The Cleveland Clinic is a world-famous medical center that is consistently ranked among the top hospitals in the country. It goes without saying that the health professionals who work there don’t condone smoking. In fact, since 2007, the clinic has refused to hire anyone who smokes.

There are many reasons an employer – especially a healthcare provider – would want to implement a no-smoking policy for its new hires. A Perspective essay published online this week by the New England Journal of Medicine mentions several:


* It sends a strong message to employees and the community that smoking is harmful.

* It gives job applicants a strong incentive to quit.


* It saves employers money, since smokers incur more medical expenses than nonsmokers.

* It appeals to patients who are put off by the smell of cigarette smoke on the clothing of people taking care of them.


But are these reasons good enough to justify the harms to smokers? No way, argues in another Perspective essay in the journal.

“Categorically refusing to hire smokers is unethical,” that essay argues. In the case of a health provider, it’s also hypocritical, since doctors and nurses pledge to care for patients suffering from ailments brought on in part through their own bad behavior, the essay adds.


And it’s not like smokers necessarily have the power to quit. Both sides acknowledge that the majority of people who want to quit smoking are unable to do so. They each cite studies showing that aggressive smoking cessation programs can drastically increase a smoker’s chances of kicking the habit, but even the best programs fail 85% to 91% of the time.

One factor that makes it so hard is that the downsides of quitting – nicotine withdrawal, weight gain and the cost of gum and patches – are immediate, while the benefits – improved health, lower medical expenses – come later.


That’s another reason why it makes sense for employers to implement smoke-free hiring policies, according to the first essay – it offers an immediate benefit that helps “to counterbalance the costs of quitting.”

The other side remains unconvinced. These writers note that smokers are disproportionately poor, less educated and unemployed. Policies that cut them off from job opportunities and health insurance are thus a “double whammy,” they write.


Besides, plenty of nonsmoking employees make choices that affect the healthcare costs of their employers and make them less productive than their co-workers, the authors add. They have babies. They go rock climbing and break their arms.

“Promoting public health is a shared responsibility, and employers have a social obligation to contribute to the public health mission,” these authors conclude. “By cherry-picking ‘low-risk’ employees and denying employment to smokers, employers neglect this obligation, risk hurting vulnerable groups and behave unethically.”


The Cleveland Clinic sympathizers say it’s time for something more radical than sticking with the status quo. The 440,000 Americans who die due to tobacco each year outnumber the people who die as a result of homicides, suicides, car crashes, drug and alcohol use and HIV combined.

The solution is for more employers to join the Cleveland Clinic – and Baylor Health Care System, the University of Pennsylvania Health System, Union Pacific Railroad, Alaska Airlines, Scotts Miracle-Go and others – and implement no-smoking hiring policies of their own. There is much to gain by doing so, they write:


“The Cleveland Clinic moved to a smoke-free campus in 2005 and stopped hiring smokers in 2007. Reportedly, smoking rates decreased in Cuyahoga County (where the Cleveland Clinic is located) from 20.7% in 2005 to 15% in 2009, whereas the overall rate in the state decreased only from 22.4% to 20.3%.”

What do you think?


You can read both essays in full here and here on the New England Journal of Medicine website.

Return to the Booster Shots blog.


Follow me on Twitter @LATkarenkaplan