INTRODUCTION

Tobacco, one of the major causes of mortality worldwide, accounts for the death of more than eight million people yearly. Approximately seven million of those deaths are attributed to direct tobacco use while around 1.2 million deaths result from the exposure of non-smokers to secondhand smoke (SHS)¹. According to the International Labor Organization (ILO), exposure to secondhand smoke at the workplace causes the death of 200000 workers yearly². This is because most working age people spend about a third of their day at work, making interventions in such settings effective in reducing the smoking burden³.

In Lebanon, smoking is prohibited in all open public places, public transport, workplaces and outdoor areas of education, health and sports facilities⁴. However, the policy is not properly enforced and the smoking prevalence is still considered among the highest in the Eastern Mediterranean Region. More than 1.3 million adults aged >15 years (37% men and 21% women) were daily smokers in 2015, with the highest proportions aged 40–69 years^5,6. Data on the exposure of adult non-smokers to secondhand smoke are not available, however, according to the 2011 Global Youth Tobacco Survey (GYTS), 70% of students aged 13–15 years are exposed to secondhand smoke at home and 65% are exposed to it outside home⁷.

Tobacco-free workplaces, including tobacco-free universities, have been effective in decreasing exposure to secondhand smoke, reducing cigarette consumption, increasing smokers’ intention to quit and increasing the likelihood of cessation^8-11. Non-smokers’ exposure to secondhand smoke decreased by 28% in workplaces banning tobacco smoking in the US¹². These policies are also associated with a 4% decrease in the total prevalence of tobacco consumption and 29% reduction in the total consumption per employee according to a systematic review including smoke-free workplaces in the United States, Australia, Canada and Germany⁸. Chapman et al.¹³ found that the number of daily smoked cigarettes decreased by 3.5 cigarettes per smoker in workplaces having these restrictions in Australia and the US¹³. Such workplaces not only provide a supportive environment for smokers willing to quit but also decrease the likelihood of initiation¹⁴. They result in positive changes in the social norms associated with smoking that can disseminate to other environments such as employees’ homes¹⁵. The reduced smoking behavior results from the inconvenience of leaving the work area to smoke, from the negative image of behaviors attributed to nicotine dependence or from the reduction of smoking cues (as other colleagues are not witnessed smoking)¹⁴. In addition to their effect on the smoking behavior, these policies increase productivity and decrease absenteeism rates as smokers miss more work days due to illness^16,17. Salti et al.¹⁷ reported that ex-smokers and smokers’ absenteeism in Lebanon leads to a loss of production of $102.2 million per year.

Workers have generally shown support for smoking bans at the workplace, although non-smokers typically have a more favorable attitude towards them^8,11. In college and university settings, compliance to tobacco-free policies among staff and faculty members has been substantial and support has ranged between 64% and 76%¹⁸. However, the effect of tobacco-free policies has been much dependent on their strength, meaning that comprehensive tobacco policies decrease smoking prevalence and cigarette consumption twice as much as partial bans⁸. Demographic factors, such as workers’ socioeconomic status (SES), represented by education level, and occupation and income, were also found associated with the effectiveness of the policy in reducing the smoking behavior as workers with higher SES have been reported to have higher quit attempts and cessation rates^19-21. Additionally, Mamudu et al.²² reported that faculty members with higher educational attainment and income are more likely to support university tobacco control policies. Thus, investigating the changes in the attitude and smoking behavior of employees with lower educational attainment particularly, could be key in determining the effectiveness of the tobacco control measures.

The American University of Beirut (AUB) is one of the largest employers in Lebanon with more than 5635 staff and faculty members. The university started its tobacco-free policy initiative in 2008 by banning smoking in all university buildings except faculty apartments. In January 2018, AUB adopted a comprehensive tobacco-free policy as instituted by national policy, although it was the first Lebanese higher educational institution to do so. AUB tobacco-free policy prohibits: smoking any kind of tobacco (including cigarettes, cigars, pipe tobacco, e-cigarettes or any other electronic smoking devices, waterpipes, hookah tobacco, snuff, chewing tobacco, dipping tobacco, bidis, blunts, and clove cigarettes) in all indoor and outdoor areas on campus and in university operated facilities off-campus, selling or promoting tobacco and tobacco-related products on university premises, and accepting research funds or event sponsorships from tobacco or tobacco-related companies. Signage, banners and large promotional cubes with messages about the tobacco-free policy were placed at all university gates, major buildings, halls, gathering places and on all AUB social media platforms and screens. Recycling receptacles were placed at all entry points to the university, which later on developed into a cigarette litter-recycling program. The recycled cigarette filters were used to form paddleboards. Free access to a smoking cessation program, including counseling sessions and nicotine replacement therapy, was also made available for students, staff or faculty wishing to quit²³.

Here, we report specifically on the attitudes, perceptions and behavior changes amongst university faculty and staff at 1 year post adoption of the tobacco-free policy. This is done by examining more closely differences in attitudes, perceptions and behaviors between smokers and non-smokers as well as by educational attainment of faculty and staff surveyed. To our knowledge, this study is the first to evaluate the effectiveness of a university tobacco-free policy on employees in the context of Lebanon and the region. It was hypothesized that there would be a higher level of support, an improvement in the perception of policy benefits and a positive change in the smoking behavior.

METHODS

RESULTS

Of the faculty and staff who were invited to participate, a larger proportion of females completed the questionnaire in the first cross-sectional survey compared to the follow-up survey (56% compared to 49%). The distribution of participants by faculty and staff was similar in both years. The smoking status did not significantly vary with 18% and 21% of participants being smokers in 2017 and 2018, respectively (Table 1). When stratified by educational attainment, the proportion of smokers with higher educational attainment decreased from 41% to 35% at 1 year post policy implementation, yet the change was not statistically significant (Table 1).

DISCUSSION

This study reports on the change of attitude, perceived benefits and smoking behavior of staff and faculty at 1 year post implementation of a tobacco-free policy in a university in the Middle East. We found a significant effect of the policy on smokers, particularly those with lower educational attainment. Although the smoking prevalence did not significantly change, the policy had an effect on the smoking behavior as a large proportion of participants reported a decrease in their smoking frequency outside campus, supporting the hypothesis made at the beginning of the study.

Consistent with many US studies, the majority of faculty and staff in both surveys had a positive attitude towards the policy with non-smokers always showing greater support and the proportion of smokers favoring such policy on campus significantly increasing post policy implementation^18,22,25-27. Other studies, however, reported that smokers and ex-smokers are more likely to oppose and violate tobacco control policies^28-30. Although ex-smokers could be more supportive, they still believed in the freedom of choice and showed sympathy towards current smokers’ need for tobacco^28-30. The proportion of smokers with lower educational attainment believing that there should be exceptions to the policy significantly decreased at 1 year post policy implementation, suggesting an improvement in the attitude of smokers known to be less likely to support such policies. The improvement seen in this particular group of employees suggests that educational institutions could be considered as important venues to develop strong and effective tobacco-control policies even in environments generally known for being tobacco friendly. As for the perception of compliance, results were in line with previous studies showing that when the policy is properly enforced, compliance increases over time³¹. The change in social norms resulting from the implementation of the tobacco-free policy could lead to a shift towards a more socially accepted behavior, at least on campus³². The fact that the overall smoking prevalence did not significantly change at 1 year post policy implementation may be attributed to the pro-tobacco environment and the weak enforcement of the tobacco control law at the national level. However, the high proportion of smokers reporting a decrease in their smoking frequency outside campus suggests some effect of the policy on smoking behavior. These results are promising, as Lechner et al.⁹ reported, in their study assessing changes in smoking prevalence over four years post implementation of a university tobacco-free policy, that the decrease was not significant until the second year, thus, illustrating the importance of examining changes over a longer period.

Although great effort has been made to understand the attitude and perception of students towards university tobacco control policies, little is known about the attitude of faculty and staff, the most stable population, towards such policies, especially in the Eastern Mediterranean Region. Few studies have investigated the general attitude of faculty and staff towards such policies in the region, however, none has looked for a change post policy implementation or has tested for policy effectiveness^33,34. This study could set the stage for similar research in the region, thus informing future development of legislation and reducing overall tobacco consumption.

CONCLUSIONS

The university tobacco-free policy had a positive effect on the attitude, behavior and perception of policy benefits among smokers with lower educational attainment, who constitute the majority of smokers. This study highlights the effectiveness of tobacco-control policies in universities and promotes this setting as an important venue for the implementation of such policies. In the Eastern Mediterranean Region, known for being generally tobacco-friendly, all educational institutions should consider implementing such university tobacco-free policies to support national tobacco control regulatory measures in place.