2.0 Background BACKGROUND. Understanding the Issue of Tobacco Use. 1 Project Health Tobacco-Free Living: What Works at Work!

Transcription

1 2.0 Background BACKGROUND Understanding the Issue of Tobacco Use 1 Project Health Tobacco-Free Living: What Works at Work!

2 Making the Case for Tobacco-Free Living at Work In today`s economy, many workplaces are identifying the benefits of promoting wellness in the workplace. Helping employees be tobacco-free is one of the best things employers can do to improve worker health and it can improve the company s bottom line. The workplace is an ideal setting to encourage tobacco free living because many people spend a large portion of their waking time at work, where accessing information and supports may be more convenient and therefore more likely to be used. Workplaces can provide a supportive social environment that is helpful for quitting, and workplaces with restrictive smoking policies encourage smokers to cut down or quit and help those who are already smoke-free to remain so. 1 Smoking has been reported to cost the Ontario economy $2.6 billion in lost productivity each year. 2 Research into the return on investment (ROI) of smoking cessation programming in workplaces has shown workplaces to experience a ROI of at least $3 and up to $10 (USD) for each $1 spent. 3 Workplaces have been reported to experience net financial savings (net profit) three or four years after cessation program implementation in the workplace, with ROIs estimated at 39 per cent to 60 per cent within ten years of program implementation. 4 Workplace cessation programs are identified by the World Bank as economical interventions, being relatively low cost, and producing financial returns over the long-term that far outweigh their costs. 5 Although opponents have voiced concern that smoking bans may damage business, research indicates this to be false. 5 Furthermore, the majority of smokers and non-smokers prefer smokefree work environments, and smoke-free workplaces improve company image and employee morale. 6-7 The following sections detail further the legal implications of the Smoke-Free Ontario Act, health implications of tobacco use, trends in smoking, and costs of tobacco use to the employer. 11 Project Health Tobacco-Free Living: What Works at Work!

3 7 Reasons Employers Should Promote Tobacco-Free Living 1,8 1. Improved employee health employees who don t smoke take fewer sick days, go on disability less often, and are less likely to retire early because of poor health 2. Increased productivity employees may take fewer unscheduled smoking breaks which could impact productivity 3. Reduced costs if employees who smoke are helped to quit, the workplace will reduce potential loss of skills, knowledge, and corporate memory due to premature death and early retirement; the Conference Board of Canada has estimated it costs workplaces an additional $3, 396 per year per smoking employee due to increased absenteeism, reduced productivity, increased insurance costs, and additional facilities costs (maintenance and clean up costs associated with littering of and damage caused by discarded cigarettes) 4. Enhanced job satisfaction most people who smoke want to quit; a study from Health Canada s Tobacco Demand Reduction Strategy shows many smokers would welcome smoking cessation programs offered by their employers; the majority of smokers and non-smokers prefer to work in a smoke-free environment; employees have been shown to be more productive, have an increased morale, and an increased sense of loyalty in smoke-free environments 5. Effective setting workplaces are ideal settings in which to address tobacco use because many people spend a large proportion of their time at work; workplaces are convenient locations for people to access information and support; workplaces can provide the supportive social environment necessary for quitting smoking; smokers can get support from colleagues and others who promote health in the workplace; smoke-free workplaces encourage those who smoke to cut down or quit, and help those who are already tobacco-free to stay that way 6. Better corporate image workplaces that are committed to the health of their employees portray a positive image and are respected within the workplace and broader community; a better corporate image may help to attract and retain talented workers 7. Complying with legislation the Smoke-Free Ontario Act came into effect on May 31, 2006, making all enclosed public places and enclosed workplaces 100 per cent smoke-free to protect employers and employees from exposure to SHS; by providing a smoke-free environment, employers protect themselves from liability related to the exposure of employees to an identified workplace hazard 12 Project Health Tobacco-Free Living: What Works at Work!

4 The Smoke-Free Ontario Act Workplaces have a legal responsibility to comply with the Smoke-Free Ontario Act (SFOA), a provincial strategy to protect non-smokers from exposure to second-hand smoke, help smokers quit, and to encourage young people to never start. Enacted on May 31, 2006, the Smoke-Free Ontario Act bans smoking in all enclosed public places and workplaces at all times, even when people are not working. The Smoke-Free Ontario Act defines an enclosed workplace as the inside of a building, structure, or vehicle that is covered by a roof An enclosed workplace is a place where employees work or go regularly as part of their work, whether or not they are acting in the course of their employment at the time. Washrooms, lobbies, and parking garages are all part of an enclosed workplace, therefore smoking is not permitted in any of these locations. An employer who provides an outdoor shelter for smoking must ensure it consists of no more than two walls and a roof. Employer Responsibilities Ensure employees are aware of the SFOA and where smoking is prohibited Post No Smoking signs at entrances/exits, in washrooms, lobbies, and other appropriate locations Ensure there are no ashtrays or any object that could serve as one within enclosed workplaces Ensure that no one smokes in the workplace Ensure that anyone not complying with the act, does not remain in the workplace Employee Rights An employee cannot be dismissed, threatened to be dismissed, disciplined, suspended, penalized, intimidated or coerced for obeying the Act or making a complaint regarding non-compliance with the Act If an employee experiences any of the above, the employee can direct complaints to the Ontario Labour Relations Board ( 13 Project Health Tobacco-Free Living: What Works at Work!

5 The Smoke-Free Ontario Act is enforced by Ontario Public Health Units Public Health Units are authorized by the Ontario Ministry of Health and Long-Term Care to investigate complaints and carry out workplace inspections in order to enforce the Act. Both employees and employers have a legal requirement to comply with the regulations of the Smoke-Free Ontario Act and could be subject to a fine if convicted of an offence: Penalties: Action Smoke tobacco in an enclosed public place $365 Hold lighted tobacco in an enclosed public place $305 Smoke tobacco in an enclosed workplace $305 Smoke tobacco in a motor vehicle with person under 16 $155 Fine Hold lighted tobacco in a motor vehicle with person under 16 $155 Hold lighted tobacco in an enclosed workplace $305 Smoke tobacco in a prohibited place or area $305 Hold lighted tobacco in a prohibited place or area $305 Failure of employer to ensure no ashtrays or similar equipment Failure of proprietor to give notice that smoking is prohibited Failure to post no smoking signs when smoking is prohibited $365 $365 $240 Source: SFOA, Project Health Tobacco-Free Living: What Works at Work!

6 In accordance with the Smoke Free Ontario Act Section 9 (1)(2), the maximum fine for an individual convicted of smoking tobacco or holding lighted tobacco in any enclosed public place or enclosed workplace with no earlier convictions is $1,000 and with one or more previous convictions for the same offence in the past five years preceding the current conviction is $5,000. In accordance with the SFOA Section 9(3)(6), the maximum fine a corporation can receive for not complying with the SFOA employer obligations, is $100,000 with no previous convictions and $300,000 with one or more previous convictions for the same offence in the past five years preceding the current conviction. In accordance with SFOA Section 9(4), an individual could receive a maximum fine of $4,000 and a corporation could receive a maximum fine of $10,000 if convicted of taking action against an employee because the employee has acted in accordance with or has sought the enforcement of the SFOA. Health Consequences of Tobacco use Tobacco use is the leading cause of preventable illness and death in Ontario and across Canada. 9 It is estimated that, in Canada, smoking is responsible for 30 per cent of all cancer deaths and is related to more than 85 per cent of lung cancer cases. 10 Smokers are about 10 to 20 times more likely to develop lung cancer than non-smokers, and the longer one smokes and the more cigarettes smoked each day, the greater the risk. 10 Smokers are two to four times more at risk of developing coronary heart disease and stroke than are non-smokers, 11 and cigarette smoking has been identified as the principal underlying cause in per cent of chronic obstructive pulmonary disease (COPD) cases. 12 Risk of illness and disease is increased further if a smoker is also exposed to radon or other harmful chemicals, which are present in some workplaces. 10 Smoking also has adverse reproductive and early childhood effects, including risk of infertility, preterm delivery, stillbirth, low birth weight, and sudden infant death syndrome Project Health Tobacco-Free Living: What Works at Work!

7 All Forms of Tobacco Are Harmful Tobacco is a plant that contains nicotine, which is the major addictive component in all tobacco products. However, it is not the nicotine that causes the most harm. Tobacco smoke contains over 4,000 chemicals, of which 60 are known carcinogens 10 and there are more than two dozen carcinogens in smokeless tobacco products such as chew or snuff. 13 It is these harmful chemicals, not nicotine, that lead to preventable illness and death. 14 Researchers know the most about the health effects of cigarette smoking, as it remains the most common form of tobacco used. However, any form of tobacco use (smoked, chewed, or inhaled second hand smoke) 9 has been shown to increase the risk of developing cancers of the bladder, kidney, cervix, colon and rectum, larynx, mouth and throat (pharynx and esophagus), pancreas, stomach, nasal cavity, liver, myelogenous leukemia, and some types of ovarian tumours. 10 It is important for workplaces to be aware of other available tobacco products so that health promotion programming can be tailored to the needs of all employees, including those who use alternate forms of tobacco. See the Tobacco Industry Products factsheet in the Appendix for a brief description of other tobacco products. Nicotine has similar addictive characteristics to drugs such as heroin and cocaine. 15 Most tobacco users are aware of the detrimental health effects of using tobacco, but find it very difficult to quit even though quitting is the single most effective thing they could do to enhance the quality and length of their life. 15 This shows the highly addictive properties of nicotine, which is one of the hardest substance use dependencies to break. Statistics show that most smokers want to quit, however it usually takes more than one attempt to stay tobacco-free for life. Of smokers and recent quitters in Canada in 2011, almost half (46 per cent) reported making at least one quit attempt in the past year, and 30 per cent had made multiple quit attempts. 16 Data from the 2010 Canadian Tobacco Use Monitoring Survey shows former smokers who have tried to quit an average of 3.4 times before succeeding. 17 The average number of quit attempts made by those requiring more than one quit attempt before success has been reported to be Each quit attempt increases the chances of staying quit, therefore smoking relapse should not be seen as failure but instead viewed as a step along the journey to becoming tobacco free. 1 Encouraging and supporting quit attempts as much as possible is an important component of addressing tobacco use among employees. 16 Project Health Tobacco-Free Living: What Works at Work!

8 Not Only Tobacco Users Are At Risk Tobacco smoke not only harms users, but also those who breathe in the toxic second-hand smoke. Second-hand smoke is the side-stream smoke from a lit tobacco product as well as the smoke exhaled by a person who is smoking. Second-hand smoke contains the same harmful chemicals as first-hand smoke (the smoke that is inhaled) and has been classified as a Group A human carcinogen by the U.S. Environmental Protection Agency. 18 Each year, exposure to second-hand smoke while at work, home or elsewhere causes the death of about 1,000 nonsmoking Canadians. 19 Second-hand smoke is also an irritant, causing congestion, coughing, and irritation to the skin, eyes, nose and throat, and can worsen allergies or breathing problems like asthma in both people who smoke as well as those who do not. 19 In Waterloo Region in , 15.5 per cent of non-smoking individuals 12 years of age and older reported being regularly exposed to second-hand smoke. 20 While much has been done to reduce tobacco use and exposure to tobacco smoke in Ontario, more work is still needed. In Ontario, workers continue to be exposed to second-hand smoke in enclosed as well as non-enclosed workplaces, despite implementation of the Smoke-Free Ontario Act (SFOA) in 2006, which requires all enclosed workplaces in Ontario to be smoke-free. Workplace exposure, both indoor and outdoor, did not decrease significantly among Ontario workers aged 15 years and older between 2005 (31 per cent of workers reporting exposure) and 2010 (26 per cent of workers reporting exposure). 21 In 2011, 14 per cent of Ontario workers were exposed to second-hand smoke indoors at work or in a workplace vehicle. 22 Ontario workers in trades, construction, transport, equipment operations, primary industry, processing, manufacturing, and utilities occupations continue to have significantly higher levels of exposure to second-hand smoke while working compared to workers in other occupations Project Health Tobacco-Free Living: What Works at Work!

9 Tobacco Use Rates Some occupations and industries display high rates of smoking, much higher than other occupations and higher than the national and Ontario averages (see Tables 1, 2, and 3). Workers in these settings are at increased risk of tobaccorelated illness, and their companies are at risk of incurring greater costs associated with employing tobacco-users. In workplaces where rates of smoking are lower, addressing employee tobacco use is still cost-effective. Table 1. Proportion of Current Smokers, Ontario & Canada, Occupation Trades, transport and equipment operators and related occupations; primary industry; processing, manufacturing and utilities Sales and service workers Management; business, finance and administration; natural and applied sciences; health occupations; social science, education, government service and religion; art, culture, recreation and sport Population average (15 years +) Proportion of Current Smokers (past 30 days, 15 years +) Ontario 2005 Ontario 2010 Canada 2005 Canada % 29.3% 31.5% 28.2% 16.4% 14.4% 21.9% 18.7% 13.6% 11.8% 15.7% 12.8% 15.9% 14.0% 18.2% 16.0% Source: Tobacco Informatics Monitoring System, data from Canadian Tobacco Use Monitoring Survey, 2005, Project Health Tobacco-Free Living: What Works at Work!

10 Table 2. Proportion of Workers who Smoke by Occupation in Canada, 2011 Occupation % Trades, transport, and equipment operators 28 Processing, manufacturing, and utilities 24 Management 23 Primary industry 22 Sales and service 20 Business, finance and, administration 16 Health 12 Natural and applied science and related occupations 12 Social sciences, education, government, and religion 9 Art, culture, recreation, and sport 9 Source: Statistics Canada, CTUMS 2011 Table 3. Prevalence of Smoking by Industry in Canada, 2011 Industry % Construction 34 Mining and oil and gas extraction 29 Transportation and warehousing 29 Administrative support, waste management, and remediation 27 services Accommodation and food services 27 Wholesale trade 26 Manufacturing 24 Retail trade 23 Real estate and rental leasing 23 Agriculture, forestry, fishing and hunting Other services (except public administration) Health care and social assistance 18 Arts, entertainment, and recreation 18 Utilities 17 Information and cultural industries Professional, scientific, and technical services Public administration 16 Finance and insurance 15 Educational services 10 Source: Statistics Canada, CCHS Project Health Tobacco-Free Living: What Works at Work!

11 Waterloo Region In Waterloo Region in 2010, about one in five adults (19 per cent) over 19 years of age reported being current smokers, with most smoking daily. 23 The rate of adult smoking in the Region is just above the provincial rate of 16 per cent in The demographic with the highest proportion of smokers in Waterloo Region is the age group of years, which makes up a large portion of the workforce (adults able to work over the age of 15). 24 In Waterloo Region (Kitchener Census Metropolitan Area [CMA]), the unemployment rate in July 2013 was 8.1 per cent, 25 just above Ontario s unemployment rate of 7.6 per cent in July When looking at the main industries within Waterloo Region, the manufacturing sector employs 18.4 per cent of the workforce, followed by the trades sector at 15.1 per cent. 24 The largest proportion of occupations are in the service sector (22.2 per cent), and these jobs tend to be characterized by lower wages, fewer benefits, and more part-time employment. 27 Keeping in mind, the rates of smoking by occupations and industries presented previously in Tables 1, 2, and 3, there are many workplaces in Waterloo Region that likely display higher rates of tobacco use than the local or provincial average, and that could greatly benefit from addressing employee tobacco use. The older worker population (aged years) showed the greatest percentage of growth in the Kitchener CMA between 2001 and 2006 (Table 4), 24 indicating the need to target workplace tobacco-free living interventions towards this age group. Table 4. Population Growth by Select Age Groups, 2001 and 2006, Census Metropolitan Area of Cambridge, Kitchener, and Waterloo Population Population Absolute Age Group growth % Growth ,960 29,345 1,385 5% ,845 96,910 3,065 3% , ,180 4,410 3% , ,710 20,130 17% ,820 60,610 6,790 13% ,520 15,350 3,830 33% Source: Statistics Canada, Census 2001 and Project Health Tobacco-Free Living: What Works at Work!

12 Understanding trends in tobacco use among specific groups of people can help workplaces tailor their tobacco-free living strategies to the make-up of their workforce. A number of demographic, socio-economic, and related factors are strongly linked to tobacco use (see Table 5). For instance, there are disparities in smoking by sex, age, education, and income within Waterloo Region: 1. Smoking is more common among men than women. 22 per cent of adult men smoke whereas 16 per cent of women smoke. 2. Smoking is most common among adults aged 50 to 64 years compared to younger adults. While 26 per cent of adults between 50 and 64 years smoke, only 19 per cent of younger adults (19 per cent of adults years and 19 per cent of adults years) report that they smoke (Table 5). 3. Education and income have a significant impact on smoking. People with post-secondary education and higher income are much less likely to smoke (Table 5). This reflects the situation across Canada, where socioeconomic inequalities in smoking, tied to education and income, have persisted over time. 28 Education tends to be lower in occupations that also experience higher rates of tobacco use. 4. Tobacco use is affected by income. Smoking is far more common among low earners in Canada than among workers with comparatively higher earnings. Recent statistics show that Canadians who earn less than $20,000 are twice as likely to report smoking compared to those who earn over $80,000 (33 per cent versus 16 per cent, respectively). 29 Individuals who work part-time and/or at minimal wage-paying jobs may be at particular risk of using tobacco products and costing their workplace as a result something for employers to keep in mind. 21 Project Health Tobacco-Free Living: What Works at Work!

13 Smoking rates also vary across Waterloo Region municipalities and townships, due to the diverse population mix, living conditions, or other factors that affect tobacco use such as occupation and income. Table 5. Proportion of adults aged 18 years and older who were current smokers* by age group, sex, education and municipality in Waterloo Region, Age Factors that affect tobacco use current smokers (%) years years years 26 Sex Males 22 Females 16 Education Less than high school 25 E High school diploma 26 Some post- secondary 19 E Post-secondary degree 15 Factors that affect tobacco use Household Income current smokers (%) Less than $40, $40, $69, $70, $99, E $100, 000 or more 13 E Don t know/refused Municipality (residence) 12 E Cambridge 18 Kitchener 24 Waterloo Townships Source: Canadian Community Health Survey, , Statistics Canada, Share File, Ontario MOHLTC *Current smokers: currently smokes cigarettes daily or occasionally E: High sampling variability, estimates must be interpreted with caution 12 E 11 E 22 Project Health Tobacco-Free Living: What Works at Work!

14 Dollars and Cents It costs employers $3,396 per year more to employ someone who smokes Conference Board of Canada (2006) In 2006, The Conference Board of Canada (CBC) updated their report to Health Canada detailing the costs of employing workers who smoke. Tobacco use causes poor health, and poor employee health results in increased absenteeism, higher health insurance claims, and a higher number of workplace injuries. 30 A comprehensive and integrated workplace wellness strategy that includes support for smoking cessation can help improve worker health and reduce tobacco-use related costs. 30, 31 For a detailed breakdown of estimated costs associated with smoking, and to estimate the cost at your workplace, refer to Smoking and the Bottom Line in the Appendix. Statistics Canada provides wage data by job type, industry, sector, and province, which can be applied to the absenteeism and lost productivity calculations in the Appendix to obtain a more accurate cost figure for smokers in a specific category. Smoking occurrence data such as that provided at the beginning of this section (Tables 1-3) can be used to determine a per-workplace cost by industry or occupation. The CBC estimated costs associated with employing workers who smoke in their 2006 report, Smoking and the Bottom Line: Updating the Costs of Smoking in the Workplace. These estimates are provided next. The following section details the impact of tobacco use on employee absenteeism, employee productivity, insurance costs, and facilities costs. Employee Absenteeism Employees who smoke have been shown to be absent from work an additional two days per year compared to their non-smoking colleagues. 30 The CBC calculated the average daily per employee payroll cost of absence from work in 2005 to be $ This figure 23 Project Health Tobacco-Free Living: What Works at Work!

15 includes average daily wage, taxes, and benefits paid by the employer, including Canadian Pension Plan, Employment Insurance premiums, and supplementary health insurance premiums. If this average daily payroll cost is multiplied by the two additional days of absence estimated for a smoker, the estimated average annual cost to employ a smoker is $ The actual costs of employing someone who smokes may be higher or lower than this estimate, which is an average across industries and occupations. Employee Productivity Employee productivity is impacted by many different factors and can be measured using a number of different criteria. One factor used by the CBC for tobacco use is the amount of time spent on break during work hours. There are a number of assumptions within this premise, but the following arguments have been presented based on employees who smoke. Note that employees who do not smoke may also engage in activities that reduce their productive time and may also take unscheduled or extended breaks for various reasons. The average Canadian smoker consumes 14 cigarettes per day 21 over approximately 16 hours, assuming no smoking during an average eight hours of sleep. 32 The CBC report assumes most cigarettes are consumed outside of work time, leaving five cigarettes to be consumed during an 8 hour work day. Of these, three would likely be consumed during employer-sanctioned breaks, leaving two additional 15-minute breaks needed to smoke. Additionally, many workplaces have opted to make their grounds entirely smoke-free: of 129 Canadian organizations surveyed recently, 19 per cent indicated that smoking is not permitted anywhere on company property. 31 A smoke-free grounds policy would likely require employees to travel a greater distance to smoke, extending the amount of time needed to consume a cigarette. 30 With this assumption, an employee who smokes now spends an estimated 40 minutes every day consuming cigarettes outside of sanctioned break time. Using the average daily per-employee payroll cost mentioned previously and assuming 227 working days per year (365 days minus 104 for weekends, 10 for holidays, 15 for vacation, and 9 sick days), the estimated annual cost of lost productivity per smoking employee is $3, However, the assumption that time spent smoking a cigarette is time lost to otherwise productive work may be inaccurate as employees could discuss matters of business while using tobacco. 24 Project Health Tobacco-Free Living: What Works at Work!

16 Insurance Costs Insurance costs were included in the CBC s model of costs associated with employing workers who smoke based on the concept that smokers have greater health problems and may make more health claims for health benefits which could increase insurance premiums. It is difficult to identify exactly how much of an impact smokers have on insurance costs, but the workplace can play an important role in improving employees overall health. 30 Smoking Facilities Costs Since the Smoke-Free Ontario Act was implemented in 2006, smoking has been prohibited in enclosed workplaces in Ontario. Therefore smoking facilities here refers to items that might be offered for smokers outdoors, such as ashtrays and designated smoking areas (DSAs) or smoking shelters. (For more information about smoking shelters, see the Supportive Environment section.) The CBC estimates the annual cost of ashtrays per smoking employee to be $8.50, with an annual cleaning cost per smoking employee of $11.34 (for details on how these cost were estimated please see Smoking and the Bottom Line in the Appendix), equalling a total annual per smoking employee facilities cost of $20. This cost provides rationale for instituting a property-wide smoke-free policy, as no smoking facilities costs would be incurred (although decreased productivity may result from added distance smokers must travel to use tobacco, outlined previously). While implementing a complete smoking ban is an effective approach to promote tobacco-free living (see the Policy Development section for more information), this may not be a realistic approach for all workplaces. 25 Project Health Tobacco-Free Living: What Works at Work!

17 Summary of Employer Costs Associated with Employees who Smoke Cost Factor Cost in 2006 (Cdn $) Increased absenteeism 323 Decreased productivity 3,053 Increased life insurance costs Not available Smoking facilities costs 20 Workplaces in industries with a high smoking prevalence may have higher costs associated with employee tobacco use and will have the much to gain from encouraging and supporting employees to quit. However, all workplaces who promote tobacco-free living will see benefits such as improved employee health, greater job satisfaction, and better corporate image. The remainder of this toolkit provides strategies, tips, tools, and resources to create a comprehensive workplace wellness program to support tobacco-free living among employees. 26 Project Health Tobacco-Free Living: What Works at Work!

18 References 1 York Region. Good Business... better health. A comprehensive guide for smoke-free workplaces [Internet]. [place unknown]; date unknown [cited 2013 Jul 10]. Available from: rtmaezu4yi3qbbsxuvm2ghb4cf/york-% v1- Good_business_better_health_Workplace_guide_1.pdf 2 Patten B, Bovett M. Creating a comprehensive tobacco strategy for your workplace. Ontario Occupational Health Nurse Association Journal winter;5-9 3 Mulligan P. Corporate smoking cessation on Long Island. Health Promotion Practice. 2010;11: Halpern MT, Taylor H. Employee and employer support for workplace-based smoking cessation: results from an international survey. Journal of Occupational Health. 2010;52(6): World Bank. Smoke-free workplaces [Internet]. Washington (DC): World Bank; 2002 [cited 2013 Jun 26]. Available from: 6 Fronzi L, Haughey K. Creating a supportive environment: smoke-free policy & cessation support [PowerPoint slides]. Brant County Health Unit; Global Smokefree Partnership. Designing a 100% smokefree workplace policy [Internet]. [place unknown]: Global Smokefree Partnership; date unknown [cited 2013 May 28]. Available from: 8 Health Canada. Smoking Cessation in the Workplace: A Guide to Helping Your Employees Quit Smoking [Internet] [cited 2013 Jul 10]. Available from: 9 Cancer Care Ontario. Tobacco: Facts about tobacco [Internet]. [place unknown]: Cancer Care Ontario; 2009 Nov 20 [cited 2013 Jun 17]. Available from: 10 Canadian Cancer Society. Smoking and tobacco [Internet]. Canadian Cancer Society; 2013 [cited 2013 May 28]. Available from: 11 Centers for Disease Control and Prevention. Health effects of cigarette smoking [Internet]. Centers for Disease Control and Prevention; 2012 January 10 [cited 2013 May 28]. Available from: 12 Ontario Lung Association. Smoking and tobacco [Internet]. Toronto (ON): Ontario Lung Association; 2011 [cited 2013 Jul 17]. Available from: 13 Ontario Tobacco Research Unit. Smokeless tobacco and snus: The current evidence for health risks [Internet]. [place unknown]: Ontario Tobacco Research Unit; 2007 [cited 2009 Jan 23]. Available from: 14 Selby P, Herie M, Dragonetti R, Chapchuk R, Lecce J, Baarker M, fahim M, Parchment S, Sliekers S, Czyzewski K, Timothy V. A comprehensive course on smoking cessation: Essential skills and strategies. [place unknown]: TEACH PROJECT, Centre for Addiction and Mental Health; Registered Nurses Association of Ontario. Integrating smoking cessation into daily nursing practice. Toronto (ON): RNAO; Reid JL, Hammond D, Burkhalter R, Rynard VL, Ahmed R. Tobacco use in Canada: Patterns and trends, 2013 edition [Internet]. Waterloo (ON): Propel Centre for Population Health Impact, University of Waterloo [cited Jul 17]. Available from: 17 Health Canada. Quitting smoking among adults [Internet]. Canadian Tobacco Use Monitoring Survey; 2011 [cited 2013 May 28]. Available from: 18 United States Environmental Protection Agency. Health effects of exposure to secondhand smoke [Internet]. [place unknown]: US EPA; 2011 Nov 30 [cited Jul 10]. Available from: 19 Canadian Cancer Society. Smoking and cancer [Internet]. Canadian Cancer Society; 2013 [cited 2013 May 28]. Available from: 20 Non smoker second-hand smoke exposure, Waterloo Region and Ontario, 2005, and [Internet]. [place unknown]; Canadian Community Health Survey, 2005, , , Statistic Canada, Share File, Ontario MOHLTC; 2012 August 21 [cited 2013 June 27]. Available from: 27 Project Health Tobacco-Free Living: What Works at Work!

19 21 Health Canada. Canadian Tobacco Use Monitoring Survey [Internet]. [place unknown]: Health Canada; 2010 [cited 2013 Jul 10]. Available from: 22 Ontario Tobacco Research Unit. Smoke-Free Ontario strategy evaluation report [Internet]. Toronto (ON): Ontario Tobacco Research Unit, Special Report; 2012 Nov [cited 2013 Jul 10]. Available from: 23 Smoking Status, Waterloo Region & Ontario, 2005, & [Internet]. Canadian Community Health Survey, 2005, , , Statistic Canada, Share File, Ontario MOHLTC; 2012 August 21 [cited 2013 June 27]. Available from: 24 Region of Waterloo Public Health. Profile of workplaces in Waterloo Region. Project Health; 2012 Apr. 25 Statistics Canada. Labour force survey estimate (LFS), by census metropolitan area based on 2006 census boundaries, sex and age group, 3 month moving average, unadjusted for seasonality. [Internet]. Statistics Canada; 2013 Aug 8 [cited 2013 Aug 27]. Available from: 26 Statistics Canada. Labour force characteristics, seasonally adjusted, by province (montly). [Internet]. Statistics Canada; 2013 Aug 9 [cited 2013 Aug 27]. Available from: 27 Waterloo Region Profile: Statistics, trends & forecasts towards understanding implications for the future. Background document for the strategic planning process.2011 Feb 4 [cited 2013 Jun 24]. Available from: 28 Corsi DJ, Lear SA, Chow CK, Subramanian SV, Boyle MH, Teo KK. Socioeconomic and geographic patterning of smoking behaviour in Canada: A cross-sectional multilevel analysis. Plos ONE Feb 28;8(2): Stonebridge C, Bounajm, F. Smoking cessation and the workplace: Briefing 1 Profile of tobacco smokers in Canada [Internet]. Ottawa (ON): The Conference Board of Canada; 2013 April [cited 2013 June 7]. Available from: 30 Hallamore, C. Smoking and the Bottom Line: Updating the costs of smoking in the workplace [Internet]. Ottawa (ON): Conference Board of Canada; 2006 [cited 2013 May 28]. Available from: 31 Lamontagne E, Stonebridge C. Smoking cessation and the workplace: Briefing 2 Smoking cessation programs in Canadian workplaces [Internet]. Ottawa, (ON): The Conference Board of Canada; 2013 June [cited 2013 June 28]. Available from: 32 Hurst M. Who gets any sleep these days? Sleep patterns of Canadians [Internet]. [place unknown]: Statistics Canada; 2008 [cited 2013 Jun 21]. Available from: x/ /article/10553-eng.htm 28 Project Health Tobacco-Free Living: What Works at Work!