For all employers' focus on curbing obesity statistics through healthy eating and exercise programs, it can be easy to forget that smoking remains the leading cause of preventable death in the United States. One employer, Nelnet, is remaining vigilant about stamping out smoking among its employee population.

Back in 2005, 22% of Nelnet's population smoked, higher than the current national average of 19.3%. Since that year - when the firm launched a wellness program tightly focused on smoking cessation - Nelnet has seen a 73% decrease in smoking, and the employee population that still smokes hovers around 6%. Within the first two years there was 10% reduction in health care claims; over the past four years, health care costs have remained flat.

Coincidence? Nelnet's leaders and wellness partners don't think so.

Tobacco use is responsible for about one-in-five deaths annually (443,000 deaths per year, with an estimated 49,000 of these smoking-related deaths as a result of second-hand smoke exposure), and on average, cigarette smoking costs more than $193 billion ($97 billion in lost productivity plus $96 billion in health care expenditures).

"Companies want their employees to live and be healthy. Cost also plays a huge role. There are chronic disease costs, but also missed work, and it's not just for the smoker, but for the smoker's family from second- hand smoke," says Henry Albrecht, CEO of Limeade, Nelnet's wellness platform.

The company's success against smoking was hard won with slow and steady progress. In 2005, Nelnet conducted its first overall health screenings, keeping smokers from ignoring the health risks of the habit. It followed up with comprehensive anti-smoking education. The percentage of smokers ticked down to 20%.

After that came an online smoking cessation program, which led to another slight drop to 19%. An additional four percentage points was knocked off in 2008, thanks to an enhanced prescription plan that covered smoking cessation drugs.

The real change driver was rolled out in 2009, when Nelnet offered a 20% health insurance premium discount to employees who were tobacco-free or participating in a smoking cessation program. The move dropped the firm's smoking population from 15% to 9% that year.

Since then, Nelnet has implemented a tobacco-free workplace policy, bringing the smoking population to its all-time low, 6%.

Albrecht says most companies are concerned about smoking, but there are "degrees of wellness" that a company is interested in investing in. Overall, the use of penalties is expected to climb in 2012 to almost 40% of large and midsized companies, up from 19% this year and only 8% in 2009, according to an October survey by consulting firm Towers Watson and the National Business Group on Health.

"We're seeing companies ratchet up that pressure to [use testing] detect nicotine in the blood," he says. "We've found that having a more positive, populationwide, socially engaging approach tends to work well. Instead of saying smokers pay more, we say smoking isn't good for you, and we try to support it in a positive way."

Nelnet does just that. Executives made the decision a few years ago to not do comprehensive blood tests for nicotine, but to instead sign affidavits. At open enrollment, each plan participant is prompted to sign if he/she is tobacco-free.

"It was a senior leadership decision; they talk about tobacco use and the program regularly, and the code of ethics they have to sign, so they wanted to build a wellness program on a culture of trust, which was important because it's part of the fabric of culture," says Colleen Reilly, Nelnet's director of wellness. Nelnet, a provider of federal and private education loans and resources for student and graduates, has a large proportion of call-center representatives who are typically low-wage earners. Though Nelnet doesn't sort out smoking rates by worker population, the link is unmistakable: the higher the education and income level, the lower the rate of tobacco usage. Forty-five percent of adults with a GED diploma smoke, while 9.9% of adults with an undergraduate college degree smoke. "So there are a lot of stressors there, which is why we may have had a higher tobacco use at the beginning," Reilly says. "We had to put in carrots and sticks, and reinforce them."

Cynthia Sims, a senior risk analyst for Nelnet, was one of 22% of people who smoked in 2005. She's been with the company since 1983 and had smoked the entire time. Her father smoked and eventually died from a tobacco-related illness, as well as several of her close friends. She'd tried multiple times to quit, but had little luck and had always gone back to the habit. When she heard about the smoking cessation program, she jumped on board after she'd started having chest pains, headaches and insomnia.

"I had talked about it for years, but talking about it and doing it are two different things," Sims acknowledges. "Stress would come up, and my vice was to smoke a cigarette." Now that she's tobacco-free, Sims estimates she saves some $300 a year in the reduced premiums and around $800 a year from not buying cigarettes.

Building on the success of employees like Sims, Reilly's goal is to get Nelnet's smoking population down to the 2% to 4% range.

"In a lot of parts of the country, many people still smoke. Obesity and smoking are related in a lot of ways," Reilly says. "They're behaviorally connected, so if you have a program that just focuses on obesity or just on smoking, you're missing underlying connections," he says. "So we try to focus on those underlying things. That helps them present it in a more positive light so when you quit, you can do it."

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