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Wednesday, 3 November 2010

Nanny Employer or Public Health Leader?

The Massachusetts Hospital Association announced yesterday that as of January 1, tobacco users will not be eligible for employment. The blogosphere responded quickly. "Big Brother," "totalitarianism," and "fascism" were among the terms applied to the MHA policy.

Apart from fiery rhetoric, the most persuasive critique of what the MHA is doing is the "slippery slope" argument. Even those who favor high tobacco taxes and other preventive messages worry about the potential for employers to develop hiring policies that reflect prejudice, not public health. (In the 1980s, Electronic Data Systems banned facial hair and fired an employee who claimed that he wore a beard for religious reasons!)

In my view, it is entirely justifiable for a health organization to do what the MHA is doing. I formed this opinion as a fourth year medicine student on a medicine rotation at the Boston City Hospital. A man in his 50s died of lung cancer. I joined the resident in meeting with the family. As would be unthinkable now but was not so shocking in the 1960s, the resident was holding a cigarette. The widow was outraged - "How can you talk to me about my husband's death and smoke cigarettes yourself?" Of course she was right. It would be hypocritical at best for the MHA to preach public health without taking a strong stand against tobacco use.

But what about organizations not in the health sector? Banning smoking on the premises is justified by the risks second hand smoke poses to fellow employees. But not hiring smokers is problematic. The policy would contribute to anti-tobacco pressure, but it would have greater impact on low income workers, since tobacco use is more prevalent in low income groups. And it would fly in the face of the strong value Americans place on individual liberty.

In principle, further increases in tobacco taxes would be a preferable approach. Price increases lead established smokers to cessation efforts, reduce the rate of smoking, and discourage adolescents from initiating tobacco use. Critics, including tobacco company lobbyists, are correct in arguing that "sin taxes" are regressive - the poor pay proportionally more than the wealthy. But since there are more low income smokers, the relatively larger number who quit will, over time, make the tax less regressive. And, as a practical matter, determined low income smokers generally have access to lower cost black market products.

But we are likely to see non-health organizations following organizations like the MHA (or the Cleveland Clinic, which instituted a non-hiring policy in 2007), driven by concern about health care costs. Employers will justify the policy by (1) public health values but also (2) the potential that reducing (and ultimately eliminating) smoking among employees has to lower insurance costs for the company. Insofar as health care costs come out of wages, my liberty to smoke comes out of my fellow employee's paycheck. As I argued in a previous post, my liberty right to smoke if it's legal doesn't give me the right to lower your pay.


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