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Estimating the cost of a smoking employee



Objective We attempted to estimate the excess annual costs that a US private employer may attribute to employing an individual who smokes tobacco as compared to a non-smoking employee. Design Reviewing and synthesising previous literature estimating certain discrete costs associated with smoking employees, we developed a cost estimation approach that approximates the total of such costs for US employers. We examined absenteeism, presenteesim, smoking breaks, healthcare costs and pension benefits for smokers. Results Our best estimate of the annual excess cost to employ a smoker is $5816. This estimate should be taken as a general indicator of the extent of excess costs, not as a predictive point value. Conclusions Employees who smoke impose significant excess costs on private employers. The results of this study may help inform employer decisions about tobacco-related policies.
Estimating the cost of a smoking employee
Micah Berman,
Rob Crane,
Eric Seiber,
Mehmet Munur
The Ohio State University,
College of Public Health &
Moritz College of Law,
Columbus, Ohio, USA
College of Medicine, The Ohio
State University, Columbus,
Ohio, USA
College of Public Health,
The Ohio State University,
Columbus, Ohio, USA
Tsibouris & Associates LLC,
Columbus, Ohio, USA
Correspondence to
Micah Berman,
College of Public Health &
Moritz College of Law, The
Ohio State University, Cunz
Hall, 1841 Neil Ave.,
Columbus, OH 43210, USA;
Received 15 November 2012
Accepted 25 April 2013
Published Online First
4 June 2013
To cite: Berman M,
Crane R, Seiber E, et al.Tob
Control 2014;23:428433.
Objective We attempted to estimate the excess annual
costs that a US private employer may attribute to
employing an individual who smokes tobacco as
compared to a non-smoking employee.
Design Reviewing and synthesising previous literature
estimating certain discrete costs associated with smoking
employees, we developed a cost estimation approach
that approximates the total of such costs for US
employers. We examined absenteeism, presenteesim,
smoking breaks, healthcare costs and pension benets
for smokers.
Results Our best estimate of the annual excess cost to
employ a smoker is $5816. This estimate should be
taken as a general indicator of the extent of excess
costs, not as a predictive point value.
Conclusions Employees who smoke impose signicant
excess costs on private employers. The results of this
study may help inform employer decisions about
tobacco-related policies.
Smoking by employees costs businesses money. But
just how much? Previous studies provide only very
rough (and often inaccurate) estimates of the excess
costs imposed by employeessmoking. For
example, the Centers for Disease Control (CDC)
estimates that smoking-attributable productivity
losses and medical expenditures amount to
approximately $3400 per year for each adult
The CDCs report, however, looks only at
the overall economy; its calculations of productivity
losses and medical expenditures do not distinguish
between costs borne by employers and those
absorbed by others (the smokers themselves, insur-
ance companies, taxpayers, etc.). Moreover, the
CDCs study looks only at mortality-related prod-
uctivity losses, that is, lost productivity caused by
premature smoking-related deaths. Although
smoking-attributable deaths surely reduce economic
productivity in a general sense, the lost earning
potential due to premature death is not an accurate
reection of an employerscosts. The CDCsgure
thus provides a poor estimate for employers to use
in gauging their own costs.
This paper estimates the average excess cost of a
smoking employee (over a non-smoking employee)
from a private employers perspective. Such an esti-
mate can provide important factual context to
employer decisions about tobacco-related policies.
Numerous employers have begun charging smokers
higher premiums for health insurance,
and several
large employers including Turner Broadcasting,
Alaska Airlines, Union Pacic Railroad and a number
of large hospital systems have decided to hire non-
smokers only.
Other companies, such as
Ohio-based Scotts Miracle-Gro and Michigan-based
Weyco, Inc, have gone a step further and decided that
they will no longer retain employees who do not quit
smoking within a given period of time.
With o u t a n
accurate estimate of smoking-related costs, such pol-
icies may seem arbitrary or unreasonable. A
well-reasoned estimate allows companies to more
fairly analyse the costs and benets of such tobacco-
free workforcepolicies.
Javitz et al
conducted what appears to be the most
exhaustive review of the various costs that smoking
employees impose on their employers. That review
does not, however, estimate an overall sum of these
costs. Chris Hallamore calculated such a sum for
the Conference Board of Canada, but the
Conference Board report is written for Canadian
employers (who do not pay any healthcare costs)
and ignores some of the other employer costs (such
as presenteeism) discussed by Javitz.
upon these analyses and a review of other pub-
lished research, this paper constructs a cost estima-
tion approach for the excess costs incurred by a
private-sector US employer for each employee who
smokes. It considers excess absenteeism, presentee-
ism, lost productivity due to smoking breaks,
excess healthcare costs and pension benets.
Our analysis omits several other costs that
employers may face as a result of hiring employees
who smoke, such as higher workerscompensation
costs and higher life and re insurance premiums.
We did not include these costs because they vary
widely by industry and recent studies do not
present reliable cost estimates. For example,
although Musich et al
showed that workerscom-
pensation costs were dramatically higher for
smokers than for non-smokers among Xeroxs
employees, Boyce et al
found no statistically sig-
nicant difference in workerscompensation claims
between smoking and non-smoking police ofcers
in Charlotte, North Carolina. In addition, we
excluded facilities-related costs such as the cost of
maintaining smoking hutsor installing ventilation
systems. These costs are largely within the control
of the employer, unlike the other major costs dis-
cussed in this paper, and they can be reduced or
eliminated by employer policies (or state or local
laws) requiring a smoke-free workplace. Our
approach may underestimate the relevant costs as a
result of omitting these considerations and others.
Table 1 summarises the ndings of this paper.
For each category of expense, we present our best
estimate of an employers costs, followed by a high
range and a low range. As discussed in each subse-
quent section, we arrived at our estimates by sur-
veying existing research and applying the high and
low ranges of that research, as well as what we
428 Berman M, et al.Tob Control 2014;23:428433. doi:10.1136/tobaccocontrol-2012-050888
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considered to be best estimate(either the average of previous
research or a more conservative estimate). Where necessary, we
then used standard government statistics to convert the ndings
of previous research into a per-employee cost. In some cases,
this required an adjustment for ination. All costs have been
adjusted to 2010 levels using the U.S. Bureau of Labor Statistics
Consumer Price Index (CPI) ination calculator. Because
smokers are, on average, paid less than non-smokers, we have
adjusted the average wage level used in our calculations.
Following the ndings of the Medical Expenditure Panel Survey,
as reported by Cowan and Schwab,
we have discounted the
average hourly wage reported by the U.S. Bureau of Labor
Statistics by 15.6%.
Given our need to standardise and combine a range of studies
that employed different methodologies, the results should be
not taken as predictive point estimates. Rather, we believe our
paper accurately shows the general range of costs that private
employers who hire employees who smoke may bear. As dis-
cussed below, individual employers may adjust the calculations
used in our cost estimation approach in order to better estimate
their own costs.
Prior studies calculating workplace absenteeism due to smoking
have come to surprisingly similar results. Some of these studies,
while nding that smoking led to excess absenteeism, did not
translate that nding into an average number of absences per year.
For example, Robbins et al examined the records of nearly 90 000
U.S. Army personnel and concluded that current smoking was
associated with a 60% increase in risk of lost workdays among
men and a 15% increase in risk among women.
11 12
The recent
US studies that did compute average excess annual absences by
smokers are summarised in table 2.
There are also a number of non-US studies that have looked at
workplace absenteeism caused by smoking. These studies are not
directly applicable to the US context, but are instructive nonethe-
less. These studies have all found an association between smoking
and absenteeism, but have varied more widely in their calculation
of the average number of excess absences. The variation appears to
be due to national and cultural differences with regard to work-
place absenteeism in general. For example, a study in Taiwan by
Ts a i et al
found that male smokers took off an average of
4.36 days, while male non-smokers missed only 3.3 days. Female
smokers took off 4.96 days, while non-smoking women were
absent 3.75 days. Thus, Tsai found an average of 1.03 excess days
of absenteeism for male smokers and 1.21 days for female
smokers. Taiwan, however, has extremely low rates of absenteeism,
compared to the international average.
On the other end of the
spectrum, Lundborg
looked at Swedish employees and found
that smokers were absent 10.7 days more than never smokers.
After controlling for health status and other risk factors, Lundborg
concluded that smoking accounted for 7.7 days of excess absence
per year. These results matched earlier studies in Sweden that
found 7.6 days of excess absence for smokers.
Sweden, however,
has the highest rate of absences in the Organisation for Economic
Co-operation and Development countries, with an average of 25
absences per year, compared to nine in the USA.
We compute the cost of excess absenteeism by taking the
number of days of excess absenteeism for current smokers and
multiplying by the number of hours worked during the day
and the average wage and benets paid to the employee
($26.49). As noted above, the average wage is discounted by
15.6% to account for the lower average pay of current smokers
(benets are not discounted).
According to the Employee
Benet Research Institute, the average for wages and benets
paid by employers in 2010 was $29.72.
The wage portion of
that amount, $20.71, is discounted by 15.6% to reach an
average wage for an employee who smokes of $17.48. Including
benets, the average hourly amount paid to an employee who
smokes is estimated to be $26.49. Using the lowest calculation
of smoking-related absences in the USA0.9 excess days in a
dated 1991 study
the average cost would be $178.81. At the
high end of the range, using the 2.9 days of excess absence cal-
culated by Tsai et al in their US study,
the average cost would
be $576.16. In between those extremes, using an estimate of
2.6 days (the average of the recent US studies and slightly less
than the estimate of excess absenteeism produced by a recent
meta-analysis of US and international absenteeism studies
would result in an average annual per-smoker cost of $516.56
(box 1).
Table 2 Estimates of annual excess absences
Author Sample
Annual excess absences
(smokers compared to never
et al
300 airline reservation agents 2.6 (2 year average)
et al
2203 Shell Oil Company
et al
45 630 employees at 147
companies (voluntary
Box 1 Lost productivity due to excess absenteeism
=Days Lost
Worked×Compensation Cost=$516.56.
=Total annual per-employee cost due to
increased absenteeism in smoking employees.
Days Lost
=Number of additional days of absenteeism
taken by an average smoking employee compared to an
average nonsmoking employee (2.6 daysthe average of
recent US studies).
Hours Worked=Number of hours worked in a day (7.5).
Compensation Cost=Average hourly wage and benets paid
to an employee who is a current smoker ($26.49).
Table 1 Total annual excess cost of a smoking employee to a
private employer
Best estimate annual
Excess absenteeism $517 $576 $179
Presenteeism 462 1848 462
Smoking breaks 3077 4103 1641
Excess healthcare
2056 3598 899
Pension benefit (296)* 0 (296)*
Total costs $5816 $10125 $2885
*For employers with defined-benefit pension plans.
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Another cost to employers from smoking employees is present-
eeism’—lower on-the-job productivity that results from nicotine
addiction. Though all employees are occasionally unproductive
in one way or another, research suggests that smoking status
negatively impacts productivity separately and apart from lost
work time due to smoking breaks and absenteeism. This is
because nicotine is a powerfully addictive drug. Although cigar-
ettes satisfy a smokers need for nicotine, the effect wears off
quickly. Within 30 min after nishing the last inhalation, the
smoker may already be beginning to feel symptoms of both
physical and psychological withdrawal.
(Much of what
smokers perceive as the relaxing and clarifying effect of nicotine
is actually relief from their acute withdrawal symptoms.) Now
that the vast majority of workplaces are smoke-free, the repeti-
tive, prolonged withdrawals that smoking employees suffer pre-
dictably diminishes their productivity at work.
Accurately measuring lost productivity due to presenteeism,
however, is difcult. As Mattke et al
write, Conducting such
research is by no means a straightforward task, particularly in
knowledge-based occupations. Even when objective measures
are used to compare the productivity of smokers and non-
smokers, monetising the cost to the employerespecially in a
way that would be relevant to different rms or different profes-
sionsremains problematic.
But although the specic amount
of lost productivity remains difcult to determine, studies have
consistently demonstrated that employees who smoke are less
productive than employees who do not.
Studies that have tried to quantify smoking-related presentee-
ism have, despite the imprecision of the evaluation tools,
reached similar results. Bunn et al
reviewed more than 10 000
employee records from 147 US employers. They found that
mean hours of lost productivity per year due to presenteeism
were 76.5 h for a smoker compared with 42.8 h for a never
The excess presenteeism of 33.7 h/year equals
approximately 1.9% of hours worked per year. Burton et al
looked at a cohort of employees at a Midwestern nancial ser-
vices company and evaluated self-reported indicators of prod-
uctivity. They concluded that smoking was associated with a
2.8% reduction in productivity.
Other estimates of lost prod-
uctivity due to presenteeism range up to 4%.
We compute the annual cost of smoker-related presenteeism by
taking the percentage of lost productivity for current smokers and
multiplying it by the cost of compensation per hour, hours worked
per day and days worked per year. Estimates of smoker-related lost
productivity range up to 4%, which would result in an annual
per-smoker excess cost of $1847.68. Averaging the results of the
Bunn and Burton studies would result in an estimated
smoking-related productivity loss of more than 2%. Nonetheless,
due to the difculties in measuring presenteeism, the possibility
that employees may compensate for lost productivity, and the
potential for employers to adjust for such costs (eg, by paying
lower wages to less productive employees), we use a very conserva-
tive estimate of 1% for the productivity loss due to presenteeism.
This results in an average annual cost of $461.92 (box 2).
Productivity loss due to smoking breaks is by far the largest
single cost that a private employer incurs from a smoking
employee. Fortunately, it is a cost that can be completely elimi-
nated by smoking cessation (unlike healthcare costs and absen-
teeism, for which former smokers will still have higher average
costs than never smokers).
Previous studies have found that the amount of time lost to
unsanctioned smoking breaks ranges from 8 to 30 min/day.
This number may vary substantially depending upon rm policy.
As Javitz et al
state, the number of lost minutes to the
employer depends on the amount of exibility that employees
have concerning when they may smoke and when they may take
their breaks.
The Conference Board of Canada report estimated that
employees smoke a majority of their daily cigarettes outside of
work, with an average of ve cigarettes consumed in an 8-h
workdaythree of those during sanctioned breaks.
This esti-
mate is supported by studies focusing on smoking breaks that
were conducted in Canada.
Since the number of cigarettes
consumed per smoker in Canada (15.2)
and the USA (16.8)
is similar, the assumption that only two cigarettes are smoked in
non-employer sanctioned times may be applied to the USA as
well. Though the average amount of time spent by employees
on smoking breaks is debatable (the Conference Board estimated
20 min), 15 min/cigarette break is a conservative estimate that
matches employer estimates of time lost to smoking breaks.
more and more US companies adopt smoke-free campus pol-
icies, requiring employees to leave the companys property in
order to smoke, the amount of time taken to consume each cig-
arette may increase.
We calculate the annual cost of lost productivity due to
smoking breaks by taking the number of cigarettes consumed
per day outside of employer sanctioned times, multiplying it by
the amount of time it takes to consume each cigarette (adjusted
as a fraction of an hour), the cost of the compensation per
and the number of days worked. Assuming that only
two cigarettes are smoked outside of sanctioned break times
each day, and that it takes 15 min to smoke each cigarette, the
annual per-smoker cost of lost productivity due to unsanctioned
smoking breaks is $3077.24. Using an estimate of 20 min/day, as
estimated by the Conference Board of Canada, would result in a
per-smoker cost of $4102.85. Utilising the lowest available esti-
mate of 8 min/day
would result in an annual cost of $1641.14
(box 3).
Smoking by employees, whether on or off the job, also leads to
excess healthcare expenses. Estimating an average excess cost
per smoking employee, however, is complex. Even assuming
that an employer knows the smoking status of its employees, it
is no simple task to estimate the increased costs that are attribut-
able to smoking. The higher healthcare costs of smoking
employees may be in part the result of other coexisting risk
factors such as a poor diet, lack of exercise, or abuse of alcohol.
Box 2 Lost productivity due to presenteeism
=Excess Presenteeism Rate×Compensation
Cost×Hours Worked×Days Worked=$461.92.
=Annual per-employee cost due to loss of
Excess Presenteeism Rate (1%).
Hours Worked: Number of hours worked during the day
Compensation Cost: Average hourly wage and benets paid
to an employee who is a current smoker ($26.49).
Days Worked: Number of days worked per year (232.5).
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In addition, many employees pay a substantial portion of their
health insurance premium; although uncommon, employers
may be able to reduce their share of excess smoking-related
costs by requiring smoking employees (and dependents) to pay
higher healthcare premiums.
Employer costs may vary depending upon whether the
employer is self-insured or purchases private insurance. For
employers who purchase private insurance, their responsibility
for healthcare expenses ends when their share of health insur-
ance premiums is paid. At that point, smoking-related illnesses
do not produce an increase in healthcare costs for the employer.
Nonetheless, an employer with no smoking employees could
presumably obtain a discount in insurance premiums, due to the
fact that the employee pool is likely to have lower overall
healthcare costs. Correspondingly, health insurance premiums
are higher for employers when there are more smokers in the
labour force. However, there is no available data with which to
measure the amount of excess premium costs on a per-smoker
Our cost estimation approach therefore addresses only the
excess healthcare costs of smoking employees for employers
who self-insure. These businesses, which bear their own health-
care costs more directly, employ about 55% of private employ-
Although our approach may not produce as accurate an
estimate if the employer is not self-insured, usually an employ-
ers claims experience will eventually be reected in that
employers health insurance premiums.
There are many studies focusing on the overall healthcare
costs caused by smoking, although, as noted above, employers
do not bear all of these costs. Warner et al
surveyed studies
that estimated overall smoking-attributable healthcare expendi-
tures. Their survey showed that estimates of the healthcare costs
due to smoking ranged from 3.5% to 14% of all healthcare
Though the average conclusion of previous studies
was that 68% of healthcare costs were due to smoking-related
diseases, Warner et al
expressed their opinion that the correct
percentage was likely higher.
More recent studies have produced somewhat higher esti-
mates of the smoking-attributable fraction (SA%) of healthcare
costs, due in part to the fact that these studies correct for some
of the deciencies noted by Warner et al. For example, Max
et al studied the healthcare cost of smoking in California, which
totalled approximately $8.6 billion in 1999 (or $1798.74 per
They concluded that smoking-related costs
accounted for 11.4% of all healthcare costs for men and 8% of
all healthcare costs for women. It should be noted, however,
that smoking prevalence in California was (and is) lower than
the national average. Other studies have estimated
smoking-attributable costs to be signicantly higher.
29 30
We compute the annual cost ( per smoking employee) of
excess healthcare to a private employer by multiplying the total
cost of healthcare to private employers
by the SA% and then
dividing this total by the number of private employees who
smoke in the workforce.
32 33
Using an SA% of 8%, this results
in a total of $2056. At the high end of scale, using a SA% of
14% results in a per-smoker cost of $3598, while the lowest
estimate of 3.5% results in $899. Since most studies of the SA%
cluster around 68% and older studies have tended to systemat-
ically underestimate the SA%, we believe that 8% is an appro-
priate gure to use (box 4).
Some have argued that although smokers require higher average
healthcare costs while alive, they incur fewer costs overall due
to their shorter lifespan.
Though Philip Morris has played a
role in popularising this theory, it turns out to be false.
Rasmussen et al
conrmed that even though never smokers
lived longer than current smokers, their lifetime direct and
indirect healthcare costs were lower. In a separate study, they
conrmed that quitting smoking leads to substantial savings in
terms of both healthcare costs and overall economic
The more pertinent question for this analysis is whether
smokersshorter life spans end up providing employers with a
death benetbecause they receive fewer pension payments
before death. Though in some cases this may occur, it could
happen only in dened benet plans. Under such an arrange-
ment, the employer pays a set amount in pension each year, and
thus an employee with a short postemployment lifespan may
end up receiving less in benets than he paid into the fund
while employed. (By contrast, an employee with a long post-
employment lifespan may end up receiving more in benets
than he paid into the system while employed.) Thus, smokers
contributions to the companys pension fund could theoretically
end up subsidising the retirement benets of non-smokers.
More and more employers, however, are moving away from
dened benet plans into dened contribution plans (such as
In such plans, there is no potential for a death
benetbecause the employee is entitled to all of the assets in
the fundno more and no lessregardless of life span. The
employer may pay into the retirement fund during the course of
employment, but it does not make annual payments after
Nonetheless, our cost estimate incorporates a death benet
for those employers that still use dened benet pension
Box 4 Excess healthcare costs
=(Employer Healthcare Expenditures×Adjusted SA
%)/Smoking Private Employee=$2055.77.
: Cost of healthcare to self-insured private
employers for each smoking employee.
Employer Healthcare Expenditures: 2010 Total Healthcare
Expenditures by Private Employers ($534.5 billion).
Adjusted SA%: Smoking Attributable Fraction of healthcare
expenses (8%).
Smoking Private Employee: Number of employees in private
employment who smoke. (108 million×19.3%=20.8 million).
Box 3 Lost productivity due to breaks
=Annual per-employee cost due to loss of
=Average number of cigarettes smoked per day
at work during non-sanctioned break periods (2).
=Time (in hours) taken to travel to smoking area
and consume each cigarette (0.25).
Compensation=Average hourly wage and benets paid to an
employee who is a current smoker ($26.47).
Days Worked=Number of days worked per year (232.5).
Berman M, et al.Tob Control 2014;23:428433. doi:10.1136/tobaccocontrol-2012-050888 431
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systems. Sloan et al
calculated the subsidy that smokers
provide to their employers through their use of the dened
benet plans. They found that on average, each male smoker
subsidised non-smokers pension plans by $10 123, and each
female smoker by $383 (the variation is caused by the fact that,
on average, women have lower pension wealth than men).
The Sloan study was based on self-reported data collected from
more than 10 000 subjects for the Health and Retirement Study
at the University of Michigan Institute for Social Research. Our
research did not reveal any other recent studies that considered
the impact of smoking on dened benet plans in the USA.
Using Sloansnumbers,weestimatethedeath benetper
smoker participating in a benet plan by calculating the individual
contributions of male and female
workers in the private sector
to the subsidy, adjusting for ination for 2010, and then annualis-
ing it by dividing the total over 24 years (the average number of
years of employment
) for a total of $295.50. Since, the amounts
were already discounted by Sloan et al, no discounting was per-
formed on these results. Again, it should be noted that only 21%
of all private employers use dened benet pension plans,
an employer who does not have a dened contribution will not
benet from such a subsidy (box 5).
This paper examines only the excess costs of an employer hiring
a smoker under the employers existing benets structure.
However, these costs may be partially offset if smokers are paid
lower average wages, as some research suggests that they are.
Cowan and Schwab, for example, found that of workers with
equivalent experience and occupation, a smoker enrolled with
employer sponsored health insurance will earn less than the
equivalent non-smoking worker insured through their employer,
averaging $1.72 less per hour or over $3400 per year in lower
wage income.
Our cost estimate suggests, however, that even
if employers pay lower wages at the levels suggested by Cowan
and Schwab to adjust for the cost of smoking employees, the
lower wages will not fully compensate for the additional costs
Building upon the work of Javitz et al, the Conference Board of
Canada, and other previous studies, we have estimated that
employers face an annual excess cost of approximately $5816
for each employee who smokes. As noted above, this estimate
assumes that the employer is self-insured and maintains a
dened benet pension system. When these assumptions are
incorrect, employers can adjust our cost estimate approach to
more accurately predict their own costs (eg, by ignoring the
excess cost for health insurance if they are not self-insured). We
caution, however, that our review does not include all possible
smoking-related costs. For example, employers may face higher
maintenance costs as a result of permitting smoking on the
premises. In addition, allowing smoking in the workplace may
lead to legal claims by employees exposed to secondhand
Our cost estimate is built around several assumptions about
average costs. Average costs are just thataverages. For any
given particular employer, costs may be higher or lower due to
the makeup of employees or a variety of costs that vary by
industry. Our calculations can, however, be easily modied
where employers are aware of their costs. For example, employ-
ers could better estimate their own costs by using their com-
panys average per-hour wage in place of the national average.
It should also be noted that for some variables (such as absen-
teeism and healthcare costs), former smokers still impose higher
costs than never smokers. (Indeed, some evidence suggests that
the number of absences increases in the short term when an
employee quits smoking, though the level of absences drops in
the long run.
) In addition, effective smoking cessation pro-
grammes are not free. Thus, eliminating all costs described in
this paper may not be an obtainable goal. Nonetheless, employ-
ers can signicantly reduce long-term costs by implementing
smoking cessation programmes.
Employers with the largest
numbers of smoking employees have the most potential to
benet from helping employees to quit smoking, and Halpern
et al
estimate that the benets of a worksite cessation pro-
gramme are likely to outweigh the costs to employers in
approximately 4 years.
As suggested above, employers may also consider reducing
smoking-related excess costs by hiring only non-smokers or
increasing healthcare premiums for non-smokers. The ethical
and legal implications of such policies have been extensively dis-
cussed elsewhere,
including by two authors of this paper.
The purpose of this paper is to provide needed factual context
to discussions about worksite tobacco policies, not to add to the
debate on the normative value of such policies. What seems
clear, however, is that this evidence does not simply relate to a
dispute about whether an employer has a moral or legal right to
regulate behaviour that occurs away from the workplace. These
substantial costs detailed in this paper suggest that the employee
brings his or her addiction to work even if the act of smoking
occurs elsewhere. This is not unexpected, as smoked nicotine is
a powerful modulator of important neurotransmitters and its
effects persist well beyond the time spent with a cigarette. Just
as employers may reasonably address the behavioural side
effects of alcohol abuse or legal use of prescribed narcotics, they
may have a valid interest in the workplace effects of legal
tobacco use that occurs off-premises. Of course other counter-
vailing concerns, such as the potential of smoker-free work-
forcepolicies to further exacerbate existing health disparities,
must also be considered.
44 48
In addition, it should be noted
that employer policies to hire only non-smokers are not legal in
all states.
Finally, we need to point out two obvious, yet often over-
looked facts. First, it is important to remember that the costs
imposed by tobacco use are not simply nancial costs. It is not
possible to put a price on the lost lives and the human suffering
caused by smoking. The desire to help ones employees lead
Box 5 Death benet
Subsidy=((Subsidy Male×Percent Male) + (Subsidy
Female×Percent Female))×Ination/Years Worked=$295.50.
Subsidy: Benet offered by smoker to a private
dened-benet plan offering employer.
Subsidy Male: Subsidy of male a smoker ($10 123).
Percent Male: percent of male workers in the private
industry (53.4%).
Subsidy Female: Subsidy of female smoker ($383).
Percent Female: Percent of female workers in the private
industry (46.6%).
Ination adjustment: Adjustment for ination from 2000.
Years Worked: Average number of years the smoker
contributes the subsidy (24).
432 Berman M, et al.Tob Control 2014;23:428433. doi:10.1136/tobaccocontrol-2012-050888
Research paper on August 14, 2014 - Published by tobaccocontrol.bmj.comDownloaded from
healthier and longer lives should provide an additional impetus
for employers to work towards eliminating tobacco from the
workplace. Second, many current smokers are addicted in large
part because of the tobacco industrys aggressive advertising of a
deadly product and because of the industrys decades-long cam-
paign to hide and distort the truth about the dangers of
smoking. The need for private action to eliminate smoking from
the workplace should not detract from efforts to implement
public policy changes (such a smoke-free workplace laws, higher
cigarette taxes, and increased funding for counter-marketing
programmes) that will counteract the industrys advertising and
reduce smoking prevalence in the next generation.
What this paper adds
Numerous studies have demonstrated that employees who
smoke tobacco have higher levels of absenteeism,
presenteeism and healthcare costs, in comparison to
employees who do not smoke.
No previous US studies have aggregated these costs to
quantify the excess costs that employees who smoke
tobacco impose on their employers.
By analysing previous studies, we estimate that US
businesses incur excess costs in the range of $5816 per year
for each employee who smokes.
Such information may help inform employer decisions about
tobacco-related policies.
Contributors MLB and RC conceived the article and drafted the initial manuscript.
MM provided supporting research, helped design the cost estimation approach, and
reviewed drafts. ES reviewed drafts and contributed to the analysis.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
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doi: 10.1136/tobaccocontrol-2012-050888
2014 23: 428-433 originally published online June 3, 2013Tob Control
Micah Berman, Rob Crane, Eric Seiber, et al.
Estimating the cost of a smoking employee
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... [16,20] More specifically, the present study found that heavy smoking and high-risk alcohol drinking were related to presenteeism. Many employees had health issues that significantly affected presenteeism, [19,21] including psychological distress and mental health problems [14,19,21] ; in recent studies, smoking [5,19,23] and alcohol consumption problems [6,7,19] were considered factors related to presenteeism. Though all employees can occasionally be unproductive, research suggests that smoking alone negatively impacts productivity due to loss of work time smoke breaks. ...
... Though all employees can occasionally be unproductive, research suggests that smoking alone negatively impacts productivity due to loss of work time smoke breaks. [5] It can be assumed that presenteeism might occur when employees take more frequent smoking breaks and face decreased concentration due to craving and withdrawal symptoms related to smoking even if they are at work. High-risk drinking and alcohol dependency are not equivalent dimensions of alcohol use, and most heavy drinkers are not dependent or addicted. ...
... [6] Similar to results of previous studies, [6,7,38] the present study found associations between heavy smoking and alcohol drinking with presenteeism, even after adjusting for physical illnesses, which implies high costs to employers. Research suggests that high costs are incurred due to smokers' absenteeism, presenteeism, smoke breaks, healthcare costs, and pension benefits, [5] and heavy drinking increases absenteeism and leads to declines in productivity, which can be more harmful to the company than absenteeism. [39] However, in this study, we did not analyze the relationship between heavy smoking and high-risk alcohol drinking and absenteeism; we found instead that absenteeism related to presenteeism. ...
Full-text available
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... Cessation 2023;9(March):7 recoup and prevent costs incurred due to increased sick leave or disability, productivity losses owing to smoking breaks and increased healthcare costs 8,9 . Reduced smoking prevalence also translates into lower healthcare costs and increased quality of life years 10,11 . ...
... Time-related barriers to participation such as a high workload, inflexibility to leave their immediate work area and competing work obligations have also been reported for other workplace programs [28][29][30][31] . Whilst it may not be possible for employees who work from home or who have demanding or incongruous work schedules to participate in a group-based program, these groups should not be forgotten or treated with less priority, as both they and their employer can still benefit from reduced illness and disability as a result of quitting 8 . Temporary workers hold a particularly unstable position in the workplace and may therefore experience more stress 32 , furthering their need for cessation support. ...
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Introduction: Randomized controlled trials have demonstrated the effectiveness of workplace smoking cessation programs. However, with low participation rates reported, it is important to understand the barriers and facilitators for the reach and participation of employees in workplace smoking cessation programs. The objective of the present study is to uncover the needs of employees regarding reach and participation when implementing a workplace program to address smoking cessation. Methods: We carried out 19 semi-structured qualitative interviews in 2019 based on the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Framework with current and former smoking employees of organizations with ≥100 employees in the Netherlands. Some of the interviewees had experience with a cessation program. Data were analyzed using the Framework method. Results: The main barriers according to employees were insufficient promotion of the cessation program, completing the program in the employee’s own time and working night shifts and peak hours. Facilitators included being actively approached to participate by a colleague, positive reactions from colleagues about employee’s participation in the program, providing the program on location and integrating the program as part of the organization’s vitality policy. Conclusions: Effective workplace programs for smoking cessation can stimulate cessation but implementers often experience low participation rates. Our study presents recommendations to improve the recruitment and participation of employees in a workplace smoking cessation program, such as using active communication strategies, training managers to stimulate smoking employees to participate and making the program as accessible as possible by reimbursing time spent and offering the program at the workplace or nearby. Integrating the smoking cessation program into wider company vitality policy will also aid continued provision of the program.
... Next to the health burden, tobacco use also imposes substantial economic costs via health expenditures and through productivity losses [4]. Smoking is associated with reduced work performance and a 31% higher likelihood of workplace absenteeism; smokers annually take approximately three more sick days than non-smoking colleagues [5][6][7]. Estimates show that employers suffer an excess expense of $5816 annually to employ a smoker in comparison to a non-smoker [7]. ...
... Smoking is associated with reduced work performance and a 31% higher likelihood of workplace absenteeism; smokers annually take approximately three more sick days than non-smoking colleagues [5][6][7]. Estimates show that employers suffer an excess expense of $5816 annually to employ a smoker in comparison to a non-smoker [7]. ...
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... Smokers' life expectancies are up to 10 years shorter than non-smokers' (3), resulting in societal and human capital losses. Further, ill health can diminish worker productivity (4)(5)(6), ultimately hindering economic growth (7). Tobacco use inflicts many other negative consequences on sustainable development. ...
... According to Euromonitor, around 24 % of cigarettes in El Salvador are purchased on the illicit market (see footnote 2) (34), meaning about seven million untaxed packs were purchased in 2017. 4 The investment case examined a hypothetical scenario in which illicit trade is eliminated and cheaper cigarettes are not available to be purchased at lower prices than on the licit market. ...
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... Our observation that 24% of participants who agreed to re-engage were abstinent at 12 months supports the utility of proactive re-engagement for the 53.9% of participants who were still smoking three months following their initial quit attempt. Berman et al. 21 have estimated that each smoker generates, on average, an additional $2056 in healthcare expenses annually. Thus, the 30 quits we enabled through re-engagement may have saved the Military Health System up to $62000 in the year following the study period. ...
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Introduction While tobacco Quitlines are effective in the promotion of smoking cessation, the majority of callers who wish to quit still fail to do so. The aim of this study was to determine if 12-month tobacco Quitline smoking cessation rates could be improved with re-engagement of callers whose first Quitline treatment failed to establish abstinence. Methods In an adaptive trial, 614 adult smokers, who were active duty, retired, and family of military personnel with TRICARE insurance who called a tobacco Quitline, received a previously evaluated and efficacious four-session tobacco cessation intervention with nicotine replacement therapy (NRT). At the scheduled follow-up at 3 months, callers who had not yet achieved abstinence were offered the opportunity to re-engage. This resulted in three caller groups: 1) those who were abstinent, 2) those who were still smoking but willing to re-engage with an additional Quitline treatment; and 3) individuals who were still smoking but declined re-engagement. A propensity score-adjusted logistic regression model was generated to compare past-7-day point prevalence abstinence at 12 months post Quitline consultation. Results Using a propensity score adjusted logistic regression model, comparison of the three groups resulted in higher odds of past-7-day point prevalence abstinence at follow-up at 12 months for those who were abstinent at 3 months compared to those who re-engaged (OR=9.6; 95% CI: 5.2–17.8; Bonferroni adjusted p
... More so, the cost of health insurance coverage for smokers is expensive as insurance companies charge smokers higher premiums compared to non-smokers. 21 This combined with the medication cost of cancer treatment further compounds the nancial situation of cancer survivors, thereby increasing their likelihood of skipping medications. A study found that the cost attributable to rst-line cancer treatment failure associated with continued smoking in patients with cancer was $10,678 per smoking patient, $2.1 million per 1000 total patients, and $3.4 billion in incremental cost if extrapolated to the 1.6 million individuals diagnosed with cancer annually. ...
Full-text available
Purpose: This study aims to describe the characteristics of cancer survivors who are at heightened risk of adopting cost-saving behaviors as a means to cope with financial hardship. Methods: Study data were derived from the 2018 National Health Interview Survey. Weighted multivariable logistic regressions were used to assess the relationship between cost-related medication rationing and non-adherence and the sociodemographic and behavioral characteristics of US cancer survivors. Results: A total of 2594 cancer survivors were respondents. As income increased, the odds of medication rationing and non-adherence decreased. Cancer survivors aged 65 years and older were less likely to skip or take less medication to save costs than those aged < 45 years. Compared to respondents with health insurance coverage, those without health insurance coverage were over two folds (aOR: 2.38, 95% CI: 1.07-5.29) more likely to skip medications (aOR: 2.38, 95% CI: 1.07-5.29) and take less medication (aOR: 3.53, 95% CI: 1.62-7.72) to save cost. Current smokers were more likely to skip medications (aOR: 1.98, 95% CI: 1.13-3.48) or take less medication (aOR: 1.99, 95% CI: 1.16-3.42) to save money compared to never-smokers. Conclusions: Cancer survivors who skip or ration medications are more likely to be younger, low-income, current smokers, with no health insurance coverage. Results call for multi-pronged interventions targeting at-risk groups identified in this study. Implications for Cancer Survivors: Smoking cessation, expanding insurance coverage for cancer survivors, and furthering ongoing governmental-level efforts aimed at reducing drug prices can help tackle financial hardship and improve outcomes for cancer survivors
... This result supports the findings of an earlier longitudinal study which found that non-smokers were more likely to be employed compared to smokers but where no comparison between never smokers and former smokers was made (Prochaska et al., 2016). A meta-analysis on smoking and employment concluded that smokers were 33% more likely to be absent from work and to take extra sick leave compared to non-smokers (Weng et al., 2013) and a study by Berman et al. estimated that in the US, a smoking employee costs an extra $5816 annually (Berman et al., 2014). These issues could discourage employers from recruiting smokers. ...
This study aimed to examine the prospective association between tobacco, alcohol and cannabis use with attaining employment among unemployed job seekers. Data from the French population-based CONSTANCES cohort on 5114 unemployed job seeking adults enrolled from 2012 to 2018 were analyzed. Binary logistic regressions were computed. Odds ratio (OR) and 95%CI of remaining unemployed at one-year of follow-up (versus attaining employment) according to substance use at baseline were obtained. The following independent variables were introduced into separate models: tobacco use (non-smoker, former smoker, light (<10cig/day), moderate (10-19cig/day) and heavy smoker (>19cig/day)), alcohol use according to the Alcohol Use Disorder Identification Test (non-users (0), low (<7), moderate (7–15) and high or very high-risk (>15)) and cannabis use (never used, no use in the previous 12 months, less than once a month, at least once a month but less than once per week, once per week or more). Analyses were adjusted for age, gender and education. At follow-up, 2490 participants (49.7%) were still unemployed. Compared to non-smokers, moderate and heavy smokers were more likely to remain unemployed, with ORs (95%CI) of 1.33 (1.08–1.64) and 1.42 (1.04–1.93), respectively. Compared to low-risk alcohol users, no alcohol users and high or very high-risk alcohol users were more likely to remain unemployed, with ORs (95% CI) of 1.40 (1.03–1.83) and 2.10 (1.53–2.87), respectively. Compared to participants who never used cannabis, participants who use cannabis once a week or more were more likely to remain unemployed, OR (95%CI) of 1.63 (1.33–2.01). Substance use may play an important role in difficulty attaining employment.
... These trends improved significantly after cessation of smoking-workers who quit smoking up to four years prior experienced both significant increases in work productivity and fewer days of absence from work. Other studies have shown that US workers who smoke cigarettes lose an average of 2-3 working days per year due to health consequences when compared to workers who have never smoked [16][17][18]. Studies conducted in the Netherlands, Germany, and China gave similar results [19][20][21]. ...
Full-text available
Smoking is a leading cause of preventable mortality. It affects both the health and economic situation within societies. The aim of the study is to perform an epidemiological analysis of smoking among professionally active adults in Poland in the years 2016–2020 and its Strong Relationship with Cardiovascular Co-morbidities. The article retrospectively analyzed the records of 1,450,455 who underwent occupational medicine examinations between 2016 and 2020. Statistical analyses performed using IBM SPSS Statistics 25 software were performed. In general, irrespective of the year of measurement, 11.6% of women and 17.1% of men declared smoking. After sorting by year of measurement, we found that the percentage of female smokers was decreasing, while that of males remained relatively consistent. In the case of BMI, it was found that among tobacco smokers the percentage of people with normal body weight decreases with successive years of measurement, while the percentage of overweight and level I obesity increases. Moreover, we analyzed in detail the occurrence of particular comorbidities in the group of people who declared smoking. The most common diseases in this group were: arterial hypertension (39%), lipid disorders (26.7%), and hypertension and lipid disorders (16.5%). Active preventive measures are necessary to reduce the number of smokers and the negative impact of smoking on the occurrence of comorbid diseases.
Introduction Information on morbidity-related productivity losses attributable to cigarette smoking, an important component of the economic burden of cigarette smoking, is limited. This study fills this gap by estimating these costs in the U.S. and by state. Methods A human capital approach was used to estimate the cost of the morbidity-related productivity losses (absenteeism, presenteeism, household productivity, and inability to work) attributable to cigarette smoking among adults aged ≥18 years in the U.S. and by state. A combination of data, including the 2014–2018 National Health Interview Survey, 2018 Current Population Survey Annual Social and Economic Supplement, 2018 Behavioral Risk Factor Surveillance System, 2018 value of daily housework, and literature-based estimate of lost productivity while at work (presenteeism), was used. Costs were estimated for 2018, and all analyses were conducted in 2021. Results Estimated total cost of morbidity-related productivity losses attributable to cigarette smoking in the U.S. in 2018 was $184.9 billion. Absenteeism, presenteeism, home productivity, and the inability to work accounted for $9.4 billion, $46.8 billion, $12.8 billion, and $116.0 billion, respectively. State-level total costs ranged from $291 million to $16.9 billion with a median cost of $2.7 billion. Conclusions The cost of morbidity-related productivity losses attributable to cigarette smoking in the U.S. and in each state was substantial in 2018 and varied across the states. These estimates can guide public health policymakers and practitioners planning and evaluating interventions designed to alleviate the burden of cigarette smoking at the state and national levels.
Smoking is a leading cause of diseases and death, with significant socioeconomic consequences. The purpose of this study was to evaluate the health and economic effectiveness of a workplace smoking cessation program. A total of 89 smokers from seven workplaces in Korea were the participants of the program. For 4 months, individual counseling based on the transtheoretical model (TTM) was conducted and interpersonal and organizational components were applied to encourage entire workplaces to encourage employee smoking cessation. The primary outcome was whether participants quit smoking or not. We also evaluated the changes in attitude and perceptions related to smoking cessation before and after the program and estimated the program's economic effects. Economic effects were defined as reductions in productivity losses and medical expenses. We calculated the return on investment (ROI) values representing the averted cost through the program compared to program cost. At the end of the program, 40.4% of participants quit smoking. Improvements were observed in TTM-based attitudes and perceptions. The mean reduction in productivity losses was estimated to be $187,609.94 for 2 yr and the mean reduction in medical expenses was $3,136.49 at 20 yr among seven workplaces. When accounting for these reductions, the ROI was 15.39 (ranging from -1.00 to 44.53). These effects were robust under various scenarios. The smoking cessation program should be expanded to a wider variety of workplaces. In the future, more sophisticated economic assessment methods should be developed and applied to facilitate workplace recruitment and attract management support.
Full-text available
Tobacco use is responsible for approximately 440,000 deaths in the United States each year - about one death out of every five. This number is more than the annual number of deaths caused by HIV infection, illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined(1) and more than the number of American servicemen who died during World War II. A small but increasing number of employers - including health care systems such as the Cleveland Clinic, Geisinger, Baylor, and the University of Pennsylvania Health System - have established policies of no longer hiring tobacco users. These employers . . .
Nicotine maintains tobacco addiction and has therapeutic utility to aid smoking cessation and possibly to treat other medical diseases. Nicotine acts on nicotinic cholinergic receptors, which demonstrate diversity in subunit structure, function, and distribution within the nervous system, presumably mediating the complex actions of nicotine described in tobacco users. The effects of nicotine in people are influenced by the rate and route of dosing and by the development of tolerance. The metabolism of nicotine is now well characterized in humans. A few individuals with deficient C-oxidation of nicotine, unusually slow metabolism of nicotine, and little generation of cotinine have been described. Nicotine affects most organ systems in the body, although its contribution to smoking-related disease is still unclear. Nicotine as a medication is currently available as a gum, a transdermal delivery device, and a nasal spray, all of which are used for smoking cessation. Nicotine is also being investigated for therapy of ulcerative colitis, Alzheimer's disease, Parkinson's disease, Tourette's syndrome, sleep apnea, and attention deficit disorder.
From 1992-93 to 2005, there was an overall drop in retirement coverage; participation in defined contribution plans eclipsed that in defined benefit plans, and the features of retirement plans changed in tandem with the declining participation.
Background: Tobacco use remains the leading cause of preventable morbidity and mortality in the United States. Methods: The 2005--2010 National Health Interview Surveys and the 2010 Behavioral Risk Factor Surveillance System survey were used to estimate national and state adult smoking prevalence, respectively. Current cigarette smokers were defined as adults aged ≥18 years who reported having smoked ≥100 cigarettes during their lifetime and who now smoke every day or some days. Results: In 2010, 19.3% of U.S. adults were current cigarette smokers. Higher smoking prevalence was observed in the Midwest (21.8%) and South (21.0%). From 2005 to 2010, the proportion of smokers declined from 20.9% to 19.3% (p<0.05 for trend), representing approximately 3 million fewer smokers in 2010 than would have existed had prevalence not declined since 2005. The proportion of daily smokers who smoked one to nine cigarettes per day (CPD) increased from 16.4% to 21.8% during 2005--2010 (p<0.05 for trend), whereas the proportion who smoked ≥30 CPD decreased from 12.7% to 8.3% (p<0.05 for trend). Conclusions: During 2005--2010, an overall decrease was observed in the prevalence of cigarette smoking among adults; however, the amount and direction of change has not been consistent year-to-year.
Finding employment is becoming increasingly difficult for smokers. Twenty-nine U.S. states have passed legislation prohibiting employers from refusing to hire job candidates because they smoke, but 21 states have no such restrictions. Many health care organizations, such as the Cleveland Clinic and Baylor Health Care System, and some large non-health care employers, including Scotts Miracle-Gro, Union Pacific Railroad, and Alaska Airlines, now have a policy of not hiring smokers - a practice opposed by 65% of Americans, according to a 2012 poll by Harris International. We agree with those polled, believing that categorically refusing to hire smokers is unethical: it . . .