The “Costs of Tobacco Use” section provides facts to support what you probably already know—tobacco use has serious health consequences and results in significant costs to individuals, organizations and society as a whole. This section focuses on the latest information about program components that have demonstrated the best results and will lead to the greatest likelihood of success for your employees. Here we provide information about the nature of tobacco use and addiction, explain why it is so difficult to stop using tobacco, and discuss how organizations can implement programs to support employees in their efforts to stop tobacco use.

Nicotine—the reason tobacco is so addictive

In 1989, the U.S. Surgeon General issued a report indicating that nicotine is the drug in tobacco that causes addiction¹; it is at least as addictive as heroin or cocaine (and many people think it is more so). Regardless of whether the nicotine comes from cigarettes, cigars, pipes or chewing tobacco, nicotine is absorbed into the system². Over time, the body becomes both physically and psychologically dependent on nicotine—a synergistic combination.

If a regular smoker abruptly stops using tobacco or greatly reduces the amount smoked, withdrawal symptoms will occur. These symptoms may include any of the following³:

• depression
• feelings of frustration and anger
• irritability
• trouble sleeping
• trouble concentrating
• restlessness
• headache
• tiredness
• increased appetite
• gastrointestinal upset

These symptoms may start within a few hours of the last cigarette and peak about two to three days later. It may be a few days or several weeks before these symptoms disappear. The difficulty of dealing with these symptoms can lead the smoker to resume smoking in order to stop the symptoms. It’s no wonder that 23 percent of adult Americans continue to smoke and that each year only about three to five percent of smokers quit for a year, for longer or for good⁴.

If you talk to any former smoker, he’ll likely tell you that quitting was the hardest thing he has ever done — and continues to do. To the smoker, the nicotine in tobacco produces a feeling of calmness and satisfaction as it feeds the addiction and relieves the withdrawal symptoms. In addition to physical addiction, smoking is also about the habits, or the associations one has with lighting up. The smoker gets in the habit of having a cigarette at certain times during the day— for example, with morning coffee or after a meal—or when experiencing certain emotions, such as frustration, anger, hunger, anxiety or boredom. Quitting involves addressing both the physical dependence on nicotine, as well as making major behavior changes to help break the psychological reinforcement of the addiction. It takes most smokers several tries to stop smoking permanently.

Health benefits of quitting  

Anyone can benefit from quitting smoking—regardless of his or her age, smoking history, or whether he or she already has a smoking-related disease(s). Consider the following⁵:

• Former smokers live longer than continuing smokers. For example, people who quit smoking before age 50 have half the risk of dying in the next 15 years compared with continuing smokers.
• Quitting smoking decreases the risk of lung cancer, other cancers, heart attack, stroke and chronic lung disease (although less so for long-term smokers).
• Women who stop smoking before pregnancy or during the first three to four months of pregnancy reduce their risk of having serious complications.
• The health benefits of quitting smoking far exceed any risks from the average 5- to 10-pound weight gain or uncomfortable psychological effects that may follow quitting.

While it is difficult to combat the withdrawal symptoms of tobacco use, the health benefits of quitting range from immediate relief to long-term health⁶:

• Twenty minutes after quitting: Heart rate drops.
• Twelve hours after quitting: The carbon monoxide level in the blood drops to normal.
• Two weeks to three months after quitting: Circulation improves and lung function increases.
• One to nine months after quitting: Coughing and shortness of breath decrease; cilia (tiny hair-like structures that move mucus out of the lungs) regain normal function in the lungs, increasing the ability to clean the lungs and reduce the risk of infection.
• One year after quitting: The excess risk of coronary heart disease is half that of a smoker’s.
• Five years after quitting: Stroke risk is reduced to that of a nonsmoker five to 15 years after quitting.
• Ten years after quitting: The lung cancer death rate is about half that of a continuing smoker’s. The risk of cancer of the mouth, throat, esophagus, bladder, cervix and pancreas decrease.
• Fifteen years after quitting: The risk of coronary heart disease is that of a nonsmoker’s.

While quitting tobacco use benefits anyone, at any age, the fact also remains that the benefits are more substantial for short-term users—in other words, it’s best to quit as soon as possible. This message needs to be communicated as well.

Smoking cessation programs: what works?

The following are critical elements impacting the success of any smoking cessation program:

• Supportive counseling – Whether face-to-face or telephonic, supportive counseling for those who want to quit using tobacco can help individuals develop their own, individualized quitting strategy, based on their own concerns and patterns of use. Telephone counseling is one of the most successful and cost-effective forms of cessation treatment. It emphasizes problem solving, behavior change and social support. The effectiveness of services increases as the number and length of sessions increase⁷.

• Nicotine-replacement therapies and medication – Research shows substantially greater success rates when counseling is paired with nicotine-replacement therapies (NRT) or other cessation medication. Employers will maximize the number of successful quitters by providing employees with the ability to easily obtain these approved medications at no cost to them. In fact, programs that provide NRT or other cessation medications free of charge are more effective than those that require the employee to bear some or all of the cost.⁸ The following first-line pharmacotherapies have been identified to reliably increase long-term smoking abstinence rates⁹:

• Bupropion (Zyban®) (prescription)
• Nicotine gum (over the counter)
• Nicotine inhaler (prescription)
• Nicotine nasal spray (prescription)
• Nicotine patch (prescription and over the counter)
• Nicotine lozenge (over the counter)

• Communication – Employees need to be made aware of the resources available to them to help them quit tobacco use. Communication about tobacco cessation might help some employees who haven’t made a decision to quit consider the benefits of quitting. Information also can help smokers or quitting smokers move further along in the process of making this important behavior change. Information about tobacco cessation can be provided through articles placed in company newsletters and/or intranet on the benefits of cessation or posters that encourage tobacco users to quit, for example. The “Strategy” section offers guidelines, tips and tools that you can use at your workplace.

• Incentives – Incentives to quit using tobacco might include the provision of nicotine-replacement products, reduced premium differentials or cash to a flexible spending account for enrolling in a tobacco cessation program. Even small rewards or recognition can help individuals succeed.¹⁰

• Integrated approach – A successful tobacco cessation program is integrated with available supportive counseling, disease management and wellness programs, company policies, health plans and other workplace programs to have the maximum impact.

• No stigmatization of smokers – It’s very important that the workplace be an environment that does not stigmatize or blame smokers or other tobacco users. The organization’s strategy ought to consider tobacco use as an addiction, and support employees in their efforts to become tobacco-free.¹¹

• Ability to access interventions repeatedly – Nicotine addiction is a chronic condition that often requires repeated interventions; policies and programs should support this process. Experts agree that because smokers typically make seven or more attempts before they are successful, employers should cover multiple quit attempts during a year.¹²

• A variety of resources – Make resources available to individuals who are in various stages of readiness to quit. This includes tobacco users who are not planning to make an attempt in the near future but who may benefit from information on the advantages of quitting, tobacco users who are willing to make a quit attempt but are unsure—or too frightened—to try at this time, tobacco users who are actively quitting, and former tobacco users who want to remain abstinent from tobacco. Your program can include a supportive option available for each type of tobacco user.¹³

Breaking a nicotine addiction is a challenge. The workplace provides a great venue to help employees quit and remain tobacco-free. According to the National Business Group on Health, “payment for an employee’s tobacco cessation treatment provides more return on investment than any other adult treatment or prevention benefit.”¹⁴

Now that you’re ready to design and implement a tobacco cessation program for your organization, review the section on “Building Organizational Support.”

¹National Institute on Drug Abuse
²U.S. Department of Health and Human Services, Office of the Surgeon General
³American Cancer Society
⁴Reducing Tobacco Use: A Report of the Surgeon General , 2000.
⁵U.S. Surgeon General
⁶U.S. Surgeon General
⁷National Heart, Lung and Blood Institute
⁸National Heart, Lung and Blood Institute
⁹U.S. Department of Health and Human Services, Office of the Surgeon General
¹⁰U.S. Department of Health & Human Services, Office of the Surgeon General
¹¹Free & Clear, Inc.
¹²Free & Clear, Inc.
¹³U.S. Department of Health and Human Services, Office of the Surgeon General
¹⁴National Business Group on Health, Center for Prevention and Health Services, Issue Brief, 2003.