Comprehensive smoke-free policy

The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) is an evidence-based health and legally-binding treaty that requires its 181 Parties to implement evidence-based measures to reduce tobacco use and exposure to tobacco smoke^1,2. Article 8 of the WHO FCTC refers to the need for protection from exposure to tobacco smoke³. It emphasizes the need for ‘100% smoke-free environments in all indoor public places, indoor workplaces, on all means of public transport, and, as appropriate, other public places’.

Workplace designated smoking area

Article 8 also stipulates that the use of designated smoking areas (DSAs) does not provide effective protection³. Nonetheless, DSAs still exist in public places in both developed and developing countries. Indoor areas for smoking are mostly common in airports and are considered as ‘smoking lounges’ while DSAs exist in many workplaces⁴. This situation is not in line with the WHO FCTC because Article 8 of the WHO FCTC highlights the need for a comprehensive smoking ban for effective protection from secondhand smoke. The FCTC does not recommend enclosed areas for smoking in public places or workplaces⁵.

It is interesting to appraise the qualitative study by Burton et al.⁶ who revealed that smokers never smoked in indoor designated areas but preferred to go outdoors to prevent others from being exposed to tobacco smoke⁶. Another qualitative study by Bondy and Bercovitz⁷ highlighted the need for a complete smoking ban on construction worksites, instead of making provisions for DSAs. On the other hand, Sherriff and Coleman8 revealed employers’ belief that they would violate the rights of their employees if they did not allow them to smoke on the worksite. It has also been reported by Kaufman et al.⁴ that community members considered law enforcement as a violation of smoker’s rights.

Workplace smoking cessation intervention

The evaluation of the first smoking cessation workplace intervention in Hong Kong showed that smoking cessation programs, chosen by smokers and supported by employers without further incentives, were feasible in a busy working environment⁹. A pilot clinical trial of smoking cessation services implemented in the workplace has demonstrated the feasibility and efficacy of providing workplace smoking cessation services¹⁰. A qualitative study exploring employees who were involved in a workplace smoking cessation programme showed that contributors to quit success were the workplace setting, quitting with colleagues, competition and motivation, as well as group strategies to resist smoking¹¹. In Iowa, workplace smoking bans were nearly universal and two-thirds of the workplaces offered activities to help employees quit smoking within the context of the Iowa Smokefree Air Act; there was practically no barrier to adoption and implementation of workplace smoking cessation interventions¹².

Controversy on human rights of smokers vs non-smokers

Graff¹³ confidently put forward the fact that ‘there is no constitutional right to smoke’. Referring to the 1948 Universal Declaration of Human Rights, Article 1 states that ‘All human beings are born free and equal in dignity and rights’¹⁴. Article 3 states that ‘Everyone has the right to life, liberty and security of person’¹⁴. Article 25 of the same Declaration mentions ‘health as part of the right to an adequate standard of living’¹⁴. Internationally, the right to health was first articulated in the 1946 Constitution of the World Health Organization¹⁵. The General Surgeon¹⁶ put forward that ‘Non-smokers have as much right to clean air and wholesome air as smokers must have their so-called right to smoke, which I would define as a right to pollute’. However, in the preamble of the WHO FCTC, the Parties expressed their determination ‘to give priority to their right to protect public health’³. Also, the preamble to the Constitution of the WHO states that ‘the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition’³.

Concerning Article 12 of the 1966 International Covenant on Economic, Social and Cultural Rights, ‘it is the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ (WHO 2003)³. Considering the Convention on the Elimination of All Forms of Discrimination against Women, adopted by the United Nations General Assembly on 18 December 1979, Parties will eliminate gender discrimination in the field of health care³. Focusing on the Rights of the Child, Parties to the Convention acknowledge ‘the right of the child to the enjoyment of the highest attainable standard of health’³.

In 2017, on the occasion of the Human Rights Day, health was emphasized by the WHO Director-General as a fundamental human right, with good health being the resultant of other basic human rights including access to safe drinking water and sanitation, nutritious foods, adequate housing, education and safe working conditions¹. The WHO Director-General, in 2017, stated: ‘The right to health for all people means that everyone should have access to the health services they need, when and where they need them, without suffering financial hardship…’. The central principle of the 2030 Agenda for Sustainable Development is to ensure that no one is left behind.

Justification for the study

The Constitution of the Republic of Mauritius puts forward the protection of one’s right to live in a healthy environment as follows: ‘Everyone shall have the right to an environment that is not harmful to their health or well-being’¹⁷. Considering the no-smoking policy in public places in Mauritius, which has been implemented since 2008–09, smoking is banned in all indoor public places including indoor workplaces unless a DSA is available¹⁸. Therefore, the island of Mauritius does not have a comprehensive smoking ban in workplaces. The International Tobacco Control (ITC) team highly recommended the elimination of DSAs, emphasized as essential to protect non-smokers from exposure to tobacco smoke and to provide a smoke-free environment for smokers to quit¹⁹. The loopholes related to DSAs that exist in Mauritius, and certain legislations in other countries, prevent non-smokers to live in a 100% smoke-free environment.

This situation prevails because of the standpoint of trade unions in Mauritius. However, it is not in line with Article 8 of the FCTC³; it also does not align with Article 3 of the Universal Declaration of Human Rights that ‘Everyone has the right to life, liberty and security of person’¹⁴. At the local level, it is in contradiction with Chapter 2 of the Constitution of the Republic of Mauritius that highlights the protection of one’s right to live in a healthy environment as follows: ‘Everyone shall have the right to an environment that is not harmful to their health or well-being’¹⁷. DSAs in the workplace are controversial. Since the implementation of the non-comprehensive smoking ban in Mauritius, there has been no study to explore the views of stakeholders on this issue of DSAs in workplaces.

In light of the controversial status of the smoke-free policy in Mauritius, this study was designed with the following objectives: 1) to explore the perception of stakeholders on the DSAs prevailing in workplaces in Mauritius, and 2) to explore the feasibility of smoking cessation interventions in the workplace. It is the first research that puts forward the views of stakeholders on DSAs in workplaces in Mauritius. The outcome of this study is the provision of the means for policy makers in Mauritius, and other African countries, to address the gap in the implementation of comprehensive smoke-free policies.

Theme 1: Support for tobacco control policies

The first theme has two sub-themes: strengthening the law by adopting a 100% smoke-free environment, and enforcement of the tobacco control policies.

Theme 2: Actions for implementation of stop-smoking services

The second theme had four sub-themes: sensitization of smokers, identification of funding, provision of counseling/treatment, and involvement of stakeholders.

Theme 3: Benefits of workplace stop smoking services

Further data analysis revealed the emergence of sub-themes related to the benefits to employees, company, and country. Improvement of the health of employees, the enhanced reputation of the company, and benefits to the economy of the country will be illustrated with the quotes of participants.

Theme 4: Controversy on the human rights of smokers and non-smokers

Last but not least, the human rights of both smokers and non-smokers were discussed. It was thought that a complete smoking ban and removal of DSAs will prevent smokers from being free. However, it was also acknowledged that smoking is harmful to non-smokers and violates their right to live in a 100% smoke-free environment.

Controversy on the human rights of citizens

In this study, participants perceived that smokers have a right to smoke, provided that they do not smoke in restricted areas. Participants who had expressed support for DSAs on work premises perceived that a comprehensive smoking ban will deprive smokers of their rights to freedom. This finding is in line with Sherriff and Coleman⁸ who revealed employers’ belief about employees’ rights to smoke on the worksite and also with Kaufman et al.⁴ who reported the perception of community members about smoker’s rights. However, these views do not corroborate with Article 3 of the Universal Declaration of Human Rights, which does not mention the ‘right to smoke’ (Graff¹³).

Participants in this study referred to the right of non-smokers to be free from exposure to tobacco smoke. This finding is in line with Katz²¹ who stated that failure to provide a smoke-free environment would transgress the individual’s right to lead a healthy life. The WHO put forward the role of public health law reform to advance the right to health and to create an environment for people to live healthy lives²². Smoking is rather a personal choice than a human right. The choice of a person to start smoking is his or hers. Nonetheless, the personal choice of a smoker impedes the rights of non-smokers for unpolluted air, in line with the well-known phrase ‘my liberty ends where yours begins’. Quote Investigator on its website²³ states that the authoritative source of the origin of this quote has not been found but considers Finch (1882) as the one who stated: ‘Your right to swing your arm leaves off where my right not to have my nose struck begins’. From the same website²³, we can read that Camp (1887) made the statement: ‘I have no right to throw my arms out in a crowd, for I might hit somebody on the nose. My right stops where his nose begins. I have no right to drink if my drinking injures others’. By extension, we will put forward: ‘I have no right to smoke if my smoking affects others’.

Need for smoking cessation services

One of the four major themes emerging from this qualitative study was: actions for the implementation of stop-smoking services. Referring to the contribution of stakeholders in tobacco cessation programs, participants pointed out the role of three pillars, namely the government, employers, and health professionals, in such programs. Health professionals need to be recruited by the Ministry of Health for workplace health promotion that includes smoking cessation services. The findings of this study are in line with the study among hospital staff in Egypt. Radwan et al.²⁴ demonstrated the urgent need for the provision of smoking cessation programs to both medical and administrative staff of hospitals (85.4%) and the provision of smoking cessation training for physicians (84.8%). Another finding from this qualitative study pertains to the view that employers are to be involved in sensitization programs. This is also in line with Radwan et al.²⁴ who highlighted the need for the establishment of a tobacco control committee in hospitals (81%) and the provision of logistical support for tobacco control programs and policies (77%).

Benefits of workplace smoking cessation programs

Benefits for the country, highlighted by participants, are in line with various studies demonstrating cost benefits. The very recent mathematical modeling by Honeycutt et al.²⁵ showed that the potential costs of interventions were substantially larger than actual costs. Benefits included savings in terms of medical costs in the range US$700–750 million and in terms of life-years gained in the range of 21000 to 22000 years. More than a decade ago, Warner et al.²⁶ had shown that smoking cessation was a significant economic investment for companies with long-term benefits with a benefit-cost ratio of nearly 9 times. Benefits for employees include financial savings and health improvement upon successful smoking cessation. Mache et al.²⁷ showed that the intention to quit smoking significantly increased over time with employees participating in smoking cessation intervention. Participants put forward that decreased absenteeism and increased productivity as favorable outcomes for the company providing smoking cessation services. These views are supported by Halpern et al.²⁸ who demonstrated that absenteeism was significantly higher among current smokers than former smokers, with a significant decline with years following smoking cessation. Productivity assessment by peers showed significantly higher values for former smokers than for current smokers.

Support for tobacco control policies

Participants of this study expressed support for the adoption of a 100% smoke-free workplace environment, which shows that they are in favour of the removal of workplace DSAs. This is in line with the Article 8 of the WHO FCTC³, the recommendation made by the ITC¹⁹ for the removal of DSAs in workplaces, and the recommendation by Bondy and Bercovitz⁷ for a complete smoking ban on construction worksites⁷. Concerning the support for the adoption of a 100% smoke-free workplace environment in Mauritius, there is a need for the clause that allows the current existence of workplace DSAs to be removed from the law. We trust that the removal of workplace DSAs needs to be undertaken in a planned phase-out manner with the provision of supportive measures for smoking cessation services in the workplace.

The idea of a planned phase-out of workplace DSAs with the provision of smoking cessation services now leads to a new concept: workplace ‘Designated Stop Smoking Areas’ (DSSAs). A DSSA in the workplace is an area designated by employers to provide stop-smoking support to employees who smoke, resulting from a workplace policy to gradually divert smokers away from a DSA to DSSA for smoking cessation. Therapeutic means will include motivational group therapy, dedicated individual counselling, and tobacco treatment prescription by tobacco treatment specialists to be made available in DSSAs. The right to have access to smoking cessation services when and where smokers need them, as specified by the Director-General of the WHO¹, justify the new concept of DSSA. Also, the principle of leaving nobody behind lends support to the provision of support to smokers having difficulty to quit smoking.

Recommendations

This qualitative study led to a new concept: workplace DSSA, which will help to address the issue of DSAs in the workplace. We recommend the creation of DSSAs in the workplace in Mauritius while maintaining DSAs during a period of one or two years with planned phasing out of DSAs for comprehensive smoke-free workplaces in Mauritius. The role of three main stakeholders, the government, employers, and health professionals has been highlighted for the implementation of smoking cessation interventions in the workplace in Mauritius. Finally, this innovative call for DSSAs is meant to sensitize policy makers of developing countries on how to proceed for the elimination of DSA.

Strengths and limitations

This is the first qualitative study in Mauritius whereby the views of stakeholders were explored. However, the duration of interviews was limited in light of the busy schedule of the stakeholders. The number of participants was only eight, but it was verified that saturation of data was reached.