Where There’s Smoke, You’re Fired

The University of Pennsylvania Health System recently announced that they will no longer hire smokers in any of their Pennsylvania facilities. Harald Schmidt, Kristin Voigt, and Ezekiel J. Emanuel argue that policies like this are misguided:

The broader claim that it is fair to exclude smokers because they are responsible for raising health care costs is too simplistic. It ignores the fact that smoking is addictive and therefore not completely voluntary. Among adult daily smokers, 88% began smoking by the time they were 18, before society would consider them fully responsible for their actions. Much of this early smoking is subtly and not so subtly encouraged by cigarette companies. As many as 69% of smokers want to quit, but the addictive properties of tobacco make that exceedingly difficult: only 3 to 5% of unaided cessation attempts succeed. It is therefore wrong to treat smoking as something fully under an individual’s control.

David Asch, Ralph Muller, and Kevin Volpp are more supportive:

[W]e conducted a randomized trial comparing the use of employer-provided financial incentives for smoking cessation, aided by counseling, with an approach in which the same sorts of counseling programs were made available to employees but no incentives were given — effectively comparing enabling choice (rung 3) with guiding choice through incentives (rung 5). In one sense, the results were dramatic: during 12 to 18 months of follow-up, employees in the incentive group had a quit rate that was approximately three times that in the comparison group.5 But in absolute terms, even the incentive group had an 18-month quit rate of only about 9% — meaning that even with an aggressive system of rewards, 91% of employees who wanted to quit could not. We believe that the severe harms of smoking justify moving higher up on the ladder when lower-rung interventions don’t achieve essential public health goals.