In many states (21, to be precise), it is perfectly legal for an employer to not hire someone who smokes. This might seem understandable, given that health insurance is often coupled to employment, and since healthcare risks and costs are increasingly pooled. And so: if employers can exclude smokers, should they also be able to weed out junk-food lovers or motorcyclists — or perhaps anyone who wants to have a baby?
That question is the thrust of this podcast, which features a conversation with Zeke Emanuel. He is a Penn medical professor/bioethicist; a former White House healthcare adviser; the author of Healthcare, Guaranteed (and Brothers Emanuel, about growing up with Rahm and Ari); and a coauthor, with Harald Schmidt and Kristin Voigt, of a recent New England Journal of Medical article (previewed on our blog) called “The Ethics of Not Hiring Smokers”:
EMANUEL: I’m a cancer doctor. I find smoking disgusting. I find smoking horrible. I wish that everyone who did it could quit. But I also recognize that it’s not voluntary, that most people start before they’re adults and that it’s incredibly hard to quit once you’ve started.”
Emanuel also appeared in an earlier Freakonomics podcast, “Is the Obesity Epidemic for Real?” In this podcast, he argues that not hiring smokers lies somewhere between discriminatory and unethical. Give us a listen and let us know your thoughts.
Kai RYSSDAL: Time now for a little Freakonomics Radio. It’s that moment every couple of weeks we talk to Stephen Dubner, the co-author of the books and blog of the same name. It is “the hidden side of everything.” Dubner, long time, no talk, man!
Stephen J. DUBNER: Great to be back, Kai. Thanks for having me. I know you trained as a Navy pilot -- I wonder if you ever thought about afterward working as a commercial pilot? Was that ever a plan?
RYSSDAL: No, not really. That was never my thing.
DUBNER: Well, if you had, and if you had interviewed with, let’s say, Alaska Airlines, there’s something you would have needed to know. Here’s airline spokesperson Marianne Lindsey:
Marianne LINDSEY: “In general, there’s a question that’s asked, ‘have you smoked or used tobacco products within the last six months?’ And we go by how the employee responds to that question. And then, before they’re hired, they have a drug test that they take that detects nicotine use.”
RYSSDAL: So Alaska Airlines would not hire me, were I a smoker. Yes?
DUBNER: Alaska Airlines would not hire you if you were a smoker. Now, they’ve had this policy for quite a few years. And more and more companies now are refusing to hire anyone who uses tobacco -- a lot of healthcare firms, especially, and hospitals.
RYSSDAL: This has to be about cutting healthcare costs, right?
DUBNER: That’s a primary reason, for sure. Smokers are more expensive than non-smokers, if you’re the company. By one estimate, about $4,000 a year more in terms of healthcare and lost productivity and so on. But there’s also the idea that you want to make every workplace healthier, which means smoke-free seems to be a good idea there.
RYSSDAL: Right, OK. That makes sense. Question number two, though, Dubner, is this: Last time I checked, smoking is legal, man.
DUBNER: Yes it is. So, as it turns out, in terms of the legality of hiring smokers: 29 states have passed laws that don’t let companies turn down smokers, but the other 21 states do allow you to do that. So if I’m a company in New York or North Carolina or California, I cannot reject an employee because he or she smokes. But if I run a company in Pennsylvania or Florida or Alaska, I can. So that’s a pretty severe split – which recently led to a piece in the New England Journal of Medicine about the ethics of not hiring smokers. Here’s one of the authors, Zeke Emanuel, who is a bioethicist and a professor at the University of Pennsylvania.
Ezekiel EMANUEL: “I’m a cancer doctor. I find smoking disgusting. I find smoking horrible. I wish that everyone who did it could quit.”
DUBNER: All right. So it’s not hard to think that he’s in favor of not hiring smokers. Right? But wait, there’s more:
EMANUEL: “But I also recognize that it’s not voluntary, that most people start before they’re adults and that it’s incredibly hard to quit once you’ve started.”
RYSSDAL: OK, wait. “Not voluntary?” I mean, Zeke Emanuel is a smart guy and all, but huh?
DUBNER: That is really the basis of his argument – which is that most smokers want to quit, but can’t, and to refuse to hire them is therefore discriminatory or at least unethical.
RYSSDAL: Does this break down on socioeconomic lines? Is there a low-income, low-wage worker versus high-wage, high-income person thing?
DUBNER: Yeah, that’s a great question. So low-income people are substantially more likely to smoke than high-income people across the board. So, if you’re a low-income smoker and now can’t get a job because you smoke, it’s sort of a double jeopardy. But there’s also the fact that smoking is one of those activities – legal, as you noted, but publicly frowned upon – that seems to open a bigger can of worms in terms of hiring. Here’s Emanuel again:
EMANUEL: “Once you’re on this kick, you can say, ‘Look at those Seventh Day Adventists! They’re the people we really want to employ because those guys -- they don’t smoke, they don’t drink, they eat very healthy, they don’t engage in high-risk sporting activities.’ That just seems to me exactly where we don’t want to be going”
DUBNER: So Kai, you can imagine a future where nobody wants to hire anybody who does anything at all risky. Maybe not even risky, but just expensive -- like becoming pregnant and having kids. Because, as we all increasingly share healthcare costs, that means that you increasingly are thinking about what I do because it affects what you’ll pay in insurance and taxes. In the case of smoking, it’s really all about the incentives. In a tough labor market like ours, will it turn out to be that getting a job is a such a strong incentive that it might help a smoker who has tried everything, but everything else else has failed? I have no idea if that will work, but it will sure be worth keeping an eye on.
RYSSDAL: Stephen Dubner. Freakonomics.com is the web site. Stephen, we’ll see you in a couple of weeks.