Employee smoking bans ignite debate

"All of us have had bad habits. This is more of a badge of shame in healthcare more than anywhere else.” - Stefan Kertesz, MD

Teetering between proactive and punitive, the rise of employee smoking bans challenges health leaders to confront a long-festering issue

Fifty years after the U.S. Surgeon General’s report on smoking, it’s still not uncommon to see workers puffing cigarettes on the grounds of hospitals. To address this incongruence, some health systems have started taking a bold strategy – barring smokers from employment, even those who don’t work in clinical and patient support roles.

By one estimate, some 70 U.S. health systems have enacted such bans, from the Cleveland Clinic in 2007 to the University of Pennsylvania Health System last summer. It is a matter of maintaining consistent principles, supporters of the approach argue, and to a lesser extent, as an added benefit, it helps save money on healthcare costs.

But critics of health system smoker bans argue that the bid to address a contradictory image ends up creating a policy that is incompatible with the mission of healthcare providers: to treat all who suffer, including “those whose ill health might be their own doing,” as Thomas Huddle, MD, and Stefan Kertesz, MD, wrote in the Journal of the Association of American Medical Colleges.

Last July, the University of Alabama Hospital, the flagship of the UAB Health System and one of Alabama’s largest employers, started screening all new applicants for smoking and nicotine use, from physicians to food service staff, after a unanimous vote by clinical leadership to ban tobacco use for all new employees.

Around the 1,046-bed UAB Hospital, anyone other than staff can still smoke: As an urban campus, with hospital property abutting city streets and sidewalks, banning smoking outright would require city council approval.

Helping people quit rather than barring employees from smoking should be the goal, Huddle and Kertesz argue.

“All of us have had bad habits,” said Kertesz, a UAB professor who specializes in addiction research and also works at the Birmingham VA Medical Center. “This is more of a badge of shame in healthcare more than anywhere else.” This is why Kertesz, who himself tried clove cigarettes once in high school, thinks the most aggressive cessation efforts should be focused on healthcare staff.

“The strongest efforts should be made with the established workforce,” he said. “Nicotine replacement products, gum, patches, lozenges ... should be provided for free by the employee health programs.”

Are smoker bans discriminatory?

Part of the problem with smoker bans at healthcare institutions, Huddle and Kertesz argue, is that the policies may disproportionately impact lower-skilled and lower-paid staff.

Smokers comprise 18 percent of the U.S. adult population, but 26 percent of those with incomes of less than $35,000 per year and 25 percent of those without high school diplomas. In healthcare, as of 2007, according to data Huddle and Kertesz compiled, about 25 percent of food preparation and service staff and 20 percent of maintenance staff smoked, compared to 10 percent of registered nurses and less than five percent of physicians and pharmacists.

“It is extraordinary likely that the people who are denied employment are those of lower-socioeconomic classes,” Huddle said.

But William Ferniany, CEO of UAB Health System, sees it differently. “This is a non-event here. We hire as many underprivileged people as we did before,” said Ferniany.

After screening more than 1,000 applicants at UAB hospital, less than 20 have failed the nicotine test and only a few more have failed the drug test, he said. “I don’t worry that people of lower socioeconomic classes are impacted, because many of them don’t smoke,” Ferniany said. “We’re not having trouble hiring.”

Another sign of the smoker ban’s general success, Ferniany said, is that regional nursing students are quitting because they want to work at UAB; at least that’s what he hears anecdotally from educators.

Huddle and Kertesz, though, counter that it’s not clear how many people the ban is persuading to quit smoking and how many are simply dissuaded from applying.

While young smokers like nursing students may be able to shake a habit they’ve have for only few years, “there are still likely to be a lot of middle-age individuals who smoke who will have lost another employer,” said Huddle, an internist and professor of medicine who briefly experimented with smoking tea in junior high.

“We’re not going to know how successful policies like these are for prospective applicants unless it’s formally studied,” Kertesz said. “What we do know is that institutional smoker bans have not altered smoking prevalence at the community or population level.”

That last point is actually subject to some debate. As the region’s largest employer, the Cleveland Clinic claims that its 2007 smoker ban helped bring the countywide smoking rate down from 20 percent in 2005 to 15 percent by 2009, much faster than the statewide decline of 22 percent to 20 percent. Huddle and Kertesz find it hard to attribute that to Cleveland Clinic’s policy. “It was on a long, steep decline long before Cleveland Clinic instituted their policy,” Huddle said.

Looming decisions for institutions

Aside from treating those maladies related to smoking, for healthcare institutions in many places, the issue of smoking on location – by workers or patients – is an ongoing challenge.

“I would put in a smoke-free campus if I could,” said Ferniany who has never smoked. “The city won’t give us control. I don’t know why, I’ve asked.”

Ferniany, who worked at the University of Mississippi Medical Center when it went smoke-free, thinks health systems have to weigh the benefits and drawbacks of smoke-free policies based on their local context and consider the decisions at a facility-by-facility level, as UAB has done. Its Montgomery hospital, for instance, is smoke-free but doesn’t ban employees from smoking off the grounds.

“They have to give it careful thought, talk it over with their medical staff and their board,” Ferniany said. “Each institution is going to come to a different decision. We think we are a healthcare leader in our state and will set an example. There’s no right or wrong; it’s what works for each institution.”

But skeptics of smoking bans, like Huddle and Kertesz, think that smoking and other unhealthy behaviors are waiting to be addressed proactively, not with punitive policies.

“It bothers me that they seized upon an individual health risk behavior. It’s easy to single out one behavior that’s infrequent among higher classes and easier to single out via chemical testing,” Kertesz said. “There’s never going to be a ban on people with high weights, who BASE jump or don’t keep their guns locked.”