Two views on a ban: Smokers need not apply?

Hospitals vary in approach to smoking HCWs

Are you helping smokers by banning them from your staff? Are you serving as a model of health by taking a tough stand — or by promoting wellness and accepting that some employees will continue to smoke?

Recent opinion pieces in the New England Journal of Medicine weighed in on this controversial topic. Medical ethicists at the University of Pennsylvania and McGill University in Montreal argue that policies against hiring smokers, and even financial penalties for smokers, are unethical.1 “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,” the authors said. “Just as they should treat people regardless of their degree of responsibility for their own ill health, they should not discriminate against qualified job candidates on the basis of health-related behavior.”

Behavioral economists and the chief executive of the University of Pennsylvania Health System argue that the hiring ban helps smokers overcome the short-term discomfort of quitting and ultimately saves lives.2 As of July 1, the University of Pennsylvania will hire only non-smokers. (While some employers test for nicotine, the University of Pennsylvania asks new hires to self-report their smoking status.)

“In many surveys, about 70% of smokers say they want to quit, but only 2% to 3% succeed each year,” the authors said. “One reason for this huge gap is that smoking cessation has immediate costs in the form of nicotine withdrawal (i.e., the symptoms of withdrawal and the costs of antismoking treatments), but its benefits in terms of improved health are considerably delayed. Thus, although some people may see anti-tobacco hiring policies as adding economic injury to physical injury, we would argue that such policies also make the benefits of smoking cessation more immediate and so help to counterbalance the immediate costs of quitting.”

A growing number of hospitals have implemented a ban on hiring smokers, although the practice is prohibited by law in 29 states and the District of Columbia. To explore both sides of this issue, HEH is presenting the experiences of two hospitals that have taken different approaches.

A workforce of wellness – and no smoking

For the Cleveland Clinic in Ohio, not hiring smokers is more than a policy decision. It’s part of the health system’s culture, says Paul Terpeluk, DO, medical director of employee health.

“Our belief is that health care workers and health care institutions have a different responsibility than non-health care institutions,” he says. “Their workers need to emulate and model healthy behaviors because they’re caring for people, they’re caring for the sick.”

The push for a truly smoke-free hospital campus began in 2005, when cardiothoracic surgeon Toby Cosgrove, MD, became CEO. The Cleveland Clinic offered free smoking cessation classes to employees — and to the community. In 2007, it became one of the first hospitals in the country to stop hiring smokers.

All new hires are tested for cotinine, a metabolite of nicotine. If they test positive, they can reapply for the position in 90 days (and re-test). “We encourage them to reapply if the job is available, and we would encourage them to actually stop smoking,” says Terpeluk.

Few smokers actually apply for jobs at the Cleveland Clinic. The hospital system hires about 4,000 to 5,000 employees a year and only about 1% test positive, Terpeluk says.

“People who chose to apply here either quit smoking, or if they’re smokers they chose not to apply,” he says.

The point is not to discriminate, he says. Smoking cessation is part of a vigorous wellness program that includes chronic disease management, health promotion activities and a healthy environment, he says. There are no sugared drinks or trans fats in the hospital’s cafeteria. A Healthy Choice program offers discounts on insurance premiums if employees take steps to improve their health, including smoking cessation, weight management and physical activity.

“We’re trying to fit this into an overall strategy that tries to convince people to do the right thing for themselves,” Terpeluk says. “It’s actually a good place to work because we encourage people to take care of themselves and we give them the tools to do that. Smoking is just one small part of that.”

As with many hospitals, the Cleveland Clinic is a tobacco-free zone, which means that employees, visitors, vendors and patients cannot smoke or use other tobacco products on the grounds.

Having healthier workers brings lower medical claims. But it also is better for patients, who don’t want to smell the residue on smokers, he contends.

The policy hasn’t hurt the Cleveland Clinic’s ability to recruit quality staff, including nurses, he says. “People actually think it’s a good idea to work for an institution that cares that much [about their health],” he says.

Terpeluk says he doesn’t know how many current employees are smokers, but he suspects the number is small and getting smaller.

“Essentially, you’re promoting a healthier workforce by not hiring smokers,” he says. “We offer free smoking cessation program. Over time because of attrition and turnover, you’ll eventually move toward a zero prevalence rate.”

Smoking declines through wellness

At Vanderbilt University, smoking is not allowed — but smokers are. The hospital system has a tobacco-free campus and uses incentives to reduce smoking among employees.

The strategy has been successful. “In 2003, when started our current wellness program, we had [a smoking rate among employees of] about 12% percent. Now we’re down to 6.4%,” says Mary Yarbrough, MD, MPH, executive director of Occupational Health and Wellness.

For employees who have participated in the wellness program each year, the smoking rate is just 4.2%, she says.

The Go for the Gold wellness program gives employees a financial incentive (a discount on insurance premiums) for participating in a health risk assessment. They receive additional incentives for maintaining a Wellness Actions Log with improvement goals and viewing a Game Plan for Your Health video on ways to improve health.

Employees with identified health risks, including smoking, receive follow up. “Smokers would be invited to come to the occupational health clinic where we would explain all the ways to quit smoking,” Yarbrough says. “A health coach follows up with them if they choose to participate with that.”

About 80% of employees participate in the wellness program, she says. Those who don’t participate are disproportionately young medical residents or older faculty members and, as a group, the non-participants don’t have higher-than-average medical costs, she says.

Yarbrough says she prefers a positive, voluntary approach to reducing smoking among employees. “To me, it is a social problem we’re trying to overcome,” she says. “But there are many problems and things people could do to be healthy. Exercising, diet, mental health. How do we pick out one thing to penalize and say we won’t hire? People who don’t sleep 8 hours a day, should we not hire them?”

Wellness interventions take a holistic approach and try to inspire an intrinsic desire to change, she says. “We don’t just want people who don’t smoke or who exercise, we want people who are productive, healthy and happy,” she says.

Yarbrough recalls an experience that resonates from her own medical training, when she was on rounds with a teaching physician and a group of residents and students. A patient’s medical problems were related to alcohol. “Somebody was presenting the case and they were being a little bit non-flattering to the patient,” she says. “He said, ‘If you want to be a judge, go into law. If you want to be healer, go into medicine.’”


1. Schmidt H, Voight K and Emanuel EJ. The ethics of not hiring smokers. N Engl J Med 2013;368:1369-1371.

2. Asch DA, Muller RW and Volpp KG. Conflicts and compromises in not hiring smokers. N Engl J Med 2013;368:1371-1373.