To hire or not to hire smokers? A medical journal faceoff

David A. Asch argues that polices that ban the hiring of smokers are necessary when less draconian interventions fail.
David A. Asch argues that polices that ban the hiring of smokers are necessary when less draconian interventions fail.
Posted: March 29, 2013

In dueling commentaries in the prestigious New England Journal of Medicine, top ethicists and behavioral economists debate the growing trend toward policies that ban the hiring of smokers - most recently by their own employer, the University of Pennsylvania Health System.

Writing for medical journals is a far cry from Washington partisanship. Still, the papers are unusually impassioned and down-to-earth. And the topic, as both make clear, is anything but academic - with real-world consequences affecting the lives, and livelihoods, of millions of Americans.

For hospitals, "categorically refusing to hire smokers is unethical," writes one trio of authors, among them former White House health adviser Ezekiel J. Emanuel, now a vice provost and bioethics professor at Penn.

The other group, while conceding that denying jobs to smokers may be unfair, at least in the short term, argues that "the severe harms of smoking" - an estimated 440,000 deaths a year in the United States - justify more draconian policies when easier interventions don't succeed.

The three writers behind the pro-ban paper, which was submitted to the journal in response to the first, include two authors of one of the largest smoking-cessation studies ever done, and health system chief executive Ralph W. Muller. Their paper essentially agrees with Penn's policy, which calls for hiring only nonsmokers beginning July 1.

All six authors "want to encourage people to quit smoking. All of us think that this is a problem," Emanuel said in an interview Wednesday evening, shortly after the papers were posted online.


Indeed, both papers cited some of the same research and challenges - about 70 percent of smokers say they want to quit, but only 5 percent or less are able to do so without help, the result of tobacco's addictive qualities - in reaching different conclusions.

"It is callous - and contradictory - for health-care institutions devoted to caring for patients regardless of the causes of their illness to refuse to employ smokers," write Emanuel and his coauthors, Harald Schmidt of Penn and Kristin Voigt of McGill University in Montreal.

Penn and other health systems that have decided not to hire smokers, beginning with the Cleveland Clinic, often note that smoking increases health-care costs for other workers. But Emanuel's group counters that all diseases and many behaviors, including having babies - which costs thousands, if not tens of thousands, of dollars that is typically covered by insurance - do the same thing.

And while many opponents of such policies point out that the impact of nonsmoker-only hiring policies is far from uniform - 32 percent of adults with less than a high school education smoke, vs. 13 percent of college graduates - the Emanuel group notes a "double whammy" for many unemployed people: Nearly 45 percent of them smoke, compared with 28 percent of those employed full time, and so would have an even harder time finding work.

Emanuel also disagrees with less controversial and far more common policies that add surcharges to smokers' health insurance, arguing that evidence of effectiveness is far from clear. Until it is, he said, employers should be offering workers help, such as smoking-cessation programs - which many hospitals already do, for free.

Financial incentives might also work, he said, noting a large 2009 study at a General Electric plant that found that a combination of incentives amounting to $750 led to smoking-cessation rates triple what was achieved through information alone.

Among the researchers on that study were Penn behavioral economists David A. Asch and Kevin G. Volpp - the two authors, along with Muller, who took the opposite side in the New England Journal on Wednesday.

While the financial incentives tripled the quit rate over 12 to 18 months, they write, it still amounted to only 9 percent. So even with an aggressive system of rewards, 91 percent of employees who wanted to quit could not.

Key factor

That, they wrote, is not enough. (And General Electric, perhaps responding to arguments that giving money to smokers was unfair, ended up implementing the policy as a stick rather than a carrot: Instead of incentives to quit, it added a $620 surcharge for workers who continued to smoke.)

The Asch group also turns the disproportionately affected argument on its head. Nonsmoker-only policies in the short term would deny more jobs to people in certain groups, such as the poor, they concede.

But in the long run, they write, the increased stigma of smoking - a key factor in driving down national smoking rates over the years - would disproportionately benefit members of those same groups. After the Cleveland Clinic banned smoking in 2005 and then stopped hiring smokers in 2007, they write, smoking rates in the surrounding county decreased significantly more than the statewide average.

Controversies over policies that attempt to influence behavior, from soda taxes to nonsmoker-only hiring, are likely to increase along with the recognition that changes in disease patterns require different interventions.

"Health is not just about doctors and patients," Asch said in an interview. "It is also about farm stands, mayors of large cities, and employers.

"Everyone knows that tobacco is dangerous," Asch said, and if current efforts aren't working, it's time to take another step.

Contact Don Sapatkin

at 215-854-2617 or

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