Smoking Cessation in the Workplace: A Guide to Helping Your Employees Quit Smoking

Acknowledgements

Health Canada would like to thank the following people for their valuable contribution to this guidebook:

• Dr. Jean-Marc Assaad, McGill University
• Dan Boone, Canadian Auto Workers (CAW)
• Janet Carr, Ottawa Public Health
• Judy Elliott, Durham Region Health Department
• Dr. Pebbles Fagan, National Cancer Institute (U.S.)
• Melissa Feddersen, Okanagan University College
• Niki George, Lung Association of Newfoundland
• Eugene Haslam, Zaphod Beeblebrox
• Brenda Keenan, Irving Paper
• Lise Labrie, Montreal Public Health
• Dr. Kelli-ann Lawrence, Brock University
• Neil MacKenzie, Windsor-Essex County Health Unit, Ontario
• Heidi McGuire, Hamilton Public Health and Community Services
• Donna McNamara, Medcan Health
• Anne Meloche, Program Training and Consultation Centre
• Sherry Mooney, Wellness Institute
• Yvette Penman, Calgary Health Region
• Bev Pitfield, Sudbury & District Health Unit
• Denise Polson, Natural Resources Canada
• Brenda Stankiewicz, Sudbury & District Health Unit
• Dan Steeves, Capital District Health Authority
• Bonnie Topic, Dofasco
• Cathy Walker, Canadian Auto Workers (CAW)
• Michelle Walker, Manitoba Lotteries Corporation
• Steve Widmeyer, Secunda Marine Services

Section I: Introduction

What Is This Guide About?

This guide is for employers and others who promote health in the workplace. It outlines the reasons why workplaces should get involved and support employees' efforts to cut down or quit smoking. It also provides practical, relevant material on smoking cessation that can be used either as part of a comprehensive wellness program or as an initiative on its own. The kinds of smoking cessation activities that can be offered are explained, the necessary steps are outlined, and handouts, tools and a list of further resources and references are also included.

Who Is This Guide For?

This guide is for employers who want to help their employees quit smoking. It is also for any workplace leaders such as union representatives, workplace health promotion or occupational health representatives, human resource managers, and employee assistance program representatives.

For What Types of Workplaces and Workers?

The guide is for all types of workplaces - small, medium, and large, public and private sector, unionized and non-unionized, and any type of industry or sector. It is also for all types of workers - men and women of various ages who have different levels of education, experience and training, and who may be full-time, part-time or casual employees.

Tobacco Control Policies and Other Workplace Wellness Initiatives

This guide builds on the information available in Health Canada's Towards a Healthier Workplace: A Guidebook on Tobacco Control Policies, designed to help employees and employers who are creating or strengthening tobacco control policies in their workplaces. This guide can also complement workplace wellness initiatives that are already taking place or that are being developed. Smoking cessation is one factor that will greatly improve employees' health. Workplace wellness initiatives can also support employees to make healthy choices around physical activity, nutrition, work-life balance, mental health and a variety of other factors.

How This Guide Was Developed

The information in this guidebook is based on a literature review that looked at various sources dealing with smoking cessation in general, and smoking cessation in the workplace in particular. The methodology for the review included an information database search and an Internet search that was limited to research reports published after 1994. Interviews were carried out with experts in workplace health issues and tobacco cessation, as well as workplaces themselves. Feedback on a draft version of the guide was also provided by the workplace health and tobacco cessation experts and the workplaces highlighted in this guide. Refer to Section VII: References for a list of many of the sources from the literature review. This guidebook was partially revised in 2006 using new information from the Canadian Tobacco Use Monitoring Survey (CTUMS) as well as updated information from the Conference Board of Canada on the costs associated with employing people who smoke.

Section II: The WHY, WHO and WHAT of Quitting Smoking in the Workplace

WHY Should Employers Be Involved?

There are six main reasons for employers to support smoking cessation in the workplace:

• improved employee health;
• increased productivity;
• reduced costs;
• enhanced job satisfaction;
• effective setting;
• better corporate image.

Improved Employee Health

You cannot put a dollar value on good health. Good health is an invaluable resource. As an employer you need to invest in the health of your employees - they are your organization's most important asset. Employees who do not smoke take fewer sick days, go on disability less often, and are less likely to retire early because of poor health. Most people want to quit smoking.

Increased Productivity

Helping employees quit smoking is good for business. On average non-smokers take fewer sick days than smokers. Non-smokers can be more productive because they do not take the unscheduled smoking breaks that some smokers do.

Employees who smoke may also take longer breaks than non-smoking employees. Because of new municipal bylaws and stronger provincial legislation smoking is no longer allowed in most workplaces. This means that employees must go outside to smoke a cigarette, often to a designated smoking area and sometimes they must leave the premises completely. Because it now takes more time for employees to reach a place where they can smoke this translates into longer breaks. It also costs employers to pay for and install commercial ashtrays outside as well as to clean the ashtrays and the surrounding area.

Reduced Costs

Supporting employees to quit smoking is an investment worth its return. If employees who smoke are helped to quit, employers will see less loss of skills, knowledge and corporate memory due to premature death and early retirement. Many companies that have offered smoking cessation activities to their employees report positive results. According to the Canadian Lung Association, smoking cessation support is a sound economic investment and is especially profitable when offered over the long term (five or more years).

The Conference Board of Canada estimates the cost each year for every employee who smokes as up to $3,396 through increased absenteeism, decreased productivity and the costs associated with maintaining and cleaning outside smoking areas. Refer to Section V: Tools For Employers and Others Who Promote Health in the Workplace for a formula to calculate some of the costs of smoking in the workplace.

Enhanced Job Satisfaction

There are many reasons for wanting to quit smoking, but health concerns are the number one reason. According to a national survey that Statistics Canada carries out for Health Canada on a regular basis, fewer people are smoking, and those who do smoke are smoking less. The majority of people who smoke want to quit. Several studies show that a large majority of both smokers and non-smokers would rather work in a smoke-free environment. Another Health Canada study shows that many smokers would welcome smoking cessation programs offered by their employers.

When employees are healthy and have a strong sense of personal well-being, there is an improvement in their morale and the overall quality of the work environment. In this environment, employees are more productive and feel a greater sense of loyalty.

Effective Setting

Workplaces and homes are the two environments that can have the greatest effect on people's health. Workplaces in particular are an ideal setting to help people quit smoking for several reasons:

• Many people spend a good part of their time at work.
• Workplaces have access to a large number of people on a regular basis. They have the opportunity to reach a high number of smokers on an ongoing basis.
• Workplaces have access to some groups that would be hard to reach otherwise, such as different minority groups, and people who do not visit doctors and other health care professionals regularly.
• Workplaces are convenient places for people to get information and support for quitting on an ongoing basis.
• Workplaces can provide the supportive social environment necessary for quitting smoking. Smokers who want to quit, and recent ex-smokers can get support from other employees, and from others who promote health in the workplace.
• Smoking bans in workplaces encourage employees who smoke to cut down or quit, and help those who are already smoke-free to stay that way.

Employers can make a difference. People try to quit when they are presented with opportunities and options, and are more likely to succeed when they have support. By providing and publicizing cessation activities, and offering a smoke-free working environment, employers and others who promote health in the workplace can help employees to quit smoking.

Better Corporate Image

Workplaces that care about the health of their employees portray a positive image within the workplace and the larger community. A better image helps to attract and keep talented workers. Workplaces that comply with non-smoking legislation are respected in the community. Those that go beyond these requirements by offering cessation support display an even greater commitment to the health and welfare of their employees. Some workplaces take a comprehensive approach to workplace health, and include tobacco reduction as part of a larger workplace health promotion strategy. Workplaces that are committed to the health of their employees become workplaces of choice.

WHO Smokes and Who Wants to Quit?

Most smokers want to quit, and among those who do quit, more than half stay smoke-free. According to the Canadian Tobacco Use Monitoring Survey (CTUMS) carried out by Health Canada in 2005:

• 19 percent of Canadians aged 15 and older are current smokers.
• 58 percent of current smokers are considering quitting in the next 6 months and of these, half are considering quitting in the next 30 days.
• 34 percent of Canadians feel that smoking should not be allowed in any area of a workplace, either inside or outside.
• 51 percent of Canadians feel that smoking should be allowed only in designated outdoor smoking areas of the workplace.
• 94 percent of Canadians report some sort of smoking restrictions at their workplace and 54 percent report that smoking is banned completely from their workplace.

For more information about smoking trends in Canada, refer to Health Canada's Canadian Tobacco Use Monitoring Survey (CTUMS) at www.gosmokefree.gc.ca/ctums.

WHAT Are the Options for Employers Who Want to Support Their Employees to Quit Smoking?

The Basic Approaches and Options

Workplaces have a variety of approaches and options to help employees quit smoking. Smoking cessation supports can be offered as part of a workplace wellness program, but they can also be offered on their own. Having a non-smoking policy in the workplace not only protects employees from dangerous second-hand smoke, it also supports those employees who want to quit smoking and underlines employers' commitment to employee health. There are a variety of approaches and options for employers to help their employees quit smoking, and different combinations of approaches and options can be offered in the workplace.

The basic workplace smoking cessation approaches include:

Comprehensive - This approach involves offering programs and activities at the workplace. Employees can then access the supports on-site, and often during work hours.

Facilitated - This approach involves working with outside agencies to deliver programs and activities off-site, and providing self-help materials.

Education and Information - Providing employees with information including self-help materials. Refer to Section V: Tools for Employers and Others Who Promote Health in the Workplace for a detailed comparison of the various approaches, including the pros and cons identified with each.

Smoking cessation options include:

Self-help

Most people who quit smoking get information from self-help materials such as pamphlets or Web sites. Information is available from many organizations across the country including local public health departments, authorities and districts, the Canadian Cancer Society, Heart and Stroke Foundation, and Lung Association. Health Canada also has many resources for people who want to quit smoking including On the Road to Quitting which is available in hardcopy and can be found online at www.gosmokefree.gc.ca. Workplaces can order self-help information and make it available to employees. Refer to Section IV: Resources for more information.

Brief, Professional Advice

A doctor, pharmacist or nurse can give some advice on quitting smoking as well as provide self-help material to take home. These health professionals can provide services at the workplace or off-site. Telephone quit-lines across the country also provide counselling and information. Refer to Section IV: Resources for toll-free quitline numbers across the country.

Individual Counselling

Individual counselling, usually by a physician, nurse, addictions specialist, employee assistance program (EAP) provider, or quit-line counsellor can help people who smoke adapt to life without cigarettes. Counselling can be offered at the workplace or employees can be referred to services off-site, including their own family physicians or public health nurses.

Group Programs

Group programs can be offered on-site or off-site and provided by the workplace itself, a public health department, authority or district, voluntary health agency, or community group. They usually include weekly sessions over a period of time, and can take place during or after work hours. Workplaces can subsidize these programs in whole or in part, and allow employees to attend during work hours. Spouses and other family members can also be invited to participate.

Quit-Smoking Medications

Nicotine gum and nicotine patches have been shown to help smokers quit and stay smoke-free. They are available without prescriptions. Bupropion is a prescription medication that may help reduce withdrawal symptoms and cravings. The nicotine inhaler is another option that requires a prescription. In general, people are more likely to quit smoking if they use a combination of quit-smoking medications, self-help materials and counselling or group programs. Workplace benefit plans can cover the cost of these medications for both the employees and their family members.

Incentives, Contests and Special Events

Offering incentives is one way to encourage employees to think about quitting smoking and to take action. Holding contests or special events, including piggybacking on those taking place in the community is another way to get people interested and involved. A smoking employee can pair up with a non-smoking buddy and both team members can be eligible for prizes. Some examples are:

• health fairs;
• lunch and learn sessions with guest speakers;
• quit and win contests;
• smoke-free homes and cars challenges;
• reimbursing employees for program costs for quitting smoking.

Hold activities in conjunction with national, provincial and community events such as:

• National Non-Smoking Week (third week in January);
• Weedless Wednesday
  (third Wednesday in January);
• World No Tobacco Day on May 31;
• Canada's Healthy Workplace Week (last week in October);
• National, provincial or local quit and win contests;
• Implementation of new or stricter municipal non-smoking bylaws or provincial legislation.

Tips for Success

Some workplaces have more resources than others and can offer more comprehensive cessation support. However, there are a variety of ways that employers can help their employees quit smoking and any workplace that offers cessation activities shows a commitment to employee health and wellness. There are some proven strategies that can make cessation activities in the workplace more successful:

• Use an integrated approach that includes non-smoking policies, health benefit plans, and cessation information and activities.
• Ensure broad representation by involving staff and management, different departments, union representatives, and both smokers, ex-smokers and non-smokers.
• Subsidize quit-smoking medications.
• Understand that quitting is a process. Allow employees to participate in activities and access quit-smoking medications as often as they need to make the various quit attempts often necessary to stay smoke-free for good.
• Remove as many barriers as possible around participating in activities such as cost, location and time.
• Tailor the program to your workplace, taking into consideration the needs of your employees, including accommodating shift workers and making sure written materials are language-appropriate.
• Extend cessation benefits and activities to spouses and family members.
• Take a long-term approach. This will result in long-term results and long-term benefits.

Section III: The HOW of Quitting Smoking in the Workplace

Carrying out smoking cessation activities in the workplace can be complex. The practical steps needed to successfully plan, develop, communicate and implement cessation activities are outlined below.

Understand the Process of Quitting Smoking

Smoking is a serious addiction and quitting is a difficult process. Most people make four or five quit attempts and may use a variety of methods before they quit for good. These attempts are an important part of the journey to becoming smoke-free. An attempt is not a failure. Smokers learn more about quitting each time they try, and the fact that they have tried to quit before increases the chances of them eventually quitting for good. If employees are supported each time they try to quit smoking they have a much better chance of getting quit and staying quit.

Adopt Positive Values

Workplaces that offer wellness activities already show they are committed to improving their employees' health. Cessation activities that are built on the following values can be more effective and more attractive to all employees:

• Open communications. Keep employees informed at all times. Let them know in advance if any policies or activities are being introduced or changed. Also, explain why and how policies are changing.
• Respect. Be respectful of employees' concerns and ideas.
• Inclusiveness. Include employees in the decisions and the discussions. Keep them informed and encourage them to participate. Encourage both smokers and non-smokers to voice their opinions.
• Non-stigmatizing. Use an approach that does not label or stigmatize smokers, and does not make non-smokers feel left out.
• Privacy and confidentiality. Respect the privacy and confidentiality of smokers who want to take advantage of any cessation supports offered in the workplace.

Develop a Plan

Once the decision has been made to support employees to quit smoking, you need to develop a plan that details:

• Goals and objectives - what you want to achieve and why.
• An inventory of available resources -include what is available in the workplace and in the community.
• A needs assessment - ask employees what they want.
• Who is involved - identify the organizers and the target audience you want to reach.
• Activities - what you are going to do and when.
• Communication - including to whom, how often, and how.
• Evaluation - looking at whether you have met your goals and objectives.

Draft Goals and Objectives

Setting down goals and objectives will make clear to everyone what you are trying to achieve and why. They will also help in the evaluation process to gauge the success of the cessation supports, and help you improve them in the future.

SMART objectives are ones that are:

• Specific;
• Measurable;
• Attainable;
• Realistic;
• Timely.

Make an Inventory of Available Resources

This can include the budget you have for cessation activities, the time you can allot to it, and the people who will be able to help. If your workplace offers a benefit plan, check what it already offers and get in touch with your provider to see what else they can offer. Also look into what is offered in the community, for example through community health centres, public health department, authority or district, hospitals and other organizations. Refer to Section V: Tools for Employers and Others Who Promote Health in the Workplace for a checklist for assessing smoking cessation programs. Health Canada and other national and provincial health organizations offer a variety of resources for people who want to quit smoking.

Quitlines across the country also offer support for smokers and their friends and family members through trained cessation specialists, at no cost.

Refer to Section IV: Resources for a list of the quit-line numbers across the country.

Conduct a Needs Assessment

Before you decide what you want to do, you should get a feel for what employees want. You may already know from other surveys, needs assessments, or informal discussions that smoking cessation is high on the priority list at your workplace. What you may not know is what stage employees are at in the quitting process, or how they would like to quit. A needs assessment will help you find out more about how motivated employees are to quit, what will help them quit, and what they feel is standing in their way. Include questions for all employees, with some targeted specifically at non-smokers, and some at ex-smokers and smokers. For small workplaces, a needs assessment can be conducted through a staff meeting or other discussions.

Refer to Section V: Tools for Employers and Others Who Promote Health in the Workplace for a sample needs assessment. You can offer an incentive, such as a draw for a prize or other token reward to encourage all employees to participate in the survey. Also refer to the Health Canada document Workplace Health - Discovering the Needs, a guide for planning a needs assessment for workplace health programs. It is available at http://www.hc-sc.gc.ca/ewh-semt/pubs/occup-travail/health-sante/program-programmes_2_e.html.

Decide Who Should be Involved

Everyone in the workplace should be represented in discussions around planning, developing, and implementing wellness activities. This will ensure that more people will support the activities and more people will participate. Setting up a committee to plan, manage activities and events, deal with volunteers, and communicate with employees is an effective way of ensuring any wellness initiative is a success. You will need to build a commitment with management, staff and labour groups, and identify champions and influential leaders to help get others on board. In small workplaces, all employees can be involved. In larger workplaces, try to involve the following (where appropriate):

• Management - Although initiatives do not have to be driven by management, it is important for them to be involved from the beginning;
• Unions;
• Different departments and/or groups of workers;
• Workplace wellness and health and safety representatives or medical staff;
• Human resources;
• Employee assistance program (EAP) representatives.

Choose Your Activities

Choosing your activities will depend on a variety of factors, including:

• How motivated employees are to quit smoking. If many employees are not that interested in quitting smoking, more work may need to be done around information and education before group programs and quit medications are introduced.
• The information gathered at the needs assessment stage, including the support employees have identified.
• Available resources. Make sure you have the people, time and budget to do what you want to do. Remember that many activities can be done for little cost. Refer to Section IV: Resources for agencies and organizations that may be able to help.

Smoking cessation activities and support can be offered on their own, but it is preferable if they are part of a larger wellness initiative. It is especially important to establish a strong tobacco control policy in the workplace to provide the supportive environment necessary for employees to quit smoking. All smoking paraphernalia such as ashtrays should be removed from the workplace. For information on how to implement a new non-smoking policy in the workplace, or to strengthen an existing one, refer to Health Canada's Towards a Healthier Workplace: A Guidebook on Tobacco Control Policies. For information on how to implement workplace wellness initiatives, refer to Health Canada's Workplace Health System.

Refer to Section IV: Resources for information on how to obtain these and other resources.

Communicate Well

When it comes to smoking cessation and other wellness initiatives, communication is extremely important for generating interest and encouraging employee participation. The following tips will help you communicate effectively and get your messages out.

Do it often and do it early. Make sure employees know about any changes to smoking policies and smoking cessation activities well in advance so they can plan, and keep employees informed every step of the way.

Communication is a two-way activity.
Encourage employees to get involved, allow them to participate in the discussion and listen to their opinions. Provide a forum or venue to solicit feedback.

Use a variety of channels. Take advantage of various channels to communicate information about the benefits of quitting, and about what cessation supports are available to employees. Large workplaces will have more options, but even small workplaces can take advantage of different means of communication, including:

• word-of-mouth;
• managers;
• staff meetings;
• posters;
• written materials in staff and lunch rooms;
• e-mail;
• employee newsletters;
• workplace intranets.

Evaluate

There are a number of good reasons to evaluate cessation activities:

• to assess the effectiveness of the activities;
• to identify ways to improve the activities;
• to justify future activities.

There are three different types of evaluations:
Formative evaluations - These are used for planning and include the needs assessment survey described earlier in this section. Refer to Section V: Tools for Employers and Others Who Promote Health in the Workplace for a sample employee needs assessment.

Process evaluations - These focus on activities that are underway, and can help you make adjustments to your initiatives. Use a process evaluation to gather employee feedback on the activities, resources, and support offered. Try to get feedback from smokers and non-smokers, management, and labour representatives. Refer to Section V: Tools for Employers and Others Who Promote Health in the Workplace for a sample process evaluation.

Summative evaluations - These try to answer the questions: "Did the activities make a difference?" and "Did the activities meet the goals and objectives?" This type of evaluation can track the number of employees who participate, track the quit rates at three months, six months and one year, and help you develop a cost-benefit analysis that looks at changes in absenteeism, increases in productivity, decreases in disability claims and insurance costs, and improved employee satisfaction and health.

Deal with Barriers

You may be faced with some challenges around cessation in the workplace. The following are some barriers you may face and some strategies for dealing with them.

Some employees are not ready to quit smoking

• Some employees will be in the pre-contemplation stage in the quitting process - they won't have any intention of quitting smoking in the short term. And although this means they may not take advantage of the cessation activities and benefits that are offered in the workplace, they can still be supported to start thinking about making changes in their smoking habits. Non-smoking policies in the workplace help people cut down by providing fewer opportunities to smoke. Having information readily available can also help get people thinking about quitting.
• Cessation information, including contests and self-help material that is readily available can encourage people to start thinking about quitting smoking. Refer to Section IV: Resources for organizations that distribute self-help and other materials.
• Peer support. Watching other employees as they quit smoking with the help of peer support can be encouraging to smokers.

What about employees who live with smokers?
Supporting employees in the workplace will help them quit smoking, but if they have family members who smoke at home, it will be more difficult for them to quit. Offer the same cessation supports and benefits to household family members.

What about managers who are not supportive?
Immediate supervisors are the gatekeepers when it comes to many workplace activities. Make sure managers are on board, because if they are supportive of wellness initiatives, staff members are more likely to participate.

Smoking at the workplace
Workplaces that allow smoking, even in designated areas, send a mixed message. A smoke-free environment helps employees cut down or quit smoking.

Section IV: Resources

Also refer to Section VII: References for further background information about smoking cessation in the workplace, including other Health Canada references.

Health Canada

Health Canada offers a range of smoking cessation and other health promotion resources which are available online at www.gosmokefree.gc.ca. Hard copies can also be ordered through the Web site.

Health Canada Smoking Cessation Resources

On the Road to Quitting - This guide for smokers who want to quit is available in booklet form and online. It includes information about nicotine addiction, the health benefits of quitting smoking and dealing with stress, and it outlines practical steps for quitting. Strategies for dealing with relapses, slips, cravings and withdrawal are also outlined. It is available online at www.gosmokefree.gc.ca.

Towards a Healthier Workplace: A Guidebook on Tobacco Control Policies - This guidebook outlines the importance of workplace tobacco control policies and the practical steps for implementing them with case stories from workplaces across the country illustrating concrete examples. It also includes practical tools for employers and handouts for employees. It is available online at www.gosmokefree.gc.ca.

www.gosmokefree.gc.ca - This Health Canada Web site contains comprehensive tobacco information including health effects of smoking and second-hand smoke, quit resources, Canadian smoking trend data, and information on the tobacco industry. Resources for professionals and the general public are available, including specific resources for youth.

Other Health Canada Resources

Corporate Health Model - A Guide to Developing and Implementing the Workplace Health System in Medium and Large Businesses. This guide provides an outline of the steps required to develop and implement a Workplace Health System using the Corporate Health Model. A workplace health system refers to the process of developing a comprehensive health program to help employees maintain or improve their health. It outlines the steps necessary to plan, develop, and implement a workplace health system. It is available online at www.hc-sc.gc.ca/ewh-semt/pubs/occup-travail/work-travail/model-guide-modele/index_e.html and copies can also be ordered through the Web site.

Workplace Health - Discovering the Needs. This guide was developed for use by committees or coordinating groups to plan a needs assessment for workplace health programs. It is available online at http://www.hc-sc.gc.ca/ewh-semt/pubs/occup-travail/work-travail/index_e.html workplace and copies can also be ordered through the Web site.

Canadian Tobacco Use Monitoring Survey (CTUMS). A national survey of over 20,000 Canadians, it is designed to provide timely, reliable and continual federal and provincial access to important information related to tobacco use in Canada, especially for populations most at risk for taking up smoking, such as 15- to 24-year-olds. Since February 1999, CTUMS has provided six-monthly and yearly data on changes in smoking status and amount smoked, both nationally and provincially. CTUMS is conducted by Statistics Canada on behalf of Health Canada. CTUMS is available at www.gosmokefree.gc.ca/ctums.

Resources for Youth

Some of the hyperlinks provided are to sites of organizations or other entities that are not subject to the Official Languages Act. The material found there is therefore in the language(s) used by the sites in question.

Quit4Life - Health Canada's Quit4Life is designed to help Canadians between the ages of 12 and 18 quit smoking, including those who smoke occasionally. Using a four-step plan, the program helps build motivation and confidence and outlines tips for dealing with roadblocks and stress. It is available online at www.quit4life.ca, or as a booklet.

SMOKE-FX is a Web site that includes Ontario resources, tobacco quizzes, e-mail postcards, fact sheets, and an advocacy tool kit. It is available at www.smoke-fx.com.

The TeenNet Project is a University of Toronto Web-based research project that includes young people from diverse backgrounds in all stages of design, development, and dissemination. The main site is available at www.teennetproject.org and there are individual project sites such as CyberIsle (www.cyberisle.org) that includes health information, online discussion groups, links and games;

Smoke Free World (www.smokefreeworld.com) that focuses on tobacco and globalization;

Smoking Zine (www.smokingzine.org), a multilingual, five-stage, interactive smoking prevention and cessation resource for smokers and non-smokers.

Allumelagang.com is a French language youth-oriented Web site that includes cessation information, resources, a discussion forum, interactive games, and links. It is available at www.allumelagang.com.

Provincial Quitlines

Quitlines offer support for smokers who want to quit, may be thinking of quitting, have quit and need support, or enjoy smoking and do not want to stop. Trained cessation specialists can help them develop a structured plan, answer their questions and refer them to other smoking cessation services in their community. They can also provide support for family and friends who want to help a smoker. Self-help materials can be ordered through quitlines and there is no charge to use quitline counselling services.

• Newfoundland and Labrador residents
  1-800-363-5864
• New Brunswick and Nova Scotia residents
  1-877-513-5333
• Prince Edward Island residents
  1-888-818-6300
• Quebec residents
  1-866-527-7383
• Ontario residents
  1-877-513-5333
• Manitoba and Saskatchewan residents
  1-877-513-5333
• Alberta residents
  1-866-332-2322
• British Columbia residents
  1-877-455-2233
• Yukon residents
  1-866-221-8393
• Nunavut residents
  1-866-877-3845
• Northwest Territories residents
  1-867-920-8826

National and Other Organizations

Some of the hyperlinks provided are to sites of organizations or other entities that are not subject to the Official Languages Act. The material found there is therefore in the language(s) used by the sites in question.

For further information and resources on smoking cessation, please contact any of the following:

• Canadian Cancer Society
  Tel.: (416) 961-7223
  E-mail: ccs@cancer.ca
  Web site: www.cancer.ca
• Canadian Centre for Occupational Health and Safety
  Tel.: 1-800-668-4284
  E-mail: clientservices@ccohs.ca
  Web site: www.ccohs.ca
• Canadian Labour Congress
  Tel.: (613) 521-3400
  E-mail: health&safety@clc-ctc.ca
  Web site: www.clc-ctc.ca
• Canadian Lung Association
  Tel.: (613) 569-6411
  E-mail: info@lung.ca
  Web site: www.lung.ca
• Heart and Stroke Foundation of Canada
  Tel.: (613) 569-4361
  Web site: www.heartandstroke.ca
• National Clearinghouse on Tobacco and Health
  Tel.: (613) 567-3050 or
  Toll-Free: 1-800-267-5234
  E-mail: info-services@cctc.ca
  Web site: www.ncth.ca/NCTHweb.nsf
• Non-Smokers' Rights Association
  Tel.: (613) 230-4211
  E-mail: ottawa@nsra-adnf.ca
  Web site: www.nsra-adnf.ca
• Ontario Tobacco Research Unit
  Tel.: (416) 595-6888
  E-mail: otru@camh.net
  Web site: www.camh.net/otru
• Physicians for a Smoke-Free Canada
  Tel.: (613) 233-4878
  E-mail: ccallard@smoke-free.ca
  Web site: www.smoke-free.ca
• Conseil québécois sur le tabac et la santé - available in French only
  Tel.: (514) 948-5317
  E-mail: info@cqts.qc.ca
  Web site: www.cqts.qc.ca

Resources are also available by contacting the public health department, authority or district in your area.

Section V: Tools for Employers and Others Who Promote Health in the Workplace

These tools are to help employers and others who promote health in the workplace as they plan, develop and implement cessation activities for their employees. You may adapt them to suit your particular needs.

Employee Needs Assessment: Smoking Cessation in the Workplace

This is a sample employee needs assessment for gathering information about how workplaces can help employees quit smoking.

Estimating the Cost of Smoking in Your Workplace

Using a formula developed by the Conference Board of Canada and updated in 2006, this tool outlines how you can estimate the cost associated with smoking in the workplace in terms of increased absenteeism, decreased productivity, and providing commercial ashtrays for outside smoking areas and keeping these areas clean.

Smoking Cessation in the Workplace: Comparing the Different Approaches

The three basic approaches are outlined in Section II: The Why, Who and What of Quitting Smoking. These approaches are compared in a chart format, including the pros and cons associated with each.

Checklist for Assessing Smoking Cessation Programs

This tool includes questions to consider when choosing a cessation program for your workplace. Both program content and program leaders are considered.

Evaluation Tool

This HTML document is not a form. Its purpose is to display the information as found on the form for viewing purposes only. If you wish to use the form, you must use the alternate format.

This tool is a sample evaluation questionnaire employees can be asked to fill out after they participate in a group program. It can also be modified to gather feedback about other cessation activities offered in the workplace.

Employee Needs Assessment: Smoking Cessation in the Workplace

Part A - About You

• 1. I am (circle one):
  
  
  • male   
  • female
• 2. My age is
  
• 3. Which of the following describes you best? (check one only)
  
  
  • I am a non-smoker.
  • I am an ex-smoker.
  • I am a smoker who would like to quit.
  • I am a smoker who does not want to quit.

Part B - Non-smoking Policies and Supports in the Workplace

• 4. Are you aware of the smoking policy in our workplace? (circle one)
  
  
  • Yes
  • No
• 5. Do you know where smoking is permitted in our workplace? (circle one)
  
  
  • Yes
  • No

  If yes, please explain.

• 6. Do you know what cessation supports are available to employees? (circle one)
  
  
  • Yes
  • No

  If yes, please list the cessation supports you are aware of:
  

  If you are a non-smoker, this completes the questionnaire. Thank you. If you are a current smoker please continue to question 7a and if you are an ex-smoker, please go to question 7b.

Part C - About Supporting People Who Want to Stop Smoking and Who Want to Stay Quit

• 7a. For smokers: Would you like to quit smoking? (circle one)
  
  
  • Yes
  • No

  If yes, how soon?

• 7b. For ex-smokers: How long ago did you quit?
  
  
• 8. How many times in the past year have you quit smoking for at least 24 hours? (circle one)
  
  
  • None
  • One
  • or more
• 9. Have you used any cessation supports in your previous attempts to quit smoking? (circle one)
  
  
  • Yes
  • No

  If yes, please describe the types of supports you have used (e.g., self-help materials, group cessation programs, quit-lines, doctor's advice, counselling from a pharmacist, use of nicotine gum, use of the patch, prescription for Zyban™, etc.)

• 10. Would you participate in smoking cessation assistance that was offered through our workplace? (circle one)
  
  
  • Yes
  • No
    
  • Not sure (please explain)
• 11. What types of support and activities would you use to help you stop smoking or to help you stay smoke-free? (check as many as apply)
  
  
  • Group program offered on-site
  • Group program offered off-site
  • Brief, professional advice
  • One-on-one counselling
  • Quit medications (patch, nicotine gum, etc.)
  • Self-help information (brochures, Web sites, etc.)
  • Telephone quit-line
  • Contests and challenges
  • Health fairs
  • Lunch and learn sessions
  • Peer support
  • 100 percent smoke-free policy in the workplace
  • Other (please explain)
• 12. What would stop you from participating in smoking cessation activities offered through our workplace?
  For example, cost, time, family members or spouses not being able to participate, etc. Please explain.
  

Thank you for taking the time to complete this survey. This information will assist us in planning cessation activities and supports.

Estimating the Cost of Smoking in Your Workplace

In 2006 the Conference Board of Canada updated a formula it had developed in 1997 to estimate the cost of smoking to a business or organization. According to this new information the estimated annual cost is up to $3,396 for each employee who smokes. This includes costs associated with increased absenteeism, decreased productivity, and providing commercial ashtrays for outside smoking areas and keeping these areas clean.

Increased absenteeism

The most recent Canadian research data indicate that smokers take two more sick leave days per year than their non-smoking counterparts. Calculating the cost of additional absenteeism is a matter of multiplying the difference between the annual number of sick days taken by smokers and non-smokers by the average daily per-employee payroll cost. The formula for calculating the additional absenteeism cost of smoking employees to employers is:

COST Absent = DAYS LOST Smoker × DAILY WAGE ×
(1 + BENEFITS and TAXES) = $323

COST Absent

Annual per-employee cost due to increased absenteeism (in dollars per employee)

DAYS LOST Smoker

Number of additional days in absenteeism taken by a smoking employee compared with a non-smoker

DAILY WAGE

Average daily wage (weekly wage of $717.50, divided by five working days)

DAILY WAGE

average daily wage (industrial composite: divide average weekly wage by 5 working days)

BENEFITS and TAXES

Payroll taxes and benefits paid by employer (supplementary labour income) expressed as a percentage of payroll

Decreased productivity

The second part of the model examines the cost of cigarette breaks taken by smoking employees during the workday. This cost only applies to employees who are unable to smoke in their immediate work area and must travel to another location to have a cigarette. But because of new municipal bylaws and stronger provincial legislation prohibiting smoking in public places and workplaces this cost now applies to a large majority of employees who smoke.

It is assumed that on average smokers consume five cigarettes in an eight-hour workday and that three of these are consumed during employer-sanctioned breaks. In terms of lost productivity it is assumed smokers take two smoking breaks on time not sanctioned by employers as rest time. Also, given the increased bans on smoking in public places it is also reasonable to assume that smoking breaks now take longer as employees usually have to travel longer to a location where they are permitted to smoke. In total each smoking employee now spends 40 minutes every day (two 20-minute breaks) consuming cigarettes outside sanctioned rest time.

The average hourly wage, combined with payroll taxes and benefits is used to calculate the cost of extra smoking breaks to employers using the following formula:

COST Prod =
CIGS × (TIME ÷ MINUTES) × WAGE Average ×
(1 + BENEFITS and TAXES) × DAYS WORKED
= $3,053

COST Prod

Annual loss of productivity (in dollars per employee)

CIGS

Average number of cigarettes smoked per day at work during non-sanctioned break periods (assumption: two)

TIME

Time taken to travel to smoking area and consume cigarette (assumption: 20 minutes per break)

MINUTES

Number of minutes in an hour (60)

WAGE Average

Average hourly wage (weekly wage of $717.50, divided by 40 hours)

BENEFITS and TAXES

Payroll taxes and benefits paid by employer (supplementary labour income) expressed as a percentage of payroll

DAYS WORKED

Number of days worked per year

Smoking facilities costs

Because smoking is now banned in most public places very few workplaces offer designated smoking rooms or other indoor areas. Workplaces no longer have to incur the associated costs of insuring, cleaning, maintaining and ventilating these spaces. In an effort to encourage their employees to quit smoking, most organizations also do not install expensive outdoor shelters but some do install industrial ashtrays outside.

The costs to employers for smoking facilities include purchasing and replacing a limited number of commercial ashtrays and cleaning them as well as the surrounding area. The formula for calculating these costs is:

Formula 1 (Ashtrays)

Ashtray = [($ ASHTRAY) ÷ (ASHDURA)] ÷ SMOKE-EMP = $8.50

ASHTRAY

Overall cost of ashtrays to employers (dollars per employee)

$ ASHTRAY

Median annual cost of three ashtrays (assumption: $212.50)

ASHDURA

Lifespan of an ashtray (assumption: three years)

SMOKE-EMP

Number of employees served by one ashtray (assumption: 25)

Formula 2 (Cleaning time)

ASHCLEAN =
[(CLEANTIME÷MINUTES) × WAGECLEAN × (1 + BENEFITS and TAXES) × WORKYEAR]
÷ SMOKE-EMP
= $11.34

ASHCLEAN

Cost of cleaning ashtrays in workplace (dollars per employee)

CLEANTIME

Average amount of time taken to clean ashtrays (assumption: 20 minutes

MINUTES

Number of minutes an hour (60)

WAGECLEAN

Average hourly earnings for administration and support, waste management and remediation services ($581.30 divided by 40 hours)

WORKYEAR

Number of weeks in a year (52)

BENEFITS and TAXES

Payroll taxes and benefits paid by employer (supplementary labour income) expressed as a percentage of payroll

SMOKE-EMP

Number of employees served by one ashtray (assumption: 25)

Total smoking facilities Costs
ASHTRAY + ASHCLEAN = $20

(Source: The Conference Board of Canada, 2006.)

Smoking Cessation in the Workplace: Comparing the Different Approaches

Checklist for Assessing Smoking Cessation Programs

If you are going to establish an in-house program or partner with an outside agency, there are some factors you may want to consider:

• Can the program be offered at times and in locations that are convenient for your employees?
• Will the program suit your employees' personalities and styles of learning?
• Do the program leaders recognize that not all smokers are at the same stage in the quitting process? Can they modify their approach accordingly?
• Has the program been evaluated and does it have a proven (but not exaggerated) success rate based on a thorough three-and six-month follow-up?
• Is the program offered by or associated with a credible organization?
• Is there sufficient follow-up and support?

Consider asking the following questions about the program content and its leaders (the more "yes" answers the better).

Does the program:

• Help the smoker deal with the physical addiction of smoking?
• Incorporate the use of quit medications?
• Help the smoker deal with the psychological addiction of smoking?
• Help the smoker deal with the social nature of smoking?
• Prepare the smoker for a future without cigarettes?
• Reinforce the smoker's motivation to quit?
• Provide tips to control urges to smoke?
• Make use of the special support systems and other wellness activities in the workplace?
• Provide information about stress management, physical activity and nutrition?

Are the program leaders:

• Knowledgeable about behaviour change in general and smoking cessation in particular?
• Supportive and genuinely interested in helping people quit smoking?
• Do a reference check. Call other health organizations to ask about the program and speak with people who have participated in the program.

Do a reference check. Call other health organization to ask about the program and speak with people who have participated in the program.

(Source: Adapted from Selecting Smoking Cessation Programs: A Manager's Guide, Health Canada.)

Evaluation Tool

This HTML document is not a form. Its purpose is to display the information as found on the form for viewing purposes only. If you wish to use the form, you must use the alternate format.

1. How did you hear about the program? (Please check all that apply)
   
   
   • newsletter
   • manager
   • staff meeting
   • e-mail message
   • bulletin boards
   • word-of-mouth
   • ccupational health and safety nurse or other health promoter in the workplace
   • other (please explain)
2. What was your goal when you joined the group? (check one only)
   
   
   • stop smoking
   • reduce smoking
   • other (please explain)
3. Did your goal change as you went through the program? (circle one)
   
   
   • Yes
   • No

   If yes, how did it change? Please explain.

4. Are you smoke-free today? (circle one)
   
   
   • Yes
   • No

   If yes, please skip to question 8; if no, please continue.

5. Why do you think you started smoking again or did not quit?
   Please explain.
   
6. Are you thinking about quitting smoking again?
   
   
   • Yes
   • No
   
   
   
   • Within 1 year
     • Yes
     • No
   • Within 6 months
     • Yes
     • No
   • Within 1 month
     • Yes
     • No
7. Was the program offered at a time and location that were convenient? Please explain.
   
8. Which tools, techniques or resources did you find useful? (Please check all that apply)
   
   
   • group leader
   • breathing/relaxation exercise
   • positive self-talks
   • handouts and self-help material (please specify)
   • telephone quit-line
   • group discussions
   • contest
   • buddy system
   • quit medications (please list)
   • other (please specify)
9. Is there anything you would suggest adding or changing about the program?
   
10. Was there anything else that you found helpful that was not part of the program?
    
11. How many sessions did you attend?
    session(s) of
    
12. What will you remember most about the program?
    
13. Would you recommend the program to other people? (circle one)
    
    
    • Yes
    • No
14. Would you be interested in volunteering to help with other cessation activities or workplace wellness initiatives?
    If yes, on a separate piece of paper please write your name and phone number and give it to your group leader. (circle one)
    
    
    • Yes
    • No

Thank you for completing this evaluation form. And congratulations on your decision to become smoke-free!

(Source: Adapted from Stop Smoking: A Program for Women.)

Section VI: Handouts for Employees

These handouts are designed to provide employees with information about quitting smoking. They can be photocopied and distributed at meetings or through internal mail, posted on notice boards or put in pay envelopes.

Health Benefits of Quitting Smoking

This handout spells out the immediate and longer-term benefits of quitting smoking. It can be used to help motivate employees to take advantage of on-site or community-based smoking cessation programs and resources.

10 Ways to Help a Friend Quit Smoking

This handout describes 10 ways to help people who are in the process of becoming smokefree. It is intended to help increase support for employees who want to quit smoking.

Dealing with Withdrawal

This handout outlines the most common withdrawal symptoms and suggests ways of coping with them.

Dealing with Cravings

The times, places and situations that can trigger the urge to smoke are outlined as well as some strategies for coping with them. A sample daily record is included to help people keep track of their triggers and cravings.

Tips for Cutting Down or Quitting Smoking

This handout includes a list of quick tips to help people cut down or quit smoking and a table to fill out the advantages and disadvantages associated with quitting.

Slips and Relapse - Learning from Them and Getting Back on Track

The difference between a slip and a relapse are explained in this handout, as well as tips for coping with each and getting back on track. Also included are some ideas for developing a plan to prevent slips and relapse.

The Five Stages of Quitting

The five stages of quitting are outlined to allow smokers to identify where they are in the quitting process.

What Would You Buy?

This handout encourages people to figure out how much they will save when they quit smoking over days, weeks, months, and years. It also includes a section for them to fill out what they will buy with the money they will save.

Top 10 Reasons to Stop Smoking

A top 10 list of reasons to stop smoking, with space for people to add their own reasons.

Health Benefits of Quitting Smoking

Quitters immediately begin to reduce the risks of developing heart disease, cancer and breathing problems. Former smokers live longer than those who continue to smoke. For example, those who quit before age 50 have only half the chance of dying from a smoking-related disease in the next 15 years compared with those who continue to smoke.

Your body will start to heal within 24 hours of quitting...

• 20 minutes after quitting, your blood pressure drops to your pre-cigarette level.
• 8 hours after quitting, the carbon monoxide in your blood drops to normal and the oxygen level in your blood increases to normal.
• 24 hours after quitting, you lower your chances of having a heart attack.
• 48 hours after quitting, your sense of smell and taste improve and begin to return to normal.

In the months and years to come, your body continues to recover...

• 2 weeks to 3 months after quitting, your circulation improves and your lungs work better. (Try taking the stairs now!)
• 9  months after quitting, you experience less coughing, sinus congestion, fatigue and shortness of breath.
• 1 year after quitting, your risk of heart disease is about half of what it would have been if you had continued to smoke.
• 5 years after quitting, your risk of stroke is greatly reduced. Within 5 to 15 years after quitting, it becomes about the same as a non-smoker's risk.
• 10 years after quitting, your risk of dying from lung cancer is about half of what it would have been if you had continued to smoke. Your risk of cancer of the mouth, throat, esophagus, bladder, kidney and pancreas also decreases.
• 15 years after quitting, your risk of heart disease is the same as a person who never smoked.

Over half the people who have ever smoked in Canada have quit.

You can too!

(Source: Adapted from materials from Health Canada's www.gosmokefree.gc.ca, the Program Training and Consultation Centre, and the Alberta Tobacco Reduction Alliance.)

10 Ways to Help a Friend Quit Smoking

People who smoke need support and understanding when they are struggling to become smoke-free. Here are 10 ways you can help.

1. Ask how you can help. Make yourself available as much as possible, especially during the first few days.
2. Be patient. Most people who quit smoking experience physical and psychological withdrawal symptoms. These symptoms usually peak within 48 hours, but might last as long as four weeks. Be especially understanding during this time.
3. Listen. Don't preach or counsel; Just listen. Hostility and irritability can be a normal - and temporary - part of the withdrawal process. Encourage him to talk about his feelings.
4. Encourage her to seek help. Suggest she participate in smoking cessation activities at work or in the community and that she ask her doctor or the workplace nurse for help. Encourage her to use self-help materials available at work or from community agencies such as the Lung Association or the Cancer Society.
5. Help him avoid smoke and others who smoke as much as possible. Invite him to join you in activities that are not associated with smoking, such as walking, swimming, or going to theatres, libraries and department stores.
6. Offer practical support. Quitting can be very stressful. Offer to help minimize other pressures by taking her kids for a few hours or helping with difficult work situations.
7. Keep a supply of smoking substitutes on hand. People who quit smoking miss the satisfaction of handling and inhaling a cigarette. Keep a supply of gum, mints, toothpicks and straws on hand.
8. Be supportive if your friend has a relapse. Sometimes it takes five or more attempts before a smoker quits for good. Encourage your friend to build on what he has learned and to try again.
9. Celebrate success. Help mark significant milestones such as three days, one week, or one month of being smoke-free. Send her a note of congratulations, take her out to lunch, send flowers.
10. Reinforce the benefits of staying smoke-free. Encourage your friend to use the money he has saved to purchase something special. Celebrate the health benefits by participating in a charity walk or run.

(Source: Adapted from materials from the Program Training and Consultation Centre and the Alberta Tobacco Reduction Alliance.)

Dealing with Withdrawal

When you stop smoking, your brain and body begin the process of healing themselves. At the beginning of the quitting process, some people experience symptoms of nicotine withdrawal, and this is part of the recovery process. For most people, withdrawal is at its worst one day after they stop smoking. It starts to get better after three or four days. After a week to 10 days, all withdrawal symptoms should be gone.

Because the symptoms are most intense in the first few days after you stop, this is when you are most likely to start smoking again. Therefore, it is important to find positive ways to cope. Your main task in quitting is to find a way to get through the first few days. If you do, you have a much better chance of succeeding for good.

If you expect your withdrawal symptoms to be severe, consider using a quit medication that does not require a prescription such as the nicotine patch or nicotine gum. Bupropion (brand name Zyban™) is a prescription medication that may help reduce withdrawal symptoms.

(Source: Adapted from materials from Health Canada's www.gosmokefree.gc.ca, Capital District Health Authority, Halifax and Department of Family and Community Medicine at the University of Toronto.)

Dealing with Cravings

There are times, places and situations that will trigger the urge to smoke, even after you have stopped feeling withdrawal symptoms. It is important to be aware of what triggers your cravings and have some strategies for coping with them.

Some common triggers include:

• coffee or alcohol;
• other people smoking;
• first thing in the morning;
• after school or work;
• talking on the phone;
• driving in the car;
• after eating;
• at parties;
• stress;
• anger;
• feeling lonely or sad;
• feeling bored.

Try using the 4 Ds

• Drink plenty of water - between 6 and 8 glasses per day.
• Delay for 5 to 7 minutes. The urge should pass.
• Do something else.
• Deep breathing.

Daily Record

Keep a daily record form, using it to keep track of:

1. what happens to you around cigarettes;
2. what makes you crave a cigarette;
3. what you do to follow your quitting plan.

Tips for Keeping Track

• Write things down when they happen, not later.
• Be accurate. Try to write down the details every time a situation happens.
• Keep your notes simple. Filling the form out has to fit in with your usual habits.

Daily Record

• Trigger
• Behaviour/Actions/Thoughts/Emotions
• Consequence

Date:

Other ways to cope with cravings include:

• In the short term, stay away from social situations where others will be smoking, and ask friends not to smoke around you.
• Keep your home, car and workplace smoke-free.
• Avoid alcohol and coffee. Choose water or fruit juices instead.
• Change your routine when you get up in the morning.
• Get up immediately after you eat and brush your teeth if it helps.
• Try to avoid situations that you find stressful.
• Continue to visualize yourself as a non-smoker.
• Remind your family and friends that you have quit smoking and you need their support.
• Remind yourself of why you quit smoking and the positive things you have experienced since you have quit. Remind yourself you can do it.
• Go for a walk or do some other physical activity.
• Reward yourself for not smoking by going to a movie or buying yourself a treat.
• Chew on a toothpick, chew gum or munch fresh veggies.
• Do an activity that will take your mind off your craving, such as playing cards, listening to music, doing a crossword puzzle, doodling or watching TV.

(Source: Adapted from Health Canada's www.gosmokefree.gc.ca, Capital District Health Authority, Halifax and Department of Family and Community Medicine at the University of Toronto.)

Tips for Cutting Down or Quitting Smoking

Use the following for-and-against list to outline the short-and long-term advantages to quitting smoking. In one column write down the advantages for smoking and in the other your reasons for quitting. Keep in mind the advantages and disadvantages to your health, family, friends, finances, self-esteem, and emotional well-being. Refer to the list from time to time to remind yourself of why you are quitting.

Advantages of Quitting

• Short-Term Advantages of Quitting
  5. 
     
• Long-Term Advantages of Quitting

Disadvantages of Quitting

• Short-Term Disadvantages of Quitting
  5. 
     
• Long-Term Disadvantages of Quitting

Other tips for cutting down or quitting smoking

• Write down your plan for quitting, which can include your reasons, potential pitfalls, stages of progress, and how you'll deal with temptations.
• Think positively, especially by focusing on one day at a time and on each of your achievements.
• Be sure to ask for help and support from those around you. Having at least one friend you can count on and share your feelings with may improve your chances of quitting for good. If your partner smokes, see if you can encourage him or her to join you on your journey.
• Decide whether you're going to quit cold turkey or gradually, and what kind of professional support services you want to use, if any. You may want to consider counselling, group programs or nicotine replacement therapies.
• Learn about and prepare yourself for possible withdrawal symptoms.
• If you slip, don't be too hard on yourself. Keep focused on sticking to your quit plan. Look at what triggered the lapse and figure out how to handle it differently next time. A slip or two does not mean you've failed in your effort to quit.
• Don't worry about weight gain, it doesn't happen to everyone and is often insignificant when it does. Control it by sticking to the same diet you usually eat, choosing low-calorie snacks, and by increasing exercise and physical activity.
• If you experience cravings, try the four Ds: Drink water, Delay, Do something else, and Deep breathing.

If you believe you're someone who smokes to deal with stress, look into new ways of coping; there are many. Tips for dealing with stress can be found on Health Canada's Web site www.gosmokefree.gc.ca.

(Source: Adapted from Health Canada's www.gosmokefree.gc.ca.)

Slips and Relapse - Learning from Them and Getting Back on Track

Slips

A slip is when you have a cigarette or two after you have quit smoking. It is not uncommon for people who are trying to quit to have an occasional slip. Because smoking can be so automatic, you may not even be consciously aware that you've smoked until after you've finished.

A slip or two does not mean that you have failed. If you slip, the best thing to do is to keep it minor, and go back to quitting as soon as you can. Look at what led up to the slip and figure out how to handle it differently next time. A slip will not prevent you from quitting successfully -you just have to get back on track.

Tips for preventing slips:

• Reinforce why you want to quit.
• Continue positive self-talk; do not get discouraged.
• Get help and support from friends.
• Ride out the temptation; the urge passes quickly.
• Look at what caused you to smoke and how you plan to get back on track.
• Develop a plan to deal with the situation in the future.

Relapse

A relapse is when you start smoking again on a regular basis. A relapse will not prevent you from quitting successfully. Quitting smoking is a process and most people make more than one quit attempt before they quit for good. Don't feel discouraged. As long as you learn something positive with each quit attempt, you will be further ahead than before you made the attempt. Relapse only becomes a negative thing if you let it get you down.

How to overcome relapses:

• Do not beat yourself up.
• Think of the relapse as a learning experience and one more step in your journey to becoming smoke-free.
• Be proud of the time you were smoke-free.
• Start planning a new quit attempt right away, including developing a plan to prevent relapse.

Plan to Prevent Slips and Relapse

The key to staying smoke-free is to be aware of the people, places, situations, thoughts, and emotions that trigger you to smoke. Then plan ahead what you will do to cope with each trigger. You may have to keep thinking about your triggers for a long time after you quit because some situations, especially unexpected ones such as crises, can catch you by surprise. If you figure out ahead of time how you will deal with difficult situations, you are more likely to stay quit.

This is how it works

Identify your high-risk situations.

Identify ways you could cope with each trigger situation and write it down. Keep this as a written action plan. Try to think of a three-way strategy for each situation:

1. What will you tell yourself? It helps to have this written on a small card that you carry with you.
2. Who will you ask for help and what type of help can you ask for?
3. What will you do?

Rehearse each situation ahead of time so it doesn't feel awkward. Rehearsing puts your coping plan in the front of your mind.

Review the plan often to keep it fresh in your mind.

When you find yourself in the trigger situations, put your plan into action.

Write down what happened and how you did with a daily record form (refer to the Dealing with Cravings handout for an example of a daily record form). If you resist the urge to smoke using your plan, your confidence will go up and you will know what strategies work for you. If you can't resist the urge to smoke, review what happened and revise your plan to deal with the difficulties.

(Source: Adapted from materials from Health Canada's www.gosmokefree.gc.ca and Capital District Health Authority.)

The Five Stages of Quitting

Quitting usually happens in five stages. People can move from one stage to another in order, but they can also move back and forth between the various stages before they quit for good. Again, a slip is not a failure, but an important part of the learning and quitting process. Most smokers try to quit several times before they succeed and the chance of success increases every time they try to quit. What stage are you at?

• Stage One (Pre-contemplation): I'm not thinking about quitting, at least not in the next six months. In this stage, you may feel it is hopeless to even think about trying to quit smoking. You may even feel your smoking is not a problem.
• Stage Two (Contemplation): I'm thinking about quitting someday, but not right now. In this stage, you know that you have a behaviour you wish to change and are trying to figure out how to do that.
• Stage Three (Preparation): I want to quit within the next month or two, and I want to know more about how to do it. By now, you are ready to plan your quit program and to set a specific quit date.
• Stage Four (Action): I have just quit and I am going through withdrawal. My body is reacting in uncomfortable ways. This can be a tough stage. You may have been through withdrawal before but started smoking again. Hang in there. If you do slip and have a puff, just forget about it and continue with your plan to quit.
• Stage Five (Maintenance): I have quit smoking and I want to know more about how to never smoke again. Some people find this the hardest stage of all. You've reached your goal, but you have to really work at staying smokefree for good.

(Source: Adapted from Health Canada's www.gosmokefree.ca.)

What Would You Buy?

What would you do with the money you would save if you quit smoking? Use the chart below to figure out what you would buy if you did not buy cigarettes for the next 10 years. In the second column put in the amount you spend on cigarettes starting at 1 day and ending with 10 years. For example, if you smoke one pack a day and each pack is $7.00, in one day you would save $7.00, in one week you would save $49.00 ($7.00 × 7 days) and in one month (4 weeks) you would save $196.00 ($49.00 × 4 weeks).

If you and your partner both smoke, fill out the table for both of you to see what you could buy if you combined your cigarette money.

• Time
  • 1 day
  • 1 week
  • 2 weeks
  • 3 weeks
  • 4 weeks (1 month)
  • 2 months
  • 3 months
  • 4 months
  • 5 months
  • 6 months
  • 1 year
  • 2 years
  • 5 years
  • 10 years
• Amount spent on cigarettes
• What would you buy?

Source: Adapted from Health Canada's www.gosmokefree.gc.ca.)

Top 10 Reasons to Stop Smoking

1. Better health. Improved health is the number one reason to quit smoking. As soon as you quit your body starts to heal itself.
2. Better breathing. Smoking affects your breathing - the longer you smoke the harder it is to breathe.
3. Personal appearance. Quitting will improve personal appearance by reducing bad breath, yellow teeth and fingers, and prematurely aging skin.
4. Role model for children. Be a positive role model for your own children, and for everyone else's children.
5. No more second-hand smoke. If you quit smoking you will help protect your friends and family from the dangers of second-hand smoke.
6. Better smell. When you quit smoking, your sense of smell will increase and everything will smell better - including yourself, your house and your car.
7. Fewer places to smoke. With increased smoking restrictions in public places, including workplaces, there are fewer places to smoke these days.
8. Smoking is expensive. You will save hundreds or thousands of dollars each year if you quit smoking.
9. Smoking is a fire hazard.
10. It is never too late to quit smoking. If you have tried to quit before, take this as a positive sign, not a failure. It often takes several quit attempts to quit for good - each time you try to quit smoking you are closer to your goal.
    Keep trying and don't get discouraged!

Add your own reasons for quitting smoking to the list:

Section VII: References

This section includes a list of many of the documents that were part of the literature review that guided the development of this resource. They are organized according to topic for ease of reference.

Health Canada References and Resources

Health Canada provides a variety of resources and reference materials around tobacco control issues including policy information and cessation resources for individuals and professionals. The Canadian Tobacco Use Monitoring Survey (CTUMS) provides timely, reliable and continual data on tobacco use and related issues, including changes in smoking status. Also refer to Section IV: Resources for other Health Canada resources.

• 1994 Youth Smoking Survey: Technical Report - Chapters 9 and 10. Ottawa: Department of Public Works and Government Services Canada. Health Canada, 1997.
• Toward a Healthy Future Second Report on the Health of Canadians. Ottawa: Department of Public Works and Government Services Canada. Health Canada, 1999.
• Canadian Tobacco Use Monitoring Survey (CTUMS). www.gosmokefree.gc.ca/ctums
• Towards a Healthier Workplace: A Guidebook on Tobacco Control Policies. Ottawa: Department of Public Works and Government Services Canada. Health Canada, 2003.
• A "how-to" for health and business success. HealthWorks. Health Promotion and Programs Branch, Health Canada, 1999.
• Health Canada. Literature Review: Evaluations of Workplace Health Promotion Programs. Health Promotion and Programs Branch, Population Health Directorate, Adult Health Division, Health Canada.
• Health Canada. Program Evaluation Manual. Key Issues and Strategies for Evaluating Your Workplace Health Promotion Program. Workplace Health System, Health Promotion and Programs Branch, Population Health Directorate, Adult Health Division, Health Canada.

The Desire to Quit Smoking and Cessation Activities at Work

The following resources provide information around who wants to quit smoking and the desire for cessation support at work. Also refer to the above section for Health Canada resources for additional information.

• Canadian Fitness and Research Lifestyle Institute (1995). Smokers interested in workplace quitting programs. Lifestyle Tips. www.cflri.ca
• Millar, W. (1997). Reaching smokers with Lower Educational Attainment. Canadian Social Trends, Summer: 18-23.
• Moskowitz, J. (2001). The Impact of Smoking Ordinances in California on Smoking Cessation. American Journal of Public Health, 90: 757-61.

The Case for Supporting Cessation in the Workplace

The following references outline the key reasons for supporting smoking cessation in the workplace, including better health, reduced costs, better business, employee satisfaction, effectiveness and a positive image.

• Bialous, S. and S. Glantz (1997). Tobacco Control in Arizona. Institute for Health Policy Studies, University of California. Access date: 8 August 2001.
• Bourns, B. and A. Malcomson (2001). Economic impact analysis of the non-smoking bylaw on the hospitality industry in Ottawa: KPMG.
• Canadian Lifestyle and Research Institute (1995). Kicking the Habit at Work. The Research File. Reference No. 95 - Supplementary.
• Canadian Lung Association (Summer 1999). Beyond the Smoke-Free Workplace. Secondwind.
• Cancer Care Nova Scotia (date unknown). Cost of Tobacco in Your Workplace. Cancer Care Nova Scotia: Halifax.
• Center for Prevention and Health Services (2003). Reducing the Burden of Smoking on Employee Health and Productivity. Issue Brief, Volume 1, Number 5.
• Doll, R., R. Peto, K. Wheatley, et al. (1994). Mortality in relation to smoking: 40 years' observations on male British doctors. British Medical Journal, 309:901-911.
• Henningfield, J., R. Fant, J. Gitchell, et al. (2000). Tobacco dependence. Global public health potential for new medications development and indications. Annals of the New York Academy of Sciences, 909:247-256
• Moher, M., K. Hey, and T. Lancaster (2004). Workplace Interventions for Smoking Cessation (Cochrane Review). Cochrane Library, Issue 1.
• Professional Assisted Cessation Therapy (PACT) (2003). Employers' Smoking Cessation Guide. Practical Approaches to a Costly Workplace Problem. Second edition. www.endsmoking.org
• Single, E., L. Robson, X. Xie, J. Rehm, et al. (1996). The Costs of Substance Abuse in Canada - Highlights. Ottawa: Canadian Centre on Substance Abuse.
• Workers Compensation Board of British Columbia (WCB) (1999). Lost Lives: Work-Related Deaths in British Columbia, 1999. www.worksafebc.com
• World Bank Health, Nutrition and Population Web site at World Bank Group, Health, Nutrition and Population (2002). Smoke-free workplaces (PDF Version - 110 K). [Fact sheet] http://siteresources.worldbank.org/INTPHAAG/Resources/AAGSmokeFreeWorkplaces.pdf

Legislation Across the Country

This report reviews legislative protection from second-hand smoke in federal and provincial jurisdictions.

• Collishaw, N. and H. Meldrum (2003). Protection from Second-Hand Smoke in Canada: Applying Health Science to Occupational Health and Safety Law. Ottawa: Physicians for a Smoke-Free Canada.

The Cost of Implementing Cessation Activities in the Workplace

The following references outline some of the costs associated with implementing smoking cessation activities in the workplace.

• Borland, R., S. Chapman, N. Owen, et al. (1990). Effects of workplace smoking bans on cigarette consumption. American Journal of Public Health, 80(2); 178-180.
• Canadian Lung Association (Summer 1999). Beyond the Smoke-Free Workplace. Secondwind.
• Conference Board of Canada (2006). Smoking and the Bottom Line: Updating the Costs of Smoking in the Workplace. Ottawa, ON: Conference Board of Canada.
• DePaul, J.L., T. Lesowitz, et al. (1989). A Worksite Smoking Cessation Intervention Involving the Media and Incentives. American Journal of Community Psychology, 17:785-99.
• Depaul, J.L., S. McMahon, D. Salina, et al. (1994). Assessing a Smoking Cessation Intervention Involving Groups, Incentives, and Self-help Manuals. Behavior Therapy. 26:393-408.
• Erfurt, J., A. Foote, M. Heirich, et al. (1991). Worksite Wellness Programs: Incremental Comparison of Screening and Referral Alone, Health Education, Follow-up Counselling, and Plant Organization. Journal of Occupational Medicine, 33:962-70.
• Jeffery, R., D. Hennrikus, H. Lando, et al. (1993). The Smoking Cessation Process: Longitudinal Observations in a Working Population. Preventive Medicine, 24:235-244.
• Moher, M., K. Hey, and T. Lancaster, (2004). Workplace Interventions for Smoking Cessation (Cochrane Review). Cochrane Library, Issue 1.
• Windsor, R. and J. Lowe (1989). Behavioral Impact and Cost Analysis of a Worksite Self-Help Smoking Cessation Program. Progress in Clinical and Biological Research, 293:231-242.

Benefits to Workplaces

The following resources outline some of the benefits to workplaces that offer smoking cessation supports to their employees. Also refer to the above section on Health Canada references and resources for further information.

• Professional Assisted Cessation Therapy (PACT) (2003). Employers' Smoking Cessation Guide. Practical Approaches to a Costly Workplace Problem. Second edition. www.endsmoking.org
• The Hartford Loss Control Tips, Smoking Cessation: Worksite Programs www.thehartford.com/corporate/losscontrol

Workplaces as Effective Settings

The following resources explain why workplaces are an ideal setting for helping people quit smoking.

• Centres for Disease Control (2000). Work, Smoking, and Health: A NIOSH Scientific Workshop. Washington: Centres for Disease Control.
• Moher, M., K. Hey, and T. Lancaster (2004) Workplace Interventions for Smoking Cessation (Cochrane Review). Cochrane Library, Issue 1.

Cessation Interventions, Including Approaches and Options

The following resources highlight important issues to consider when implementing cessation activities, and outline the available options and approaches.

• Centres for Disease Control (2000). Work, Smoking, and Health: A NIOSH Scientific Workshop. Washington: Centres for Disease Control.
• Coleman, T. (2004). ABC of Smoking Cessation, Use of Simple Advice and Behavioural Support. British Medical Journal Clinical Review, 328:631-633.
• Grigg, M. and H. Glasgow (2003). Subsidised nicotine replacement therapy. Tobacco Control. 12:238-239.
• Henningfield, J. (2000). Tobacco dependence treatment: scientific challenges; public health opportunities. Tobacco Control, 9(Suppl 1): i3-i10 (Spring).
• Lancaster, T. and L. Stead (1999). Review: self-help interventions alone minimally increase smoking cessation rates. Evidence-Based Nursing, 2(3): 80.
• U.S. Department of Health and Human Services, Centres for Disease Control and Prevention, Office on Smoking and Health (1996). Making your Workplace Smoke-Free: A Decision Maker's Guide. Atlanta, GA: U.S. Department of Health and Human Services, Centres for Disease Control and Prevention, Office on Smoking and Health.

Establishing Cessation Activities

This section includes further information around establishing cessation activities in the workplace including design steps and successful intervention strategies.

• Center for Prevention and Health Services (2003). Reducing the Burden of Smoking on Employee Health and Productivity. Issue Brief, Volume 1, Number 5.
• Professional Assisted Cessation Therapy (PACT) (2003). Employers' Smoking Cessation Guide. Practical Approaches to a Costly Workplace Problem. Second edition. www.endsmoking.org
• The Hartford Loss Control Tips, Smoking Cessation: Worksite Programs. www.thehartford.com/ corporate/losscontrol
• U.S. Department of Health and Human Services, Centres for Disease Control and Prevention, Office on Smoking and Health (1996). Making your Workplace Smoke-Free: A Decision Maker's Guide. Atlanta, GA: U.S. Department of Health and Human Services, Centres for Disease Control and Prevention, Office on Smoking and Health.
• U.S. Office of Personnel Management (date unknown). Guidance on Establishing Programs Designed to Help Employees Stop Smoking. www.opm.gov/ehs/smokgud3.asp

Tailoring Cessation Efforts to Different Workplace Settings

The following resources include information on tailoring cessation activities to different workplace settings. Also refer to the above section on Health Canada references and resources for further information, including Canadian Tobacco Use Monitoring Survey and Towards a Healthier Workplace: A Guidebook on Tobacco Control Policies.

• Ashley, J., J. Eakin, S. Bull, et al. (1997). Smoking Control in the Workplace: Is Workplace Size Related to Restrictions and Programs? Journal of Occupational and Environmental Medicine, 39(9): 866-873.
• Canadian Centre for Occupational Health and Safety (2002). www.ccohs.ca/oshanswers/psychosocial/ets_resolutions.html