Is Sitting Really the New Smoking? Health of North American Workers Exposed to Prolonged Static Standing

Abstract

In Canada and the United States, many low-paid service providers are required to work long hours in a static standing posture. Women, young people, and low-paid workers are significantly more likely to report standing without moving at work. Prolonged sitting has received negative publicity, being associated with low caloric expenditure and, in some studies, with heart disease. Standing is often recommended, with static standing often conflated with walking. But prolonged standing has been associated with pain in the lower limbs and back, varicose veins, damage to arteries, heart disease, and problem pregnancies. Many US and Canadian jurisdictions such as the province of Quebec, Canada, include mandatory provision of seats in their occupational health regulations. Despite these regulations and subsequent jurisprudence, few cashiers, receptionists, or retail sales staff in these two countries can access seats at work. This article suggests some reasons for the lack of enforcement, describes efforts to transform this situation, and critically examines approaches to legislation, inspection, and intervention.

Introduction

In Quebec, Canada, in 2021, one-third of workers worked standing with little or no possibility of sitting down, and half of them had no access at all to seats. ¹ Static standing has been found to be more common among lower income workers, those with less education, and those exposed to a host of other difficult conditions such as repetitive work, handling heavy loads, and forceful exertion. Among all standing workers, men are more likely to move around and women are more commonly exposed to standing still with no possibility of sitting. ² According to the most recent data available, those exposed to such constrained standing are more likely to report distal lower-extremity and low-back pain.^3,4

In Quebec, as in several other Canadian and US jurisdictions, occupational health regulations provide for seats to be offered to workers under some circumstances. ⁵ Article 170 of the Quebec Regulation respecting Occupational Health and Safety reads, for example: “Chairs and benches: Workers shall have chairs or benches put at their disposal when the nature of their work so permits.” ⁶

In Quebec and elsewhere, cases that involve seating have been brought before labor tribunals. For example, in 1991, a Quebec judge ruled that the Provigo chain of supermarkets (one of the five largest in Quebec) had to provide a seat for its cashiers. ⁷ A similar ruling in 2017 involved bookstore staff from the Renaud-Bray chain. ⁸ These judgments did not consider whether the existing physical structures would accommodate seating, since it was recognized that the environment could be modified. Thus, the “nature of their work” does not include the way the worksite has been set up. The environment is considered to result from employers' choices. Therefore, the employer cannot argue that the existing architecture or setup is incompatible with sitting.

In California, however, the regulation provides that “All working employees shall be provided with suitable seats when the nature of the work reasonably permits the use of seats.” ⁹ Over 25 suits involving “suitable seating” have been brought before California courts. ¹⁰ Several California cases have involved discussions of the “nature” of the work performed, and to what extent the existing physical environment of the job should be taken into account. ⁹ For example, some cases involved discussion of the proportion of time that a particular job could be done while sitting or whether sitting was possible given a specific environmental configuration. One California decision found that:

A workspace's physical layout may inform the expectations of both the employer and employee with respect to job duties. To the extent it does, the physical workspace would be relevant in defining an employee's job duties and should be accounted for in the totality of the circumstances inquiry. ¹¹

Thus, the jurisprudence in California has been less favorable to workers than the Quebec experience. In California, there has been a two-stage process for examining the right to sit: First, the “nature of the work” is examined, including the time passed in a specific place; the longer the worker spends in a single place, the more favorable the judge will be toward providing a seat. Second, the “reasonable” nature of the worker's request for a seat. Here the California tribunals, unlike their Quebec counterparts, will take into account the “business judgment” of employers as well as the existing physical arrangements.

However, the end results in the two jurisdictions appear to be similar. Observations by the present authors in 2024 inside stores belonging to several supermarkets and bookstores in Quebec, as well as two California CVS pharmacies, did not reveal any seated cashiers, nor seats anywhere near their cash registers. When asked why, a cashier in one of the Quebec stores replied that she knew about the ruling and knew that her union was in favor of seats, but “My manager doesn't want me to sit [personal communication, our translation].” A similar question asked of a unionized hotel receptionist whose employer had been the subject of one of the Quebec seating decisions elicited a similar answer.

In the United States and Canada, most receptionists, fast-food servers, and bartenders have no access to seats. This is in contrast to the situation in countries outside North America, where cashiers can be observed to be seated in countries like France, Brazil, and Turkey. ^a A variety of seats adapted to the requirements of these jobs are marketed in Europe. ^b Perhaps the strength of the labor movement could explain some of the differences since the extent of coverage by collective bargaining of unionization is 31.3% in Canada (37.3% in Quebec), compared to 12.1% in the United States (15.9% in California) and 98.0% in France,^12–14 and article 8.1.6.3 of the collective agreement negotiated by the French retail food industry and their union provides for access to seats. ¹⁵

Recent decisions in Quebec have ordered employers to provide seats, for example, for casino workers assigned to blackjack tables. ¹⁶ Nevertheless, employers have the choice of means to fulfill their obligation, which allows them to offer alternative solutions considered by the tribunals to be similar, such as an anti-fatigue mat ¹⁷ or a 5 min “physical break” every 25 min, during which workers can carry out their tasks in a seated position. ¹⁸ But we must ask whether anti-fatigue mats are as helpful as seats, and whether such physical breaks are accessible under the actual working conditions of casino or hotel workers in direct contact with clients.

The present article will discuss the sources and effects of employer resistance to seats and its effects on occupational health. We start with an examination of quality concerns about the scientific literature in relation to exposure variables, outcome variables, and the statistical treatment of gender ¹⁹ and social class. We present some suggestions for scientific solutions that have not yet been adopted in situations where Quebec workers serve the public.

In order to explain the failure of prevention, we then present the governmental context for prevention in Quebec, how priorities for prevention have been determined, and the ways in which women's jobs have been excluded from those priorities. We examine how, in practice, inspectors have not been active in applying the regulations about seating and some reasons for this lack of activity. Among them, we point to employer reluctance to see workers sitting in the presence of customers, a low priority for prevention in women's jobs, and confusion about whether sitting is good or bad for health. We conclude with a description of current attempts to transform the situation in Quebec, describing efforts to integrate women's jobs in prevention efforts and to obtain seats for cashiers and other retail workers.

Sources of Confusion in the Scientific Literature: Exposure Variables

Ergonomists in hospitals, restaurants, factories, stores, mines, forests, and sports arenas can see workers sit and stand, but also run, walk, amble, crouch, skate, bend, lean, wiggle, and squat, while handling weights, tools, small children, older patients, products, and machines. But epidemiologists who want to predict and prevent occupational illnesses need to prune the number of variables they use to study general working postures, so “sitting,” “standing,” “walking,” and “sedentary” are names that have been commonly used to describe these kinds of postural exposures. ²⁰ Also, occupational and leisure-time physical activity may be combined in their analyses, resulting in confusion.

Failure to Distinguish Between Leisure-Time and Occupational Physical Activity

Many early studies attempting to predict cardiovascular problems in humans ascertained “physical activity” or “sitting” or “standing” over entire days and concluded that physical activity and (sometimes) standing were beneficial. This approach did not separate leisure-time (LTPA) and occupational physical activity (OPA) and sometimes produced confusing results. Holtermann et al. ²¹ explain why it is important to distinguish between LTPA and OPA when studying effects on cardiovascular health: Differences in duration and intensity between LTPA (usually high-intensity, relatively short-duration) and OPA (more constant, low-level demands), resulting in different effects on heart rate and blood pressure; likely lack of adequate recovery time with OPA, resulting in inflammation. We would add to the list the relative lack of operational leeway ²² in OPA, where the timing, equipment, and often, techniques used are imposed on workers without any possibility of adjustment to their specific capacities and current state (whereas people engaged in exercise on their own time can modulate their activity in response to whatever signals their bodies are sending them). When considering musculoskeletal outcomes, we would add another factor: the repetitive nature of some occupational physical activity, which can minimize time for recovery. ²³

Failure to Separate Sitting, Standing, and Walking

Measuring OPA to predict cardiovascular health can be done by questionnaire or using various technical means like having subjects wear accelerometers. The aim is generally to find out whether the circulatory system is being stimulated enough but not overstrained. Instruments or questions can capture levels of energy consumption, fatigue after work, and overstrain. However, the details of working posture are not always sought in epidemiologic studies, and standing still is often conflated with sitting (both reported as “sedentary”) or with moving around (both reported as “standing”).

Admittedly, it is difficult to classify standing as distinct from walking. Since it is impossible for most people to stand without moving their feet for longer than a few minutes, static standing must be carefully defined, and the definition varies. ²⁴ A useful consensus document produced by the Sedentary Behavior Research Network differentiates among sitting, sedentary behavior, and standing on the basis of posture and metabolic energy expenditure/time (MET). ²⁰ However, although METs are important indicators of heart function, they are not as good indicators of the effects of static standing on blood pooling in the lower limbs or stress exerted on muscles, joints, and connective tissue. Even when observations are done on site in workplaces, it is difficult to decide when standing becomes moving and how many steps end a bout of standing.^24,25 Some studies define moving in relation to a minimum number of steps, while others consider whether the individual is confined to a small area. Also, static standing itself is a large category that can include more or less rigid stances as well as crouching, squatting, reaching, and leaning, ²⁶ not included in the consensus definition of standing, but important when musculoskeletal outcomes are considered.

The total time spent in a standing position is also characterized in varying ways. Prolonged standing has been defined as spending more than half of a work shift in a standing position, ²⁷ 2 h ²⁸ or more than 10 min. ⁴ One meta-analysis defined it as standing for over 8 h. ²⁹

A 2024 study pointed out the problems with previous publications that had conflated sitting and standing, and used equipment that was able to distinguish sitting, standing, and walking, with 83% accuracy. ³⁰ Unfortunately, this study did not distinguish between occupational and leisure-time postures, and it adjusted its analyses by gender, which is highly correlated with standing time and walking time (see below for a discussion of adjustment by gender). The authors found that prolonged sitting and, to a lesser extent, prolonged static standing predicted orthostatic circulatory disease. They stated that added risk for static standing began at 2 h/day and concluded that static standing should not be proposed to prevent diseases associated with sitting.

Sources of Confusion in the Scientific Literature: Sample Selection and Statistical Treatment

Many studies of working postures exclude women workers. Eight of 23 studies included in a recent meta-analysis relating cardiovascular outcomes to occupational physical activity excluded women entirely. ³¹ This is particularly unfortunate because women who stand at work are more likely than men who stand at work to be exposed to standing without moving. ²⁶

When both women and men are included in population-based studies and there is reason to suppose that their results will differ, researchers often include an adjustment for gender ^c in their analyses. This procedure has the unfortunate effect of adjusting the results for all unmeasured gender-based differences in exposures. Thus, in a study where static standing is conflated with walking, if women who stand at work walk less at work than men who stand at work, and if standing without moving is associated with a higher probability of a health effect, adjusting the results for gender will conceal the association between static standing and the health effect. ³²

Typical professions where women are exposed to prolonged static standing postures are sales staff (seventh most common profession among women), and customer service staff (ninth). ³³ These workers are also poorly paid (mean annual income of 23 600$ and 19 400$ CAD ^d , respectively). If studies that conflate static standing with sitting adjust (as is common) for social class or some proxy for social class like income or education, the relationship with static standing can be further obscured. An example of this problem can be seen in a meta-analysis by Bonde et al., who studied exposure to “standing” without further definition with regard to movement and eliminated studies that did not adjust for social class. ³⁴ But adjustment for social class might also adjust for static standing versus sitting and thus confuse associations with health outcomes.

These arguments apply, mutatis mutandis, to studies that adjust for other sociodemographic variables such as age or racialization/ethnicity/minority status/migratory status. Recourse to more sophisticated analyses becomes necessary since simultaneous stratifying for multiple variables and variable categories is impractical. ³²

Treatment of Standing in the Scientific Literature: Outcomes

Cardiovascular Outcomes

Cardiovascular outcomes considered have included incident heart disease, progression of carotid atherosclerosis, orthostatic hypotension, varicose veins, and symptoms such as orthostatic hypotension and blood pooling in the lower limbs. In a meta-analysis of 23 studies relating cardiovascular outcomes to occupational physical activity, only two separated standing from both sitting and walking ³¹ (see the authors' Supplemental table 3). It is also notable that fewer than half the studies were balanced with regard to gender (40%-60% women). Eight of the 23 only included male subjects, three others had fewer than 40% women and only one had more than 60% women. No study excluded men. The meta-analysis concluded that occupational physical activity, unlike leisure-time occupational activity, could not be shown to be related to cardiovascular problems.

However, a more recent Canadian study that was not included in the meta-analysis but did carefully consider gender ³⁵ found that a mix of occupational sitting, and standing/walking was associated with a lower risk of incident heart disease than sitting, among men only. After examination of occupations among women and men in the sample, the authors postulated that the lack of effect among women could be due to the different mix of postures among those women and men whose occupations were known to include a combination of sitting, standing, and walking (with the men doing more walking, as had been shown in a Canadian population ²⁶ ). However, when the same authors performed a nonstratified analysis including both women and men with adjustment for gender, no association with heart disease was seen, presumably because adjusting for gender also adjusted for nonascertained gender-associated exposure variables like the proportion of static standing time versus moving time. ³⁶

Other studies of working populations have shown that prolonged static standing leads to symptoms of circulatory disturbance (orthostatic intolerance) like dizziness, as well as to foot sensitivity, and varicose veins.^37–39 Laboratory studies have shown that leg pain is associated with blood pooling in the lower limbs, which increases during standing work. ⁴⁰

Musculoskeletal Outcomes

Laboratory and field studies of the effects of prolonged standing on musculoskeletal disorders and pain in general define static standing and differentiate it from walking, although there is no consensus on the length of time standing that constitutes static standing (reviewed in Ref. ²⁵ ). Prolonged static standing is associated with discomfort and pain in the lower limbs and back. ⁴¹ Some researchers have distinguished between pain developers and nondevelopers in working populations, and test pain developers for their reaction to different imposed working postures, showing more pain among pain developers.^42,43

In general, women report more work-related musculoskeletal disorders than men. ⁴⁴ Since most of these studies were done in laboratories, most samples were balanced with regard to gender.

Pregnancy and Reproductive Outcomes

In the 1990s, Paul and Frings-Dresen ⁴⁵ produced a series of ergonomic studies contrasting working postures during mid-pregnancy with those of nonpregnant women in the same work environment, showing a need for adaptation of the physical work environment to the pregnant body. In the only epidemiological study we found where static standing during pregnancy was defined separately from walking and sitting, Haelterman et al. ⁴⁶ found that preeclampsia, a hypertensive condition dangerous for women and their fetuses, was associated with standing without walking more than 1 h/day at work. A 2007 meta-analysis of a number of exposures and outcomes ⁴⁷ pointed out the difficulties of estimating relative risks for exposures during pregnancy: a major problem is retrospective assessment of exposures once the outcome of the pregnancy is known, but there was also lack of precision and uniformity in the definition of standing. In a meta-analysis conducted in 2013, ⁴⁸ where the authors pointed out that no other study than Haelterman et al. identified static standing specifically, and where availability of seating was not studied, standing more than 4 h/day did not significantly predict preterm delivery, low birth weight, or small size for gestational age, although all relative risks were somewhat greater than 1.0. A more recent review carried out by the National Institutes of Occupational Safety and Health found “limited but consistent” evidence that “postural load” (standing, bending, twisting, flexing shoulders) during pregnancy was associated with musculoskeletal disorders. ⁴⁹ Definitive studies of the effects of static standing on pregnant women's health and on pregnancy outcomes have yet to be carried out.

Despite the various problems in the scientific literature, we can conclude that prolonged static standing is undesirable and that seats should be made available to standing workers.

Scientific Solutions for Seating

Ergonomists have recommended the sit-stand chair as a part of the solution to health problems of both sitting and standing workers, and they are used in other countries, along with job rotation. ⁵⁰ In Québec, sit-stand chairs were recommended to supermarkets in 1997 by a team led by ergonomics researcher Nicole Vézina, an expert witness in the 1991 Provigo case. ⁵¹ However, scientific research on solutions for cashiers seems to take a back seat to preoccupations regarding too-long sitting for office workers, generally of higher social status. A 2024 PubMed search using the search term “sit-stand chair*” yielded 43 references, of which only one ⁵² dealt with prolonged standing among retail workers, while the others dealt with seated office work or people with physical handicaps. At the same time as cashiers struggle for seats, campaigns are in progress to keep office workers from sitting at work: standing is presented as healthier than sitting and workers are urged to ask for standing desks. Slogans like “Sitting is the new smoking” ^e and “Beware of the chair” ^f are gaining in popularity.

Avenues Toward Prevention

Despite gaps in the research, prolonged static standing is a recognized occupational health risk in many jurisdictions, as previously mentioned. Specific regulations in North America, such as in California, United States, and the provinces of Quebec, Saskatchewan, Newfoundland, and Labrador, as well as the Yukon, Nunavut, and North-West Territories in Canada, require employers to provide seats when the nature of their work so permits. In other states or provinces, the general duty to protect workers' health can be invoked to mandate the provision of seating. Sit-stand stools have been developed to allow employees to adjust their posture, switching from sitting to standing according to the varying demands of jobs. ⁵³ Why, then, are so many workers still standing at work? Why are so many women in service occupations denied seats? The situation in Quebec, where 33 years have elapsed since the first decision requiring seats for supermarket cashiers, may provide some answers.

Governmental Provisions for Occupational Health and Safety Protection in Quebec

The Quebec Commission for Norms, Equity and Health and Safety at Work (CNESST), a governmental organization, is responsible for prevention of occupational accidents, injuries, and illnesses and for compensating affected workers under the “Act respecting occupational health and safety” and the “Act respecting industrial accidents and occupational diseases,” as modified by the 2021 “Act to modernize the occupational health and safety regime,” ⁵⁴ their regulations, and other relevant legislation. In Quebec, prevention and compensation activities are financed exclusively by employer contributions (with amounts determined by previous compensation levels in their employment sector and, for some, by their own history of claims) and administered by joint employer and labor governance.

The CNESST employs inspectors to identify and sanction dangerous situations, and labor tribunals oversee the enforcement of these legislations, particularly concerning compensation. The CNESST's research arm, the Robert Sauvé Institute for Research in Occupational Health and Safety (IRSST), is responsible for identifying emerging risks and following the evolution of health effects. The activities of the CNESST are deployed according to priorities dictated by labor laws and regulations and largely determined by compensation levels (see below). The Ministry of Health shares some of these responsibilities. It employs physicians and ergonomists who can identify and remedy problematic situations and researchers who study occupational health issues at a population level.

Thus, seats could be imposed by labor inspectors or be implanted as a result of interventions by public health practitioners.

Administration of Prevention in Québec in Relation to Seating

Prevention could occur if unions negotiate seats for workers in their contracts, if they initiate formal complaints concerning the nonapplication of the regulations, if more inspectors enforced these regulations, and/or if public health authorities ran a campaign about seats for service-sector workers.

Under access to information legislation, we asked the CNESST to send us all inspection reports that mentioned article 170 (about the right to have a seat), from January 1, 2023, to December 31, 2023. Note that this was a limited request that did not access reports where seating was involved but the specific article was not cited. We received reports on 11 inspections relating to seven workplaces. ⁵⁵ Only one of the seven workplaces was visited in response to a formal complaint that dealt specifically with seating, and another was visited with respect to a specific position that lacked seating. Others were inspected with a view to identifying compliance with all regulations and the lack of seats was only one of several irregularities noted. The 11 reports highlight situations where workers, including cashiers, production line workers, and daycare educators did not have access to appropriate seating. For example, daycare staff were being asked to sit on children's chairs, and convenience store workers sat on milk crates. (The inspectors intervened to require appropriate chairs in the daycare but did not object to the milk crates.) The case where the inspector examined seating specifically for a receptionist position was resolved by installing a backless rotating stool. Generally, the inspectors tended to adopt a supportive approach, encouraging employers' compliance through reminders and allowing time to introduce improvements rather than enforcing compliance under penalty of fines. It should be noted that, as of 2000, Quebec was ranked 63rd among the 63 North American jurisdictions in the application of sanctions to occupational health and safety violations, among other criteria. ⁵⁶ The weakness of enforcement has been criticized more recently by the Quebec Auditor General ⁵⁷ and by others, especially regarding prevention in women's jobs. ⁵⁸ The government's continuing gentle approach (and the overall lax regulatory environment) can lead to employers complying with specific requirements, but it does not encourage them to be more generally proactive in ensuring workplace comfort and safety.

More generally, one can ask whether it is possible for 266 nonmanagement inspectors to meaningfully inspect the 281,282 establishments covered by the legislation (numbers obtained in response to our access to information request). ⁵⁵ Note that about 80 of the inspectors are assigned specifically to the construction sector. An optimistic calculation yields a ratio of 266/281,282 or one inspector per 1057 establishments, with some workplaces needing several return visits. Inspectors may therefore show flexibility when they find that the official joint employer-employee workplace health and safety committees are already addressing an issue, reinforcing a practice of internal controls.

Obstacles to Enforcement of Seating Regulations in Quebec

Employer Reluctance

Despite occasional encouragement from the CNESST and even faced with tribunal decisions, employers have not invested in seating. In 2004, in collaboration with ergonomics researcher Nicole Vézina, the CNESST developed a guide ⁵⁹ for cashiers' work stations including a “sit-stand stool” that allowed workers (after a short training period) to transition at will between sitting and standing. The seat was developed in collaboration with various partners from the food industry. A pilot project introducing the seat was implemented in 2006 in one supermarket but was abandoned after 4 months. To our knowledge, no seat of this type has since been installed in any supermarket in Quebec, despite the fact that a substantial body of research exists on sit/stand chairs. ⁵² Although many employers have installed new self-checkout stations, they have not profited from the rearrangements to re-engineer the work stations at the conventional cash registers, nor have they supplied seats for the workers who stand by to help customers use self-checkout.

Neither the food industry partners nor the CNESST have reactivated the seat implantation project. The CNESST's prevention strategy for 2020 to 2023 ⁶⁰ focused on other work-associated musculoskeletal risks such as excessive physical exertion, repetitive movements, and other movements causing physical stress and tension. Neither static standing nor the provision of seating was emphasized. A study done in Sweden (where cashiers sit) showed that job rotation among assignments to positions at checkout, delicatessen, and stocking shelves produced the fewest physical (neck pain) and psychological symptoms, despite the heavier weights involved in stocking shelves. ⁶¹ This approach has not been adopted in Quebec.

To understand why workers stand, Quebec researchers interviewed 30 young workers from a variety of employment sectors who usually worked standing. ⁶² All but one reported discomfort and two-thirds said the effects (pain and fatigue) overflowed into their personal time. Each of the interviewees said that their employers were opposed to seats. They interpreted this attitude as resulting from a hypothetical image problem for the customer (“it could make the customer feel a bit ill at ease”; “it's a less attractive image”) or as a measure to prevent the workers from getting lazy or falling asleep on the job. Some mentioned their employer's indifference to their well-being (“he's not going to give me a back rub”). These perceptions of customer rejection and laziness were echoed in arguments provided by California employers to justify withholding seats. ¹⁰

Historical Exclusion of Women's Jobs From Prevention Priorities in Health and Safety Administration

In Quebec, 80% of cashiers are women, ⁶³ and women are over-represented in customer service in general. Women's jobs have historically been excluded from health and safety priorities in Quebec.^64,65 The CNESST is governed by a board with equal numbers of union and employer representatives chosen from among the “most representative union and employers' associations.” ⁶⁶ The current union representatives are in fact chosen by the two largest union associations, the Fédération des travailleurs et travailleuses du Québec (FTQ, with over 500 000 members, 37% women) and the Confédération des syndicats nationaux (CSN, with 330 000 members, 50% women), plus a much smaller union confederation, the Centrale des syndicats démocratiques (CSD, with 79 000 members, 35% women). The Centrale des syndicats du Québec (CSQ, with 225 000 members, 80% women, mostly from the health and education sectors), was only briefly represented on the board. The Fédération interprofessionnelle de la santé du Québec (FIQ, with 80 000 members, 90% women) has never been represented.

Under the occupational health and safety laws prevailing from 1979 to 2021 (see below for details), Quebec industries were assigned to one of six sectors, ranked in order of priority for intervention. Those with the highest priority benefited from public health prevention programs and remunerated worker participation in health and safety matters. The priorities were also reflected in the number of inspections initiated by the CNESST (not instigated by a complaint), as well as in the CNESST-associated research institute's activities; there were eight times more inspections in the three highest groups, compared to the other three. ⁶⁴ This priority ranking correlated perfectly, if inversely, with the proportion of female workers, with top priority granted to the first group of industries (11% women), the second priority to those with 12% women, and so on through 25%, 38%, and 45% to the lowest-priority group, including hospitals and educational establishments, with 60% women. ⁶⁴ Eighty-five percent of working women (and 60% of men) were in the three lowest-priority sectors. Most of the jobs where people were exposed to static standing were in the sectors with the lowest priority.

Social Power Influence on Prevention Priorities

The lack of importance given to the health and safety of cashiers is not only attributable to their gender. Standing can be seen as a gesture of courtesy offered to people of superior social status. ⁶⁷ In Quebec, cashiers are paid an average of 15$ CAD/h, equivalent to the minimum wage, ending up with 27 000$ CAD/year. ⁶⁸ But, as French cashier Anna Sam has pointed out, ⁶⁹ this profession is so disdained that mothers bring their children to watch cashiers at work in the hope that they will be frightened into studying hard. “You see, if you don't work hard at school, you will end up a cashier like the lady,” one customer said to her daughter, in front of the cashier who was serving her. Although, in France, cashiers cite their seated posture as one of the advantages of their jobs, ⁷⁰ in Canada, their inferior social status seems to legitimize insisting that cashiers stand. ⁶⁷

Another consequence of the low social status of North American cashiers is that prolonged standing is only one of several difficult conditions to which they are exposed. Questionnaires, observations, and interviews with supermarket workers revealed that their major concern was with getting enough hours of work per week to feed themselves and their families and ensuring that the work schedules (which changed every week with 2- or 3-days' notice) were compatible with their other obligations. Since the supervisors are in charge of day-to-day scheduling, this contributes to a power imbalance even when the workers are unionized.^71–73 These other preoccupations may push their unions' priorities away from their personal comfort or even their health.

Current Struggles

In 2020, when the Quebec government proposed a modification of the health and safety and compensation laws, the proposal again included a priority ranking of industries, this time based on an analysis of their history of compensation for occupational health problems. This ranking would again determine the level of resources for prevention.

The fact that the health care sector was still given the lowest priority for intervention under the proposed legislation seemed particularly strange in that pandemic year. Scholars from the SAGE research team ^g (including the present authors) felt that the proposal reflected a kind of vicious cycle where those sectors that had benefited from government intervention in the past would continue to do so, since the level of information and support available to workers depends on the priority of their sector and determines their ability to claim compensation. ⁷⁴ Also, researchers noted that women in Quebec had experienced discrimination by tribunals determining compensation for occupational health and safety problems. SAGE researchers Katherine Lippel and colleagues had showed that women's claims for compensation for musculoskeletal disorders ⁷⁵ and for stress ⁷⁶ were more often refused by the relevant tribunals. Similar discrimination against women workers' claims for compensation has been identified in Sweden ⁷⁷ and France. ⁷⁸

Over the preceding 25 years, SAGE researchers had been part of recurring coalitions with unions, feminist groups, and public health authorities in order to protect the rights of workers exposed to danger at work during pregnancy or nursing. The work of the Quebec coalition was facilitated by two formal agreements between the outreach service of the University of Quebec at Montreal and consortia of unions and women's groups, guaranteeing research time and some money for joint activities. ⁶⁷

Faced with the new proposal, the coalition revived to produce and publicize analyses concerning women's place in occupational health, showing (among other issues) that women's jobs were severely underrepresented in the priority areas. ⁷⁹ In response to the coalition's well-publicized demands and its members' testimony before the National Assembly (governing body in Quebec), the government abandoned its proposal for priority sectors, relegating the determination of such priorities to a regulatory committee meeting behind closed doors. The new law specified that any regulation had to “take into account the specific realities of women and men,” in other words, be submitted to a gender-based analysis. Under pressure from the coalition, there was also some inclusion of domestic workers in the compensation regime, and the government withdrew a proposal to subject protection of pregnant workers to approval by company physicians. ⁸⁰

Two of the scientists involved in the struggle for higher priority for women workers were also able to use the momentum generated by this struggle to produce a report ⁸¹ that quickly led to a law ⁸² respecting sexual violence in the workplace.

Inspection, however, is still a problem. In addition to the inspectors, who are employed by the CNESST, Quebec public health authorities also employ ergonomists who have intervened in workplaces given priority by the CNESST, although they do not have powers of enforcement. The regulation concerning CNESST health and safety priorities for prevention has not been announced as of this writing, so all workplaces now are supposed to receive the same attention. But the public health authorities have been wondering how they are going to choose where to intervene. In a meeting with public health specialists in occupational health in 2024, one of the authors (KM) was told that the number of workers fully covered has gone from about a third in 2020 to 100% of the workforce since 2021, without any increase so far in the number of (for example) ergonomists.

Toward Action on Legislation, Inspection, and Intervention

Currently, the coalition is still trying to peek under the closed doors where the process of prioritizing CNESST interventions is taking place, submitting comments as opportunities arise. The existence of the coalition and its publicizing of the treatment of women may result in improvements in inspection and prevention practices. The fact that public health authorities have been sensitized to women's issues during the passage of the new law seems to have already produced changes in the government's approach. For example, the CNESST has been publicizing the importance of health and safety representation for all workers (as opposed to representation of those given the highest priority for intervention) in its most recent public communications.

A representative from the United Food and Commercial Workers Union (UFCW) highlighted, in 2015, a perceived lack of empathy from employers and inadequate recognition of the need for seats by the CNESST. ⁸³ The cashiers' unions have collaborated for years with scientists, notably Nicole Vézina, ⁸⁴ to promote seating for cashiers despite competition from other priority issues for its workers (the aforementioned low pay and extremely variable and unpredictable work schedules). ⁷²

Among the 11 inspection reports referencing seats in 2023, all the inspections that originated from a formal union complaint concerned supermarket cashiers. This was due to a campaign initiated in 2022 by the Conseil d'intervention pour l'accès des femmes au travail (CIAFT), a feminist community group with representation from trade unions. CIAFT also commissioned a poll among retail customers that showed that they were largely in favor of allowing access to seats, and will be sponsoring an observational study of the available seating with collaboration from some retail stores. ⁸⁵

Mobilizing could be broadened by an approach like that of the Korean union-backed “Chair Campaign” which, in somewhat similar social and regulatory circumstances, was partly successful in winning the right to sit for retail workers. ³⁸ The strategy involved pressure on employers through appeals for enforcement as well as tactics to evoke sympathy among customers. In addition to traditional cashier positions, the Quebec unions are also concerned with the working posture of those who help customers use the growing number of self-service checkout stations. That position also requires static standing, without even the possibility of leaning on the counter that is available to regular cashiers.

Conclusion

Although the intervention by CIAFT may eventually bear fruit, the 35-year struggle for seats illustrates the widespread, successful resistance of employers to regulations and inadequate enforcement of occupational health and safety standards, a resistance found not only in Quebec but more widely in Canada and the US. It is also emblematic of the poor bargaining power of low-paid workers and of women workers in North America, those most likely to be exposed to requirements for prolonged static standing. The struggle also underlines the need for reinforcement of access to unionization and protection of the rights of union members.

On the other hand, coalitions among feminist groups, researchers, and unions are a promising avenue for advancing health protection for women workers. In the Quebec case, the existence of such coalitions is greatly facilitated by the existence of the community outreach policy and practices at the Université du Québec à Montréal. The university has for the last 45 years maintained an outreach service that employs coordinators who interpret community needs to researchers, and vice versa. Seed money is available for accepted projects although many succeed in attracting conventional research grants. The professors' contract includes language providing for released time for educational and research programs carried out in response to community requests, access to which is administered by a university-community committee. ⁸⁶

Scientific solutions for the cardiovascular and musculoskeletal risks in cashiers' jobs in the United States and Canada can involve work stations that allow workers to choose and modulate their working posture (such as sit/stand stools and access to seats); scientific participation in union and community campaigns to make customers aware of the need for seating; and scientific interest in the pros and cons of job rotation. In the specific case of supermarket workers, stabilizing work schedules would alleviate much of the power imbalance between employer and workers that deters workers from asking for other improvements in their work environment. However, the current standard, obtained in response to a joint union-university study of work schedules, and providing that workers can refuse to work if schedules are given less than 5-days’ notice, ⁸⁷ is widely ignored, according to union representatives.

This article is, for us, an opportunity to call for broader changes in general prevention practices so that real improvements in occupational health can be attained. A short list could include: increase in the number of inspectors; increase in the number and amounts of sanctions for employers who defy regulations; education of tribunals on the risks of unconscious discrimination; a tighter legal control on last-minute scheduling; and mechanisms for effective inclusion of all workers in health and safety programs. Anti-union practices of some of the employers targeted by the seating struggles should also be targeted. ⁸⁸

We hope that the silent suffering of thousands of workers can be made visible so that solutions can be found. Some reassurance can be found in the inclusion of gender-based analysis in the latest modification of the health and safety laws and in the recent inclusion of the majority-female CSQ union on the board of the CNESST, 25 years after their first request.^89,90 One major supermarket employer seems to be reconsidering seats for cashiers and has announced a pilot project. ⁹¹ We are also encouraged by the fact that the newly announced 2024 to 2027 CNESST prevention and inspection plan had added to its priority list of risk factors “stay in a static posture.” ⁹² We hope that this evolution will continue.