January 11, 2014 marks the 50th anniversary of the release of Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service, the landmark first report of the surgeon general on smoking.1 Since the publication of this report, remarkable progress has been made in reducing cigarette smoking society-wide by implementing measures that have driven up the cost of smoking, that have banned smoking in workplaces and public places, and that have changed social norms around smoking. Within the health care environment, there have been radical changes since the report was published in 1964, when patients smoked in their hospital rooms, charting areas were smoke filled, and physicians smoked during rounds. Since 1992, the Joint Commission has required that hospitals be smoke free for accreditation,2 and many health care institutions have banned smoking on their campuses. Now, some health care institutions, along with other employers, are limiting new hires to people who do not use tobacco products.
In this issue, Huddle et al3 consider whether academic health centers (AHCs) should entertain such policies and offer the conclusion that AHCs “should welcome all potential employees committed to caring for the sick, and they should seamlessly extend their posture of caring for patients to employees who engage in unhealthy practices, including smoking.” Their article is motivated by the decision that the health institutions of the University of Alabama at Birmingham (UAB) School of Medicine and its health system will no longer hire tobacco users, making it the first state AHC to do so. Other prominent health and health care institutions have already implemented similar policies, including the Cleveland Clinic4 and the University of Pennsylvania Health System.5 The World Health Organization’s (WHO’s) highly controversial 2005 decision to not hire people who use tobacco products and are unwilling to quit (based only on self-reporting during the recruitment process) was based on its leadership mission in tobacco control globally, a rationale relevant to AHCs that also seek to advance population health.6 The WHO was the largest international employer at the time to put such a policy in place.
Should We Ban the Hiring of Tobacco Users?
These initial policies have already led to widespread discussion and an enumeration of the arguments for and against such policies7–9 (see List 1). Some of the arguments for such policies are economic and solidly based on evidence: Smokers are not as healthy as nonsmokers, they are more often absent from work, and their health care costs are higher for employers.10,11 The symbolism or “expressive function” of such policies is also used as an argument in their favor. Additionally, there is the potential for broader impact if prospective job applicants successfully quit in advance of seeking employment or receive free cessation treatment based on a positive test for nicotine during the recruitment process, as is offered by the Cleveland Clinic. It is possible that large employers could, in fact, favorably affect smoking prevalence in the surrounding area by reducing smoking among their workers and potential employees. The policy of the Cleveland Clinic, for example, may have accelerated the decline in smoking prevalence in Cuyahoga County where the clinic is located.12 If such policies were to become widespread, there might be an acceleration of the rate of decline of smoking, which has stalled in recent years.
A number of arguments against policies to not hire tobacco users have also been advanced (see List 1). Of these, Huddle and colleagues emphasize the differential consequences of not hiring tobacco users across groups defined by socioeconomic status and race/ethnicity. They propose that those groups needing employment the most (i.e., those with lower incomes) are also more likely to smoke, an argument well supported by current data on smoking in the U.S. population.13 Huddle and colleagues suggest that the loss of employment opportunities will actually harm poorer and more disadvantaged communities.
The argument can also be made that the higher rates of smoking in particular population groups reflect their vulnerability to the marketing of the tobacco industry. Arguably, smokers have become addicted in large part because of the successful marketing of cigarettes, which are engineered to deliver a large dose of a highly addicting pharmacological agent—nicotine. Thus, the actions of the tobacco industry figure in the causal pathway that increases smoking in some populations, and, if policies banning the hiring of smokers increasingly become the norm over time, they reduce the likelihood of people from these populations finding employment.
Tobacco Users Are Citizens Too
Are these policies discriminatory? Socioeconomic inequalities, often the result of discrimination, are strongly associated with lack of opportunity and ill health.14,15 Arguably, a ban on hiring tobacco users, because of the strong variance in prevalence across population groups, has the potential to impose a disproportionate burden on populations already facing discrimination. International human rights standards make clear that the prohibited grounds of discrimination include race, ethnicity, age, disability, and HIV and other health status determinants.
Given that the UAB policy is intended for all employees of a state academic complex, from physician to custodian, one must ask not only whether it is discriminatory, but whether it is ethical or appropriate for a state institution to put into place a policy that will disproportionately affect those residents with the lowest incomes and with the fewest job prospects. As a state institution, if the purpose of the policy is to improve public health, why is the emphasis not on smoking cessation and the promotion of healthy behaviors amongst current and prospective employees? And, if public health is not the purpose of the policy, is it ethical or appropriate for a state institution to place the cost savings associated with not hiring smokers above and beyond the opportunity to improve the health of the community it is intended to serve?
We find that one of the most challenging issues of the UAB policy relates to the rights of workers to use a legal product outside of their workplace, even if that product damages health. The legality is particularly complex when the employer is the state: It is not illegal to use tobacco products within the state, and yet a state employer would see fit to test and ban tobacco users from employment. Although this may ultimately be resolved in the courts, these are currently unchartered waters.
Huddle and colleagues base their conclusions not on the balance between the difficult arguments for and against policies that ban the hiring of smokers (List 1) but primarily on their view of the societal role of caregiving by AHCs. Not hiring smokers, they argue, is counter to the inclusive nature of academic values, divisive in its impact on health care professionals, and reflective of management-driven priorities. Is not hiring smokers antithetical to the mission of the UAB School of Medicine and its health care system? Its mission16 is given as follows:
The School of Medicine is dedicated to excellence in the education of physicians and scientists in all of the disciplines of medicine and biomedical investigation for careers in practice, teaching, and research. Central to this educational mission are the provision of outstanding medical care and services and the enhancement of new knowledge through clinical and basic biomedical research. We embrace the University of Alabama at Birmingham’s commitment to creating an inclusive environment that values differing perspectives and experiences. This diversity is essential to fulfilling the enduring mission of our medical school.
Certainly, employees’ use of tobacco has no implications for achieving excellence nor for “providing outstanding medical care and services.” In fact, not hiring tobacco users would seem at odds with the emphasis on inclusion and diversity, consistent with one of the concerns raised by Huddle and colleagues. Clearly, “diversity” does not directly refer to smoking status, but, as considered above, a policy of hiring based on tobacco use may have an unintended impact on rates of hiring from different population groups and, therefore, may ultimately affect the diversity of the organization if certain populations are more often excluded from employment on the basis of smoking status.
What If “Smokers” Are Not Actually Smoking?
There are other issues raised by the UAB policy. The concept of not hiring tobacco users relates to a context in which tobacco products are the predominant vehicle for nicotine delivery. That context has changed rapidly as electronic cigarettes (e-cigarettes) are quickly gaining popularity, and the tobacco industry is offering an array of noncombusted products, including snus (a moist oral tobacco product) and dissolvable tobacco products. Increasingly, the cigarette is only one element of the suite of products that may be used to obtain nicotine.
The UAB policy defines tobacco use as “smoking, sucking, chewing or snuffing any tobacco product.”17 Is the intent of not hiring tobacco-consuming workers to avoid hiring users of either nicotine-delivering products or tobacco products specifically, who may or may not be addicted? The UAB policy mandates nicotine testing, which would detect nicotine not only from tobacco products but also from e-cigarettes as well as from nicotine-replacement therapy. The policy and its enforcement through nicotine testing may come into conflict with future harm-reduction strategies, including those that might involve long-term use of nicotine from noncombusted products, such as e-cigarettes or pharmacologic nicotine-replacement therapy.
The UAB policy will employ preemployment testing for nicotine, while the Cleveland Clinic policy specifies testing for cotinine, the major metabolite of nicotine. Any policy that involves testing for biomarkers of nicotine needs to take into account the imperfections of such assays. Secondhand exposure can elevate levels of nicotine and cotinine, as does any form of nicotine-replacement therapy. If an employee is tested only once, during the job application process, there is little opportunity for assessing compliance or enforcing requirements around the use of tobacco products.
We are also concerned that the policy represents an instance of “tobacco exceptionalism”—that is, the handling of the tobacco industry and tobacco products as a unique category, with potential increased stigmatization of smokers and little attention to providing them the support they need to quit. Additionally, policies governing the hiring of tobacco users have implications for other personal health behaviors that have direct implications for the health care costs of workers and for the public image of health care institutions. The rise of obesity with the associated risk for type 2 diabetes is an evident example. Should health care institutions base hiring on body mass index? Should they require obese individuals to lose weight? Such policies have been considered but raise complex questions about criteria and implementation, let alone ethics and rights.
We Must Proceed With Evidence-Based Caution
We need to learn from the experience that will follow from the UAB policy as well as from other state and nonstate institutions that have implemented similar employment policies. Undoubtedly, other institutions will follow with comparable measures. Data need to be collected and shared on the demographics of those who are not hired, on trends of quitting smoking and other tobacco products, and on cotinine levels among employees at hiring and over time. Some difficult issues raised by the UAB and similar policies remain unresolved. Huddle and colleagues have provided a thoughtful contribution to a complex and inevitably continuing discussion.
1. U.S. Department of Health Education and Welfare. Smoking and Health: Report of the Advisory Committee of the Surgeon General of the Public Health Service. Report of the Advisory Committee to the Surgeon General. 1964 Washington, DC U.S. Government Printing Office
2. Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals. Volume 1: Standards. 1992 Oakbrook Terrace, Ill Joint Commission of Accreditation of Healthcare Organizations
3. Huddle TS, Kertesz SG, Nash RR. Health care institutions should not exclude smokers from employment. Acad Med. 2014;89:843–847
5. Penn Medicine. . Toward a tobacco free future. 2013 http://www.pennmedicine.org/careers/working-at-penn-medicine/tobacco-free.html
. Accessed February 28, 2014
6. World Health Organization. . WHO policy on non-recruitment of smokers or other tobacco users: Frequently asked questions. 2008 http://www.who.int/employment/FAQs_smoking_English.pdf
. Accessed February 28, 2014
7. Leichter HM. “Evil habits” and “personal choices”: Assigning responsibility for health in the 20th century. Milbank Q. 2003;81:603–626
8. Schmidt H, Voigt K, Emanuel EJ. The ethics of not hiring smokers. N Engl J Med. 2013;368:1369–1371
9. Asch DA, Muller RW, Volpp KG. Conflicts and compromises in not hiring smokers. N Engl J Med. 2013;368:1371–1373
10. U.S. Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General. 2004 Atlanta, Ga U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health
11. Berman M, Crane R, Seiber E, Munur M. Estimating the cost of a smoking employee [published online June 3, 2013]. Tob Control..
12. Kleinerman E. Cuyahoga County smoking rate is lowest in Ohio. September 15, 2010. http://www.cleveland.com/healthfit/index.ssf/2010/09/cuyahoga_smoking_rate_lowest_i.html
. Accessed February 28, 2014
13. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. 2014 Atlanta, Ga U.S. Department of Health and Human Services
14. Centers for Disease Control and Prevention. . CDC health disparities and inequalities report—United States, 2013. MMWR Surveill Summ. 2013;62(suppl 3):1–187
15. World Health Organization, Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. 2008 Geneva, Switzerland World Health Organization
16. UAB School of Medicine. . Mission statement. http://www.uab.edu/medicine/home/welcome/mission-vision
. Accessed February 28, 2014
17. UAB School of Medicine. . Tobacco free hiring policy. 2013 http://www.uabmedicine.org/careers/tobacco-free-hiring-policy
. Accessed February 28, 2014