Should hospitals discriminate against smokers?

As I walk into the hospital each day, I notice patients and families sitting outside on benches that are surrounded by large signs prohibiting smoking on hospital grounds. For over five years, a collaborative and concerted effort by Memphis hospitals has successfully made all the hospital campuses smoke-free.

Now, in other states, hospital systems like Cleveland Clinic and Baylor Health Care have taken another bold step forward. They have stopped hiring smokers to their workforce.

So, I wondered, is it appropriate to deny employment to capable workers, just because they smoke? This was a topic debated in a recent issue of the New England Journal of Medicine.

Undeniably, smoking is the greatest public health challenge of our time. Each day, I see patients who become short of breath, lose their limbs and even die from the long-term effects of smoking. Despite all the public health efforts, 1-in-5 Americans still smoke, and tobacco use leads to 440,000 deaths each year.

The journal article points to some interesting facts. First, hospitals can have a significant impact on the community. When Cleveland Clinic became a smoke-free campus in 2005 and stopped hiring smokers in 2007, the rate of smoking in the county plummeted from 21 percent to 15 percent from 2005 to 2009, twice the state’s rate of decline.

Second, smokers are a burden to their employers and their work colleagues. Studies show that smokers have higher absenteeism, lower productivity and add an estimated $4,000 to the employer’s annual cost.

Third, a policy prohibiting employment to smokers could disenfranchise the poor and minorities, because 36 percent of those living under the poverty line smoke, compared to 23 percent of those above the poverty line. Also, among those who are unemployed, 45 percent are smokers compared to 28 percent of those fully employed.

So where do I stand on this issue? I am not sure, but according to the 2012 Harris International Poll, 65 percent of Americans oppose discriminatory policies on smokers. In fact, while there are no federal smoker protection laws, 29 states, including Tennessee and Mississippi, have state laws that prevent employers from discriminating against smokers in hiring.

Are smokers the victims of addiction or perpetrators of bad behavior that costs money to society? In some ways, smokers are victims. Nearly 90 percent of adult smokers today began their smoking habit at age 18, and nearly 70 percent want to quit, but only 3 percent to 5 percent of those who attempt are successful.

In some ways, I believe smokers lack personal responsibility for a bad habit. I know patients who will say they do not have money for their insulin, antibiotics or health insurance yet buy a $5 pack of cigarettes each day, amounting to $150 a month and $1,800 a year. Should nonsmokers tolerate and accept this behavior, or be compassionate toward the addictive nature of tobacco?

I sometimes wonder why employers such as Cleveland Clinic and others put such harsh policies in place. Is it because of their self-interest in reducing the cost of health care for their workforce, or is it to provide an incentive for employees and the community at large to reduce tobacco use? I think it is a little bit of both.

Even though not hiring smokers is discriminatory, many employers do urine drug testing on the job, and a positive drug test is a cause for termination. Yet, this can become a slippery slope. Can employers one day discriminate against obese workers, or those with high cholesterol, or uncontrolled sugar?

Ultimately, I believe we will get to a smoke-free and tobacco-free society. If it were not for our historical ties to tobacco, and the ongoing lobbying efforts by tobacco farmers and corporations, tobacco, a carcinogenic and atherogenic product, would not be authorized to be shelved at any store.

Tobacco is more toxic than most prescription medicines and multitudes of x-rays and CT scans. Over a year, the radiation exposure from one pack of cigarettes per day is nearly equal to 2,000 chest x-rays. So why wait to become a tobacco-free society?

I believe we need to act now. The present-day smoking cessation programs barely work. One study found that if employers provide a smoking cessation program, it leads only 3 percent of employees to quit smoking over a year. When a financial incentive was included, the rate went up to 9 percent. All of this means that the incentive failed to dissuade 91 percent of employees from smoking.

Lack of employment opportunity is a powerful disincentive for an employee to change behavior.

We need to raise the bar on smoking cessation. Not allowing smoking outside the hospital campus is good, but not having any hospital employees smoke sets an example for the community. Health care workers who value the health of their patients need to value their own health by not smoking.

Manoj Jain is an infectious disease physician and contributor to the Washington Post and The Commercial Appeal.  He can be reached at his self-titled site, Dr. Manoj Jain. This article originally appeared in The Commercial Appeal.

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  • Arby

    Yes. It starts with smoking and moves on to the size of the soda you are allowed to purchase. I see no end of things that we can be told what to do, or not to do, by government and business alike.

    I saw a bumper sticker today that read “Legalize Freedom”. You know we’re in trouble when this has to be displayed on the back end of a car.

  • Luis Collar, M.D.

    Very well said, Margalit. Businesses shouldn’t get a pass on controlling what individuals can and can’t do. And those that feel government is overly intrusive (as I do) should have a consistent outlook. Individual liberties need to be respected, no matter who it is that threatens them.

  • Luis Collar, M.D.

    Great points, all of them. There is no justification for this sort of intrusion in people’s lives. I’ve expressed my concerns about this here: http://sapphireequinox.com/blog/can-health-and-freedom-coexist/ and here: http://www.kevinmd.com/blog/2014/04/relevance-physicians-dwindling-rapidly.html

    We really need to look at the root causes of illness and find ways to improve our nation’s health that don’t involve stripping away individual liberties one by one.

  • Patient Kit

    I agree that it’s an extremely slippery slope that endangers our freedom to be flawed human beings, each in our own way. I don’t object to employers’ genuine attempts to help and incentivize their employees to quit. But firing/not hiring smokers crosses a dangerous line.

    That said, I’m amazed at the high rate of smokers among the poor and unemployed. Here in NYC, one pack (20 cigs) costs between $12 and $14.50, depending on where you buy them. I can only assume that the vast majority of poor smokers are buying their cigarettes elsewhere and/or illegally.

    • Rob Burnside

      Excessive ethel alcohol consumption should be a greater concern to prospective employers, but it’s typically a non issue, and taxed well below the rate of various smoking products. And, it has destroyed outright as many lives as smoking has shortened–probably more.

      • Patient Kit

        I’m job hunting right now and I’m happy that nobody has asked me whether I drink alcohol in any of my interviews. I don’t drink excessively but I do partake in a litlle social tequila drinking. I’d hate to find out that makes me unemployable.

        • Rob Burnside

          Gotta say it, Kit—”I’ll drink to that!” Once upon a time, in a far away land, employers were happy to hire employees who gave them a good day’s work, didn’t cause trouble, and were willing to devote forty years to the company in exchange for a little job security and a modest pension. Seems like a dream to me now.

  • Rob Burnside

    When I went through basic training in the military (1968) we got cigarettes in our C-Rats and my lead Drill Instructor smoked. When we ran, he ran circles around the platoon for four or five miles, doubling the distance we covered. At the end of the run, he’s opine, “You can smoke and still be in shape, but you have to work a little harder at it.”

    When I pulled weekly ER shifts as a paramedic a decade later, and the break room was so cloudy you couldn’t see the far wall, Dr. Fisher and I would step outside for a little fresh air, and enjoy a Camel (non filter) together.

    They’re both gone, along with all the nurses from the break room, and I alone am escaped to tell you: one reason I still smoke is habit (you’d say “addiction”) and another reason is nostalgia. The third and final reason is defiance–I deeply resent “Smoke Nazis” in all their self-righteous iterations. Find someone else to pick on, please. And drop the “tobacco use disorder” label while you’re at it.

  • buzzkillerjsmith

    Define discrimination.

    I would submit that smokers should be shot, tarred and feathered, drawn and quartered, buried in an unmarked shallow grave and that we nonsmokers should then dance on their graves singing hallelujah. Cigarette smokers only of course.

    Nothing wrong with an occasional cigar.

  • Patient Kit

    I’m sure there has got to be a thriving underground cigarette market here with the aboveground price so high. “Dealers” probably get them from the places you mention and then sell them on the street for half the going $14 price per pack here. I’m glad that smoking is one problem I don’t have. But I have too many of my own weaknesses to judge smokers for theirs.

  • Rob Burnside

    This is a very interesting “take”, Nate, and I’d like to add one more. As a retired firefighter, I’m all for limiting smoking to safe areas, well apart from any at-risk structures.

  • wiseword

    Has anyone noticed that smokers stink and that indoor air at some distance from them also stinks? Smoking is on a par with defecating in public. The latter might be a more justifiable necessity.

  • SteveCaley

    You know, the doctors are outspoken about Maintenance of Certification for Boards.
    How will the patients feel about Maintenance of Insurance for smokers, overweight, lack of exercise, etc.? Now that we’ve bought onto the idea of systemic rational control…

  • SteveCaley

    PS: Here’s the basis for some of the change in society. In the US, there are almost NO prisons or jails that allow smoking:
    “In McKinney v. Anderson (1991), an inmate who was housed in a cell with a heavy smoker brought a civil
    rights action against prison officials alleging violation
    of his Eighth Amendment right not to be
    subjected to “cruel and unusual punishment” due to his exposure to SHS.
    The US District
    Court for the District of Nevada
    granted a directed verdict for the prison officials; the inmate
    appealed.
    The US Court of
    Appeals for the Ninth Circuit reversed
    in part, ruling that even if the inmate cannot show that he suffers from
    serious, immediate
    medical symptoms caused by exposure to
    secondary smoke, compelled exposure to that smoke is nonetheless cruel
    and unusual
    punishment if at such levels and under
    such circumstances as to pose an unreasonable risk of harm to the
    inmate’s health.”
    It’s not a matter of the political awareness of hospitals. JCAHO rules do not allow for smoking on hospital grounds, as a consequence of similar litigation. But it may present a legal “back-door” into MOI/Maintenance of Insurance legislation for non-exercisers, alcohol-drinkers, soda-consumers, etc.