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Should Healthcare Workers be Tested for Nicotine?

 |  By Lena J. Weiner  
   March 24, 2014

One in five healthcare organizations will not hire smokers. Some are screening for nicotine use, saying they wish to promote a healthier workforce. Not everyone is buying it.


Cigarette ad, 1931.
Source: Stanford School of Medicine

Twenty-one states do not accept smokers as a protected group of people or recognize a right to smoke, which allows employers to legally refuse to hire smokers. The most common industry banning smoking is healthcare, particularly hospitals, where 21% of organizations will not hire smokers—or, in many cases, anyone with nicotine in their system, including those currently using nicotine replacement products to break the habit.

A common argument for healthcare organizations banning smoking among their ranks is that, as healthcare staff, they should be setting a positive example for their patients and community. Many healthcare organizations also say that they wish to promote a healthier workforce and lifestyle for their employees. But not everyone is buying it.

"We have to ask ourselves what this is really about," said Philip Gordon, managing partner at the Gordon Law Group in Boston, Mass, which specializes in employment law. "It's about money. Employers think smokers are going to increase health costs," he said.

DeAnn McEwen, RN, a nursing practice specialist at National Nurses United, remembers the smoke-filled nurses' lounges of the seventies and is glad they're gone. But she also firmly believes that what healthcare employees do outside the hospital while on their own time is none of their employers' business.

"This crosses the line. If a smoking habit doesn't affect your work, employers might be going a bit too far. You have to ask what's next," McEwen said. "They say smokers take longer and more frequent breaks—but that's a management issue, and [it's] on management to fix it." "If employees are getting up every 20 minutes to have a cigarette, you can tell them you don't like it, that this isn't the kind of work environment you offer. But you can't tell people what they can't do at home," agreed Gordon.

McEwen is concerned that policing employees' lifestyles can contribute to an uncomfortable work environment. "Who is really benefiting?" she asked. "Programs like that [which] allow employers to target their employees' off-duty activities encourage workers to blame each other for the high cost of healthcare," she said, adding that these factors can contribute to infighting and bullying among employees.

Who really benefits from stringent anti-smoking bans depends upon who you ask. Gordon asserts that employers aren't really looking for nicotine or cotinine (an alkaloid found in tobacco and metabolite of nicotine) when conducting screens—they're looking for higher odds of developing other health problems related to nicotine addiction.

Under the Americans with Disabilities Act, employers cannot ask if an applicant has ever had cancer or emphysema, Gordon said—but they can legally test for the presence of nicotine, which can indicate a greater likelihood of developing these and other illnesses.

Butting Out
It's not impossible to have a firm anti-smoking policy that doesn't ask employees to take an invasive urine screen.

While Penn Medicine does have a policy against hiring smokers, its employees are on the honor system. "Penn Medicine does not test for cotinine in any applicants," said Michele Fletcher, Vice President of Human Resources-Decision Support at the University of Pennsylvania Health System. However, she added, "Applicants must attest that they are non-tobacco users when applying for a job."

Fletcher says she knows of at least two human resources employees who quit smoking as a result of Penn's smoking ban and the free smoking cessation program they offer. She believes Penn's position on smoking has made employees more aware of the importance of their personal well-being and caused it to become a more healthful organization.

But McEwen has a different perspective. "It's easy for the employer to blame the employee rather than look at problems in the system." She contends that if hospitals and healthcare systems really want to improve employee quality of life, they should look into alleviating understaffing, unsafe work environments, productivity demands, and employee exposure to workplace intimidation.

Gordon agrees that this will not be the last time working people will hear of the unhealthy being scapegoated. "Why wouldn't you want to hire an obese person? Because obesity is possibly a marker for other health conditions," he says, highlighting the similar health risk factors between smoking and being obese.

Gordon compares the situation to the unfair practice of asking young, female employees or potential employees if they were recently married, with the hidden agenda of deciding whether or not they're likely to get pregnant in the near future. "It's unlawful discrimination. You can't legally discriminate, so you find a pseudo-legal marker you can use," he said.

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Lena J. Weiner is an associate editor at HealthLeaders Media.

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