The Northwest Tobacco Control Area Network (NWTCAN) Worksite Cessation Project

The Northwest Tobacco Control Area Network (NWTCAN) Worksite Cessation Project Project Lead: Patricia M. Smith, PhD Northern Ontario School of Medicine 955 Oliver Road Thunder Bay, ON P7B 5E1 Telephone: 807-766-7341 patricia.smith@normed.ca AND InfoFinders 321 Hamstead Court Waterloo, ON N2K 2B8 Telephone: 519-896-3167 infofinder2@rogers.com Submitted May 15, 2012 To Jennifer McFarlane, Coordinator North West Tobacco Control Area Network Thunder Bay, ON

TABLE OF CONTENTS WORKSITE CESSATION PROJECT...3 EXECUTIVE SUMMARY...3 INTRODUCTION...6 BACKGROUND...6 APPROACH TO THE PROJECT...11 FINDINGS: EMPLOYER INTERVIEW OUTCOMES...12 FINDINGS: EMPLOYEE SURVEY OUTCOMES...20 FINDINGS: FEEDBACK ON STOP ON THE ROAD PROGRAM...23 CONCLUSIONS...25 RECOMMENDATIONS...26 REFERENCES...27 APPENDIX A. INTRODUCTORY LETTER...32 APPENDIX B. EMPLOYER SURVEY...33 APPENDIX C: EMPLOYEE SURVEY...37 2

Worksite Cessation Project EXECUTIVE SUMMARY Project Purpose This project examined the existing onsite cessation support and services for selected worksites in NW Ontario, seeking to understand employer and employee needs related to tobacco use and cessation needs. The North West Tobacco Control Area Network (NW TCAN) and regional partners will use the findings to guide development of effective cessation programs for individual worksites and inform future cessation work in the NW Region. Background The smoking rates among 25-34 year old males and those employed in the trades or blue-collar occupations remain higher than the general population. The smoking rates in NW Ontario are also extraordinarily high, double the national and provincial averages for people < 55 yr. The leading causes of death in NW Ontario continue to be cardiovascular disease and cancer,which are also higher than the provincial average. Approach Dr. Patricia Smith of the Northern Ontario School of Medicine at Lakehead University and InfoFinders collaborated to conduct a needs assessment of selected worksites in the NW Ontario region. This project built upon work with 3 mine sites within the NW region conducted by the Thunder Bay District Health Unit, to run cessation seminars and introduce the Centre for Addiction and Mental Health s Stop on the Roadno-cost NRT program to mine employees.the NW TCAN provided an introductory letter describing the project and identified worksites with contact information for employers representing the mining, forestry, manufacturing, transportation and service industries across the region. InfoFinders conducted telephone interviews with industry employers suggested by the NW TCAN to identify what existed at the worksite for smoking/chew tobacco cessation and what was needed from an employer perspective to build an effective cessation program. A total of 10 employers were interviewed with key question areas including organizational information, current benefits, smoking cessation benefits and communications. Additionally, employers were asked to assist in reaching employees to ask for completion of a survey. A link to an online survey or a paper copy of the survey was provided, using standardized tobacco cessation questions, in order to learn about employee smoking and tobacco use and to guide development of smoking cessation programs. Findings The literature and employer interviews were quite consistent. Smoking rates are far higher than the Ontario average, with employers estimating an average of 41% (range of 50-70%), which appears quite accurate given tobacco use surveillance data in NW Ontario. 3

Employers estimated 8-30% of employees were 25-29 year oldsthat would help account for the high estimates of smoking rates since smoking rates are highest among this age group in Canada (the proportion of 25-29 yr olds in the general population in NW Ontario is only approximately 3%). The majority of companies interviewed reported an older work force with the exception of the service sector where age mix was more evenly distributed Most employers provided smoking cessation benefits with no variation across the organization. 80% provided individual counseling; 50% provided NRT coverage and 70% provided pharmacotherapy. Employers augmented their benefit programs with cessation activities: 80% of used self-help materials, 50% provided Smokers Helpline information, and 60% participated in the Driven to Quit contest None of the companies provided group cessation programs, and there was little current use of Lunch & Learn The major barriers to cessation activitieswerelack of occupational health nurses andcompeting priorities (production and accident prevention/safety) To communicate with employees (in general), a range of strategies was used: posters, newsletters, email blasts. One employer is attempting to improve employee engagement using push media (trailers on monitors in locker room) STOP On the Road has been provided to 30% of companies interviewed Companies do not track tobacco use or cessation or cessation-related activities although one employer has begun to track Driven to Quit participants All companies have restrictions on smoking with the majority having designated smoking areas and no smoking in buildings or vehicles. Only one employer has a smoke-free property and one employer allows smoking in vehicles. None of the employers were aware of use of tobacco products other than cigarettes, although it was noted that it would be difficult to determine the difference between regular gum and tobacco products. Despite the high smoking rates in NW Ontario and companies estimates that, on average, 41% of their employees smoke, only 30% of companies were concerned with employee smoking rates the others did not see a problem Suggestions from companies for public health unit assistance: provide table tents for use with employees; information packages/pamphlets; posters about STOP program; speakers to educate employees; smoking cessation programming run by the PHU. Although 7 companies agreed to distribute a smoking history survey to employees, only 13 employees completed surveys, 11 of them from a single company where the public health nurse handed out the surveys when employees were on their way outside for a cigarette. The nurse noted that at many worksites there was a feeling of mistrust by the employee towards the employer. They were anxious that any information provided on survey would somehow get back to the employer that they smoke and that would somehow result in discrimination. Due to the low response rate, the survey data could not be meaningfully interpreted but are presented in the document for interest. 4

Anecdotal feedback from the STOP On the Road team (2 public health nurses and a tobacco enforcement officer) suggested that the no-cost NRT program seemed to be a good way to engage employees in smoking cessation. Conclusions The interviews revealed a knowledge gap 70% of the interviewed employers did not perceive smoking as a significant health issue for their workforce, and they have limited awareness about smoking cessation benefits. No employer seemed to offer a coordinated approach to smoking cessation. Most provide some self-help materials andcounseling and pharmacotherapy benefits; some provide Smokers Helpline information and occasionally provide other information through the company newsletter or lunch and learns. Some occupational health nurses offered brief advice to quit smoking when it came up in visit, but none did so systematically with every health encounter, in the most part because they did not have the time. Many expressed that safety and accident prevention, claims management, and site injuries filled their day, and the organization priorities were often focused upon production. Most interviewees were very receptive to any assistance the TCAN/health unit can provide, particularly information packages/self-help packages and educational interventions provided from outside the organization. Employees were also unaware of benefits and identified barriers to NRT: money: lack of benefits due to tight finances, layoffs. Recommendations Six recommendations were made based upon project findings. 1. Prepare a communication strategy directed to employers to increase awareness of the impact of smoking, and the value (business case) of offering cessation therapy and counselling. 2. Train existing onsite staff (health professionals and wellness coordinators) to deliver evidence-based tobacco cessation treatment(s) and provide them with information about medication coverage and the availability of local cessation supports. 3. Develop a toolkit for those in occupational health and safety. Basic info about health implications of smoking, options for quitting Offer a script for brief professional advice at every encounter. The 5As strategy needs to become a standard of care. Promote use of Smokers Helpline 4. Develop promotion/advertising campaign regarding programs, benefits, and health risks of smoking tailored to the 25-29 year old and blue-collar groups. 5. Plan for regular site visits/ on the road visits to remote locations including followup visits to employers and employees for education and service provision/cessation counselling. 6. Develop links with community health professionals such as retail pharmacists, family health teams (FHT), and community health centres (CHC) to increase access to free NRT and smoking cessation counselling. 5

INTRODUCTION Project This projectexamined the existing onsite cessation support and services for selected blue collar and service industry worksites in Northwestern (NW) Ontario, seeking to understand employer and employee needs related to tobacco use and cessation. To address this issue, the Northwest Tobacco Control Area Network (NW TCAN) in partnership with Dr. Patricia Smith, Northern Ontario School of Medicine, and InfoFinders collaborated to conduct a needs assessment. The NW TCAN and regional partners will use the findings to guide development of cessation programs for individual worksites and inform future cessation work in the NW Region. This project builds on developmental activities by the Thunder Bay District Health Unit (TBDHU) staff. In early 2012, TBDHU staff worked with three mining sites within NW Ontario to run cessation seminars along with the Centre for Addictions and Mental Health (CAMH)Stop on the Road no-cost nicotine replacement therapy (NRT) program. The miningcompanies accepted responsibility for workshop logistics and screened and registered eligible participants. The TBDHU entered into agreements with CAMH and signed medical directives for TBDHU Public Health Nurses to dispense the NRT. Tobacco-trained NW TCAN staff and TBDHU staff provided the educational component of the workshop and additional onsite support. Additionally, the Canadian Cancer Society s Driven to Quit Challenge was promoted during the January/February community and worksite workshops across the NW region. Cost of Tobacco Use BACKGROUND Tobacco use continues to be the leading cause of preventable death and disease in Ontario (Tobacco Strategy Advisory Group, 2010). Each year, more than 13,000 people die because of tobacco related disease, costing the provincial health care system $1.6 billion a year. According to an updated study by the Conference Board of Canada, each smoker in a workplace costs the employer $3,396 per year in decreased productivity, increased absenteeism, and increased costs to maintain outdoor smoking areas and also costs company health plans more than nonsmokers (Conference Board of Canada, 2006). Overall costs from lost productivity for tobacco-related diseases are estimated at $4.4 billion, which combined with healthcare costs results in a total annual cost of $6.0 billion (Baliunas et al., 2007; Ontario Ministry of Health & Long-Term Care, 2011). 6

Tobacco Use in Ontario and NW Ontario The smoking prevalence in Ontario across all ages is 15.2%. Northwestern Ontario, where this project took place, has the highest smoking rates in the province (25%; OTRU, 2011) consistent with the relatively high proportion of blue-collar occupations and lower socio-economic status (Statistics Canada, 2006), both of which have been found to be related to increased tobacco use (Buske, 1999; Gilman et al., 2008The overall smoking prevalence is 22% in the only urban centre in NW Ontario and 32% in the rural communities, ranging as high as 41-47% for 20-44 year-olds; rates remain high (above the provincial average) up to 60 yrs of age (Smith, 2011). NW Ontario also has the highest rates of lung cancer (Gehman & Ranta, 2005) and neoplasm mortality (NW LHIN, 2009) in the province consistent with the high smoking rates. Figure 1. Smoking Rates: NW Ontario by Age and Rural vs. Urban (2007-2010) % Smokers 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2007 2008 2009 2010 18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 + 18-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 + Rural (M=22,587 participants/yr) Urban (M=34,968 participants/yr) Age Categories (yr) Adapted from: Smith, 2011. The red line represents the provincial smoking rate. Compared to Canadian data, the smoking rates in NW Ontario remain at the 1999 national rates and are double the current national averages for people 25-44 years and 35-44 yr 43-44% vs. 20-22% (Smith, 2011). As shown in Figure 2, smoking rates in NW Ontario remain high even as people get older, with a smoking rate of 36% for 45-54 year olds (Smith, 2011). 7

Figure 2. Smoking Rates by Age for NW Ontario and Canada 100% 90% NW Ontario Canada % Smokers 80% 70% 60% 50% 40% 30% 20% 10% 0% 44% 43% 34% 41% 36% 23% 26% 23% 22% 20% 15% 14% 18-19 20-24 25-34 35-44 45-54 55+ Age Adapted from: Smith, 2011. Tobacco Use among Young Male Adults and Blue Collar Workers The majority of Canadian smokers are of working age, between ages 20 and 64 (Statistics Canada, 2010). Smoking rates are higher among younger males age 25-29 years (37% smoke; Schwartz et al., 2010)and people employed in the trades or blue-collar occupations (Reid, 2012). Blue-collar workers also tend to smoke more heavily, are less successful in quitting than white-collar or service workers (Barbeau et al., 2006), and experience greater exposure to workplace toxins that can add to, or even multiply, their risk of serious adverse health effects from tobacco smoking (Howard, 2004; Sorenson et al., 2007). The actual smoking rates, however, depend on the industry and the data source. Smoking rates among trade occupations has been found to be 32% whereas manufacturing is at 22% according to the 2009 Canadian Community Health Survey(OTRU, 2011). The Canadian Tobacco Use Monitoring Survey (CTUMS) data show that smoking rates are highest among young adults working in sales and services followed by those working in trades, transport and as equipment operators (Stich & Garcia, 2011). Despite the higher smoking rates for some occupations, there is limited information available about what factors influence cessation among young adults and blue-collar workers (Filsinger & McGrath, 2009; Hammond, 2005). 8

Role of the Workplace in Cessation Workplaces provide convenient and on-going access to smokers, thus making them effective sites for smoking cessation efforts. Increasing worker awareness of the bigger risks in the working environment coupled with smoking risks have been found to significantly improve cessation rates (Sorenson et al., 2002).Smoking cessation initiatives offered at the workplace, as part of a worksite health promotion program, can provide a significant return on investment to the employer in terms of health, social and economic gains (van t Klooster, 2009). Blue-collar workplaces should be specifically targeted due to the higher prevalence of smoking in this population and the challenges involved in implementing interventions in these workplaces and maintaining participation rates. To increase participation, incentives to employees are important, and workplace interventions that include follow-up are more successful (van t Klooster, 2009). The most effective and easy to implement intervention seems to be telephone-based interventions, where motivation can be increased by education around smoking risks and work-related hazards (van t Klooster, 2009). LITERATURE REVIEW Several published literature reviews for this project on young adults and smoking in bluecollar occupations were located looking. They are summarized here. Workplace Tobacco Cessation Interventions A Cochrane systematic review suggests that evidence exists regarding the effectiveness of group therapy, individual counseling and nicotine replacement therapy when offered in the workplace but the evidence for self-help methods is less clear. As somewhat of a contradiction to the rest of the literature, this review reported weak evidence for social and environmental support, competitions and incentives and comprehensive programs to help smokers quit at work. Competitions and incentives increase participation rates but not cessation rates (Cahill et al., 2008). A New Zealand review reports that a wide variety of workplace cessation interventions are effective. There is no strong evidence that any single method is more effective than another; however, there is evidence to support a need for professional support to aid and motivate people to quit. The most cost effective interventions with good success rates seem to be those offering a variety of different components, such as NRT, counseling (either group or telephone) and education. The literature does not focus much on workplaces that have implemented cessation interventions; instead, studies and interventions implemented by researchers are the focus (van t Klooster, 2009). Employers interviewed in California in 2004 did not perceive smoking as a serious health issue at their company, mentioning that employees were not seeking assistance 9

to quit smoking. While the settings were primarily white-collar and did not involve any unionized environments, the findings seem worthy of consideration. Employers need assistance to identify barriers and challenges to viewing smoking cessation as a top corporate priority. Providing a business case for cessation programming would be an effective way to help promote smoking cessation to employers (Powers, 2004). Blue Collar Workplace Tobacco Cessation Interventions Blue-collar workers are less likely to participate in community or clinic programs. Strategies to promote worksite smoking cessation in smaller worksites were presented from both employer and employee perspectives. Employers stressed the need to respect employee privacy and choices but recognized the importance of providing information about smoking cessation resources. Employers were more comfortable using passive resources (hanging posters) but employees preferred active interventions such as contests, incentives and the provision of free NRT products. Both groups demonstrated a lack of knowledge about existing smoking cessation resources provided within the organization (e.g. insurance benefits) and existing community resources (Tiede, 2007). Tobacco Cessation Interventions for Young Adults Young adult smokers may be interested in quitting, but prefer to quit on their own. Young adults are the population most apt to use other forms of tobacco such as cigars, chew, and snuff. Research is needed to examine why young adults do not want to participate in community programs and what factors would provide motivation to access available resources and interventions. Telephone quit-lines, web-based programs and text messaging appear promising (Filsinger & McGrath, 2009). Tailored programs for young adults are recommended. Young adults show a lack of awareness, lack of use of smoking cessation services and decreased use of pharmacotherapy. Improved communication between worksite and public health units is needed to increase promotion of existing services and to help develop specialized programs to meet the needs of blue-collar smokers (Minian et al., 2008). Tobacco Cessation Interventions for Young Blue Collar Workers There is very little research describing interventions targeted specifically to young blue-collar workers. Key studies were identified in the review and suggest consideration of choosing a workplace setting for the intervention versus using the workplace to recruit participants and use telephone counseling. Key supports for workplace smoking cessation include provision of NRT and including incentives for successful change (Alison & Dwyer, 2010). 10

Minimal information regarding the cost-effectiveness of smoking cessation interventions in the workplace and little information about the smoking behaviours of young adult smokers within specific occupations and industries highlight the need for more research. Yet the workplace is an ideal setting to help people quit smoking for several reasons(stich & Garcia, 2011): o Reduction of exposure to environmental tobacco smoke o Many people spend much of their time at work o Potential for higher participation rates in the workplace than other settings o Possible provision of sustained and supportive social environment to help with smoking cessation o Possible presence of occupational health staff on-site to provide professional support o Smokers can get support from peers/other employees and others who promote health in the workplace o Convenience: no need to travel for information and support o Ability to target specific industries or occupations with higher smoking rates and those less likely to benefit from existing smoking cessation services. APPROACH TO THE PROJECT This project examined the existing onsite cessation support and services for selected worksites, seeking to understand employer and employee needs related to tobacco use and cessation needs. The NW TCAN Coordinator provided a list of employers and contact information. After developing and revising an employer interview template, InfoFinders scheduled and conducted key informant interviews with employers in NW Ontario region representing the mining, forestry, manufacturing, service and transportation sectors. The NW TCAN identified sixteen worksites representing mining, forestry, manufacturing, service and transportation industries. Two worksites were dropped from the contact list: one company had merged with another worksite on the list and one was eliminated due to lack of contact information. A letter from the NW TCAN Coordinator (Appendix A)was sent to the identified contact person in the 14 sites to introduce the project and request a telephone interview. The employer interview template (Appendix B) was sent prior to the scheduled interview in order that participants understood what information was needed. An employee survey was also developed, pilot-tested, then revised and finalized with input from InfoFinders, Dr. Smith and the NW TCAN. Standardized tobacco use questions as well as items of interest to the NW TCAN were included. Participants in the employer interview were asked to facilitate employee participation in the survey 70% said yes. A link to an online employee survey (Appendix C) that was programmed into Qualtrics (a web-based tool that provides a tracking feature for sent and received surveys) was provided and paper copies of the survey were also available. One company wanted a poster with the web link to the survey and two companies wanted paper copies. In some cases, employees were provided with an incentive for survey completion. 11

FINDINGS: EMPLOYER INTERVIEW OUTCOMES Interview Response Rates Of the 14 targeted worksites that received a request for a telephone interview, 13 responded. Ten worksites agreed to participate (71%), one contact person refused to participate because the company lacked a smoking cessation program and the respondent was too busy to participate in an interview, and two contact persons requested the template interview questions to complete by email but never returned the questionnaire. Where possible, the interview was arranged with Occupational Health Nurses (5 interviews). In three cases, the interview was conducted with Human Resource Staff; in two cases, interviews were conducted with Wellness Coordinator or the Manager of Safety & Training. Table 1. Worksites % (n/n) Location Thunder Bay 60% (6/10) Region 40% (4/10) Contact person Manager/HR 40% (4/10) Professional 60% (6/10) Employees Mean ± SD 482 ± 344 (median 430, range 130-1200) Worksites/company Mean ± SD 2 ± 2 (median 1, range 1-9) Estimate: age mix of workers a <30 10% (1/10) 30-49 40% (4/10) 50+ 50% (5/10) Estimate: males 25-29 yr old a 23% (range 8-30%) Estimate: smokers a 41% (range 18-70%) Smoking rates concern company b 40% (4/10) a Age, males, and smokers were estimates only because only one worksite had accurate statistics for the age of workers and none could provide information regarding the percentage of workers who used tobacco. b Concern due to high rate, health, and managers who smoke. Not a concern because smoking is not a big issue, not a priority, and they now offer cessation benefits and there has been an improvement already. 12

Description of Participating Companies The companies varied in size from 130 to over 1200 employees. Two worksites used substantial number of contract workers in addition to regular full-time employees. Only one company used regular part-time workers and one company used casual workers. Eight companies had only one worksite; one company had 2 locations and one company had 8-10 worksites (Table 1). Age Age is important because it is directly related to smoking.companies estimated the proportion of their workers that were males 25-29 yr. was 8-30%, which is high compared to the latest NW population profile that showed this age group of males,composed about 3% of the total population (NW LHIN, 2011). Only two companies said the workforce age was evenly spread. One workforce was mostly under 30 years (77%) and one company s workforce was mainly between 20-50 years (78%). Seven companies reported an older workforce with six companies commenting that over 50% of workers were over the age of 50 years which is probably quite accurate in the mining sector, the number of workers over age 50 is two to five times the number below age 30 (Mining Industry Human Resources Council, ND). The natural resources industries in general, have an older workforce than average for all Canadian industries. The forest sector industries are no exception; over 41% of employees are over the age of 45 (Huz, 2007). Thirty-six percent of the manufacturing workforce is 45 years of age or older(lamontaigne, 2004; Canadian Manufacturers and Exporters, 2005). The percentage of older workers in the transportation sector continues to be well above the average for all industry sectors (Lochead, 2003). Smoking Rates One participant could not guesssmoking rates at the company whereas estimates from the other companies ranged from 15-70% (average 41%), which is relatively high given the relatively older employees. However, it might not be unreasonable. The 2007-2008 Canadian Community Health Survey shows the prevalence of current smoking was highest among workers in manufacturing (29%) and trades occupations (34%) (Schwartz et al., 2010); combined with the high rates of smoking in NW Ontario up to age 55 (see Figure 1 & 2 in the Introduction) the 41% estimate might be in the true range. None of the employerswere aware of employees using smokeless tobacco/snuff (i.e., tobacco that is chewed, sucked or sniffed) which is consistent with the 2010 CTUMS report that showed use of chewing tobacco/snuff in the past 30 days was too low to report (less than 1%) in Ontario (Reid, 2012). CTUMS data also show thatsmokeless tobacco is more prevalent among young adult males (OTRU, 2006) so given the relatively older workforce at the sites interviewed, smokeless tobacco is likely not an issue. Some 13

employersnoted that if other products are used, it would have to be in the designated area but another commented that it is difficultto identify whether employeesare chewing gum or tobacco. Company concern regarding employee smoking rates Only 3 out of 10 employers expressed concern regarding employee smoking rates (these 3 companies reported the highest smoking rates of 50% and 70%). Among these, one company recognized the rate to be high and two companies noted they are already following employees with respiratory health issues and are concerned the high smoking rate will exacerbate these existing health concerns. Several interviewees commented, however, that currently, there did not seem to be a huge need for smoking cessation programming at their organization. Two organizations noted there were no requests for smoking cessation assistance over a time period of several years. These latter comments are consistent with a survey of California employers who largely perceived that smoking was not a problem in their workforce (Powers, 2004). Smoking restrictions in the workplace Only one employer had a smoke-free property. The others allowed smoking outside the buildings in a designated area or away from the doorway but not in any inside or outside work area. One employer allowed smoking in work vehicles whereas others stressed this was not allowed, and one of the mining companies noted that there is no smoking underground but above ground employees are allowed to smoke in four designated areas but not in buildings. One company noted that they have a policy that dictates discipline for not adhering to the restrictions but that there is no way of knowing if chewing tobacco at work is happening. Extended Health Benefit Plans for Smoking Cessation Support Smoking cessation support was provided by the majority of companies for counselling and prescription medications (bupropion and varenicline) but only 50% covered NRT products (Table 2), which is not uncommon in benefit plans since NRT became available over the counter without a prescription. In eight of ten employers, the benefits available did not vary across the organization. In one case, for the first two years of employment, part-time employees pay 25% of the cost (others have 100% coverage; after two years, part-timers also receive 100% coverage). In the other case, unionized employees have $550 total/year for extended health benefits for other health professional coverage; nonunion employees had $650/year. In terms of what was provided, 8/10 employers provided individual counseling for employees and family members under Employee Assistance Programs (EAPs). Tobacco cessation counseling was offered in different formats: telephone, online and face-to-face 14

and there was considerable variation in the amount of counseling service provided from unlimited lifetime to specific numbers of visits per year. In some cases, counseling was provided on a case-by-case basis. For some companies, the prescription medications have a deductible and an overall limit, usually $1000 per employee lifetime but other companies have a generous plan with only $1 deductible and no limits. Table 2. Benefit Plans for Smoking Cessation (N=10) Benefit Employee Family Counselling 80% 70% NRT Gum 50% 40% Patch 50% 40% Inhaler 50% 40% Bupropion 70% 60% Champix 70% 60% Table 2a. Comments about the Benefit Plan The company has experienced hard times: under bankruptcy protection, downsized, NRT benefits were eliminated Unionized employees have $550/ year; non-unionized employees have a total of $650 for all professional services including acupuncture (e.g. massage, physio). There is a 90 day waiting period for benefit coverage for union employees; no waiting period for non-union employees The free NRT is being used by employees. Brief intervention and ongoing support is given to employees trying to quit smoking. We encourage a buddy system on site for smokers trying to quit Employees chose from benefits to tailor them to their need, deductible depends on what they choose, can be up to 90% covered Through our regular drug plan prescription drugs (prescribed by a physician) for smoking cessation are covered for every employee & their family members with a one time max of $1000.00 while that employee is employed with us. Support through counselling by psychologist and/or psychiatrists are covered at the rate of $15.00 per visit according to our policy with our insurance carrier covers employee or family members) No coverage for smoking cessation aids. The company has never been approached and asked to provide this benefit Coverage for smoking cessation drugs is special coverage paid directly by the company and we generally offer it for the 1st three months each year as part of our wellness initiative for employees only (usually $500.00 per employee and it has to go toward drug prescriptions for smoking cessation medication) Despite offering cessation support in benefit plans, there were various limitations on the amount of coverage available. One employer who did not have coverage for NRT and 15

prescription smoking cessation medications did provide a Healthy Lifestyle reimbursement: $150/year for unionized employees and up to $250-300 /year for management staff to support any healthy lifestyle activity. One employer had no benefit package but provided free NRT upon request. (This company estimated the smoking rate at 50%.) Two companies stated that employees have never requested these type of benefits of which one reported a smoking rate of 20-50% and the other reported an overall smoking rate of less than 20%. Interestingly, one company provides benefit coverage for using acupuncture to quit smoking, despite the lack of research evidence for this treatment in the literature (Crane, 2003). Another employer provides coverage for hypnosis for smoking cessation as part of an extended benefit package and reports some success with quitting smoking. Once again, the research evidence is limited for hypnotherapy (Barnes et al., 2010). Tracking Smoking and Smoking Cessation Activities None of the companies keep statistics on smoking rates or smoking cessation activities with one exception: one employer tracks employees who participated in the Driven to Quit contest over the last two years 26 people enrolled and 12 were smoke-free after 30 days; 39 have enrolled this year but no success rates as yet. Smoking rates of employees and use of counselling and/or pharmacotherapy would be difficult if not impossible to track due to privacy of information. Participation in STOP On the Road Free NRT Program Three of 10 employers participatedin this program offered by the Ministry of Health and delivered by CAMH. The other seven employers had no knowledge of the program despite radio advertising by at least one of the area s Public Health Units. One employer stated that providing posters for use by employers about the STOP program would help target any smokers including family members. Other Smoking Cessation Supports Additional supports provided by companies are in Table 3. The majority of employers use self-help materials, mostly pamphlets from the Canadian Cancer Society, Smokers Helpline and the Lung Association of Ontario. Two employers use regular Lunch & Learn meetings for employee education. None of the employers offer group support programs either on or off site. In half the companies, the occupational health nurses will offer brief professional advice if the topic of smoking comes up during an employee visit but they do not offer cessation services, per say. Half the companiesprovide information on the Smokers Helpline (did not specify whether fax referral or self referral). Six employers encouraged participation in the Driven to Quit provincial contest; one employer offered smoking cessation incentives/issued challenges within the organization and one encourages use of a buddy system to quit smoking. 16

Table 3. Smoking Cessation Supports Offered (Non-benefit-related; N=10) Other Supports Offered % Comments Self-help materials 90% SHL pamphlets; CCS pamphlets; Lung Association info. All on display; may vary by month what is out Pamphlets brought in by the physician ; Display of pamphlets Pamphlets only We have a few pamphlets available but they aren't used ; Yes but some employees throw them out ; Yes. I have a different wellness theme each month; make 2-3 trips a year to the health unit ; Not recently; have distributed in past Education /information sessions 20% Yes, by Sue Armstrong PHN ; Regular mandatory Accident Prevention meetings are held. Employees are paid to attend ; No lunch room No, no time Not offered recently; have done in past Group support program on/off site 0% No; have offered in past Brief, professional advice 50% Yes if smoking is an issue, comes up in conversation (5 companies) No. I inform employees privately of counseling services available No. We refer to the employee Great West Life. We don't have a nurse Referrals to Smokers Helpline 50% Yes, pamphlets are available Contests /challenges to stop smoking 60% I register everyone and do all the paperwork associated with the contest. Gold Corp offers $150 Canadian Tire gift certificate to the winner also ; We put up the poster given to us by the Health Unit each March but don t know if any employees participate ; Drive to Win Contest Driven to Quit Contest and Posters for Driven to Quit Challenge Driven to Quit; I set up company challenges /draws /incentives No. Have participated in Health Unit and provincial programs Smoking cessation medications 60% Yes, refer to family physician the patch ordered by the physician Pharmacy; physician Other 10% I encourage a buddy system with employees trying to quit 17

Communication to employees regarding programs The communication media used to inform employees in general about company information are presented in Table 4. For smoking cessation, the majority have posters to promote the Driven to Quit contest. There are some innovative communication strategies (e.g., table tents) but not frequently done by the majority. One company is attempting to improve employee engagementusing push media. Due to the type of worksites, however, many employees do not have access to email and do not have computers at work. There are often common lounge areas with a television monitor and one company plans to use trailers on the monitor to offer updates and other information and plans to enhance the intranet to permit two-way communications. Table 4. Communication to Employees Media % Yes Comment Posters 60% To promote Driven to Quit contest Company Newsletters 30% Monthly safety meeting In January of each year, quitting smoking is the theme of the month Fliers/Postcards 10% Website 40% for younger workers, not older workers ; No computer access for employees Payroll stuffers 10% direct deposit; Payroll is automated CCMS System used to communicate with employees Table Tents 30% [table tents n/a] We keep the cafeteria as a free zone to promote relaxation; no notices, pamphlets etc. [tents] would work Other: Please identify 50% Uses health tips at health & safety meetings that all staff attend; has a health bulletin board Emails are posted in a common area Weekly Safety Talks; Wellness Bulletin Boards; Events; WIFI; Email blast; Hard copy; General staff meetings; Wellness Fair Email blast (2) hard copy general staff meetings or Accident Prevention meetings (3) Wellness Fair;health bulletin board (2) 18

Barriers to cessation services The barriers are listed in Table 5.The most frequently noted barrier was the lack of an occupational nurse (50%) yet four of the occupational health nurses interviewed were concerned about a lack of time to complete their assigned work without adding smoking cessation. Three employers identified that they had other priorities in two cases, the priority noted was production; in the other, accident prevention/safety was more of a priority. Environmental issues that did not come up as a barrier included: being in a small town environment which did not offer anonymity for cessation counselling;lack of community support for cessation; delivery of resources from other agencies not being timely; population or company not interested in smoking cessation; and poor capacity for adequate follow-up for off-site programs. Lack of employee motivation to quit was not a barrier ( employees are very interested ; they are interested but can t afford it ), and one company said it was very supportive of helping employees quit smoking. Table 5. Barriers to Cessation Services Barriers to cessation services % Yes Comments Lack of company financial resources 10% no interest in smoking cessation. Hard to get support for a program (? not concrete enough, first aid supplies come immediately) mine productivity is the priority ; There have been lay-offs and cutbacks in NRT to reduce layoffs Geographic area 10% remote Competing company priorities 30% Not enough time Production is priority; safety is priority Lack of occupational health nurses 50% No nurse on site ; only 1 nurse ; Too busy but her goal is to have a 3rd party provide smoking cessation initiatives ; It is busy but minimal counseling is done 4 employers said lack of time Inability/difficulty to pay for nicotine 10% NRT is free replacement therapy (NRT) by company Inability/difficulty to pay for nicotine 10% replacement therapy (NRT) by employee Inadequate staff training 10% No nurse on site Lack of physician support 10% There is a shortage of physicians ; Lots of support ; Physician-on-call will see employee for smoking cessation Diverse language and culture 10% Aboriginal 19

Suggestions for Public Health Units: How They Can Help Companies with Cessation Fifty percent of companies said that there was something Health Units could do in response to the question Is there anything that the Health Unit could provide to help your employees quit smoking? (Table 6). Two of the companies said no: 1) the Health Unit has been very supportive ; and, 2) the STOP program is coming back on April 11 th. Table 6. Suggestions for Health Units: How They Can Help Companies Information packages/pamphlets regarding smoking cessation are always useful especially if new designs. (It has to look different or it is ignored.) Speakers for education of staff although some worksites are challenged since workers can be available only one day/year for education Tent table with a PHN regarding information for employees about quitting smoking Information and posters about the STOP program Free NRT Any kind of help I was not aware of the STOP program but the employees are always asking about how to get free smoking aids. I would be interested in free NRT Smoking cessation programming run by the health unit Limitations The interview was a broad first pass and there aremany limitations from the small sample size to the lack of statistics by employers regarding age, smoking rates, and inability to break out type of workers by occupational class. It is also important to recognize that most of those working to promote workplace health have had no training/education regarding smoking cessation treatments. Survey Response Rates FINDINGS: EMPLOYEESURVEY OUTCOMES Although 7 companies agreed to distribute the surveys, only 13 employees completed the survey with 11 representing a single company where the Public Health Nurse set up a table by the door they used to go outside for a cigarette. She handed out 20 surveys and received 11 back (55%). The health unit staff perceived barriers to filling out employee surveys and reported that employees were very cautious about providing smoking status information; they were worried that the employer would find out any information shared 20

and that smoking status may lead to some form of discrimination. It is unclear if this behaviour is related to knowledge of high cost health claims that may be increased by smoking or may be related to fear of potential job loss. The extremely low response overall does not allow any interpretation of the survey data. Respondents sociodemographic characteristics are summarized in Table 7, reasons for smoking in Figure 3, and methods of quitting (previous and future considerations) in Figure 4. The literature provides some background why employees may be somewhat reluctant to answer a survey on smoking at the request of an employer. A seminal article in the law literature reports that some American employers prohibited employees from smoking on their off-duty time. The article argues that smokers incur higher medical costs that adversely affect corporate profitability and terminated the employment of the smokers (Maltby, 1994). This idea keeps returning with television reports from 60 Minutes describing a situation where insurance consulting firm employees were terminated for smoking behaviour (Safer, 2005 & 2009). Recently, USA Today published a feature story reporting that American employers, primarily hospitals were refusing to hire smokers as extensions of smoke-free workplace policies (Koch, 2012). Closer to home, the Winnipeg Free Press reprinted a story about the Cleveland Clinic, Pennsylvania s Geisinger Health System and a growing number of other hospitals who are now turning away job applicants who smoke (Marcus, 2012). Little wonder that employees in Northwestern Ontario may be squeamish about filling out employee surveys! Table 7. Employee Survey Socio-demographics % (n/n) Company: Teleperformance Call Centre 85% (11/13) Location: Thunder Bay 92% (12/13) Males 54% (7/13) Age Mean ± SD 34 ± 10 (median 29, range 21-51) Caucasian 85% (11/13) Education ( high school) 85% (11/13) Income< $35,000 69% (9/13) Tobacco use Cigarettes 85% (11/13) Cigars or cigarillos 15% (2/13) Daily smokers 78% (10/13) Cigarettes/day 15 ± 8 (median 15, range 11-24) Tobacco purchased Cartons 60% (6/10) Pack at a time 40% (4/10) First cigarette within 30 min of waking 30% (4/13) Importance of quitting smoking 6 ± 3 (median 6, range 2-10) Preparation (next 30 days) 8% (1/13) Action 23% (3/13) Quit history Ever stopped for 24 hr 85% (11/13) 21

Length last quit attempt > 1 week 54% (7/13) Smoking at Work Smoke where (outside) 62% (8/13) Smoke less at work than home 46% (6/13) Smoke more at work than home 15% (2/13) Smoke same amount work and home 38% (5/13) Anything workplace could offer to help No 31% (4/13) Not sure 15% (2/13) Yes 38% (5/13) Preference for receiving materials Online 62% (8/13) Email 31% (4/13) Paper 31% (4/13) Text messages 0% (0/13) In person 54% (7/13) *The majority of respondents held staff positions such as call agent and technical support agent but there were less than 5 for any given position so data are not presented to preserve confidentiality. Figure 3. Reasons for Smoking from the Employee Survey (n=13) Boredom Habit Stress reduction Craving or addiction Relaxation Social reasons Pleasure/enjoyment Other Control emotions Hands Weight concerns Eenergy/concentration 0% 20% 40% 60% 80% 100% Figure 4. Employee Survey: Methods Used to Quit and Consider (n=13) 22

Cold turkey Cut down NRT Doctor/providers Prescription med Self-help materials Contests/challenges Group support Smokers Helpline Program at work Buddy system Would consider Used previously 0% 20% 40% 60% 80% 100% FINDINGS: FEEDBACK ON STOP ON THE ROAD PROGRAM The NW TCAN coordinator suggested that TBDHU staff might provide insight of value in completing the needs assessment of employers and employees. Since small numbers of employees returned/chose to participate in the smoking cessation surveys, the team from Thunder Bay District Health Unit provided an anecdotal report based upon their experiences with the recent Stop on the Road workshops conducted with mine employees. The team consisted of two public health nurses and a tobacco enforcement officer. They noted the talk about the fear the employees had when asked to fill out our employee survey (they think it will some how get back to the employer that they smoke and are quite anxious about that). They also thought that since employees did not respond to our survey, they could share some insight into the kinds of barriers that seem to prohibit people form accessing NRT/support. They concluded that visits for STOP program (and subsequent follow-up visits) appeared to be a very effective way to reach and engage employees. It was worthwhile to make an onsite visit and stay overnight within the remote, isolated community. Employees need easy access to NRT and appreciated one-stop shoppingfor a variety of health promotion services. Employees need increased awareness of existing services. April 25, 2012 Telephone interview to obtain feedback from TBDHU staff regarding STOP on the Road program in the mines 23

Interviewees: Susan Armstrong Worksite Welllness PHN; Carrie Breitsprecher, PHN Mike Duranceau, Tobacco Enforcement Officer Perceived barriers to filling out employee surveys and accessing NRT/support Definite feeling of mistrust by the employee towards the employer. They are anxious that any information provided on survey will somehow get back to the employer that they smoke. There appears to be a climate of fear in the workplace, may be related to fear of layoffs. Employees were very cautious about telling us information; they were worried that the employer would find out information What works? Carrie, PHN said that being onsite especially where people are living for longer periods of time (14, 21 and 28 days on the mine sites); we were there all the time-at shift change times, during meals, at any popular eating times Found that employees would come up to us and start thinking about quitting and start taking steps towards quitting; prior to our visit they weren t thinking about quitting at all; one man came to talk to us, said he loved smoking, he was never going to quit until he died. He went down into the mine for his 12 hour shift and when he came up in the morning he came right over to us and wanted to know what he had to do to sign up; there were quite a few instances like that while we were up there Being in their social setting seemed to work; you would be working with one employee who decided to quit and get him signed up and then his friend would come over and say I want to try and do this with my buddy. They were partnering up people that they usually went out for smokes with. This happened often. We went back with the STOP on the Road program a second time because they had had lots of requests for free NRT from the employees because the accompany doesn t provide that benefit; now we ve gotten a 3 rd request from employees asking when those people are coming back. We want to talk to them. We ve had more opportunities to provide smoking interventions there. For some employees it was important that their quit date began at the beginning of their time at the mine. They felt that if they could not smoke at the mine they would be okay not smoking at home. We discovered that many smokers started smoking at the mine site. It was common for employees to smoke at the mine site for several weeks and then go home and not smoke. Health unit staff observed this at 2 mine sites. Unfortunately, because the employer didn t provide NRT,an individual who was a few weeks into his quit attempt and was using NRT and was asked by the employer to stay in for 2 weeks and had no access to his patches to support him in his quit attempt. Sue PHN, said that even in Musselwhite where NRT is free and available, employees weren t necessarily using the NRT because it was one extra step for the employee to go to the Health Centre to ask for it. We discovered after talking to employees that many employees didn t know that free NRT was available in the Health Centre. The employer doesn t really promote the NRT as well as they could. It seems like you have to make it super easy to access the NRT for employees to access. It has to be in their face is the key to success 24

I went to Teleperformance yesterday and was surprised at the reduced number of workers. They had had a significant layoff a few months ago. Employees were stressed out because of the layoff. I set up a table close to where I could see smokers heading out for a cigarette. I had employee surveys and did a CO test on them to get their attention. I gave out 20 surveys, got 12 back. There may be a few more that will come through the Human Resources Manager. I think there s more success with the surveys if you are handing them a piece of paper and having them give back to you rather than doing the survey online. Kim made the online survey accessible to employees but I don t know how many took her up on that. Employees seemed pretty receptive about the whole thing. Mike, the Tobacco Enforcement Officer, found that because employees were on the site for longer periods of time (14, 21 and 28 days) they had nothing to do after their 12 hour shift so this provides them with a good opportunity to quit before they head back home. Also we were very accessible in areas where employees hung out. We were also accessible before and at the end of each shift. It was unbelievable to see the turn around from night to day shift. We were also providing other services for them so it was a one stop shop for the employees. Re STOP program: we have advertised the STOP program lots in community workshops CONCLUSIONS The literature reviews and employer key informant interviews were consistent. The interviews revealed a knowledge gap 70% of the interviewed employers did not perceive smoking as a significant health issue for their workforce (despite the high rates in the region and their estimates that 41% smoke), and they have limited awareness about smoking cessation benefits. Two American studies about smoking cessation benefits identified similar issues (Powers, 2004; Tiede et al., 2007). The majority of companies provided smoking cessation benefits for employees in their extended health benefit packages for counselling and prescription pharmacotherapy; only half provided coverage for NRT. Some of the companies offered no-cost NRT on-site, and when cessation aids were not part of extended health benefit packages, one company provided special coverage paid directly by the company. Almost all companies supported cessation through smoke-free policies within the workplace and a few companies promoted use of smoking cessation hotlines andquit contests (Quit to Win), provided self-help resources and included cessation in the monthly newsletter as a topic at least once/year, and offered various supports such as lunch and learns. None of thecompanies offered a coordinated approach to smoking cessation, and although some occupational health nurses offered brief advice to quit smoking when it came up in visit, none did so systematically with every health encounter, in the most part because they did not have the time. Health centre staff was extremely busy. Many expressed that safety and accident prevention, claims management, and site injuries filled 25

their day, and the organization priorities were often focused upon production. However, offering brief, professional advice at every health encounter by nurses is considered best practice in nursing and this project provides food for thought about how to help nurses integrate brief cessation interventions (1-5 minutes) into their busy practice.since the STOP program appeared to be an effective way to reach and engage employees and provide no-cost NRT, coordinating more STOP visits and integrating them into the occupational health nurses practice might help to increase nurses awareness and support them in their efforts. In addition, most companies were very receptive to any assistance the TCAN/Health Unit can provide, particularly information packages/self-help packages and educational interventions provided from outside the organization. RECOMMENDATIONS Actionable Message 1. Prepare a communication strategy directed to employers to increase awareness of the impact of smoking, and the value (business case) of offering cessation therapy and counselling. 2. Train existing onsite staff (health professionals and wellness coordinators) to deliver evidence-based tobacco cessation treatment(s) and provide them with information about medication coverage and the availability of local cessation supports. 3. Develop a toolkit for those in occupational health and safety Basic info about health implications of smoking, options for quitting Offer a script for brief professional advice at every encounter. The 5As strategy needs to become a standard of care. Promote use of Smokers Helpline 4. Develop promotion/advertising campaign regarding programs, benefits, health risks of smoking tailored to the 25-29 year old and blue-collar groups Based on the Following Project Data Employer interviews stated lack of concern regarding high smoking rates Literature suggests employers do not recognize smoking as a problem and respond to business case with cost benefit analysis (Health Canada, 2008; Powers, 2004; Tiede, 2007) Conference Board of Canada (2006) has published the costs to employers for employees who smoke Knowledge deficit regarding smoking cessation and treatment strategies Health staff are unaware that Brief Professional advice at every health encounter should be a part of daily practice Knowledge gap that smoking is not a problem Staff very busy so providing a script and toolkit would be helpful 25-29 year olds and blue-collar are at higher risk of current smoking although smoking rates in NW Ontario remain high until age 55 yr (Smith, 2011) 26

5. Plan for regular site visits to bring information and provide a Lunch and Learn talk and STOP On the Roadto remote locations including follow-up visits to employers and employees for education and service provision/cessation counselling 6. Develop links with community health professionals such as retail pharmacists, family health teams (FHT), and community health centres (CHC) to increase access to free NRT and smoking cessation counselling. Neither group responds well to existing smoking cessation programs more research is needed employers so over busy and requested thirdparty help anecdotal feedback from STOP visit regarding value of PHN visits several requests for informational packages Several requests for free NRT and for assistance from the PHU A new project in NW Ontario for smoking cessation counselling is currently being rolled out by Dr. Smith to all FHTs and CHCs. Information pamphlets from the program could be provided to worksites. Most of the FHT/CHCs are also on the STOP no-cost NRT initiative. REFERENCES Alison, K. R., & Dwyer, J.M. (2010). Workplace smoking cessation and fruit and vegetable consumption: Synthesis and recommendations for theory- and researchbased intervention planning. Toronto, ON: Program Training & Consultation Centre, Cancer Care Ontario. Retrieved from, http://www.ptcccfc.on.ca/common/pages/userfile.aspx?fileid+103711 Baliunas, D., Patra, J., Rehm, J., Popova, S. & Taylor, B. (2007). Smoking-attributed mortality and expected years of life cost lost in Canada 2002: Conclusions for prevention and policy. BMC Public Health, 7, 247. doi:10.1186/1471-2458/7/247 Retrieved from, http://www.biomedcentral.com/1471-2458/7/247 Barbeau, E.M., Li, Y., Calderon, P., Hartman, C., Quinn, Markkanen, P., Roelofs, C., et al. (2006). Results of a union-based smoking cessation intervention for apprentice iron workers (United States). Cancer Causes and Control, 17(1), 53-61. Barnes, J., Dong, C.Y., McRobbie, H., Walker, N., Mehta, M. & Stead, L.F. (2010). Hypnotherapy for smoking cessation. Cochrane Database of Systematic Reviews, Issue 10. Art. No.: CD001008. doi: 10.1002/14651858.CD001008.pub2. Buske, L. (1999). Smoking: an occupational hazard. JAMC, 160(5), 630. 27

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APPENDIX A. INTRODUCTORY LETTER February 13, 2012 Re: Northwest Tobacco Control Area Network Worksite Cessation Project Dear The Northwest Tobacco Control Area Network (NWTCAN) is engaged in a research project to better understand the cessation (quit smoking) needs of blue collar and service workers and the needs of their employers in providing cessation supports. The information gathered will help the NW TCAN plan programming and initiatives to assist large industries across our region support their workers in quitting smoking and harmful tobacco use. This project is being conducted by Patricia Smith, PhD, Northern Ontario School of Medicine, in collaboration with the Thunder Bay District and Northwestern Health Units. We have contracted with InfoFinders, a health research company, through its principals, Linda Corso, BScN, MA and Nancy Cobb, BScN, to assist with the key informant interviews. Your participation in an interview, via phone or email, would be greatly appreciated. InfoFinders will be contacting you in March, 2012 to 1) obtain your permission for an interview, 2) schedule an interview and, 3) share the questionnaire with you prior to the interview. We hope that you or someone from your organization will be willing to participate in this process. If you are unable to participate, please recommend someone else in your organization to assist InfoFinders. Thank you for your consideration and for any assistance you can provide. Yours truly, Jennifer McFarlane, NW TCAN Coordinator Thunder Bay District Health Unit 807-625-8816 Jennifer.mcfarlane@tbdhu.com 32

APPENDIX B. EMPLOYER SURVEY Company: Community Location: Contact person: Position: Phone: E-mail: Number of employees: Number of worksites: Approximately what percentage of your workers are 25-29 year old males? Do you know approximately what percentage of your workers smoke? % Do you have any comments about the age mix of your workers? E.g. One employer reports that ages are 50+ and 20 s but not much in between We are interested in what is offered for employee smoking cessation through extended health benefit plans and other supports. Please complete the table below. Support Employee Family Counselling (individual) Nicotine gum Nicotine patch Nicotine inhaler Zyban or Wellbutrin Champix Other Benefit 1x Annual Lifetime If you cover smoking cessation drugs, is coverage for smoking cessation drugs the same as the coverage for other drugs? Do cessation benefits and support vary within the organization? i.e. same benefits available for all employees or varies between collective agreements, varies for casual, part time, full time, contract employees 33

What other supports do you offer? Please fill in the chart below. Support None Self-help materials, e.g. pamphlets/websites Description Education/information sessions e.g. Lunch & Learn Group support program offered on site Group support program offered off site Brief, professional advice Referrals to telephone Smokers Helpline (confidential) Contests/challenges to stop smoking Smoking cessation medications Other In your organization, do any of the following barriers limit provision of programs for smoking cessation? Barrier Yes No Any comments Lack of company financial resources Geographic area Competing company priorities Inadequate staff training Population not interested in smoking cessation Company not interested in smoking cessation Inability/difficulty to pay for nicotine replacement therapy (NRT) By whom? Company, Benefit Plan, Employee? Poor capacity for adequate follow-up for off-site program Lack of occupational health nurses 34

Lack of physician support Diverse language and culture Small town environment, i.e. no anonymity Issues with community support Delivery of resources from other agencies is not always timely What do you find to be the most effective way to communicate with your workers regarding programs for smoking cessation? Posters Company Newsletters Fliers/Postcards Website Payroll stuffers Table Tents Other: Please identify Yes No Does your organization participate in the Smoking Treatment for Ontario Patients (STOP) study where eligible employees can receive clinically proven smoking cessation medications free of charge? Yes No Do you keep any statistics on smoking or smoking cessation activities? Statistical measure Yes No Description Number enrolled in counselling Medication use NRT use Quit rates Success of special initiatives Other Please identify What are the smoking restrictions at work, if any? Smoking is not allowed on the company property or in company vehicles 35

Smoking is allowed outside the building(s), not in any inside or outside work area Smoking is allowed in some work areas (specify) Smoking is allowed in all work areas Where do you allow employees to use other tobacco products at work? Are the smoking rates among employees of concern to your company? Why or why not? Is there anything the health unit could provide that would help you to assist employees to quit smoking? Do you have any other comments that you think may be helpful for us? Thank you. 36

APPENDIX C: EMPLOYEE SURVEY Smoking and Tobacco Use Survey The Northwest Tobacco Control Area Network Worksite Cessation Project Please consider completing this survey about smoking and tobacco use. The information will be used to guide programs to help people who are interested in quitting smoking to quit. What is the study about? The Northwest Tobacco Control Area Network (NWTCAN) is engaged in this survey research project to better understand the cessation (quit smoking) needs of employees in NW Ontario and the needs of their employers in providing cessation supports. The information gathered will help with program planning and initiatives to assist large industries across our region to support their workers in quitting smoking. Who is responsible for this study? This project is being conducted by Patricia Smith, PhD, Northern Ontario School of Medicine, in collaboration with the Thunder Bay District and Northwestern Health Units. Funding for the project has been provided by the Health Promotion Branch of the Ministry of Health and Long Term Care. What about confidentiality of your information? Who will have access to your information? Completing and returning this survey indicates that you consent to participate. Please be assured that your information will be held in strict confidence, will be used only for the purposes of this study, and will not be disclosed or released to anyone other than the researchers or used for any other purposes. The data collected will be stored for 5 years. We will only analyze group-level data that is, your information will be combined with information from everyone else who completes the survey. Your personal data will never be revealed or presented in reports or public presentations and papers. Does this study have ethics approval? The study received ethics clearance from Lakehead University Research Ethics Board. If you have any questions or concerns, please do not hesitate to contact Patricia Smith, PhD (807) 766-7341 or by email at psmith@nosm.ca. You may also contact Lakehead University s Research Ethics Board at 343-8283. Thank you for taking the time to complete and return this survey. 37