In total, we conducted 13 semi-structured interviews with 14 employers and four focus groups with 29 employees. We excluded one employer from our analysis after it was discovered during the course of the interview that they worked for a company employing over 250 employees; thus, the findings reported here are based on 12 interviews with 13 employers. The mean age of employers (Table 1) was 53 years (SD = 11). The largest proportions of employers were male (54%), White (92%), and Non-Hispanic (100%). Sixty-two percent had never smoked, 38% had formerly smoked, and no employers currently smoked. All employers indicated that their worksite offered health insurance to employees. The mean age of employees (Table 2) in the focus groups was 42 years (SD = 14). The largest proportions of employees were female (59%), White (76%), and Non-Hispanic (83%). About 38% of employees currently used tobacco, followed by 35% who formerly used tobacco and 28% who never used.

Table 1 Participant characteristics, employers, n = 13Table 2 Participant characteristics, employees, n = 29

Employer Interviews

Three key themes arose from our interviews: 1) the local environment played an important role in tobacco control EBI implementation; 2) tobacco control was perceived as important but not a priority; and 3) decisions made about tobacco control were driven by worksite culture. Each of these themes is described in detail below.

Theme 1: The Local Environment Shaped Tobacco Control

Participants described several features of the local environment that facilitated their worksite’s tobacco control efforts. A common facilitator was external policies, such as clean-indoor-air laws. In some cases, enactment of these laws pushed worksites to develop an internal policy or allowed for a more proactive approach to enforcement of, and compliance with, current policies. State political climate also had an impact, with participants in more liberal states noting that people tended to be more supportive and accepting of tobacco control efforts:

“So, I think people in [state] are a little bit more aware about the rules and regulations and are a little less pro-smoking than some other areas I’ve been to. The state laws help, the local laws help.” – Male, 45, Former Cigarette Use

A few participants described collaborating with local agencies on tobacco control interventions, and that this made implementation easier:

“I mean the [external agency collaboration was] huge…even to the costs of implementing, not just creating the policy and understanding best practices and how we’re going to enforce things, but the actual cost of implementation was burdened on somebody else and not on our organization. So that’s certainly helpful.” – Male, 42, Never Smoked

Of note, when we asked participants to describe how local competitors influenced their decisions around tobacco control, nearly all indicated that competitors did not influence implementation.

Theme 2: Tobacco Control Important but Not Prioritized

While participants were supportive of tobacco control efforts, most indicated that it was not a priority at their worksite. In many cases, participants felt like there were not enough employees who used tobacco or issues with compliance to warrant making tobacco control a high priority:

“I don’t think [tobacco control EBIs have] been prioritized enough, but it may have to do with the fact that we don’t have that many smokers…we’re geared more towards overall healthy lifestyle…I think we focus on that a little bit more because we have more staff who need help with it.” – Male, 45, Former Cigarette Use

Participants highlighted tobacco use as being lower and more stigmatized now than in the past, and noted that employees who did use tobacco tended to hide their behavior or do it away from others. In other cases, participants described being satisfied with interventions already in place. While COVID-19 did not have a direct impact on tobacco control efforts at most worksites, a couple of participants described tobacco control dropping in priority due to more pressing issues that had emerged since the pandemic began.

Some participants described being open to implementing new interventions if a demonstrated need among employees existed. When we asked participants to describe key attributes that they would look for when deciding whether or not to adopt a new tobacco control intervention, a few participants described the value in having a prescribed or “turn-key” program to make implementation easier (e.g., ready-made resources, draft policy language, etc.). A couple of participants described the importance of understanding the context for tobacco use and cessation, specifically motivations for use, and the extent to which employees are interested in engaging with tobacco cessation programs. Otherwise, attributes described as desirable varied substantially and included: tailored to the worksite’s industry; evidence-based; has the capability to measure work impact; contains inclusive materials and messaging (e.g., avoids stigmatizing individuals with disabilities caused by tobacco use); and has good graphic design for cessation resources (e.g., posters).

Theme 3: Decision-Making Driven by Company Culture

The culture of the worksite, including leadership support, drove decisions made about tobacco control. Several participants described having a worksite culture or mission aligned with health and wellness; it was made clear by some that tobacco use was not consistent with this culture:

“Well, I mean, we work with young children and so we talk a lot about secondhand smoke and the impact that that has on families…the fact that we work with very young, tender lives is what influences us most to promote anti-tobacco you know, promote not [using] tobacco products.” – Female, 65, Former Cigarette Use

A couple of participants described lacking management support for tobacco-free policies in the past, with subsequent changes in leadership helping to improve enforcement and compliance measures:

“Well it used to be not so good, because two of our managers smoked, and so they would take employees out on the curb across the street and have a smoke break…And now none of our managers smoke and they’re a little more mature, some of them have families, and so I think that makes a huge difference because there’s no one, at least in our businesses that foster smoking anymore.” – Male, 64, Never Smoked

One participant, an executive director, described his experience using tobacco and being exposed to secondhand smoke in his prior job, and said this influenced his decision to implement tobacco control interventions at his current worksite.

When we asked participants how their worksite makes decisions about whether to adopt a new tobacco control intervention, senior leadership was described as being at the forefront of decision making. In some cases, leaders sought feedback and/or approval from an advisory board. Though not all leaders sought feedback from employees, those that did described communicating with employees during monthly staff meetings and via informal conversations. In one case, the participant reached out to the one employee who smoked at their worksite to see if a new tobacco policy would present any issues for that individual. Participants also described receiving input from supervisors, who helped to inform decision-making and gauge buy-in from employees.

Employee Focus Groups

Three key themes arose from our focus groups: 1) employer support for tobacco cessation was limited although there was interest from employees; 2) employees who used tobacco were stigmatized for their behavior; and 3) incentives and coaching were considered ideal interventions. These themes are described in detail below.

Theme 1: Employer Support for Tobacco Cessation was Limited Despite Interest from Employees

Tobacco control EBIs were primarily limited to tobacco-free policies and provision of health insurance benefits for cessation:

“In my case, it’s you’re not allowed to smoke at work. You can smoke at about 50-100 feet away actually from the premises, but I don’t expect them honestly to offer promotions to quit smoking. It’s just kind of up to you. I think all they care about is you come to work; you show up on time and you do as you’re told. You be respectful to other employees and be respectful to your boss. You meet your quota and be respectful and do what’s being asked of you, and go home having done what you’re supposed to do. That’s really all that my work cares about. I don’t think that they care a whole lot about trying to get employees to quit smoking.” – Male, 42, Current Tobacco Use

Most employees described their worksites as having a no-indoor-smoking policy. In many cases, tobacco use was also prohibited on the premises, or there were restrictions on outdoor use (e.g., tobacco use prohibited within 50 feet from building entrances). Participants also described specific benefits offered through their health insurance (e.g., access to nicotine replacement therapy), although these were sometimes perceived as cessation programs external to their worksite. These and other programs mentioned were often described as under-promoted at their worksite and under-utilized by its employees. Some participants felt it was not the responsibility of their worksite to offer support for cessation, although perceptions of tobacco control EBIs were generally positive:

“I think it’s great that companies are encouraging people to be smoke-free and giving them the support. It’s not just telling them, “Hey, we’re not going to be—we have a smoke-free environment and just expect them to adapt I guess without the supportive services like the previous folks had mentioned with the smoking cessation programs. I think it’s helpful, too, if you’re going to evoke a smoke-free environment to assist with the supportive services necessary to do so.” – Female, 35, Never Tobacco Use

Theme 2: Employees Who Used Tobacco Stigmatized for Their Behavior

Participants who currently used tobacco discussed hiding their behavior from co-workers due to the stigma associated with tobacco use. For example, some participants described not using tobacco while at work or leaving their worksite to use tobacco (e.g., in their car parked away from building), wearing perfume to cover up the smell of tobacco smoke, or using other tobacco products like smokeless tobacco or e-cigarettes to be more discreet:

“So, in my work I think that everybody is pretty much healthy. There’s only a few of us who smoke. So, if we do decide to smoke, most of the time we will just like get in the car and then park a few blocks away. And then we smoke and then we go back again, but we would spray perfume all over our bodies so that not a lot of people could smell it. Just because it’s a co-working space so if you stink, anybody could just smell it right away.” – Female, 27, Current Tobacco Use

One employee described not disclosing their smoking status in order to obtain jobs because they believed they would not be hired otherwise. Relatedly, some participants who did not currently use tobacco described those who did getting more breaks at work, which was perceived as unfair:

“…smokers get a lot more breaks than non-smokers. So, a bunch of non-smokers took up, “Hey, can we get an extra week of vacation because we don’t take smoke breaks?” So just something similar like that, it kind of sounds selfish, but at the same time they’re going to the effort for smokers, you know? You kind of feel a little not betrayed, but a little slighted if you’re a non-smoker.” – Male, 31, Never Tobacco Use

Theme 3: Incentives and Coaching Considered Ideal Interventions

When we asked employees to describe what an ideal tobacco control EBI would look like at their worksite, several employees mentioned offering incentives for being tobacco-free as well as cessation coaching or counseling. Example incentives included money, gift cards, and lowered healthcare cost-sharing (e.g., reduced monthly premiums):

“I would tend to think an incentive also, like give me a reason why I should quit. I know that’s the addiction that’s speaking out that way. I mean, it could be money-wise, or it could be gift cards or anything to that effect. I think that an incentive would be very powerful with a lot of people — not everybody, but quite a few people.” – Female, 52, Current Tobacco Use

A few employees described wanting a designated worksite space for cessation coaching and flexibility to access these services during the workday:

“…we offer one-on-one coaching through our employee health insurance. I noticed that a lot of their meeting availability for coaches is during the day, Monday-Friday, which is typically when everybody is at work. So maybe some flexibility there and maybe having a designated room or a designated office where those employees could go and meet with their coach virtually.” – Female, 37, Former Tobacco Use

Programs mentioned less frequently included a progressive shift toward 100% tobacco-free policies, social support from co-workers to quit, and mobile phone apps for cessation.

When asked about how to best promote these interventions, employees described e-mail as the preferred method. E-mail was identified as an ideal promotion method because it was used on a daily basis by many employees and in some cases already being used to promote other worksite programs. Additional promotion methods included posting via the worksite’s Intranet site and in common areas. Some participants favored incorporating cessation support into broader health promotion programming. Regardless of program offered, participants described success being dependent on employees’ internal motivation to quit. Some participants who did not currently use tobacco expressed a desire that similar incentives be offered for other health behaviors (e.g., physical activity), and a few participants described existing wellness programs at their worksite that offered such incentives (e.g., reimbursement for gym memberships).

Additional Themes

Two additional themes arose from our analysis of the focus group data: 1) e-cigarettes and vaping were not seen as a healthy alternative to cigarette smoking and 2) the COVID-19 pandemic has influenced tobacco use. Several employees, both who used and did not use tobacco, believed that e-cigarettes should be included in tobacco-free policies and that they did not help with smoking cessation. Some participants described e-cigarettes as being more convenient and easier to conceal, and that this allowed employees to use tobacco in smoke-free locations. As such, e-cigarettes were perceived as being more addictive than cigarettes and leading to more tobacco use overall:

“I’ve had friends switch to e-cigarettes, because like someone said that they don’t smell. They don’t stink after they smoke and so it didn’t help them at all. It helped them not smell bad and it’s not noticeable that they’re smoking sometimes. But then yes, if anything, they’re smoking more and taking in more nicotine than they were before probably.” – Male, 31, Never Tobacco Use

“I think that more people are smoking because of e-cigarettes. It’s the convenience, you know? You turn it on and don’t have to finish the whole cigarette and just take two puffs, take five puffs. I notice a lot more people with their little pens running around.” – Female, 37, Former Tobacco Use

However, some participants believed e-cigarettes could help with cessation if a stepdown approach (e.g., consuming higher to lower amounts of nicotine) was taken. Participants also described e-cigarette use as being more socially acceptable than combustible cigarettes and being used most among younger employees.

Regarding COVID-19, some participants described the pandemic as contributing to an increase in tobacco use, in part due to increased stress and ease of using tobacco while working from home:

“Because labor is one of the few things they can control, so people that are still there are given I think a much heavier workload in some professions. A lot of people smoke to cope with the stress. I could see how that would equate to people continuing to smoke or smoking more than they may have prior to COVID.” – Female, 57, Current Tobacco Use

“I think with people working from home, it’s easier for people to smoke on the job I guess. I mean, I even see people when we’re having Zoom meetings, they’ll be hitting their vape which normally if we were in the office, you know, that wouldn’t be a thing…I think that it’s a game changer for people as far as the amount that they could smoke throughout their workday.” – Female, 35, Current Tobacco Use

One participant described switching from cigarettes to smokeless tobacco, since they were working from home and their roommates did not like the smell of smoke. The extent to which the pandemic influenced worksite tobacco control was less clear. A few participants described both positive and negative changes in their worksite’s practices overall, including a greater push toward wellness, cuts to health benefits, and company downsizing. Opinions of tobacco use and worksite tobacco control EBIs seemed relatively unchanged due to the pandemic.

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