Thursday, February 02, 2006

On Firing Smokers: POST #2 - Ex-Smokers Should Also Be Given the Ax

Since a major national anti-smoking group has expressed support for firing smokers in the workplace in order to save employers health care costs and protect nonsmoking employees from having to "subsidize" health care costs for smokers, I feel compelled to offer a detailed commentary on this policy issue. This is the second of a three-part series devoted to this important issue. My first post presented my own plan to save employers money spent on health care and to prevent employees from having to subsidize health care costs of their fellow workers.

The background for this commentary is as follows:

According to a press release issued by Action on Smoking and Health (ASH), a Washington, D.C.-based anti-smoking organization: "firing smokers is an appropriate and very effective way to stop burdening the great majority of employees who wisely chose not to smoke with the enormous unnecessary costs of smoking by their fellow employees."

The Rest of the Story

According to the Lung Cancer Alliance, "over 60% of new lung cancers are diagnosed in people who never smoked or who managed to quit smoking even decades ago."

In fact, the majority of lung cancer cases do NOT occur in smokers. They occur in ex-smokers. Approximately 50% of lung cancer cases occur in former smokers, compared to just 35-40% in current smokers. For an employer, hiring a current smoker is statistically less likely to result in incurring high costs for the treatment of lung cancer than hiring a former smoker.

It is quite clear that ex-smokers, even if they quit a long time ago, represent a significant and substantial risk to the employer of having to face the inordinately high costs of medical treatment of these individual employees for lung cancer.

In the CPS-II cohort study, former 1+ pack per day male smokers who quit within the past year actually had the highest observed relative risk of getting lung cancer compared to male never smokers (50.7), even higher than the relative risk for current pack a day smokers (26.9). And the relative risk for lung cancer remained quite high (12.6) for former pack a day smokers who had quit up to 15 years earlier. Even former pack a day or more smokers who quit greater than or equal to 16 years previously had a relative risk of lung cancer of 5.5 (from 1990 Surgeon General's report: U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control, 1990).

A study of 2,257 HMO members in California found that male former smokers actually had more physician visits than current smokers (Oakes TW, et al. Health service utilization by smokers and nonsmokers. Medical Care 1974; 12: 958-966). And another study found that male former smokers actually lose more days of work to illness than male current smokers (U.S. Department of Health and Human Services. The Health Consequences of Smoking: Cancer and Chronic Lung Disease in the Workplace. A Report of the Surgeon General. Office on Smoking and Health, 1985). And yet another study reported higher rates of chronic ilness, acute illness, and physician visits, and comparable rates of outpatient visits among former smokers (even those who quit more than one year previously) compared to current smokers (Balarajan R, et al. Smoking and state of health. British Medical Journal 1985; 291:1682).

If it is true that the "great majority of employees" who "wisely chose not to smoke" are being "burdened" with the "enormous unnecessary costs of smoking by their fellow employees," then it is certainly true as well that these employees are also being burdened with the enormous unnecessary costs of prior smoking by their fellow employees who most unwisely chose to smoke earlier in their lives.

Thus, to avoid burdening never smoking employees with the enormous unnecessary costs of smoking and prior smoking by their fellow employees, it only makes sense to fire both smokers and ex-smokers. I don't see any way that ASH could rationalize not including ex-smokers, who clearly represent an unfair burden on their employers and fellow employees because of their increased risk of disease. The data simply do not justify making a distinction between these two groups, if the concern is saving health care costs for the employer and not burdening fellow employees with unnecessary costs due to smoking by their fellow employees.

Now to tip my hat to myself, I must say that this policy of firing ex-smokers is a brilliant solution to getting around the problem of anti-discrimination laws in some states that prevent employers from making smoking a condition of employment. My policy doesn't make smoking a condition of employment. It makes previous smoking a condition of employment. Thus, in states where firing smokers is not allowed, employers can still save huge amounts of money by firing ex-smokers.

Second, my policy allows employers to retain young smokers, who are not likely to get sick, but to unload older ex-smokers, who are very likely to get sick and incur huge health care costs. And it avoids age discrimination by not basing the policy on age, but on former smoking status.

If ASH is serious about saving health care costs for employers and removing the burden on nonsmokers of the costs imposed upon them due to the poor choices of those who chose to smoke, then it should immediately call not only for the firing of smokers, but for the firing of ex-smokers as well.

In fact, there is every reason to believe that a policy of firing ex-smokers would be far more effective in saving health care dollars than a policy of firing smokers.

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