A Policy Guide to Support Employee Health and Wellness

Worksite Wellness

IN COLLABORATION WITH Introduction

Worksite wellness programs are recommended by the Centers for Disease Control and Prevention and other public health experts as a strategy for reducing and preventing chronic diseases and promoting community health.1 Emerging studies indicate that worksite wellness programs that are designed and implemented well bring economic benefits and improve employee health. For example, one recent systematic review of employer-sponsored worksite wellness programs found that companies’ reported return on investment (ROI) ranged from $1.6 to as much as $3.9 saved for every $1 spent on wellness programs.2 This review also found that employers’ direct costs for health care (i.e., total costs, claims, and premiums) either increased less or decreased over time compared to the general U.S. population, the U.S. healthcare industry, and similar companies.3 Several companies also reported decreases in worker compensation costs, and in indirect costs such as worker absenteeism and turnover.4 This review also found that employees experienced improved health benefits, including increases in well-being and decreases in negative health risk factors such as smoking, high cholesterol, hypertension, obesity, and lack of physical activity.5 So worksite wellness makes good business sense from both an economic and health perspective, reflecting not only higher ROI, but also better Value on Investment (VOI).

Like anything else, worksite wellness programs can be done well and they can be done less effectively. The hallmarks of successful, high-quality programs are:

1. Strong support from the organization’s leadership. 2. Clear buy-in to the importance of health and wellness, reflected in both the organization’s culture and physical environment—in other words, there is a “culture of health” within the organization.

3. Responsiveness and adaptability to employees’ changing needs. 4. Effective use of current technology. 5. Support from health organization partners within the community, such as CentraCare Health.6 Good worksite wellness programs are designed to address employees’ needs, and reducing chronic disease risk factors is sure to be high on the list. Chronic diseases such as cardiovascular disease, diabetes, cancer and chronic obstructive pulmonary disease are the leading causes of death and the primary health concern for communities across the U.S., including communities in Minnesota. Chronic diseases can be prevented and managed by addressing associated key risk factors, which include:

1. Tobacco use 5. Obesity 2. Hypertension 6. Physical inactivity 3. Elevated blood sugar levels 7. Poor dietary habits 4. High cholesterol

Knowing this, it makes sense to focus worksite wellness strategies on the prevention, reversal or management of these risk factors.7

Good implementation is also necessary to make a worksite wellness program effective. While program services (such as behavioral counseling) and educational activities (such as offering recipes and exercise tips) are important, achieving behavioral changes that will last requires leveraging an organization’s policies, systems and physical environment to embed support for health and wellness across and around the worksite. CentraCare Health and the Public Health Law Center have designed this guide to support area businesses and organizations in taking policy, systems and environmental approaches to three health areas: reducing tobacco use and exposure; supporting healthy diets; and providing opportunities to be physically active throughout the day. Of course, comprehensive worksite wellness programs also address other health aspects such as alcohol consumption, stress reduction, and vaccinations.8 But tobacco use, healthy eating, and physical activity are areas where worksite policies or guidelines can make a big difference in improving, reducing or preventing chronic disease. The next section identifies key policy, systems and environmental strategies that address each of these three areas, and explains the rationale for each strategy as well as the expected benefits. All policy approaches included in this guide are supported by scientific evidence and/or expert opinion, and have been found likely to contribute to significant ROI.9

Promoting Tobacco Cessation Tobacco-related cancers remain one of the leading causes of death. Smoke-free laws and policies decrease exposure to secondhand smoke, and are one of the most effective ways to reduce tobacco use because they remove triggers for smoking behavior and make tobacco use less convenient and less socially acceptable. Minnesota has a good clean indoor air law which requires all indoor public places and worksites to be smoke free.10 State law also defines tobacco products to include e-cigarettes and similar devices for tax purposes,11 and prohibits the use of these devices in some public indoor spaces.12 Cities and counties can pass their own laws that include protections beyond those contained in state law. For example, some local smoke-free laws require some outdoor spaces to be smoke-free, and/or restrict the use of e-cigarettes and similar devices (often referred to as “vaping”) in all indoor public places, the same as conventional cigarettes. Businesses can adopt their own tobacco-free and vape-free policies that are either the same as or go beyond state and local law. Stronger worksite policies can help further decrease secondhand smoke or vapor exposure, and support employees who are trying to quit tobacco. Here are four evidence-based policy or systems changes a worksite could implement to further reduce employees’ health risks from tobacco and tobacco-related products.

1. Extend smoke-free protections to outdoor areas on the property. Expanding a smoke-free policy to include outdoor property, such as the parking lot and any other outdoor areas, eliminates the risk of secondhand smoke exposure across the entire worksite and sends a consistent message about the value of employee health. At a minimum, if not already covered by city or county law, a business or organization should create a smoke-free zone around all entrances so that employees, customers, or guests aren’t forced to run a gauntlet of smoky haze to enter the establishment.

Expected/potential benefits include: reduced smoking; reduced tobacco consumption; increased quit rates; reduced exposure to secondhand smoke; improved health outcomes.13

Worksite Wellness | © 2017 Feeling Good MN and Public Health Law Center. | 4 2. Expand smoke-free policies to include all tobacco products. Spit tobacco and other forms of smokeless tobacco also have harmful health consequences for users, including nicotine addiction, cancer and other diseases.14 A smoke-free policy could become a tobacco-free policy to more effectively reduce health risks linked with tobacco use.

Expected/potential benefits include: increased quit rates, reduced relapse rates. • This type of policy is likely to be especially effective when part of a comprehensive indoor and outdoor smoke-free policy.

3. Expand your smoke-free or tobacco-free policy to include e-cigarettes and similar devices. Federal regulation of electronic smoking devices (aka “e-cigarettes”) is a new phenomenon, and largely focuses on how these devices are sold, and not where they can be used (except in airplanes—the U.S. Department of Transportation prohibits their use on planes, just like conventional combustible tobacco products). In Minnesota, state law treats e-cigarette retailers similar to other tobacco retailers, and includes some restrictions on indoor vaping in public places (such as child care programs, healthcare facilities, schools, government buildings, facilities licensed by the Department of Human Services, and other places).15 The Food and Drug Administration and many leading public health organizations generally agree that further scientific study is needed to assess unproven safety claims about e-cigarettes and to determine the overall public health impact of e-cigarette use. Much is still unknown about the health effects of e-cigarette aerosol on both the user and people exposed to the secondhand aerosol; emerging research indicates that secondhand aerosol may contain chemicals that raise concerns.16 Potentially harmful constituents have been documented in some e-cigarette cartridges, including diethylene glycol, genotoxins, animal carcinogens, and diacetyl, a butter flavoring known to cause serious lung damage to workers in microwave popcorn factories. The nicotine in e-cigarettes, as in all tobacco products, is highly addictive, can be toxic in high doses, and has immediate bio- chemical effects on the brain and body. The Surgeon General cautions that nicotine may harm developing fetuses, and may negatively impact adolescent brain development. For these reasons, many state and local governments and private businesses have expanded their tobacco-free policies to include e-cigarette use. Doing so also helps avoid enforcement headaches because some e-cigarettes are designed to look like regular cigarettes.

Expected benefits include: reduced cigarette smoking and improved health outcomes.17

4. Make tobacco cessation therapy more affordable for employees. Systems changes that reduce the cost of tobacco cessation therapy can reduce the financial barriers to therapies like nicotine replacement and behavioral therapies (e.g., cessation groups). Services could be included as part of employees’ health insurance benefits, or a business could offer to reimburse employees for their expenses.

Expected/potential benefits: increased quit rates; increased access to tobacco cessation services; increased use of tobacco cessation services.18

Worksite Wellness | © 2017 Feeling Good MN and Public Health Law Center. | 5 Promoting Healthy Eating and Physical Activity Employees spend a big chunk of their waking hours at work during the week, and may eat one or more meals while on the job. All too often, the food choices readily available and marketed to people at or near their worksites are high in sugar, sodium, and calories, and do not adequately support a healthy diet. To exacerbate the problem, many jobs are sedentary or allow for few opportunities for physical activity. Worksite wellness programs that use policy, systems, and environmental approaches to, at a minimum, make healthy foods desirable and convenient to purchase, have been found to increase consumption of healthy food. Similarly, worksite wellness programs that provide opportunities for increased physical activity appear to be effective in improving employees’ activity patterns.19

Thus, good worksite wellness programs should include policies, systems, and environmental strategies to support healthy dietary choices and offer opportunities to incorporate physical activity into the work day.

Promoting Healthy Eating:

1. Create a healthy food and beverages policy or set of standards. This type of approach uses evidence-based nutrition standards for food and beverages purchased, sold, or otherwise made available by or within an organization. A policy or set of standards could also incorporate other strategies proven to support healthy dietary choices (e.g., reasonable portion sizes, nutrition labeling, competitive pricing, etc. – see below). The policy or standards should apply as broadly as possible, including food and beverages served at meetings or purchased for catered events, sold through vending machines, and available in cafeterias. If one type of food outlet is more challenging due to contractual or product availability considerations, the policy or standards could be phased in across settings. For example, a worksite could start with food served at meetings or catered events, then move to vending machines. Key considerations with this kind of approach include:

a. What should the nutrition criteria be? Not all criteria are created equal—it is important to choose criteria that are backed by evidence in terms of how they support good nutrition. It may also be helpful to use criteria that are designed for the specific outlet—for catered events, or vending machines specifically, for example. Respected public health experts have already developed sets of criteria that can be used so organizations don’t have to recreate the wheel. CentraCare Health has resources and expertise to help area businesses identify what criteria would work best for their situations, and local public health staff may also be able to help.

b. Should the nutritional criteria be applied to 100% of the food and drinks sold or offered, or something less? This can depend on whether one is dealing with just food or beverages (it is much easier to go 100% healthier with beverages), how rigorous the nutrition criteria are, what kind of products are available from suppliers, how many types of outlets there are in the workplace, and how much capacity there is to monitor and enforce the policy or standards. Generally speaking, a 100% standard is likely to be easier to maintain over time because it requires less monitoring. However, to allow time for employees and vendors to adjust to changes, it may be a good idea to phase in the policy or standards over time; for example, by starting with a 50% benchmark and gradually moving higher.

Worksite Wellness | © 2017 Feeling Good MN and Public Health Law Center. | 6 c. If unhealthy options will continue to be available, what kind of point-of-purchase or point- of-decision strategies will be used to promote the healthier choices for employees? If new, healthier choices are being set up to compete with long-time junk food favorites, they will need the same marketing support—price, placement, and promotional strategies—that food companies have used to make junk food so appealing. Promotional and placement strategies include: nutritional labeling; shelf tags; posters; convenient placement near checkout or in grab-and-go places; placement at eye level on shelves or in vending machines; and using attractive signs or motivational messages that help employees identify and value healthy/ier options. Pricing strategies include: offering discounts on healthy food, charging more for nonnutritious food, or making sure healthy items are priced the same as unhealthy items.

d. Will customers buy the healthy items? The food industry’s own research shows that customers are increasingly looking for healthier snacks and choices, and that low/no-calorie drinks are selling better than sugary ones.20 While there usually are some decreases in sales and/or revenues when these types of changes are first put in place, revenues typically come back or exceed baseline within a year. Promotional strategies such as taste tests and free samples can help customers learn about and appreciate new, healthy options. Technical assistance to help with these kinds of questions is available from CentraCare Health, and also may be available from your local public health department.

Expected/potential benefits: • Policies that apply nutrition standards to food and beverages served/sold on site or at work-related meetings and events: improved dietary choices (particularly when combined with pricing strategies that make healthy options more affordable compared to less healthy or unhealthy options); improved nutrition; increased access to fruits and vegetables; increased fruit and vegetable consumption; improved weight status; increased self-confidence; reduced employer health insurance costs; increased productivity.21 Effects are likely to be enhanced when combined with strategies to promote physical activity.

• Point-of-purchase or point-of-decision prompts have these expected/potential benefits: increased fruit and vegetable consumption, reduced fat intake, improved dietary choices, particularly when implemented with other environmental changes in worksite settings.22

• Use of competitive pricing strategies for healthy foods have these expected/potential benefits: increased sales of low fat foods, fruits, vegetables, and water; increased consumption of healthier foods.23

Worksite Wellness | © 2017 Feeling Good MN and Public Health Law Center. | 7 2. Adopt a policy or guideline that sugary beverages won’t be available for purchase or offered at the worksite and at work-related meetings or events, and that limits 100% fruit juice portion sizes. Sugary beverages are the biggest source of added sugar in the U.S. diet, and these beverages typically offer little or no nutritional value. Consumption of sugary beverages also significantly increases risk of heart disease, stroke, fatty liver disease, and is associated with poorer oral health. Growing numbers of employers are removing their sugary beverage offerings, reasoning that it’s fine if an employee wants to bring in a sugary beverage but the worksite doesn’t have to make unhealthy drinks so easily available. While “diet” drinks (zero or low-calorie drinks containing artificial sweeteners) also raise health concerns for many, they are considered a less unhealthy choice compared to sugary drinks.

Expected/potential benefits: improved dietary choices; reduced sugary beverage consumption.24

3. Make systems or environmental changes that promote water consumption. For example, make sure drinking fountains are clean and readily available; provide bottle filling stations or water coolers; and make sure that bottled water is amply available in vending machines.

Expected/potential benefits: increased water consumption; improved health outcomes; positive effects on eating and drinking decisions; improved cognitive function.25

4. Adopt a policy or make systems or environmental changes to support employees who are breastfeeding. Breastfeeding provides multiple positive health benefits for women and children, including reduced rates of breast and ovarian cancer for women; and lower likelihood of childhood obesity, type 2 diabetes, and asthma for children.26 Federal and state law already require most employers to provide minimum accommodations for nursing mothers.27 Employers can adopt their own nursing mother policies that are either the same as or go beyond state and federal law to help reinforce these protections for their employees, and ensure that employees and their families are able to reap the fullest health benefit possible.

Expected/potential benefits: increased breastfeeding rates; improved health outcomes.28

1. Implement systems and environmental changes to support active commuting. Supporting active commuting, where employees bike, run or walk to work, or even just walk more to get to their cars, can be a good way to help employees build some movement into their day. Active commuting can be supported in multiple ways, including by: • Making physical infrastructure changes, such as providing secure bicycle racks or showers for bikers and runners; • Providing educational or social support programs, such as biking/walking/running commuting coordinators; walking groups; or walk/bike to work campaigns; or • Providing financial incentives such as free bicycle parking, bicycle commuting reimbursements, or charging for on-site car parking and providing free off-site parking.

Expected/potential benefits: increased physical activity, improved physical fitness, and improved health outcomes; also could have positive environmental impact of reduced emissions.29

2. Adopt policy, systems and environmental changes that help employees make physical activity part of the work day. These changes could include any or all of the following strategies: • Policy or guidelines allowing for flexible schedules, such as: allowing employees to add break time to lunch if they could use a longer exercise break, or to otherwise adjust their schedules to allow for fitness activities; • Incorporating one or more short, paid physical activity breaks into the day; • Including time for stretching or short physical activity break during meetings; • Providing standing desks for employees who request one; • Providing guidance and encouragement on how to conduct walking meetings; • Allowing scheduling of on-site fitness opportunities; • Providing showering or changing facilities; • Mapping out on-site or nearby walking or biking routes for employees; and • Providing point-of-decision prompts, such as signs encouraging the use of stairs. Of course, it will be important to be mindful of the protections of the American with Disabilities Act and the needs of employees who may have limited mobility or other physical disabilities.

Expected/potential benefits (especially when combined with healthy eating promotion strategies): increased physical activity; improved weight status; increased self-confidence; reduced employer health insurance costs; increased productivity.30

Research shows that successful worksite wellness programs leverage policy, systems, and environmental changes to embed health and wellness across their worksites. Successful programs also take advantage of partnerships with health organizations in their communities. CentraCare Health is an important resource that can offer area businesses and organizations expertise and support to help you design and implement effective worksite wellness policy, systems, or environmental strategies to achieve a healthier, more productive workforce, and make the most of your healthcare dollars.

Key Sources/Resources: Centers for Disease Control and Prevention, Workplace Health Promotion, http://www.cdc.gov/workplacehealthpromotion/index.html Lawrence P. Cahalin et al., Development and Implementation of Worksite Health and Wellness Programs: A Focus on Non-Communicable Disease, 58 Progress In Cardiovascular Diseases 94 (2015). Lisa C. Kaspin, et al., Systematic Review of Employer-Sponsored Wellness Strategies and their Economic and Health-Related Outcomes, 16 Population Health Management 14 (2013). Carol Noel Michaels and Amanda Marie Greene, Worksite Wellness: Increasing Adoption of Workplace Health Promotion Programs, 14 Health Promotion Practice 473 (2013). Univ. of Wisconsin Population Health Institute, County Health Rankings & Roadmaps, What Works for Health, http://www.countyhealthrankings.org/roadmaps/what-works-for-health (accessed on March 25, 2016). Public Health Law Center, www.publichealthlawcenter.org

The information contained in this publication was prepared by the Public Health Law Center at Mitchell Hamline School of Law, St. Paul, Minnesota, made possible with funding from the CentraCare Health Foundation. The Public Health Law Center provides information and legal technical assistance on issues related to public health. The Center does not provide legal representation or advice. This document should not be considered legal advice.

Endnotes

1 See Ctrs for Disease Control and Prevention [hereinafter, CDC], Workplace Health Promotion, https://www.cdc.gov/workplacehealthpromotion/index.html, and Univ. of Wisc. Population Health Instit., County Health Rankings & Roadmaps, What Works for Health [hereinafter, What Works for Health], Worksite Obesity Prevention Interventions, http://www.countyhealthrankings.org/policies/worksite-obesity-prevention-interventions.

2 Lisa C. Kaspin, et al., Systematic Review of Employer-Sponsored Wellness Strategies and Their Economic and Health-Related Outcomes, 16 Population Health Management 14, 17 (2013). 3 Id., at 17, 19. 4 Id., at 18.

Worksite Wellness | © 2017 Feeling Good MN and Public Health Law Center. | 10 5 Id., at 19 6 Lawrence P. Cahalin et al., Development and Implementation of Worksite Health and Wellness Programs: A Focus on Non-Communicable Disease, 58 Progress In Cardiovascular Diseases 94, 96 (2015). See also, Kaspin et al., supra note 2, 19-20. 7 Cahalin et al. supra note 6, at 95. 8 See, e.g., PartnerSHIP4Health, Making Wellness Worth Your While, https://studylib.net/doc/13708821/making-wellness-worth-your-while-worksite-wellness-toolkit. Providing workplace flu vaccinations is a well-supported approach. See Nat’l Business Group On Health, Ctr For Health And Prevention Svcs, Vaccinating Against The Flu: A Business Case (2010), http://studylib.net/doc/13440781/brief-issue-vaccinating-against-the-flu--a-business-case. Providing these vaccinations may also boost childhood immunization rates, which are a highly effective, evidence-based strategy for reducing infectious disease transmission. 9 Evidence-based policies were identified based on a review of worksite wellness toolkits and national literature, including: Carol Noel Michaels and Amanda Marie Greene, Worksite Wellness: Increasing Adoption of Workplace Health Promotion Programs, 14 Health Promotion Practice 473 (2013) and Univ. of Wisc. Population Health Instit., County Health Rankings & Roadmaps, What Works for Health, http://www.countyhealthrankings.org/roadmaps/what-works-for-health. 10 Minn. Stat. § 144.411 et. seq (2016). 11 Minn. Stat. § 297F.01 subd. 19 (2016). 12 Minn. Stat. §144.414 (2016). 13 What Works for Health, Smoke-free Policies for Outdoor Areas, http://www.countyhealthrankings.org/policies/smoke-free-policies-outdoor-areas. 14 CDC, Smokeless Tobacco: Health Effects, http://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/health_effects/ (last reviewed, Feb. 18, 2016). 15 Minn Stat. §§144.414 and 260C.215 (2016). 16 Pub. Health Law Ctr., Regulation Electronic Cigarettes And Similar Devices (2015), http://www.publichealthlawcenter.org/sites/default/files/resources/tclc-guide-reg-ecigarettes-2015.pdf. 17 What Works for Health, E-cigarette Regulations, http://www.countyhealthrankings.org/policies/e-cigarette-regulations. 18 What Works for Health, Tobacco Cessation Therapy Affordability, http://www.countyhealthrankings.org/policies/tobacco-cessation-therapy-affordability. 19 Cahalin et al., supra note 6, at 99. 20 See John Kell, Bottled Water Continues to Take the Fizz Out of Diet Soda, Fortune (April 19, 2017), at http://fortune.com/2017/04/19/ coca-cola-pepsi-dr-pepper-soda-water/; Packaged Facts, Healthy Snacks Sales Growth Outpacing Overall Food & Beverage Market, July 18, 2016, at https://www.packagedfacts.com/about/release.asp?id=3943. The International Food Information Council (a food industry trade group), publishes an annual report about consumer attitudes relating to food. Its annual consumer survey has consistently found that taste, price, and healthfulness are the three top influencers of food and beverage purchases. In recent years, the importance of healthfulness has increased compared to 2010 numbers, while the significance of taste and price (the number one and two factors) has gone down. See, e.g., Internat’l Food and Information Council Foundation, 2016 Food and Health Survey Executive Summary, at 4 (available at http://www.foodinsight.org/sites/default/files/2016_executivesummary_final_web.pdf). 21 What Works for Health, Worksite Obesity Prevention Interventions, http://www.countyhealthrankings.org/policies/worksite-obesity-prevention-interventions; Healthy Foods at Catered Events, http://www.countyhealthrankings.org/policies/healthy-foods-catered-events; Healthy Vending Machine Options, http://www.countyhealthrankings.org/policies/healthy-vending-machine-options. 22 What Works for Health, Point-of-Purchase Prompts for Healthy Foods, http://www.countyhealthrankings.org/policies/point-purchase-prompts-healthy-foods. 23 What Works for Health, Competitive Pricing for Healthy Foods, http://www.countyhealthrankings.org/policies/competitive-pricing-healthy-foods. 24 What Works for Health, School Food and Beverage Restrictions, http://www.countyhealthrankings.org/policies/school-food-beverage-restrictions. 25 What Works for Health, Water Availability and Promotion Interventions, http://www.countyhealthrankings.org/policies/water-availability-promotion-interventions. 26 What Works for Health, Breastfeeding Promotion Programs, http://www.countyhealthrankings.org/policies/breastfeeding-promotion-programs. 27 See Pub. Health Law Ctr., Legal Protections For Nursing Mothers In Minnesota (2014), http://www.publichealthlawcenter.org/sites/default/files/resources/Protections%20Nursing%20Mothers%20Sept%202014.pdf. 28 What Works for Health, Breastfeeding Promotion Programs, http://www.countyhealthrankings.org/policies/breastfeeding-promotion-programs. 29 What Works for Health, Multi-Component Workplace Supports for Active Commuting, http://www.countyhealthrankings.org/policies/multi-component-workplace-supports-active-commuting. 30 What Works for Health, Worksite Obesity Prevention Interventions, http://www.countyhealthrankings.org/policies/worksite-obesity-prevention-interventions.