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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