The recent experience of making bars in New York and Ireland smoke-free seems likely to give further impetus to the push for smoke-free workplaces and public places. The primary stimulus for the smoke-free workplace has always been employee occupational health, but an important secondary benefit is the consistently reported significant effect of reduced smoking frequency and increased quit rates among employees in smoke-free workplaces.^1,2

I have always thought the ultimate objective is a workplace which is both smoke-free and smoker-free. The practicality of this objective depends on a number of variables, especially smoking prevalence rates and applicable laws in the country concerned. While it may not be practical across the community, it seems appropriate for exemplar organisations such as hospitals, cancer charities and cancer institutes to explicitly aim for both smoke- and smoker-free workplaces.

BECOMING SMOKER-FREE

In the late 1980s, the Anti-cancer Council of Victoria (Australia) went both smoke-free and smoker-free. We had been a smoke-free workplace for some years already and there was no difficulty with the new policy as the staff understood our function as a role model for the community. However, since Victoria had an anti-discrimination Commission, we sought its permission to discriminate against smokers seeking employment with us. Given our role as exemplar, the commissioners agreed that a policy of not employing smokers was acceptable. Obviously, sacking smokers already on staff was not an acceptable option but we were quite soon down to a single continuing smoker, who was an addicted but valued employee. The efflux of time resolved this and following that individual’s departure for standard reasons we had only one difficulty—a new employee who lied about smoking when applying for a job and was later observed to be a smoker. This resulted in the employee being dismissed as the conditions of employment had been breached. As director, I felt bad about this but the dismissal was accepted as a reasonable response and showed we were serious about the policy.

We were an organisation of about 100 staff, the community smoking rate was about 30% at the time, and the public issue we were then debating was the very early one of the right of non-smokers to have a special section in restaurants.

The process takes time but is important, especially for exemplar institutions. We did not provide free nicotine replacement therapy (NRT) and counselling then, although I would do so in similar circumstances today.

EXPANDING THE POLICY

In thinking that “smoke-free and smoker-free” is a better objective than merely the former, I was initially thinking about exemplar institutions. However, the question arises as to whether this policy should be more widespread. If we take the view that reducing smoking rates by all acceptable and effective means leads to greater population wide health benefits, then “smoker-free” workplace policies merit consideration, and we need to consider just how far we are willing to go down the path of paternalism.

An entirely benevolent employer (say, Mr Bonamour) might well decide to offer education, counselling, free NRT, and financial incentives such as an extra salary premium for non-smokers. If he does this, it would be consistent, albeit somewhat paternalistic, to refuse to hire new staff who smoke.

Developed societies are paternalistic. We try to protect bar workers from drinkers’ secondhand smoke even if they say there are willing to take the risk, and we encourage insurers to support such initiatives by increasing premiums for bar owners. We also enact laws requiring seat belts and crash helmets.

On the other hand, if our employer is a money grubbing Mr Scrooge only interested in his share options, he might refuse to hire smokers because they take time off for smoking breaks and take more sick leave than do non-smokers.^3–6 Mr Scrooge’s policy is not nice, but it may also mean his company can stay in business, which means his non-smoking employees will stay employed. A few percentage points of extra productivity can be important.

Being nice myself, and seeing smokers as victims, I prefer Mr Bonamour’s approach to Mr Scrooge’s. However, I want to help smokers stop smoking and the threat of non-employment may be an effective way of doing it. This is “tough love” at work. Smoker-free policies may be on the way in.