Tobacco-Free Health Care Workplaces

Regardless of your profession, if you have applied for a job in the last, say, two decades, then you may have taken a pre-employment drug test. Increasingly, however, healthcare employers are looking to screen out not only users of street drugs, alcohol and prescription medications, but also users of tobacco.

While such policies have drawn fire from some, the consensus among healthcare organizations seems clear: It’s necessary for all providers to take the lead in promoting health in their communities.

How It Works

In 2007, Florida Hospital Waterman, located in Tavares, became one of the first major employers in its region to implement a tobacco-free campus. Effective January 1 of 2011, the hospital also implemented a hiring policy that prohibits tobacco use by all new employees.

Under the new policy, applicants being considered for employment will be tested for nicotine use as part of their regular pre-employment drug screening, according to Madge Springer, human resources director.

“First of all, we make it clear from the beginning of the application process that we have a tobacco-free hiring policy,” she explained. “And if they let us know they do smoke or use nicotine, we let them know they are welcome to apply again after 60 days.”

If the applicant is unable to pass the nicotine screening after 60 days, then they are ineligible to apply for employment for another 6 months.

Similarly, ProMedica in Toledo, Ohio, went tobacco-free as a health system in 2008, according to Laura Ritzler, director of wellness for ProMedica. And it, too, began 2011 with the introduction of a tobacco-free hiring policy.

ProMedica’s new job application asks candidates about their tobacco use. If they declare they do not use tobacco but their post-offer screening is positive, they will not be hired.

Applicants who declare tobacco use and who then quit using tobacco may reapply for a position after 90 days.

Both providers’ policies apply only to new hires; i.e., current employees were grandfathered in and not required to quit, although smoking cessation assistance is available to employees at both organizations.


The Next Step

For many healthcare organizations, tobacco-free hiring policies are a natural expression of their larger mission to improve the health of the communities they serve.

“If you can imagine a nurse who is a smoker going in to provide information on smoking cessation to a patient who’s just had a heart attack, and the nurse herself reeks of smoke, that’s a hard sell, to be sure,” Ritzler said. “So what we are saying through this type of policy is that we really need our employees to be role models – to be models of healthy living.”

Faye Rose, pastoral care director at Florida Hospital Waterman, echoed Ritzler’s comments.

“There is a growing passion for getting our employers healthy and helping to get the community healthy,” she said. “And we are a healthcare organization, so . it’s almost going beyond what we ‘should’ do to what we are compelled to do; it’s what we are at our very core.”

Lynn Nicholas is president and CEO of the Massachusetts Hospital Association (MHA), which was the first private employer in its state to implement a tobacco-free hiring policy. She agreed it’s important for healthcare organizations to project an image of being good stewards of public health. But tobacco-free hiring also reflects the increasing emphasis on preventive health that’s driving healthcare practice, policy and reimbursement in the U.S.

“In Massachusetts, because we have been so successful in getting 98 percent of our citizens covered with health insurance, the issue of affordability of care has become increasingly important to our hospitals, most of which are privately insured,” she explained. (In 2006, Massachusetts became the first state to require all residents carry health insurance.)

“Hospitals are redesigning their employee benefit plans, and they are working more along the lines of defined contribution benefit plans, which are more affordable for their employees as well as themselves,” she continued. “They are creating select networks and putting in benefits that deal with prevention and highlight personal accountability for one’s health. So I think when you look at the numbers, even if it takes a decade for an organization to become completely tobacco-free, that’s a huge savings for them.”


Is It Legal?

Efforts to restrict smoking among employees have met with a combination of support and resistance nationwide.

According to a law synopsis released in July 2005 by the Tobacco Control Legal Consortium, smokers are not guaranteed specific rights under the U.S. Constitution. In There Is No Constitutional Right to Smoke , Samantha K. Graff explains most attacks on smoke-free laws – whether they address where smoking is allowed or who is allowed to smoke – follow one of two lines of reasoning: “that smoking is a personal liberty specially protected by the Due Process Clause . or . that the Equal Protection Clause extends special protection to smokers as a group.”

Graff goes on to claim that neither of these two claims is legally valid. Still, According to the American Lung Association, 29 states and the District of Columbia have passed laws that protect smokers in some way, the earliest being Illinois, which did so in 1987.

For example, Connecticut law states “no employer or agent of any employer shall require, as a condition of employment that any employees or prospective employees refrain from using tobacco products outside the course of their employment, or otherwise discriminate with respect to compensation, terms, conditions or privileges of employment.” (CT GEN. STAT. ANN. § 31-40s (2003))

However, many hospitals are nonprofit organizations, and these, as well as entities whose focus is the cessation of tobacco use, are exempt under the Connecticut law: “Any nonprofit organization or corporation whose primary purpose is to discourage use of tobacco products by the general public shall be exempt from the provisions of this section.”


Such caveats are not uncommon in smoker protection laws. Consequently, even hospitals in states such as Connecticut with smoker protection laws in place often have legal precedence in refusing to hire tobacco users.

Graff explains that smoker protection laws are “not as protective as they sound. They do not create a right to smoke. Nor do they give people license to smoke anywhere at anytime. Instead, they merely assure some smokers that their employers will not consider their off-duty tobacco use when making employment decisions.”

Employers in states that have smoker protection laws in place must work to amend or appeal such legislation in order to move forward with certain restrictive hiring policies, Graff writes.

Promedica and Florida Hospital Waterman operate in states where no such protections are on the books, but their new policies are fairly mundane compared with some. The tobacco restrictions of some employers in such states can be even more aggressive.

Weyco Inc., Okemos, MI, is a third party administrator of self-funded health and disability plans. In 2003, it initiated a hiring policy similar to that of Promedica and Florida Hospital Waterman. But in the years to follow, it slowly expanded the policy. In 2004, it implemented an organizationwide testing program for tobacco use, bringing all employees under scrutiny. Those who refused the test or tested positive for nicotine were charged a monthly penalty, unless they agreed to quit.

In 2005, they upped the ante, announcing random mandatory testing and related penalties, which could result in termination.

In 2007, the policy expanded again to include employees’ spouses. They, too, were subject to nicotine testing, and penalties were put in place for employees whose spouses did not fall in line.


Another Perspective

As president and CEO of MHA, Nicholas has spent considerable time listening to both the proponents and critics of tobacco-free hiring. She’s appeared on several radio talk shows to speak about the topic, and she’s fielded many calls from irate listeners who question an employer’s authority to be so involved in employee’s lives.

“Some civil libertarians have asked, ‘If I want to die 14 years younger, what concern is it of yours?’ And my answer would be, ‘But we all pay for that. For every pack of cigarettes sold in Massachusetts, it costs the rest of [the state’s residents] $15 in healthcare costs.’ That shuts people down a little bit,” she said.

What’s more, Nicholas added, there is increasing evidence about the dangers of not only second-hand smoke to nonsmokers, but also so-called “third-hand smoke,” or the residue left by tobacco smoke once it has dissipated.

Those advocating for tobacco-free policies of all sorts continue to add such evidence to their case. But some – smokers and nonsmokers alike – are more than a little suspicious of the rhetoric used to support anti-tobacco viewpoints, whether it be the facts supporting the health consequences of third-hand smoke or the fiscal justifications behind tobacco bans.

Michael J McFadden is Mid-Atlantic regional director for Citizens Freedom Alliance Inc., which operates the Smoker’s Club Inc. In his book, Dissecting Antismokers’ Brains, McFadden attempts to dissect both the logic behind antismoking arguments and the motives driving those who make them.

For example, on the medical side, McFadden claims the dangers of second-hand smoke are misrepresented and exaggerated (for instance, claiming a business can’t substantially sheild non-smokers from the fumes of smokers in the same building) and that there is absolutely no real connection between third-hand smoke and health concerns.

On the financial side, McFadden suggested the idea that healthcare costs necessitate anti-tobacco policies is simply a manipulation of the issue. He wondered aloud, “How would you feel if companies refused to hire overweight people, moderate alcohol drinkers, or women who might become pregnant because of financial cost concerns? How much does the cost of raising a family cost an employee’s insurance provider a year? Healthcare costs for children are considerable, yet we generally don’t ban employees from starting a family.”

Of particular concern are some of the special interests McFadden believe help fuel misguided fear and outrage among the public.

“Generally, in the antismoking movement, it used to be in the 1960s and 70s, the idea was to tell people about smoking relative to their own health, which is fine; it’s good for people to know what’s good and bad for them,” McFadden said. “But some people are going to decide that they like smoking anyway and continue to smoke.

“What’s happened since then is various people who are profiting from the antismoking movement have created a whole stew of biased but authoritative-looking evidence they can draw from when lobbying against smoking.”

According to McFadden, these interested parties include trial lawyers, who gain from tobacco-related litigation; and pharmaceutical companies, which make money on smoking cessation products; and researchers, who receive million-dollar grants from sums made available through dedicated taxes on cigarettes. While much has been made about the tobacco industry’s attempts to manipulate policy and perception in favor of smoking, McFadden argues the same can now be said of the antismoking movement.


Forward Momentum

The issue of smoker rights is a contentious one, to be sure. But despite the concerns of McFadden and others, the healthcare industry seems to be clear on the subject of employee tobacco use: It’s a concern, it runs counter to everything they do, and it needs to be addressed proactively.

“What you are saving is human suffering,” said Rose at Florida Hospital Waterman. “People who get diseases from tobacco products die horrible deaths, and they leave a trail of grief and misery behind them. It’s not just money; it’s humanity.”

Nicholas said there really is no question about what course to take when it comes to healthcare providers and employee tobacco use.

“Some will say to us, ‘I see your concerns about tobacco and I applaud you doing everything you can, but isn’t this a slippery slope? Tobacco is one thing, but what are you going to do next, call people out for obesity, or skiing without helmets?’

“I understand that pushback,” Nicholas said, “and there are a lot of complex issues involved in those situations, but tobacco use is pretty clear cut: You either smoke or you do not. It’s a black and white issue: Tobacco is – by far – the leading cause of death among risky behaviors in this country, and it’s the leading cause of preventable death.”

In Massachusetts, more than 8,000 people die each year as a result of tobacco use, Nicholas added. It costs the commonwealth $6 billion a year, and 76 percent of that is in direct healthcare costs, while 28 percent is lost productivity and premature death.

“So the state has an enhanced policy interest in decreasing the number of smokers, as well as an obligation to the overall health and well-being of their citizenry,” Nicholas said. “We are now the second healthiest state in the nation, and we’d like to be number one.”

Rather than encountering fear and suspicion from potential and current employees, officials from Florida Hospital Waterman, Promedica and MHA all report their tobacco-related efforts have met with considerable support. Many employees at these organizations have seen the increased emphasis on well-being as an opportunity for self-improvement.

“One of our senior staffers was a serious closet smoker, and as we rolled this out and talked about it, she had a real change of heart,” Nicholas shared. “She has now completely quit and runs up to five miles on a treadmill several times a week; this from someone who used to have trouble with three flights of steps!”

Promedica’s Ritzler shared a similar anecdote.

“One of our RNs had really struggled for some time with tobacco use, quitting multiple times only to start again,” she said. “And when she heard about our program being initiated, it really was, for her, an opportunity to quit.

“We have a Facebook page for wellness, and she is sharing her journey with all our employees this time as she tries to quit once and for all,” Ritzler continued. “So there have been some really positive narratives already.”

Timothy A. Mercer is a contributor to ADVANCE.

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