Getting Help Kicking the Habit:

Transcription

1 Getting Help Kicking the Habit: The Case for Offering a Comprehensive Tobacco Cessation Presented to Participants in the Apartment Industry Tobacco Cessation Assistance Survey Prepared by: Ken Wexler, SVP Lockton Companies, LLC Date November 12, West Monroe Street, Suite 600 Chicago, IL Phone /Fax

2 Table of Contents Page White paper 3 Appendix American Lung Association Smoking Cessation Programs 15 State Cigarette Excise Taxes 17 State Smoker Protection Laws 19 2

3 Introduction A group of human resources professionals within the multi-housing property management industry are working together to decrease the number of smokers within the apartment industry workforce and promote healthier lifestyles for those employees and their families. Specific goals for this initiative include: Sharing resources across companies to identify best practices and uncover new ideas Formulating a variety of customizable tools for each company to personalize their own smoking cessation campaign according to their unique culture and environment Enlisting support from national apartment organizations (i.e., National Apartment Association (NAA) and National Multi Housing Council (NMHC)) to promote the message Conducting an in-depth survey of companies in the industry to better understand current practices. Lockton Companies, an employee benefits consulting firm, assisted in this effort by conducting an industry-wide survey to evaluate current smoking prevalence rates, the types of smoking cessation assistance programs offered, and methods for promoting participation in these programs. Lockton also agreed to research and author a detailed White Paper on tobacco assistance programs. White Paper Structure Most people have long known smoking and other forms of tobacco use are bad for one s health, yet 21% of adults in the U.S. still use tobacco products. For employers with even an average number of tobacco users in their workforce, there are significant financial implications. Direct costs include health care expenses while indirect costs include lost productivity. Companies wanting to reduce their exposure to these risks can either enhance their existing tobacco cessation assistance programs or implement a program if none exists. This paper will clarify the key issues surrounding this important topic and how to implement a comprehensive tobacco cessation assistance program. To help gain this understanding, we ve organized the paper into following sections: The facts Why nicotine is so addicting Smoking prevalence rates in the United States 3

4 What a comprehensive program should include Barriers to care Available programs Tobacco-based contribution rates and legal considerations Bringing it all together The Facts To help frame a conversation about the reasons why plan sponsors may want to offer a comprehensive tobacco cessation assistance program, consider the following facts: Tobacco use is the leading preventable cause of disease, disability and death in the United States 1. Between 1964 and 2004, cigarette smoking caused an estimated 12 million deaths, including 4.1 million from cancer, 5.5 million from cardiovascular diseases, 1.1 million from respiratory diseases, and 94,000 infant deaths related to mothers smoking during pregnancy 1. More than 443,000 Americans die each year due to tobacco-related illnesses 2. Cigarette smoking accounts for one third of all cancers, including 90% of lung cancer cases 13. Smoking causes lung diseases such as chronic bronchitis and emphysema, and increases the risk of heart disease, including stroke, heart attack, vascular disease and aneurysm 5, 13. Pregnant women who smoke cigarettes are at increased risk of miscarriage, stillborn or premature infants, or infants with low birthweight 5. Each year, 150, ,000 children younger than 18 months old experience respiratory tract infections caused by secondhand smoke 14. On average, smokers miss 2.3 more work days per year than non-smokers 3. Smokers lose 4.2 more work days per year due to presenteeism (physically at work but not fully productive) 3. The cost of medical care for smokers is 18% higher than those who had never smoked 4. On average, adults who smoke die 14 years sooner than non-smokers 5. Children who grow up with parents who smoke are more likely to become smokers themselves. 4

5 Why is Nicotine so Addicting? Like cocaine, heroin and marijuana, nicotine increases levels of the neurotransmitter dopamine, which affects the brain pathways that control reward and pleasure. For many tobacco users, longterm brain changes induced by continued nicotine exposure result in addiction a condition of compulsive drug seeking and use even in the face of negative consequences 15. A number of studies indicate children are especially susceptible to these effects and may be even more likely than adults to develop an addiction to nicotine. When addicted tobacco users try to quit, they may experience severe withdrawal symptoms including irritability, attention difficulties, sleep disturbances, increased appetite and powerful cravings for tobacco. It s no wonder why the success rate of those trying to quit is so low. Even though ~70% of smokers say they want to quit 6, each year only 4.7% of succeed 6. Smoking Prevalence Rates in the United States Smoking prevalence rates vary significantly based on a number of factors including income level, gender, age, race, ethnicity, and education level. Following are some interesting facts: Adults below the poverty level have an average smoking rate of 28.8% compared to 20.3% for people at or above the poverty level % of women in the U.S. smoke % of young adults who are college age but do not attend college smoke % of college students smoke 11 The majority of smokers begin before age 18 (nearly 80% before age 18 and nearly 90% before age 20) 8. As the below table shows, smoking prevalence rates differ significantly based on educational level achieved 7. Educational Level Attained Men Women Total High School Diploma 27.4% 20.4% 23.7% Associates Degree 21.2% 18.9% 19.9% Bachelors Degree 13.4% 9.4% 11.4% Graduate Degree 6.4% 6.0% 6.2% 5

6 Smoking prevalence rates also differ significantly based race and ethnicity: Race/Ethnicity Men Women Total Asian Americans % 4.6% 9.6% African Americans % 15.8% 19.8% Hispanics % 8.3% 13.3% White, Non-Hispanic % 19.8% 21.4% Native Americans % 36.0% 36.4% Given the above statistics, plan sponsors employing a high percentage of lower paid, less educated workers are likely to have a much higher smoking prevalence rate in their workforce, and they may benefit most from investing in a comprehensive tobacco cessation assistance program. What Should a Comprehensive Program Include? Tobacco addiction is a chronic disease that usually requires multiple attempts to quit. While some can kick the habit cold turkey, most people need some form of assistance. In its Clinical Practice Guideline called Treating Tobacco Use and Dependence 10, the U.S. Public Health Service recommends seven medications that are scientifically proven to be effective in helping tobacco users to quit successfully. Of the seven medications, five fall into the category of nicotine replacement therapies (NRTs), which deliver medicinal nicotine in small doses to help ease withdrawal symptoms. The remaining two medications do not contain nicotine, but ease withdrawal symptoms through their effects on the brain. Following are the medications and whether a doctor s prescription is needed to obtain them: # Medication Prescription Needed 1 Nicotine gum No 2 Nicotine transdermal patch Some yes, some no 3 Nasal sprays Yes 4 Inhalers Yes 5 Nicotine lozenges No 6 Bupropion (Zyban) Yes 7 Varenicline (Chantix) Yes In addition to the above medications, three types of counseling are also recommended to be included in a comprehensive tobacco cessation assistance program: Individual (face-to-face) Counseling: This is often delivered by a physician, nurse or other clinician. 6

7 Group Counseling: This can occur in many different settings include, but not limited to, hospitals, physician practices, community centers, religious institutions, or workplaces. Telephonic Counseling: This can be provided by stand-alone tobacco cessation companies such as Free & Clear, medical insurance carriers, wellness companies, state-based quit lines, and the American Lung Association. While medications combat the physical aspect of the addiction, counseling targets the social and psychological aspects. Effective counseling programs should incorporate social support and address practical coping and problem-solving skills 16. Treatment for smoking cessation is not one-size-fits-all. Just like any other medical condition, everyone responds to treatment differently. It is normal for patients to try more than one treatment option before finding the right one. Some patients also might not be able to take one or more cessation medications because of other medical conditions they have. For all these reasons, patients should have the full range of treatment options available when they want to quit 16. Barriers to Care According to the American Lung Association, plan sponsors wanting to offer the most comprehensive and accessible tobacco cessation program should offer all forms of medications and behavioral counseling and remove the following financial and administrative barriers to care 17 : Copayments Dollar limits Duration limits Prior authorizations Annual limits on quit attempts Requirements to try one medication before another (step therapy) Requirements to pair medications with counseling Available Programs There are many resources offered by organizations for individuals wanting to quit, including: Self-help materials offered online, in doctors offices, and from religious institutions State-based quit lines U.S. Department of Health and Human Services national quit line (800-QUIT-NOW) Tobacco cessation programs offered by insurance carriers (Aetna, Blue Cross Blue Shield, CIGNA, Humana, United Healthcare, etc.) and other Third Party Administrators EAP vendors Wellness vendors 7

8 Free standing vendor programs (i.e., Free & Clear, purchased by Inverness Medical Innovations in 2009) Tobacco-Based Contribution Rates Many plan sponsors have instituted tobacco-based health plan contributions in an effort to financially incent, or penalize, depending on your perspective, employees and their dependents to cease tobacco use. There are important considerations for those either already using this approach or thinking about implementing it: Depending on how employee contributions are set, tobacco-based rates can provide a more equitable sharing of cost by charging those engaging in a known high-risk behavior to pay more. Non-smoking employees are usually in support of such a program as they understand they are subsidizing the cost of health care for those not practicing good health habits. Most plan sponsors with tobacco-based contributions use a certification form. Each year during open enrollment employees wanting to pay the lower non-tobacco user rates would complete this form. In addition, employees successfully completing a tobacco cessation program (regardless of whether or not they quit) may also complete the form mid-year, which will then allow them to pay the lower contributions. The plan sponsor will need to determine how it will respond to whistle blowers who report someone they caught smoking whom they think told the company they were a non-tobacco. They will also need to determine what action to take with individuals who may have provided falsified statements as to their non-tobacco using status. Tracking the successful completion of a smoking cessation program may be difficult depending on the capabilities of the entity offering the program. Some provide certificates of completion, others offer electronic reports, and still others don t have an ability to report any data at all. Legal Considerations Tobacco Users Rights Laws It is important to note that 29 states and the District of Columbia have passed legislation prohibiting discrimination toward tobacco users in the terms and conditions of employment, which in many cases include benefits offered and contributions charged. This legislation generally prohibits employers from firing or refusing to hire tobacco users, depriving them of vacation days or, as a general rule, charging different rates for tobacco users and non-users. Please see the Appendix for a list of these states as of 9/27/10. 8

9 However, in most or all of these states an employer subject to ERISA could assert ERISA preemption of the state law. Generally, ERISA preempts all state laws except insurance and criminal laws. ERISA also provides that an employer-sponsored group plan is not an insurer for purposes of state law, preventing state insurance law from applying directly to an ERISA plan. Taken together, these provisions mean that, generally speaking, a self-insured ERISA plan dodges state law (except criminal law) while an insured ERISA plan similarly dodges state law but is indirectly subject to state insurance law because state insurance mandates will be contained in the insurance policy purchased by the plan. However, these tobacco user s rights laws are generally not laws regulating insurance, but employment discrimination laws. As such, they are likely preempted even with respect to fully insured ERISA plans While there are many plan sponsors with employees in these tobacco rights states who offer tobacco-based contributions, they have weighed the risk and determined that ERISA preemption will shield them from any liability. Any employer considering implementing this approach will need to make their own decision on this point after consultation with their internal or external counsel. HIPAA Bona Fide Wellness Rules Plan sponsors must also contend with the Health Insurance Portability and Accountability Act (HIPAA). Where a plan sponsor s wellness initiative supplies a reward (or imposes a penalty) related to the health plan through premium discounts or surcharges, adjustments to deductibles or coinsurance and the availability of the reward (or imposition of the penalty) depends on whether an employee or dependent has or lacks a certain health status factor (such as high blood pressure, nicotine addiction, excessive weight, diabetes) HIPAA sets forth very strict rules the wellness programs must follow. For example: 1. It is logical to think people are more successful in developing good habits when they are rewarded with an incentive large enough to make them want to change. HIPPA limits the size of the health plan-related reward to 20% of the full cost of employee only coverage (either the insured premium rate charged by the insurance company or the premium equivalent rates established by an insurance carrier, third party administrator, broker, consultant or actuary.) While this is the maximum, plan sponsors may set the reward at any level below the threshold. To put this into perspective, assuming a pack of cigarettes costs roughly $7, a pack-a-day tobacco user spends $217 per month on cigarettes. This should be considered when thinking about the level of reward to implement as you will want the amount to be impactful enough that they think twice. Note the newly passed health care reform law increases the allowed differential for 2014 to 30%. 9

10 2. The program must be reasonably designed to promote good health. 3. Employees who are eligible for the program must have the opportunity to qualify for the program at least once each year. This requirement means tobacco users who go through a tobacco cessation program in order to qualify for the non-tobacco user rates must be eligible to do so each year, regardless of whether they quit smoking as a result of the program. 4. The reward must be available to all similarly situated individuals. 5. If an individual faithfully participates in the tobacco cessation program but is unable to quit tobacco use due to a health risk factor (such as nicotine addiction), that individual must receive the reward (paying the lower non-tobacco user rates). The reward may be denied if the individual makes no attempt to quit, or drops out of the program. 6. Lockton believes an employer may impose reasonable conditions or restrictions on the reward. For example, we believe an employer may require a doctor s note stating the employee has a nicotine addiction in order for the employee to pay the non-tobacco user rates. If this documentation is unreasonably difficult to obtain, the employer may have to provide the reward based on representation from some other entity (i.e., wellness vendor, local hospital), the employee s physician, or even the employee, that the employee faithfully participated in the program. 7. Some individuals may not be able to achieve the wellness goal because it is medically inadvisable to do so. While this is uncommon with tobacco use, it is possible that some employees may be advised not to participate in the program. Therefore, the employer must be willing to create reasonable alternative standards for these employees, and must communicate that alternative standards are available. These standards do not need to be developed in advance of the program and may be developed according to each individual s needs. Bringing It All Together As you can see, there is much to consider when deciding whether to offer tobacco cessation assistance in the corporate setting. The facts supporting the benefits of helping tobacco users to quit are compelling. However, it may be difficult to provide data for the CFO or CEO who wants dollar for dollar year one return on investment. Plan sponsors may need to rely on broad based population studies conducted by the Centers for Disease Control, American Lung Association, and others. They may also have to take a little leap of faith that efforts in this area will pay dividends. Here are considerations for designing and implementing, or enhancing an existing, comprehensive tobacco cessation assistance program that is practical and delivers results: 10

11 Do you want to cover some or all of the seven types of medications? A comprehensive program will cover all seven. The more medications covered, the more comprehensive your program will be. Do you want to offer some or all three types of behavioral counseling? A comprehensive program will cover all three if available from your vendors. Check to see what types your vendors can offer. How will you communicate the existence of any program resources offered? Employees and their dependents can only take advantage of them if they know about them. Will you remove the financial and administrative barriers to access care? A comprehensive program will remove all barriers; however you will need to discuss this with your vendor partners to determine what they can handle administratively. Is your workplace tobacco-free? Should it be? Many states have enacted laws banning smoking in public buildings, restaurants and bars, and many companies have followed suit by banning tobacco use on or even near their premises. Will you offer incentives or rewards to non-tobacco users? If so, be sure your approach is compliant with the HIPPA bona fide wellness rules. You will also want to consider your level of risk tolerance if you have employees located in states which have smoker s rights laws. Management buy-in and support of the program is paramount. It will be difficult to expect employees to believe in the company s tobacco cessation campaign if highly visible key employees don t lead by example, or worse, complain about the program behind closed doors. Make sure you have this level of support before implementing a program; otherwise your efforts could be wasted. Conclusion Plan sponsors who see the value in a comprehensive tobacco cessation assistance program and choose to offer one can make a difference in the lives of those wishing to quit as well as limiting their financial risk tied to the direct and indirect costs of tobacco use. Before embarking on a program redesign or implementation, be sure to align all facets of your program so each feature supports and complements the others. For example, plan sponsors wouldn t want to penalize employees with higher contributions for using tobacco products, but not offer coverage for medications and counseling that could help them change the behavior. A well designed program with all the above best practices may provide financial savings and the best chance of success for those willing to invest in improving their health. Companies in the multi-housing property management industry can benefit from efforts in this area as their tobacco use prevalence rates are at least as high as the national average. 11

12 References Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Department of Health and Human Services. The Health Consequences of Smoking: What It Means to You, Available at: CDC. Annual smoking-attributable mortality, years of potential life lost, and economic costs--- United States, MMWR 2005; 54: Effect of smoking status on productivity loss. Bunn WB 3 rd, Stave GM, Downs KE, Alvir JM, Dirani R. Journal of Occupational Environmental Medicine 2006; 48: Relationship between modifiable health risks and short-term health care charges. Pronk NP, Goodman MJ, O Connor PJ, Marinson BC. JAMA 1999; 282: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Department of Health and Human Services. Smoking and Tobacco Use Fact Sheet: Health Effects of Cigarette Smoking. Updated January CDC. Cigarette Smoking Among Adults- United States, MMWR 2002; 51(29): CDC. Cigarette Smoking Among Adults United States, MMWR 2008; 57(45); Calculated based on data in Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2006 National Survey on Drug Use and Health (NSDUH), U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies CDC. Cigarette Smoking Among Adults United States, MMWR 2007; 56(44); CDC. Vital Signs: Cigarette Smoking Among Adults Aged 18 Years United States, 2009 MMWR 2010; 559(35); Johnston LD, O'Malley PM, Bachman JG.(2002) Monitoring the Future national survey results on drug use, Volume II: College students and adults ages (NIH Publication No ). Bethesda, MD National Institute on Drug Use. State of Tobacco Control 2009, American Lung Association; page

13 Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Department of Health and Human Services. The Health Consequences of Smoking: What it Means to You, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Department of Health and Human Services. Smoking and Tobacco Use, Fast Facts. National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services. InfoFacts, updated August State Cessation Coverage 2009, Helping Smokers Quit. American Lung Association. American Lung Association. What Doesn t Work to Help Smokers Quit: Barriers to Avoid. Factsheet. October 26,

14 Appendix

15 Tobacco Cessation Assistance The Case for Offering A Comprehensive Program American Lung Association Smoking Cessation Programs The American Lung Association provides several programs that help tens of thousands of smokers quit every year. Freedom from Smoking is considered to be the gold standard of smoking cessation programs and Not- On-Tobacco is the country s most widely used teen smoking cessation program. All of these programs include components of the intensive counseling interventions recommended in the Guideline. American Lung Association Website: Phone: LUNGUSA Freedom From Smoking The Freedom From Smoking program has been helping smokers quit for over two decades. The program is offered in three different formats. It began in 1980 as a self-help manual, which is still available today. The eight-session program is also offered as a group clinic in many areas of the country. Additionally, the American Lung Association offers Freedom From Smoking Online ( which takes smokers through the same recommendations online and provides interaction with other smokers from across the country. All Freedom From Smoking products are regularly reviewed and updated to make sure the program remains America s gold standard in smoking cessation programs. Participants in Freedom From Smoking develop a personalized step-by-step plan to quit smoking. Each session uses a positive behavior change approach and encourages participants to work through the problems and process of quitting individually as well as in a group. Evidence has shown that Freedom from Smoking is very effective at helping smokers quit. 16,17 Website: 15

16 Tobacco Cessation Assistance The Case for Offering A Comprehensive Program Not-On-Tobacco This program for teens aged was developed by the American Lung Association and West Virginia University. Introduced in 1997, it is now the most widely available teen tobacco cessation program in the country. The program includes 10 sessions conducted in small groups. N-O-T ( is a voluntary (non-punitive) program that offers participants support, guidance, and instruction on understanding the reasons they started smoking, preparing to quit, and preventing a relapse once they have quit. Not-On-Tobacco has proven to be effective in helping teens quit smoking. 18,19 Website: Lung HelpLine (1-800-LUNGUSA) The Lung HelpLine is a valuable resource to anyone interested in and affected by lung health. The HelpLine is staffed by registered nurses and respiratory therapists. Callers can ask about a variety of lungrelated topics but around 70% of calls are related to tobacco cessation. The Lung HelpLine can help callers quit smoking, and refer them to local programs and treatments that will also help. The nurses and therapists at the Helpline also answer questions submitted through the American Lung Association website. Quitter in You Quitter in You is a new smoking cessation campaign designed to help people quit smoking for good. It provides a fresh way to think about cessation by not viewing past quit attempts as failures or wasted efforts, but as necessary steps along the way toward quitting for good. Research shows the majority of smokers are not able to successfully quit on their first try, and require multiple attempts to quit for good. This campaign offers support through a new Web site called QuitterInYou.org that features user-generated content where people can share stories of their quit attempts and tactics that did and didn t work for them. It also provides tools and support from the American Lung Association s Freedom From Smoking program to help smokers at each step in the journey toward quitting. Website: QuitterInYou.org 16

17 Tobacco Cessation Assistance The Case for Offering A Comprehensive Program States Turn to Tobacco Taxes to Balance Budgets As states continue to face record budget deficits, many have turned to increasing cigarette taxes as a means of increasing revenue. For example, in 2009, Connecticut, Florida and Rhode Island each raised their cigarette taxes by $1.00 per pack, while Wisconsin, Hawaii, Arkansas, Mississippi, Delaware and New Hampshire increased their cigarette taxes by $.45-$.75 per pack. The average cigarette tax for all states in 2009 was $1.34 per pack, which represented a 12.6% increase over Rhode Island has the highest cigarette tax in the nation at $3.46 per pack, while South Carolina has the lowest tax at $.07 per pack. Unfortunately, at the same time states are raising cigarette taxes, many are also reducing their funding for tobacco prevention and cessation programs. For example, Wisconsin raised its cigarette tax by $.75 per pack in 2009 but simultaneously cut its prevention and cessation program funding by more than half 12. Table 1 shows state cigarette excise taxes in In addition to state excise taxes, the federal government also levies an excise tax on each pack of cigarettes. The federal cigarette excise tax increased to $1.00 on April 1,

18 Tobacco Cessation Assistance The Case for Offering A Comprehensive Program State Cigarette Excise Taxes (As of January 1, 2010) Sorted by Tax Rate From Highest to Lowest Rhode Island $3.46 Connecticut $3.00 New York $2.75 New Jersey $2.70 Hawaii $2.60 Wisconsin $2.52 Massachusetts $2.51 District of Columbia $2.50 Vermont $2.24 Washington $2.025 Alaska $2.00 Arizona $2.00 Maine $2.00 Maryland $2.00 Michigan $2.00 New Hampshire $1.78 Montana $1.70 Delaware $1.60 Pennsylvania $1.60 Minnesota $1.56 South Dakota $1.53 Texas $1.41 Iowa $1.36 Florida $1.339 Ohio $1.25 Oregon $1.18 Arkansas $1.15 Oklahoma $1.03 Indiana $0.995 Illinois $0.98 New Mexico $0.910 California $0.87 Colorado $0.84 Nevada $0.80 Kansas $0.79 Utah $0.695 Mississippi $0.68 Nebraska $0.64 Tennessee $0.62 Kentucky $0.60 Wyoming $0.60 Idaho $0.57 West Virginia $0.55 North Carolina $0.45 North Dakota $0.44 Alabama $0.425 Georgia $0.37 Louisiana $0.36 Virginia $0.30 Missouri $0.17 South Carolina $0.07 Tax Rate (per pack of 20) Sorted Alphabetically by State Name Alabama $0.425 Alaska $2.00 Arizona $2.00 Arkansas $1.15 California $0.87 Colorado $0.84 Connecticut $3.00 Delaware $1.60 District of Columbia $2.50 Florida $1.339 Georgia $0.37 Hawaii $2.60 Idaho $0.57 Illinois $0.98 Indiana $0.995 Iowa $1.36 Kansas $0.79 Kentucky $0.60 Louisiana $0.36 Maine $2.00 Maryland $2.00 Massachusetts $2.51 Michigan $2.00 Minnesota $1.56 Mississippi $0.68 Missouri $0.17 Montana $1.70 Nebraska $0.64 Nevada $0.80 New Hampshire $1.78 New Jersey $2.70 New Mexico $0.91 New York $2.75 North Carolina $0.45 North Dakota $0.44 Ohio $1.25 Oklahoma $1.03 Oregon $1.18 Pennsylvania $1.60 Rhode Island $3.46 South Carolina $0.07 South Dakota $1.53 Tennessee $0.62 Texas $1.41 Utah $0.695 Vermont $2.24 Virginia $0.30 Washington $2.025 West Virginia $0.55 Wisconsin $2.52 Wyoming $

19 State "Smoker Protection" Laws Last updated: 9/27/1 Twenty-nine states and the District of Columbia have laws in effect elevating smokers to a protected class. The American Lung Association does not support these types of laws State Year Code California 2005 CA LABOR CODE 96(k) & 98.6 Colorado 1990 CO REV. STAT. ANN Connecticut 2003 CT GEN. STAT. ANN s District of Columbia 1993 D.C. CODE ANN Illinois ILL. COMP. STAT. 55/5 Indiana 2006 IND. CODE et seq. Kentucky 2010 KY REV. STAT. ANN Louisiana 1991 LA REV. STAT. ANN. 23:966 Maine 1991 ME REV. STAT. ANN. tit. 26, 597 Minnesota 1992 MINN. STAT Mississippi 1994 MISS. CODE ANN Missouri 1992 MO. REV. STAT Montana 1993 MONT. CODE ANN & Nevada 1991 NEV. REV. STAT New Hampshire 1991 N.H. REV. STAT. ANN. 275:37-a New Jersey 1991 N.J. STAT. ANN. 34:6B-1 et seq. New Mexico 1991 N.M. STAT. ANN et seq. New York 1992 N.Y. [LABOR] LAW 201-d North Carolina 1991 N.C. GEN. STAT North Dakota 1993 N.D. CENT. CODE et seq. Oklahoma 1991 OKLA. STAT. ANN. tit. 40, 500 Oregon 1989 OR. REV. STAT. 659A.315 & 659A.885 Rhode Island 2005 R.I. GEN. LAWS South Carolina 1991 S.C. CODE ANN South Dakota 1991 S.D. CODIFIED LAWS Tennessee 1990 TENN. CODE ANN Virginia 1989 VA. CODE ANN West Virginia 1992 W. VA. CODE Wisconsin 1991 WIS. STAT et seq. Wyoming 1992 WYO. STAT. ANN et seq. Last Updated: 9/27/10 19