Thursday, January 22, 2009

Article in Tobacco Control Asks Anti-Smoking Practitioners to Rethink Promotion of Policies that Bar Smokers from Employment

An article that appears today in the journal Tobacco Control, written by me and Brian Houle - a graduate student in sociology at the University of Washington - asks anti-smoking advocates and groups to rethink their promotion of policies by which employers refuse to hire smokers or fire existing employees who are unable to quit smoking. The press release, article, and accompanying media coverage challenge the wisdom, health effects, and ethics of these policies (see: Houle B, Siegel M. Smoker-free workplace policies: developing a model of public health consequences of workplace policies barring employment to smokers. Tobacco Control 2009; doi: 10.1136/tc.2008.026229).

To the best of my knowledge, this is the first published article in the tobacco control literature that actually considers the negative health consequences of smoker-free workplace policies, including the potential negative effects of unemployment as well as stigmatization of smokers that may result from employment discrimination against smokers.

Addressing the stigmatization of smokers, the article cites research which documents that smoker-free workplace policies result in measurable stigmatization: "Our interest in creating a model to consider the effects of smoker-free workplace policies is not just a theoretical one. There is empirical evidence that smoker-free as opposed to smoke-free workplace policies have a profoundly different impact on the public; in particular, on smokers. Stuber et al recently published an analysis of the determinants of smoker-related stigma among current and former smokers. They defined stigma as ‘‘the negative labels, pejorative assessments, social distancing, and discrimination that can occur when individuals who lack power deviate from group norms.’’ Stigma was measured using a validated, 12-item scale that specifically considered the role of social policy and the perceived social acceptability of smoking. The authors found that smoke-free air laws actually lowered self-reported smoker-related stigma. In contrast, smoker-free workplace and similar discriminatory policies towards smokers significantly increased smoker-related stigma."

The article outlines a number of adverse consequences of smoker-free workplace policies: "Unemployment can lead to personal, family and economic stressors that adversely impact health outcomes. Since health insurance is often covered by employers—employer-sponsored insurance insures approximately 64.4% of adults in the United States—many of these individuals will become uninsured. In a series of landmark reports, the Institute of Medicine illustrated the potential consequences of lack of insurance on multiple domains of society. The uninsured have a more difficult time finding and utilising healthcare services and the care provided is
often non-reimbursed. Reduced access to care in turn leads to adverse economic, social and health consequences for these smokers and their families. Further, a growing uninsured population can create financial stresses that affect the ability of healthcare providers to provide services to the community." ...

"In broader social terms, smokers may feel stigmatised as well. Modified labelling theory posits that when social forces about behaviour are communicated individuals may experience social devaluation and discrimination. These feelings may increase social isolation, rejection and perceived lack of personal control. Work by Marmot and others has shown that people with the least feeling of control over their lives have the poorest health outcomes. ... Effects of labelling on individuals with mental illness and infectious and chronic diseases have been shown to impact health outcomes. ... Unemployment and potential lack of access to health insurance among some smokers may also increase health disparities. Disparities already exist among those who smoke, their risk factors, insurance coverage, access to healthcare, health outcomes, disease burden and educational and social status."

The press release states that "quite apart from infringements of personal privacy and individual rights, smokers who are sacked or forced to resign many not be able to find other work, which in itself could have a seriously detrimental impact on their and their families' health, contend the authors. Smokers will also be unjustly discriminated against in a way that people who risk their health by drinking or eating too much, and exercising too little, are not. And it may also prompt a shift in thinking about these other behaviours as well, the authors suggest, citing Clarian Health in Indianapolis, which has already pledged to sack employees who smoke, are obese, and whose blood pressure, cholesterol and glucose levels are unhealthily high. The authors call for a much wider public health debate, and for proper evaluation of these policies, on the grounds that 'the potential unintended side effects.. could be far reaching.'"

The article has received considerable media attention. Here is a partial list of the initial coverage:

Los Angeles Times


Science Daily

China View

Science Codex

ZAMP Bionews

Nursing in Practice

The Rest of the Story

I want to emphasize that my opposition to smoker-free workplace policies does not rely upon this analysis showing that there are severe negative health, economic, and social consequences of these policies. My primary opposition to these policies stems from the fact that they are simply unethical. They represent employment discrimination and I believe that such discrimination is wrong. Even if it were true that these policies had a net positive effect on health, I would still oppose and speak out against these policies. They are discriminatory and I believe that employment discrimination is wrong. It is unethical. People of a certain group should not categorically be denied employment when membership in that group is not necessarily and directly related to the qualifications for employment.

While I would hope that this article and its coverage would stimulate a debate in the tobacco control community about the wisdom behind promoting employment discrimination against smokers, I doubt that will occur. As I noted in the Los Angeles Times article, those who publicly oppose anti-smoking policies such as these are instantly viewed as traitors to the cause and thus very few tobacco control practitioners are willing to speak out in opposition to this aspect of tobacco control dogma.

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