The ethics of not hiring smokers.

n engl j med 368;15 nejm.org april 11, 2013 1369 but 21 states have no such restrictions. Many health care organizations, such as the Cleveland Clinic and Baylor Health Care System, and some large non– health care employers, including Scotts Miracle-Gro, Union Pacific Railroad, and Alaska Airlines, now have a policy of not hiring smokers — a practice opposed by 65% of Americans, according to a 2012 poll by Harris International. We agree with those polled, believing that categorically refusing to hire smokers is unethical: it results in a failure to care for people, places an additional burden on already-disadvantaged populations, and preempts interventions that more effectively promote smoking cessation. One justification for not employing smokers, used primarily by health care organizations, is symbolic. When the World Health Organization introduced a “nonsmoker-only” hiring policy in 2008, it cited its commitment to tobacco control and the importance of “denormalizing” tobacco use. Health care organizations with similar policies have argued that their employees must serve as role models for patients and that only nonsmokers can do so. A second, more general, argument is that employees must take personal responsibility for actions that impose financial or other burdens on employers or fellow employees. Accordingly, smokers should be responsible for the consequences of their smoking, such as higher costs for health insurance claims, higher rates of absenteeism, and lower productivity. These costs amount to an estimated additional $4,000 annually for each smoking employee. Yet it seems paradoxical for health care organizations that exist to care for the sick to refuse to employ smokers. Many patients are treated for illnesses to which their behavior has contributed, including chronic obstructive pulmonary disease, heart failure, diabetes, and infections spread through unprotected sex or other voluntary activities. It is callous — and contradictory — for health care institutions devoted to caring for patients regardless of the causes of their illness to refuse to employ smokers. Just as they should treat people regardless of their degree of responsibility for their own ill health, they should not discriminate against qualified The Ethics of Not Hiring Smokers