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Tob Control 21:66-72 doi:10.1136/tobaccocontrol-2011-050201
  • Special communication

Businesses' voluntary pro-health tobacco policies: a review and research agenda

  1. Ruth E Malone
  1. University of California, Department of Social and Behavioral Sciences, School of Nursing, San Francisco, California, USA
  1. Correspondence to Dr Patricia A McDaniel, University of California, San Francisco, Department of Social and Behavioral Sciences, 3333 California Street, Suite 455, San Francisco, California 94118, USA; patricia.mcdaniel{at}ucsf.edu
  1. Contributors Both authors conceived of the study. PAM wrote the first draft of the article. REM reviewed, edited and revised all drafts.

  • Accepted 24 August 2011
  • Published Online First 26 September 2011

Abstract

Research on the role of businesses in tobacco control has focused primarily on retailers, advertising firms and the hospitality industry, all of which have tended to support tobacco industry interests and resist effective tobacco control policies. However, in several countries, businesses have a history of voluntarily adopting tobacco-related policies that may advance tobacco control objectives. These phenomena have received little research attention. Existing literature on businesses ending tobacco sales, instituting voluntary workplace smoking restrictions and establishing non-smoker only hiring policies was reviewed. A research agenda on voluntary business initiatives would enhance and complement research on mandatory tobacco control policies by identifying new advocacy opportunities; suggesting avenues for strengthening or reinforcing existing policy initiatives; laying the groundwork for new mandatory policies; helping to inform ethical debates about contentious voluntary policies; and contributing to a better understanding of how alliances between the tobacco industry and other businesses might be weakened.

The business community is important in tobacco control efforts. Previous research has shown that tobacco retailers, hospitality businesses and advertising firms, among others, have allied with the tobacco industry in efforts to weaken or thwart effective tobacco control policies.1–4 For example, tobacco companies have worked with business organisations to oppose clean indoor air laws and plain packaging of cigarette packs.1–3 5 However, businesses also have a history of voluntarily adopting pro-health tobacco-related policies that may advance tobacco control objectives.6–16 Although research has explored the impact of some of these policies on cigarette consumption and smoking prevalence,17–26 little attention has focused on why businesses adopt pro-health voluntary policies, how these policies are developed and how the public and the tobacco industry respond.

Businesses' voluntary policy initiatives warrant more researcher attention for several reasons. Tobacco control has advanced through mandatory and voluntary pro-health policies. Indeed, local, voluntary policies, beyond the reach of tobacco industry influence, played a key role in the early development of the tobacco control movement and continue to be relevant today.27 Businesses' voluntary pro-health policies may also reflect and contribute to the continuing denormalisation of smoking and the tobacco industry.28 When implementing voluntary pro-health tobacco control policies, businesses signal that they no longer consider their interests to align with those of the tobacco industry. This is an important development.

In this qualitative synthesis of the literature on three voluntary business policies, we analyse gaps and identify opportunities for future research. We examined studies on retailers abandoning tobacco sales, businesses instituting voluntary workplace smoking restrictions, and employers establishing policies against hiring smokers. We identified relevant research by searching the PubMed, Sociological Abstracts, and Business Source Complete databases for peer reviewed research articles related to these topics published in English; the majority focused on the USA.

To provide additional context, we searched the University of California San Francisco's tobacco control archive for materials related to public health and tobacco control organisations' guidance to businesses seeking to implement voluntary workplace smoking restrictions in the 1980s. Relevant material came from the paper files of Californians for Nonsmokers Rights, which also included employer brochures and guidelines from other organisations, such as the American Lung Association. We also searched the Legacy Tobacco Documents library (http://www.legacy.library.ucsf.edu) for material related to the tobacco industry's efforts to discourage employers from following this advice. We found examples of materials sent to businesses in the 1980s and 1990s by RJ Reynolds and the Tobacco Institute, the tobacco industry's lobbying organisation.

Our analysis suggests that a research agenda on businesses' voluntary tobacco-related initiatives could be helpful in five ways. First, it may identify new opportunities for tobacco control advocacy, particularly among communities traditionally adverse to strong state policy intervention; second, it may suggest avenues for strengthening or reinforcing existing policy initiatives (eg, making smoke-free workplaces the norm); third, it could lay the groundwork for mandatory policies by helping to reduce opposition from businesses and legislators; fourth, it could inform the tobacco control community's response to initiatives, such as smoker hiring bans, that are the subject of debate among tobacco control advocates; and fifth, it could help advocates better understand how to weaken alliances between the tobacco industry and businesses that help perpetuate tobacco normalisation and use.

Retailers abandoning tobacco sales

Tobacco retailers play a key role in perpetuating the tobacco problem29; tobacco outlet density is linked to a greater likelihood of youth smoking.30–32 One explanation for this relationship is the presence of tobacco advertising (including visible packaging) in tobacco retail outlets, which normalises and promotes tobacco use,33–38 reduces support for tobacco control policies,33 and, among smokers and former smokers, acts as a trigger to smoke.38–42

In the US, most states (and some localities) require tobacco retailers to pay annually for a license to legally sell tobacco43; currently, there are few restrictions on the type of retailer who may apply for a license. Since the 1970s, despite tobacco's profitability, hundreds of pharmacies have abandoned tobacco sales.44 More recently, several grocery store chains based in California, New York and Ohio have voluntarily stopped selling tobacco products.11 13 Among US national retail chains, Target stopped selling tobacco products in 1996,45 and Walmart has considered doing so.46 Voluntary initiatives may enhance support for or reduce resistance to mandatory policies: voluntary initiatives by pharmacies preceded recent bans on pharmacy tobacco sales in San Francisco and Richmond, California47 48 and Boston, Everett, Lancaster, Needham and Newton, Massachusetts.48 49

To date, published research related to the voluntary abandonment of tobacco sales has focused exclusively on pharmacies, and has examined the policy climate for ending pharmacy tobacco sales and/or the characteristics that distinguish tobacco-free pharmacies from those that sell tobacco. Research among the public, pharmacy students and licensed pharmacists finds that each group overwhelmingly disapproves of tobacco sales in pharmacies.50–57 When queried further, licensed pharmacists reported that such sales were inconsistent with their role as healthcare providers.50 53 A consistent predictor of a pharmacy's tobacco sales policy was pharmacy type: independent pharmacies were more likely than chain pharmacies to be tobacco free.44 50 55 56 58 59 We found no studies exploring how or why grocery stores voluntarily end tobacco sales, and how the public and the tobacco industry respond when they do so.

Voluntary workplace smoking restrictions

Workplace smoking restrictions are an important component of comprehensive tobacco control. Smoke-free workplaces lower exposure to secondhand smoke, reduce smokers' daily consumption of cigarettes, stimulate quitting and denormalise smoking.60–74 If all workplaces were smoke free, smoking prevalence would decrease by an estimated 7%.75

In the US, workplace smoking restrictions are a mix of mandatory and voluntary policies. Mandatory policies were first enacted at the state and local level in the mid-1970s.76 77 The first initiation of voluntary policies is difficult to pinpoint, but by the mid-1980s, as scientific evidence mounted regarding the dangers of secondhand smoke,78 79 a growing number of businesses had instituted voluntary workplace smoking restrictions.80 81 From the 1980s onwards, various public health and tobacco control organisations, including the American Lung Association, the American Cancer Society, the US Department of Health and Human Services, New Jersey Group Against Smoking Pollution and Californians for Nonsmokers' Rights Foundation promoted the adoption of voluntary policies by businesses through publications providing guidance on why and how to implement policies and examples of model policies.16 27 82–87 These publications highlighted the economic and health costs of smoking and the legal risks involved in companies failing to establish workplace smoking restrictions.

In the 1980s and 1990s, the tobacco industry offered an alternative view to employers seeking advice on workplace smoking policies, arguing that there were no scientific, economic, or legal justifications for restricting smoking at work.88–90 Smoking at work was a ‘right’, the industry argued, and ‘common sense and courtesy’ (or, if necessary, physical distance and a fan) were all that was needed to settle any disputes between smokers and non-smokers. The industry's lobbying group also claimed that workplace smoking restrictions disproportionately affected women and minorities, and were thus a form of discrimination.91 To encourage labour union opposition to smoke-free worksites, the tobacco industry suggested that unilateral imposition of restrictions by management violated collective bargaining rights.92 93 When unions proved willing to accept collectively agreed-upon smoking restrictions, the tobacco industry sought to preserve union opposition by arguing that the real issue was not cigarette smoke, but overall air quality, which could be controlled through ventilation.92

Tobacco companies continue to deny that secondhand smoke causes disease, and although they prefer voluntary workplace smoking policies to legislative solutions, they also assert that ‘complete bans go too far’, particularly in restaurants and bars.94 95 The tobacco industry has aggressively promoted the (now discredited) idea that smoke-free restaurant and bar laws hurt profits.1 It has also fought mandatory and voluntary smoking bans in the hospitality sector in the US and internationally by organising or creating third party allies (such as restaurant associations) to oppose smoke-free environments on economic grounds.1 3 96–99 It has promoted as an alternative ‘accommodation’ of smokers and non-smokers in separate areas and ventilation (to minimise odour rather than protect health).1 2 100

Legislation mandating smoke-free workplaces, enhanced by voluntary workplace policies, has advanced to the point that about 77% of US indoor workers aged 18 or over are currently protected by workplace policies prohibiting smoking.101 Smoke-free workplace protections are not equitably distributed, however: in the US, 83% of white collar workers are covered by a smoke-free workplace policy, compared to 75% of service workers and 72% of food service workers.101 This disparity reflects the fact that smoke-free laws often include exemptions for hospitality venues, such as restaurants and bars. Similar exemptions are evident globally,102 due, in part, to the actions of the tobacco industry. Nonetheless, in the US, in states or localities where they are not required by law to be smoke free, more than 1000 restaurants and bars have implemented voluntary bans, along with 15 hotel chains and numerous independent hotels.103 104

Most studies examining voluntary workplace smoking restrictions (ranging from designating smoke-free areas to creating 100% smoke-free businesses) focus on employee compliance with and reaction to them,17–21 23 24 26 105–110 effects on cigarette consumption and quit attempts,17–26 and workplace characteristics associated with the creation of these policies.63 111–120 Less attention has been paid to why and how these voluntary policies were created or barriers to their implementation.63 112 113 117 121 122 In addition, no studies have explored voluntary smoke-free policy development in the hospitality sector, despite the significance of such policies in a sector heavily courted by the tobacco industry. It is also unknown how the tobacco industry responds after these voluntary policies are implemented by hospitality businesses.

We found no studies specifically examining patrons' or the public's views of voluntary workplace smoking restrictions; studies typically focus on the public's support for mandatory workplace smoking bans (or fail to specify whether the ban is mandatory or voluntary).123–128 Internationally, public support for such bans is typically lowest for bars and restaurants (with the exception of Australia), although support for bans in both venues typically increases after the introduction of smoke-free legislation.128–131

In the US, an emerging area of tobacco control activism and research interest is smoke-free multiunit housing (MUH), a type of business with public (shared common areas) and private (individual units) aspects. Some localities have passed laws requiring that some or all MUH units be smoke free132; tobacco control advocates have also begun encouraging housing providers to adopt voluntary smoke-free policies.133–136 The rationale for such policies is to protect non-smokers from secondhand smoke, which lingers in common areas and transfers from one unit to another.132 137

Research has examined preferences for and prevalence of smoke-free MUH,138–142 barriers to voluntary policy implementation,140 141 and the effectiveness of interventions to encourage voluntary policy development and implementation.134–136 Although the majority of renters in these studies supported smoke-free MUH,139 140 142 such housing was relatively rare, with MUH owners or managers expressing concerns that smoke-free policies were illegal, would make it more difficult to find tenants, or would be difficult to enforce.134 135 140 141 Nonetheless, some MUH owners reported instituting such policies in the absence of public health interventions to try to spur change134 140 141; more research is needed to understand why and how these ‘policy innovators’ took action. Research on the tobacco industry's response to these voluntary policies is also needed.

Smoker/non-smoker hiring policies

Formal non-smoker only hiring policies first appeared in the US in the 1980s. Some, which had the force of law, were aimed at firefighters and police officers and were intended to reduce future disability payments by municipal governments.143 144 In 1985, a hospital in Illinois became the first to voluntarily hire only non-smokers, citing as a rationale an interest in ‘leader[ship] in cutting down smoking’.145 In response, the tobacco industry, working in concert with its paid ally, the American Civil Liberties Union, aggressively promoted smokers' rights/smoker protection laws in state legislatures.146 147 The first such law was passed in 1989; by 1993, 25 states had passed some type of law protecting smokers from employment discrimination (although they varied in the allowable exceptions, whether non-smokers were equally protected and whether the law also outlawed charging higher prices to smokers for employer subsidised health insurance).148 Currently, 21 states have no laws governing such non-smoker hiring practices by private employers.149

In the past decade, more companies (particularly hospitals) have voluntarily implemented non-smoker only hiring policies, reportedly to promote health and/or reduce healthcare and other costs.149–156 No studies have explored employer knowledge and attitudes about how smoking affects work performance in the civilian sector, but research suggests that smokers are absent more often from work than non-smokers and, when allowed to take smoking breaks, are less productive.157–160 Employer-subsidised healthcare costs are also higher for smokers.161

While a ‘no smoker’ hiring policy may further denormalise smoking, whether it advances tobacco control efforts is subject to intense debate. Like smoke-free workplace policies, a non-smoker only hiring policy has the potential to encourage smokers to quit smoking.162 However, many tobacco control advocates characterise such policies as overly intrusive and a form of discrimination that might ultimately be counterproductive to tobacco control.163–166 Focusing on tobacco smoke, rather than stigmatising smokers, has been key to advancing tobacco control strategies165; shifting the focus to smokers, some argue, is ethically and strategically problematic.

Research on this phenomenon is limited to a handful of studies. One explored corporate policies and employee attitudes towards non-smoker only hiring policies among 287 employees of 76 New York city firms engaged in real estate, insurance, or banking.167 Although such policies are prohibited in New York, 2% of the firms surveyed hired only non-smokers. Employees had a highly negative view of this practice, with 95% opposed.167 A study of current and former smokers' perception of smoking-related stigma found that self-reported discrimination, including being turned down for a job for which one was qualified because of one's smoking status, was associated with higher reported levels of stigma.168

Opportunities for advocacy

Further research on these and other voluntary tobacco-related initiatives by businesses could identify new opportunities for tobacco control advocacy. For example, if research on retailers that have voluntarily abandoned tobacco sales should find that the denormalisation of tobacco use (or of the tobacco industry) is part of retailers' decision making, tobacco control programmes might choose to stress stronger denormalisation themes. Studies could also determine whether tobacco is regarded as somehow incompatible with the image these businesses want to project and maintain, or no longer fitting with the demographics of their preferred customer base. If so, this would also suggest avenues for advocacy. If the tobacco industry offers arguments to discourage other retailers from following suit, research on retailers' actual experiences with voluntary policies could be valuable in developing strategic counterarguments.

Similarly, research on the impetus for voluntary smoke-free policies in the hospitality and MUH sectors could determine whether employees or tenants, rather than owners, played key roles in initiating such policies. Advocacy efforts might therefore be most usefully focused on those groups. If customer or tenant complaints are found to be a major policy impetus, providing avenues for facilitating such feedback could be fruitful. Research identifying tobacco industry pressures and attempts to undermine voluntary policies in hospitality venues or MUH could be used to mobilise public support for businesses that have independently made such decisions.

Strengthening existing policy initiatives

Research on businesses' voluntary tobacco policies may also suggest avenues for strengthening or reinforcing existing tobacco control policy initiatives. Analysis of consumer support for such initiatives, for example, might indicate a policy climate ripe for an expansion of public policies, such as the pharmacy tobacco sales bans discussed above47 49 or Wisconsin's ban on smoking in hotels.10 A finding that retailers feel the legal restrictions on tobacco sales to minors make selling tobacco products too onerous might indicate that such restrictions should be strengthened or expanded at the state or local level.

Laying groundwork for mandatory policies

Research on voluntary pro-health policies by business could potentially help prepare the way for new legislative or regulatory policies by showing that such policies will not harm businesses, thereby defusing opposition from businesses or legislators. For example, research showing that discontinuing tobacco sales in grocery stores does not hurt profits or result in lost customers could help create support for legislation prohibiting such sales. In general, businesses prefer a ‘level playing field’ in which all must meet the same requirements. However, because pro-health policy initiatives may be undertaken by businesses whose owners may espouse general antiregulatory attitudes, caution is warranted in assuming that those who implement voluntary policies will also support legislative initiatives.

Informing ethical debates

Research on some business initiatives may also help inform tobacco control community responses when it is unclear whether such initiatives should be promoted or discouraged. Smoker hiring bans fall into this category, as they raise several ethical questions.169 For example, forcing employees who smoke to quit may violate the principle of liberty or autonomy, the ability to be ‘free from controlling influences by others and from personal limitations that prevent meaningful choice’.170 Others may argue, however, that people who are addicted to nicotine (the majority of whom want to quit), are not fully autonomous; helping them to quit through employment restrictions—a form of benevolent paternalism—may allow them to become fully autonomous.162 Forcing smokers to quit smoking in order to keep their jobs may also violate the ethical principle of beneficence, or doing good, by increasing unemployment among smokers and denying them workplace-based health insurance coverage. Given that smoking is increasingly concentrated among poorer and less educated populations, this raises social justice concerns.171 Still, such policies may ‘support the wellness of non-smokers by reducing their exposure to secondhand smoke from fellow smoking employees’.169

Research could provide additional insight into these questions. If smoker hiring bans simply force smokers to look for employment elsewhere rather than quit smoking, this undercuts the ‘benevolence’ argument. Similarly, if previously employed smokers are unable to find alternative employment, it may worsen tobacco-related social inequities. However, if such policies serve as incentives for smokers to quit, they may provide health benefits to employees similar to other policies encouraging weight loss, etc. and create a healthier overall workforce.

Weakening alliances between the tobacco industry and businesses

More research on these voluntary tobacco initiatives may also help tobacco control advocates better understand how to weaken alliances between the tobacco industry and other businesses.172 Investigating the tobacco industry's response to such initiatives could provide insight into how best to counter industry arguments. Understanding how businesses respond to tobacco industry pressure to reverse their voluntary tobacco-related policies may also help tobacco control advocates identify new strategies for aiding businesses in resisting such pressure.

Conclusions

Corporate and other business practices have multiple impacts on public health.173–179 Businesses of all types may directly or indirectly promote disease through their promotion of deadly or unhealthy products or their environmental, employment, or operational practices.180 However, business practices may also promote health and healthy practices. Tobacco use, and its resultant preventable morbidity and mortality, are sustained by individual behaviour and the addictiveness of nicotine, and also by the entire infrastructure that normalises use. Efforts by some businesses to alter their role in that normalising infrastructure represent an exciting opportunity to explore through research a shifting dynamic in tobacco's social construction. A research agenda focused on learning more about the extent, characteristics and effects of such efforts could enhance and complement research on mandatory tobacco control policies.

What this paper adds

  • The business community is often regarded within the public health community as an ally of the tobacco industry. However, businesses in various sectors have a history of adopting various types of pro-health tobacco policies, even in the absence of policy mandates. While research has explored the impact of some of these policies on cigarette consumption and smoking prevalence, little is known about why and how businesses adopt pro-health voluntary policies and how the public and tobacco industry respond.

  • This qualitative synthesis of the literature on three types of voluntary tobacco-related business policies identifies gaps in existing knowledge and suggests ways in which further research examining these policies could benefit tobacco control. These could include suggesting avenues for strengthening or reinforcing existing policy initiatives; laying the groundwork for mandatory policies; informing the debate around contentious initiatives; and building understanding of how to weaken alliances between the tobacco industry and businesses.

Footnotes

  • Funding This work was supported by the California Tobacco-Related Disease Research Program, grant number 18XT-0140.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

References

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