Urgent Message: Tobacco-related illness costs the U.S. healthcare system billions in preventable medical expenses, yet many employees of urgent care centers continue to light up. It may be time for your urgent care center to address the issue of employee smoking by offering incentives for smoking cessation.

Alan A. Ayers, MBA, MAcc is Vice President of Strategic Initiatives for Practice Velocity, LLC and is Practice Management Editor of JUCM—The Journal of Urgent Care Medicine.

A patient drives around the back of the urgent care facility only to see a couple of medical assistants, in uniform, huddling around a “butt tower” sharing their midmorning cigarettes. Inside, the center’s occupational medicine sales guy uses a Styrofoam coffee cup on his desk as a makeshift spittoon for his “dip.” Meanwhile, the center’s medical director likes to spend time in his car, “reading his medical books,” from which time he always returns reeking of pipe odor.

These are not images that convey a concern for health or wellness, but they do represent the day-to-day reality of many urgent care centers.

In the not-so-distant past, one could walk into an office building and see ashtrays on desks and employees smoking in the break room. In fact, it was not until around 1992 that the EPA issued the warning that secondhand smoke represents a serious and substantial public health risk.1 Only then did workplace bans on smoking indoors begin to gain traction. Today, the question of how to approach the issue of employee’s smoking habits still represents a complex problem that has not fully been resolved.

The question of just how long employee smoking will be an issue rests in the difficulty individuals face quitting the habit, as well as cultural values regarding the regulation of harmful-yet-legal behavior. As such, how to make a workplace and its workers smoke-free presents a potential legal and economic third rail for employers to navigate.

Nonetheless, smoking cessation efforts in the workplace must be addressed. Given the highly addictive nature of tobacco products and the risk to not only the smoker through firsthand smoke but also the danger presented by secondhand smoke, employers must think of smoking cessation programs not as a luxury but an economic necessity.
The Economic Burden of Smoking
Despite the fact that the smoking rate has declined significantly over the last 25 years (over 25% of adults smoked in 1990 vs just over 15%in 20152), smoking still presents a significant burden on our healthcare system and economy. According to data collected by the Surgeon General’s Office, between 2009 and 2012 smoking-attributable economic costs were between $289 and $332.5 billion each year in the United States, including $132.5 to $175.9 billion for direct medical care of adults.3

Further, several studies have indicated that employees who smoke experience substantially greater absenteeism, injuries, and accidents than do nonsmoking employees. According to the Centers for Disease Control and Prevention, it all adds up to more than $156 billion in lost productivity (including $5.6 billion due to secondhand smoke exposure).4 Tsai et al estimated the economic burden of smoking related to excess absenteeism caused by employee smoking to be $184 million per annum. The authors also estimated that time spent taking smoking breaks amounted to reduced output productivity losses of $733 million. Increased sick leave costs due to passive smoking were approximately $81 million. Potential costs incurred from occupational injuries among smoking employees were estimated to be $34 million.5 These data give the question of what interventions employers can rely on to curb tobacco use an urgency that cannot be ignored.

Smoking Cessation Efforts in the Workplace
In response to the well-documented costs of employees who smoke, employers have shifted their attention to adopting workplace interventions that deter existing smokers from smoking at work and encourage them to quit altogether. The interventions used to accomplish this goal vary ranging from “stick” methods, which provide punitive measures against smokers, and “carrot” methods that incentivize and encourage smokers to quit.

According to the Towers Watson annual survey of large employers, Reshaping Healthcare,6 one of the most common approaches involves banning smoking on campuses or directly outside buildings. Further, 52% of the companies surveyed ban smoking on campuses or directly outside buildings, and that is expected to tick up to 60% next year. Many large hospital systems have banned smoking on their campuses, although such does not stop employees from smoking in their cars, walking to the edge of the property line, or smoking at home during their off hours. It does, however, keep employee smoking out of immediate patient view.

A significantly smaller portion of firms (4%) has enacted an outright ban on hiring smokers, while another 2% stated they would adopt such a policy in the next year. However, implementing a hiring ban on smokers can have legal implications. Eighteen states prohibit discrimination against tobacco users (Connecticut, the District of Columbia, Indiana, Kentucky, Louisiana, Maine, Mississippi, New Hampshire, New Jersey, New Mexico, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Virginia, West Virginia, and Wyoming). Eight states protect employees from discrimination if they use lawful consumable products, which would include tobacco; these states include Illinois, Minnesota, Missouri, Montana, Nevada, North Carolina, Tennessee, and Wisconsin. Four states say employers cannot discriminate against employees who engage in lawful activities outside of work; those states are California, Colorado, New York, and North Dakota.7 While employers in some states may not be able to outright discriminate against employees who smoke, they may be able to require those employees pay a premium differential if they desire health insurance benefits in order to cover the added claims costs posed by smokers.

For participants in an employer-provided health insurance plan, an emerging “stick” method involves randomly testing employees for traces of nicotine metabolites in their system and either targeting these individuals for clinical interventions or levying some type of punitive action against the smoker, such as dismissal from the job (for lying about not smoking) or some type of fine (such as a benefits surcharge).

According to Towers Watson, 42% of employers surveyed levy surcharges against tobacco users, with the percentage expected to grow by 20% or more in the next few years. The efficacy of these programs appears to increase with the introduction of penalties: If an employer offers a tobacco cessation program without a financial penalty, employers surveyed reported 5% of users enroll in that program; however, coupling a cessation program with the penalty rate increases the participation rates up to 40%. These penalties could come in the form of a type of quasi fine or increased health insurance premium rates.

Another strand of smoking cessation interventions used by employers involves incentivizing quitting. Simply put, employers provide incentives, often coupled with assistance, to encourage employees to quit smoking. These programs have been shown to be successful in moving participants to quit smoking. A study conducted by RAND indicated that that fewer than 10% of companies with employee wellness programs use results-based financial incentives.8 This may be linked to the fact that among employers who do implement an incentive program, results have been largely unremarkable. Towers Watson’s survey indicates that 70% of smokers working for the employers surveyed in their research want to quit, and of those who enroll, there is a 25% success rate after a year. With incentives, the rate of employees quitting was the same as that for employees who intrinsically enroll by themselves.

An alternative proposal to overcome this lack of meaningful outcomes has been broached in research published in the New England Journal of Medicine, whereby researchers compared straight financial incentives to quit with a carrot-and-stick approach; smokers would get a similar financial reward if they quit, but would owe an equal amount of their own money if they started smoking again. The findings state, “The deposit programs were twice as effective as rewards, and five times more effective than providing free smoking cessation aids like nicotine replacement therapy,” the authors concluded.9

The main takeaway from the research on employer-sponsored smoking cessation programs is that context matters. One can judge the intervention’s likelihood of success based on location and the workforce. As research shows, cessation programs are important, but simply adding one without a strategy will likely bear unremarkable results. Thus, it is important to consider how your employees will respond and test a few methods.


  1. Secondhand smoke environmental assessment. United States Environmental Protection Agency. 2015.
  2. Centers for Disease Control and Prevention. Trends in current cigarette smoking—smoking & tobacco use. Smoking and Tobacco Use. 2015. Available at: http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/. Accessed December 1, 2015.
  3. Cancer.org. Tobacco-related cancer fact sheet. 2015. Available at: http://www.cancer.org/cancer/cancercauses/tobaccocancer/tobacco-related-cancer-fact-sheet. Accessed December 1, 2015.
  4. Centers for Disease Control and Prevention. Economic facts about U.S. tobacco production and use. 2015. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/. Accessed November 30, 2015.
  5. Tsai SP, Wen CP, Hu SC, et al. Workplace smoking related absenteeism and productivity costs in Taiwan. Tobacco Control. 2005;14(suppl 1):i33-i37.
  6. Towers Watson. Towers Watson/NBGH Employer Survey on Purchasing Value in Health Care. 2013. Available at: https://www.towerswatson.com/en/Insights/IC-Types/Survey-Research-Results/2013/03/Towers-Watson-NBGH-Employer-Survey-on-Value-in-Purchasing-Health-Care. Accessed December 1, 2015.
  7. AOL Jobs. Can an employer discriminate against me because I smoke? 2015. Available at: http://jobs.aol.com/articles/2014/04/15/employer-discrimination-against-smokers/. Accessed December 2, 2015.
  8. Mattke S, Liu H, Caloyeras JP, et al. Workplace wellness programs study: final report.Rand Corporation. 2013. Available at: http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR254/RAND_RR254.sum.pdf. Accessed November 1, 2016.
  9. Halpern SD, French B, Small DS, et al. Randomized trial of four financial-incentive programs for smoking cessation.N Engl J Med. 2015;372(22):2108-2117.


Smoking Cessation: The Time to Address Employee Smoking is Now

Alan A. Ayers, MBA, MAcc

Chief Executive Officer of Velocity Urgent Care, LLC and is Practice Management Editor of The Journal of Urgent Care Medicine
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