The aim was to investigate how Swedish small and medium enterprises (SMEs) within the manufacturing industry carry out work environment improvements, and to study if managers consider profitability to be associated with issues in the work environment. Workplace observations and interviews (n=60) with company managers were carried out. Forty-five enterprises were affiliated with an occupational health service, typically in order to get quick access to health care, rather than getting help planning and implementing changes. Fifty-eight managers believed that healthy work environments would have at least some positive effect on company profitability. Incentives for work environment improvements were external, individual and organizational and varied between companies of different sizes. External requirements from The Swedish Work Environment Authority and from established or potential customers were prioritized incentives in SMEs with < 50 employees. Organizational and individual incentives such as incident- and accident reports, productivity, health and sick-leave were prioritized in SMEs with >50 employees. Irrespective of company size, well-being among work-force was consistently mentioned as an important factor for successful business. Small companies urged quick decisions and actions while medium companies had more planned, systematic and organized work environment activities. Deliberate work environment improvements for increased profitability were for instance, changes to eliminate risks, reduce manual work and resolve planning and coordination problems in production that led to stress.