A study published in the March issue of Archives of General Psychiatry reported that current daily cigarette smokers were almost twice as likely to have suicidal thoughts or a suicide attempt over a ten-year follow-up period, controlling for baseline history of depression and other psychiatric disorders, baseline suicidal ideation, and baseline history of substance abuse (see Breslau N, Schultz LR, Johnson EO Peterson DL, Davis GC. Smoking and the risk of suicidal behavior: A prospective study of a community sample. Archives of General Psychiatry 2005; 62:328-334).
While previous studies had noted a link between smoking and both depression and suicidal thoughts and behavior, this is one of the first longitudinal studies to control for baseline history of depression and substance abuse, as well as for depression and substance abuse that was observed during the first two follow-up assessments. While the authors urge caution in drawing a causal conclusion -- that is, in concluding that smoking was a cause of the suicidal ideation and suicide attempts -- the extent to which the authors controlled for potential confounders certainly suggests that smoking may be an independent cause of suicidal behavior. Regardless of the validity of any causal conclusion, this study confirms that current daily smoking is a significant predictor of subsequent suicidal ideation and behavior.
The Rest of the Story
Combine this news that smoking predicts suicidal risk with other recent evidence that smoking predicts risk of attrition on the job and anti-smoking activists now have powerful data with which to defend employer policies that refuse to hire or that fire smokers for reasons other than the smoking having a direct impact on job performance or being inconsistent with the company's mission. After all, there is no greater form of attrition than death, and the costs of having to replace such an employee are likely to be quite high. Is it not then fair game for an employer to avoid these significant potential costs by refusing to hire persons who are at a clearly identified increased risk: namely, current smokers?
While it may be legal, that does not mean it is right. While it may be economically justifiable, that does not mean it is justified. And while it may make sense to tobacco control advocates to support such policies, that does not mean that it is sensible from a public health perspective.
There are three lines of analysis that I think are essential here:
First, one must consider what factors appropriately play into a decision about employment policies. Some have argued that economic factors are predominant: i.e., if smokers carry with them increased employer costs, then it is justified to not hire them, or to fire them if they are already employed and refuse to (or are unable to) quit. But I do not view employment decisions as being strictly economic ones. There are a host of factors that can and should play into these decisions, including not only economic impacts, but social factors as well, such as the potential impact on smokers as a social class if smoking comes to be synonymous with unemployability.
This is, I think, a serious concern. It will only take a few large employers to adopt such policies before smokers begin to feel the impact in terms of the employment choices that are available to them. And unfortunately, because smoking tends to be somewhat associated with lower income and highly associated with lower levels of education, this does become an issue of social class.
Further, one must consider the question of what other employment restrictions could be justified on similar economic grounds. Suicide has been shown to be associated with unwanted pregnancies and with having a family member who has committed suicide, but does that justify refusing to hire anyone who has ever had an unwanted pregnancy or who has ever had a family member commit suicide?
Second, one must consider what are the potential approaches to the problem? Certainly refusing to hire smokers is one of them. But isn't another approach to hire people on the basis of factors that are directly relevant to their job performance and then to implement employee assistance programs that work with employees to address factors such as smoking, physical health, and mental and emotional health and well-being? From a public health perspective, this second approach is far more sensible, compassionate, and defensible.
Third, I think it is important to note that these concerns apply equally well to problems such as attrition and absenteeism as they do to the issue of suicide risk. There really isn't much of a qualitative difference: absenteeism is a sort of partial attrition and suicide is basically complete and irreversible attrition. All the above arguments still hold with respect to economic concerns regarding employee absenteeism and attrition.
Finally, I should reiterate that I am not suggesting that it is inappropriate for employers to consider smoking as a factor in employment decisions when the smoking directly affects job performance or is inconsistent with a company mission. But I am suggesting that absent those concerns, if it is simply an issue of increased economic costs to the employer, I do not think it is sensible, compassionate, or justifiable for public health practitioners to support policies that make it more difficult for smokers to be employed in our society.