandura 1982]. 

Community factors may include environmental contamination (including exposure to respiratory hazards such as 

air pollution and secondhand smoke) and greater exposure 

to tobacco retail outlets and tobacco advertising. Yong et al. 

[2014] also found that tobacco control was less successful 

among workers who lived in homes where someone smoked.

Recommendations for Applying 

Total Worker HealthTM Concepts 

to Workplace Tobacco Prevention 

and Control 

Tobacco control initiatives are more effective when all factors influencing worker safety and health are considered 

[Baron et al. 2014; Task Force 2010; NIOSH 2011; Sorensen 

2001]. Employers should take the following steps to enhance 

workplace tobacco control initiatives: 

 Eliminate or reduce exposure to harmful substances (including secondhand smoke) in the workplace by applying 

the hierarchy of controls. 

 Adopt a tobacco-free workplace and worksite-wide tobacco-free/smokefree policies, which have a greater effect and wider reach than programs targeting only workers who want to quit using tobacco products.†

 Develop an overall, comprehensive model for tobacco 

control initiatives. Encourage worker participation in developing the initiatives.

 Educate management and supervisors on ways to reduce 

the job stress faced by workers, such as offering more autonomy over work and work schedules. 

 Identify workers’ priorities and concerns about their 

health risks, and involve them in all stages of problem 

identification and tobacco control program design. Seek 

union support where available.

 Include a worker’s family in the support network for tobacco control programs, and offer these programs to family members who use tobacco. 

 Provide information about community and public policy 

initiatives about tobacco control.

†

For workplaces that are not able to go tobacco free, visit the CDC website 

for information about going smoke-free: http://www.cdc.gov/tobacco/basic_information/secondhand_smoke/index.htm

 Consider the elements of successful programs as outlined 

in Healthy People 2020:

— Promote health education that combines skill development, lifestyle change, and information.

— Organize the social and physical work environment 

to promote healthy behaviors.

— Integrate programs into the company structure and 

other safety and health initiatives.

— Link health promotion and related programs (such 

as employee assistance).

— Provide medical screening, education, and followup services.

General Recommendations for 

Workplace Tobacco Prevention 

and Control

Employers or those responsible for health promotion in the 

workplace should take the following steps to increase the 

chances of success of workplace tobacco prevention and control initiatives [NIOSH 2015; Task Force 2010; DHHS 2008; 

Goetzel and Pronk 2010; Sorensen 2001]:

 Provide all employees with comprehensive cessation insurance coverage, including coverage of individual, group, 

and telephone counseling and all seven FDA-approved 

cessation medications with no or minimal barriers (e.g., 

no copayments or prior authorization). Include followup programs to prevent relapses and improve habits over 

a lifetime. Promote this coverage to employees and their 

health care providers, and monitor its use.

 Inform employees about health insurance coverage or 

programs that include tobacco cessation medication and 

counseling.

 Be aware that tobacco smoking is a chronic addiction 

that may require repeated intervention and several attempts to quit.

 Encourage workers to seek a health professional’s help in 

quitting tobacco use.

 Offer information about the health risks of tobacco use 

and the benefits of quitting, as well as the dangers of secondhand smoke exposure.

 Offer assessment of individual health risks with feedback 

about risk status.

 Offer individual and group counseling, as well as referrals 

to telephone quit lines, and cessation text messaging and 

Internet services, such as the National Cancer Institute’s 

SmokefreeTXT and www. smokefree.gov.

 Offer different interventions for workers’ different 

stages of readiness to quit tobacco use (e.g., provide 
motivational interviewing to smokers who are not ready 

to quit to move them towards readiness).

 Offer or make workers aware of additional support services such as support groups, educational materials, and referrals to other programs and healthcare providers.

 Bring program information directly to the work area, 

break rooms, etc., to fit into workers’ schedules.

 Structure breaks so that employees can get sufficient rest 

and smoking isn’t the only option for quick, temporary relief from a demanding job.

 Incorporate tobacco intervention programs into a broader health awareness and healthy company culture (such as 

promotion of good nutrition and physical activity). Ask 

about personal tobacco use as part of any wellness program.

Acknowledgments

This document was prepared by Susan Afanuh, in collaboration with Michelle Lee and Heidi Hudson, of the National 

Institute for Occupational Safety and Health. 

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Suggested Citation

NIOSH [2015]. Using Total Worker HealthTM concepts to enhance workplace tobacco prevention and control. By Afanuh S, Lee 

M, Hudson H. Cincinnati, OH: 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. 2015–202.

More information about the Total Worker HealthTM program can be found on the NIOSH website: 

http://www.cdc.gov/NIOSH/twh/ 

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As part of the Centers for Disease Control and Prevention, 

NIOSH is the Federal agency responsible for conducting 

research and making recommendations to prevent workrelated illnesses and injuries. All Workplace Solutions are 

based on research studies that show how worker exposures 

to hazardous agents or activities can be significantly reduced.

Using Total Worker HealthTM Concepts to Enhance 

Workplace Tobacco Prevention and Control

DHHS (NIOSH) Publication No. 2015–202

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