From the medical side, arguing for smokers' rights

In this Wednesday, Feb. 14, 2007 file photo, a man smokes in Omaha, Neb. Annual health care costs are roughly $96 billion for smokers and $147 billion for the obese, the government says. These costs accompany sometimes heroic attempts to prolong their lives, including surgery, chemotherapy and other measures. But despite these rescue attempts, smokers tend to die 10 years earlier on average, and the obese die five to 12 years prematurely, according to various researchers' estimates. (AP Photo/Nati Harnik, File

Jon Kole is in his fourth and final year of a combined MD and Masters of Medical Ethics program at the University of Pennsylvania.

By Jon Kole

What do Cleveland Clinic, the World Health Organization, and Geisinger Health System in central Pennsylvania have in common? They all reject new job applicants who use cigars, cigarettes or other tobacco products. And here in Philadelphia the University of Pennsylvania Health System recently announced that it too, effective July 1, “will cease hiring tobacco users in our efforts to improve the overall health of our workforce while reducing health care benefit costs.”

But should smokers be prohibited from employment? Is this a just policy?

There's no doubt that smoking is enormously harmful to health. The Centers for Disease Control and Prevention reports that smoking contributes to about one in five deaths (more than 400,000) a year in the United States. Smoking not only causes cancer, heart disease, stroke, and lung diseases, but it generally worsens physical condition. Because of this, policies that preclude hiring smokers have been upheld by the courts for certain jobs, such as firefighting, in which smoking can be immediately detrimental to performance .

Second-hand smoke is also a significant health problem, killing an estimated 49,000 Americans a year and worsening the health of many more. The individual act of smoking can harm others in the nearby vicinity. Justifiably, the number of public spaces that tolerate smoking has dramatically declined. Employers, interested in the safety of all of their workers, are within their legal and ethical rights to prevent smoking on company property.

But what about the individuals smoking at home, alone, on their own time – and hoping to get a job during the day?

The implications for hiring only non-smokers might, at first glance, seem beneficial. Smoking employees are estimated to cost employers nearly $3,400 a year, a large sum that any company would like to avoid. Many health systems want to model good health practices; they believe that smoke-free hiring sends a positive signal to the community. With the well-intentioned goal of encouraging Americans to stop smoking, some public health advocates and medical organizations (like the American Lung Association) support these hiring bans.

The problem is that these policies are inherently discriminatory (and, as a result, have been prohibited by 29 states, including New Jersey, and the District of Columbia). What is it about someone smoking at home that makes him or her less worthy of employment?

There are 43.8 million smokers in the U.S., many of whom, I imagine, would be ideal employees. If the federal Government had embraced a no-smokers policy in 2008, we would have a different person sitting in the Oval Office. We have numerous laws to protect those with disabilities and illnesses from stigma-based hiring practices. People who smoke deserve nothing less.

Opponents point out that smokers are different than the other protected classes because they have a choice. People don’t choose to be disabled, the argument goes, but they choose to smoke. This is simply not true. Sixty nine percent of current adult smokers say they wish to quit immediately and completely, yet most continue. The average number of quit attempts prior to successful smoking cessation is more than five. Nicotine is remarkably addictive – chemically speaking, even more so than most illicit drugs.

Even the first puff is not a free choice. If it was, differences in smoking rates would be random. Yet smoking rates are significantly higher among the long-term unemployed, homeless, mentally ill, prisoners, single parents, and certain ethnic minorities. If you are poor, you have a greater likelihood of being exposed to and starting smoking. Thus, a non-smoking-only hiring policy means that some of the people that most need jobs may be denied the right to obtain them.

Even if we could imagine smoking as purely a willful choice, the argument for non-hiring still falls short. If smoking employees cost employers a discreet amount more than non-smokers, the employees could be allowed to pay the difference. A number of employers (including Penn) create a set health insurance surcharge to allow smokers to choose to pay the toll of their behavioral choice. A hiring ban denies this opportunity. Policies should aim towards justice, whether or not it involves a Marlboro.

Beyond discrimination, singling out smokers in hiring is arbitrary. While smoking certainly is a significantly harmful health behavior, it is not the only one. A 2012 study in the Archives of Internal Medicine found that each daily increase of three ounces of processed red meat (like bacon) is associated with greater than 20 percent greater risk of cancer, heart disease, and death. People ride motorcycles without helmets, which the CDC estimates increases health costs up to $1,600 a year, without fear of unemployment. The fact that more people smoke than wrestle alligators does not change either activity’s inherent risk or unhealthiness. If we allow this ban to be justified by saving company health-care costs and improving employee health, where do we stop? Are we ready to let companies preferentially hire vegetarians after checking our stool for animal protein?

Ethics aside, the practical implications of screening for nicotine are off-putting. These nicotine tests are known to be quite sensitive. Small but detected concentrations of nicotine metabolites (up to amounts present after having smoked three cigarettes) may be found in the saliva or urine of non-smokers who have been exposed to tobacco smoke for several hours. Are we comfortable with not hiring the non-smoking roommate of a smoker? Would we hire smokers who abstain for their week of testing and then return to their habit? (The University of Pennsylvania Health System says it will ask job applicants whether they smoke but will not screen them.)

From California to Maine, Minnesota to Louisiana, a cigarette does not prevent a paycheck. We must call on our legislators in Harrisburg to join the wiser majority of the nation and prevent unjust hiring practices. Even as a non-smoking future physician imploring my patients to quit, I will fight in the defense of equality for smoking citizens. Smokers deserve fair protection under the law. And besides, I want my bacon cheeseburger.

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