Over the past decade, we have seen an increase in the number of places where smoking is banned -- bars, restaurants, clubs and so on. The days when smoking was allowed on airplanes seems like ancient history. Now we are seeing the trend of "smoke-free workplaces" across the country -- including here at Yale-New Haven Hospital. And these measures seem to be helping: Studies in the U.K. showed far-reaching effects of these bans, from improvements in asthma to reducing hospital admissions due to heart attacks.
If this is so helpful, should we just ban smokers?
This seems a bit extreme, but over the past few years, some companies have taken to policies of not hiring smokers. That's right: If you smoke, you can't work here. But isn't that discrimination? Some states think so -- 29 states have instituted laws making these practices illegal. But the rest of the country hasn't, and large companies such as Alaska Airlines and Union Pacific Railroad have stopped hiring smokers altogether. Some argue that this has helped cut down on smoking. The Cleveland Clinic, the largest employer in Cuyohoga County, Ohio, stopped hiring smokers in 2007. Between 2005 and 2009, the smoking rate in the county dropped from 21 percent to 15 percent, whereas the rate for the state as a whole only dropped from 22 percent to 20 percent. What isn't known is whether this hiring practice actually led people to quit smoking or just move out of town because they could no longer get employment.
It has long been known that smoking rates vary greatly between different socio-demographic groups. For example, 32 percent of adults who haven't graduated from high school smoke, compared to only 13 percent of college graduates. And as a recent New England Journal of Medicine article pointed out, the smoking rates for unemployed people are about 45 percent whereas they are much lower for those with full-time employment (28 percent). Is not hiring smokers adding insult to injury? The authors of a companion article in the New England Journal of Medicine have argued that these "tough love" policies, not hiring smokers or even firing smokers, "may indeed be for their own good." These policies are certainly good for the employers, as it costs them an estimated $3,000-$4,000 extra per year for employees who smoke vs. those who don't (mainly due to lost productivity and health-related issues).
Interesting. "You smoke, so I'm not going to hire you. Your obvious next step is to quit smoking." Or better yet, "You smoke, so I'm going to fire you so you'll stop smoking." Forget the fact that the stress from getting fired will probably lead you to smoke more.
Smoking is a diagnosable psychiatric disorder. It even has a code in our little book (The Diagnostic and Statistical Manual, or DSM). This means that, similar to major depressive disorder, we psychiatrists recognize nicotine dependence as a psychiatric disorder, can treat patients with it and bill insurance for it. Depression is also expensive for employers. So why don't we also stop hiring people with depression or fire those who become depressed on the job? Oh right, we can't discriminate against individuals who have psychiatric disorders!
As the push to reduce health care costs continues, it will be interesting to see how we can find creative solutions to help contain these costs (and perhaps even help to improve the health of our society). I am yet to be convinced that policies such as not hiring or going as far as firing smokers is a better solution than devoting resources to helping them quit (and work).
How about all you smokers out there? Should we fire you so you quit smoking?
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Asch, D. A., R. W. Muller and K. G. Volpp (2013). "Conflicts and Compromises in Not Hiring Smokers." New England Journal of Medicine 368(15): 1371-1373.
Nakajima, M. and M. al'Absi (2012). "Predictors of risk for smoking relapse in men and women: a prospective examination." Psychol Addict Behav 26(3): 633-637.
Schmidt, H., K. Voigt and E. J. Emanuel (2013). "The Ethics of Not Hiring Smokers." New England Journal of Medicine 368(15): 1369-1371.