Tuesday, July 26, 2005

Challenging Dogma (Post #3): Promoting a Smoker-Free Workplace

In my experience in tobacco control, I have observed a gradual bluring over time of the idea of promoting a smoke-free workplace to one that now encompasses the promotion of a smoker-free workplace.

The addition of that extra "r" makes a huge difference in my view. While it seems reasonable to promote a workplace free of carcinogens, it does not seem reasonable to me to promote worksites that are free of smokers.

In recent years, and especially over the past few months, I've observed an increasing number of employer policies that either make smoking a condition that precludes a person from being hired or that will actually cause a person to be fired from existing employment (see previous posts [1] [2] [3] [4] for examples).

And it's clear to me that a number of anti-smoking groups and advocates are supportive of these policies -- although a number are clearly not (see a debate on this issue, with arguments for and against the promotion of a smoker-free workplace, in the spring 2005 issue of Tobacco Control).

Before going further, let me emphasize that I'm not criticizing health promotion programs at the workplace that provide services to help smokers quit. And I'm also not talking about policies that relate to not hiring smokers because of a direct effect on job performance or a direct conflict with an employer's mission. I'm talking about employment policies that either: (1) refuse to hire smokers; or (2) fire existing smokers (whether giving them an opportunity to quit or not) for reasons other than the two mentioned above.

Anti-smoking advocates have justified their support for such policies primarily on the basis that smoking costs employers money in increased health care spending and therefore it is appropriate for employers to set a policy of simply not employing smokers. They have also argued that creating smoker-free workplaces will create an incentive for smokers to quit and will thus improve the public's health.

For example, one article favoring smoker-free workplace promotion argues that: "If we take the view that reducing smoking rates by all acceptable and effective means leads to greater population wide health benefits, then 'smoker-free' workplace policies merit consideration, and we need to consider just how far we are willing to go down the path of paternalism. ... if our employer is a money grubbing Mr Scrooge only interested in his share options, he might refuse to hire smokers because they take time off for smoking breaks and take more sick leave than do non-smokers. Mr Scrooge’s policy is not nice, but it may also mean his company can stay in business, which means his non-smoking employees will stay employed. A few percentage points of extra productivity can be important."

The Rest of the Story

To see just how weak the justification for policies that consider off-the-job smoking as a condition for employment is, let's take the two major arguments in support of such policies - that they will save money for employers by reducing smoking-related disease and improve the public's health by creating an incentive for people to quit smoking.

Now let's apply those same arguments to another potential condition for employment - obesity. It is well-established that obesity is a risk factor for morbidity and mortality. In fact, obesity raises health care costs for an individual considerably more than smoking. If employers are truly concerned about saving health care costs, then firing their fat workers and not hiring any fat new ones is the most important action they could take to save money and increase their bottom line.

And in fact, such a policy would certainly create an incentive for fat people to lose weight. Not being able to find a job is a powerful incentive to action. Thus, the policy would not only save money, but it would improve the public's health by reducing obesity as well as the morbidity and mortality that it causes.

A similar argument could be made for firing or refusing to hire people who eat a lot of fat in their diet. Increased fat intake has been associated with a number of diseases, including cancer.

Employers could also fire their sedentary workers - lack of physical activity is a well-documented risk factor for heart disease, which is, in fact, the predominant cause of disease and death in the United States.

And that's just chronic disease. Employers could lower health care costs and create an incentive to prevent acute disease as well -- like sexually transmitted diseases. Why not refuse to hire anyone who admits to having unsafe sex?

And imagine if we did all of those things? We could nearly eliminate health care costs for employers if we simply took all smokers, fat people, people who eat a lot of fast food, and people who watch a lot of television out of the workplace.

The problem is -- there is nothing inherent in the argument being made by the advocates who support the idea of making smoking a legitimate consideration in employment decisions that would make deem any of these other potential employment policies inappropriate.

In other words, such policies are a clear violation of the concept of privacy of workers.

Privacy is defined as "the quality of being secluded from the presence or view of others" and as a "state of being let alone and able to keep certain personal matters to oneself." Legal off-the-job activity, if it does not directly affect job performance or conflict with an employer's mission, is a matter whose privacy should be protected. There is no legitimate employer interest that I can see in terms of the above smoking-related policies that would authorize the invasion of an individual employee's privacy in this area.

From a public health perspective, I think that any interest in creating incentives for a healthier workforce are clearly and overwhelmingly outweighed by society's interest in preserving the privacy rights of its citizens.

Because some anti-smoking advocates have and are supporting such policies, which I view as an unwarranted intrusion into personal privacy of workers, I think it is not unreasonable for me to take a public position in opposition of such policies and therefore, in support of laws, such as that being discussed in Michigan (see my post supporting Senate Bill 381), which would not allow employers to use lawful, off-the-job behavior as a condition for employment unless it directly affects job performance or reflects on the company's mission.

The rest of the story reveals that the dogmatic perspective I have been exposed to in the anti-smoking movement, which views smoking as a horrible activity that we must do everything possible to eliminate, including using employment as a means of health policy promotion, lies in direct conflict with the protection of privacy rights of individuals. And there is no substantial societal interest I can see that outweighs the degree of intrusion into privacy rights that smoking-related employment policies entail.

I therefore reject the notion of creating smoker-free workplaces as being a legitimate public health approach.

Most importantly, I hope that anti-smoking groups and advocates that have supported such policies will begin to see that by doing so, they are contributing towards the creation of a second class of citizens: those for whom employment is not available because of private, lawful, voluntary behavior decisions which they have made. Is it really going to benefit society to relegate smokers, already a group with lower-income, to an even lower position in society, one in which they cannot obtain a job and support themselves and their families?

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