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“Smokers Need Not Apply” – A Byproduct Of Employer Based Health Insurance

Posted Apr 13 2013 10:01pm

Posted on | April 12, 2013 |

Enlightened employers around the world spend considerable time and resources assuring that the workplace in healthy and safe. They do so to maximize productivity, retention, worker satisfaction, and to limit liability and cost. Their efforts are guided and directed by informed legislation, administered with varying degrees of regulatory success.

Employers in the US, since the late 1940’s, have also been providers of health insurance. Compared to other developed nations, this is an oddity which historically emerged out of management concerns that workers not extend their allegiance to unions who were flirting with expanding worker benefit packages. In the beginning, this offering, compared to wage increases, was a reasonable bargain for management.(1) But as we know, health care costs over the past two decades have exceeded inflation, and employers have continued to pull back on their commitment to coverage.(2)

With the Affordable Care Act passage and gradual implementation, continued declines in employer based health coverage have been documented.(2) But at the same time, increasing numbers of employers are adjusting hiring practices, specifically with regard to cigarette smoking,  to achieve a healthier case mix among their worker population. Twenty-nine states prohibit “no smokers allowed” hiring practices, but 21 states allow it. Health care organizations have been in the lead, citing not only the health of their workers but also the value of caring professionals serving as role models of health for their patients. Noted institutions like Cleveland Clinic, Geisinger, Baylor Health Care System, and the University of Pennsylvania Health System have policies on not hiring smokers. So do non-health care corporations such as Scotts Miracle-Gro, Union Pacific Railroad, and Alaska Airlines.(3,4)

The majority of Americans remain uncomfortable with these practices. 65% in a 2012 Harris International poll were opposed. Many would rather see a continuation of gentler measures. But multiple studies show that while 70% of smokers say they want to quit, only 2 to 3% succeed each year. And even in organizations that provide cessation resources and financial incentives, the 18 month quit rate is only 9%.(3,4)

In this week’s New England Journal of Medicine, ethicists weighed in for and against. Arguments in support of hiring restrictions included:

1. “When the World Health Organization introduced a ‘nonsmoker-only’ hiring policy in 2008, it cited its commitment to tobacco control and the importance of ‘denormalizing’ tobacco use.”(3)

2. With the “right” to health coverage comes the “responsibility” to use limited health resources wisely. Health care “costs amount to an estimated additional $4,000 annually for each smoking employee.”(3)

3. It’s time to get serious here. “Tobacco use is responsible for approximately 440,000 deaths in the United States each year about one death out of every five.”(4)

4. Gentler approaches like offering or even mandating attendance of smoking employees at smoking cessation programs have low success rates. (9% at 18 months).(4)

5. Though these policies disproportionately effect lower socio-economic populations with higher rates of smoking, “…these policies may also save lives, directly and through their potential effects on social norms, and these same disadvantaged populations are at greatest risk for smoking-related harms and ensuing disparities in health.”(4)

6. Norms are changing. “Americans see it as perfectly acceptable that most workplaces are smoke-free and that smoking is prohibited in many bars and restaurants…. recall the time when airplanes had smoking sections a notion that seems absurd today.”(4)

7. Restrictive policies work. These approaches which “we now take for granted were justified not by their effects on smokers but by the harm inflicted on nonsmokers by secondhand smoke. These policies also increased the stigma against smoking, so although there’s debate over whether stigma can be used as a tool for good, ultimately these policies almost certainly contributed to the decrease in the prevalence of smoking, not just the limits on where it occurs.”(4)

8. “Policies against hiring smokers shift the debate from the question of where one smokes to that of whether one smokes.”(4)

What are the arguments against? They include:

1. Discrimination: “… although less than one fifth of Americans currently smoke, rates of tobacco use vary markedly among sociodemographic groups, with higher rates in poorer and less-educated populations. Some 42% of American Indian or Alaska Native adults smoke, but only 8% of Asian women do. Among adults with less than a high school education, 32% are smokers; among college graduates, smoking rates are just over 13%. More than 36% of Americans living below the federal poverty line are smokers, as compared with 22.5% of those with incomes above that level.”(3)

2. Callous Behviour: “Many patients are treated for illnesses to which their behavior has contributed, including chronic obstructive pulmonary disease, heart failure, diabetes, and infections spread through unprotected sex or other voluntary activities. 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.”(3)

3. Not Their Fault: “.. smoking is addictive and therefore not completely voluntary. Among adult daily smokers, 88% began smoking by the time they were 18, before society would consider them fully responsible for their actions. Much of this early smoking is subtly and not so subtly encouraged by cigarette companies… Underlying such opposition is a distorted notion of personal responsibility and deservedness…’there but for the grace of God go they.’”(3)

4. A “Double-Whammy”: Crucially, policies against hiring smokers result in a ‘double whammy’ for many unemployed people, among whom smoking rates are nearly 45% (as compared with 28% among Americans with full-time employment).”(3)

So is there a middle ground? There is considerable agreement on the basics.

1. Smoking is deadly, addictive, costly, and increasingly unacceptable.

2. As health care “rights” expand, “personal responsibility” will become an increasing focus.

3. Current approaches to worker smoking cessation have been minimally successful, in part because while some 90% of workers trust doctor and nurse involvement in their personal health, many fewer trust worker relationships.(5)

4. The US population increasingly sees good health as central to quality of life and as an expression of good citizenship.

What’s next? It’s likely that in the 21 states where it is allowed, some organizations will stop smokers at the employment door. But for most, employer involvement will ramp up short of outright bans. Doing nothing is no longer an option. Information is good, but alone is ineffective. Smoking cessation programs onsite – especially with automatic enrollment may help some. Financially rewarding success can work, but leads to a negative backlash from non-smoker colleagues. Financial penalties, in the form of higher insurance contributions, are right around the corner. Firing employees if unsuccessful during a grace period will be expanded by some. But if you are going to go that far, you are probably better off not hiring the smoker to start with.

For Health Commentary, I’m Mike Magee


1. Magee M. Employer Based Health Insurance – How It Began, Why It’s Bad For The Economy And Why Employers Want Out.

2. Kennedy K. Rate of Employer Based Health Insurance Keeps Dropping. USAToday. April 13, 2013.

3. Schmidt H et al. The Ethics of Not Hiring Smokers. NEJM. April 17, 2013.

4. Asch D et al. Compromises and Conflicts In Not Hiring Smokers. NEJM. April 17, 2013.

5. Magee M. Relationship Based Health Care: The Patient-Physician Relationship In The Consumer Health World. World Medical Association. Geneva, Switzerland. May 13, 2002.

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