A number of employers, both health-related and not, have established policies of not hiring smokers, The New England Journal of Medicine reports today as part of a larger look at the ethics of such controversial measures. These businesses, including the Cleveland Clinic, Geisinger, Baylor and the University of Pennsylvania Health System and the Union Pacific Railroad and Alaska Airlines, have various rationales for their decision to exclude tobacco users. And in an NEJM perspective piece, authors David A. Asch, M.D., M.B.A., Ralph W. Muller, M.A., and Kevin G. Volpp, M.D., Ph.D., all of Philadelphia, lay out several reasons why these policies are taking hold:
Tobacco use is responsible for approximately 440,000 deaths in the United States each year — about one death out of every five. This number is more than the annual number of deaths caused by HIV infection, illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined1 and more than the number of American servicemen who died during World War II.
A small but increasing number of employers...have established policies of no longer hiring tobacco users. These employers might justify such hiring policies in many ways — arguing, for instance, that they're taking a stand against a habit that causes death and disability, that they're sending an important message to young people and others within their communities about the harms of smoking, or that they're reducing their future costs, given that smokers, on average, cost employers several thousand dollars more each year than nonsmokers in health care expenses and lost productivity.
But in a companion piece, doctor and health policy expert Ezekiel Emanuel and others write that it's "paradoxical," and even wrong to single out smokers by refusing them employment:
Yet it seems paradoxical for health care organizations that exist to care for the sick to refuse to employ smokers. Many patients are treated for illnesses to which their behavior has contributed, including chronic obstructive pulmonary disease, heart failure, diabetes, and infections spread through unprotected sex or other voluntary activities. It is callous — and contradictory — for health care institutions devoted to caring for patients regardless of the causes of their illness to refuse to employ smokers. Just as they should treat people regardless of their degree of responsibility for their own ill health, they should not discriminate against qualified job candidates on the basis of health-related behavior.
The broader claim that it is fair to exclude smokers because they are responsible for raising health care costs is too simplistic. It ignores the fact that smoking is addictive and therefore not completely voluntary. Among adult daily smokers, 88% began smoking by the time they were 18, before society would consider them fully responsible for their actions. Much of this early smoking is subtly and not so subtly encouraged by cigarette companies. As many as 69% of smokers want to quit, but the addictive properties of tobacco make that exceedingly difficult: only 3 to 5% of unaided cessation attempts succeed. It is therefore wrong to treat smoking as something fully under an individual's control.
In addition, all other diseases — and many healthful behaviors — also result in additional health care costs. People with cancer burden their fellow workers through higher health care costs and absenteeism. People who engage in risky sports may have accidents or experience trauma routinely and burden coworkers with additional costs. Having babies increases premiums for fellow employees who have none. Many of these costs result from seemingly innocent, everyday lifestyle choices; some choices, such as those regarding diet and exercise, may affect cancer incidence as well as rates of diabetes and heart disease.
So, what should employers do? Emanuel, et al write:
We believe that offering support for healthful behaviors is the best approach. Central in this regard is assisting employees by providing evidence-based smoking-cessation programs, removing cost barriers, facilitating access, and providing necessary psychological counseling and other support. For example, many employers, such as Walgreens, provide free nicotine-replacement therapy and smoking-cessation counseling to employees.
Readers, what do you think? Should smokers be punished for their sins, or might constructive engagement be the better path? Let us know.
This program aired on March 28, 2013. The audio for this program is not available.