The ethics of not hiring smokers

Productivity costs of lifelong smoking-the Northern Finland Birth Cohort 1966 study

BACKGROUND

Smoking is one of the leading causes of impaired health and mortality. Loss of paid and unpaid work and replacements due to morbidity and mortality result in productivity costs. Our aim was to investigate the productivity costs of lifelong smoking trajectories and cumulative exposure using advanced human capital method (HCM) and friction cost method (FCM).

METHODS

Within the Northern Finland Birth Cohort 1966 (NFBC1966), 10 650 persons were followed from antenatal period to age 55 years. The life course of smoking behaviour was assessed with trajectory modelling and cumulative exposure with pack-years. Productivity costs were estimated with advanced HCM and FCM models by using detailed, national register-based data on care, disability, mortality, education, taxation, occupation and labour market. A two-part regression model was used to predict productivity costs associated with lifelong smoking and cumulative exposure.

RESULTS

Of the six distinct smoking trajectories, lifetime smokers had the highest productivity costs followed by late starters, late adult quitters, young adult quitters and youth smokers. Never-smokers had the lowest productivity costs. The higher the number of pack-years, the higher the productivity costs. Uniform patterns were found in both men and women and when estimated with HCM and FCM. The findings were independent of other health behaviours.

CONCLUSIONS

Cumulative exposure to smoking is more crucial to productivity costs than starting or ending age of smoking. This suggests that the harmful effects of smoking depend on dose and duration of smoking and are irrespective of age when smoking occurred.

Is it ethical to lie by omission for a patient?

In the age of increasing transparency, dermatologists may encounter requests from patients to alter or withhold key medical information from their electronic medical records. Per the Health Insurance Portability and Accountability Act, patients have the right to view their medical record and request amendments; however, the physician is the final decision maker on what information should be included in the chart. It is integral that medically necessary information is included in the chart in accordance with the principle of beneficence and nonmaleficence. Withholding medically pertinent history may cause harm to the patient. Navigating such challenging situations while maintaining transparency requires a thorough understanding of the patient's dilemma. This contribution provides a framework by applying multiple ethical principles and will empower dermatologists to navigate such requests.

An assessment of workplace wellness policies and programs of universities in the Asia-Pacific

BACKGROUND

Universities could positively impact the health and well-being of employees through workplace wellness programs (WWP).

OBJECTIVE

To assess the prevalence of WWP among Asia-Pacific universities, identify gaps and challenges, and solutions to challenges.

METHODS

An online survey was sent to members of the Association of Pacific Rim Universities to assess programs on physical fitness, nutrition/weight, mental health/stress, family support, chronic disease prevention, and safety.

RESULTS

Employees at 28 universities in 13 economies completed the survey on behalf of their university. Most common WWP were paid maternity/paternity leave (89.3% /85.7%), disaster preparedness training (85.7%), fitness challenges (78.6%), written policies regarding discrimination/hate speech (75.0%), and quiet rest areas (71.4%). However, few addressed childcare, breastfeeding support, workplace sexual harassment, tobacco use, or mental health. Programs rarely aligned with the reported goal of increasing employee morale, but instead resulted from government mandates. Many universities offered sporadic, one-off programs but lacked comprehensive, coordinated programming and adequate evaluation procedures. Key challenges were low employee participation, limited budget, and lack of leadership support. This study highlights the need for improved program administration, information dissemination, data collection to evaluate impact, and leadership support.

CONCLUSION

WWP could benefit universities and employees but should be implemented and evaluated as part of a comprehensive campus wellness culture.

Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user's adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

The Ethics of Workplace Health Promotion

Companies increasingly offer their employees the opportunity to participate in voluntary Workplace Health Promotion programmes. Although such programmes have come into focus through national and regional regulation throughout much of the Western world, their ethical implications remain largely unexamined. This article maps the territory of the ethical issues that have arisen in relation to voluntary health promotion in the workplace against the background of asymmetric relationships between employers and employees. It addresses questions of autonomy and voluntariness, discrimination and distributive justice, as well as privacy and responsibility. Following this analysis, we highlight the inadequacy of currently established ethical frameworks to sufficiently cover all aspects of workplace health promotion. Thus, we recommend the consideration of principles from all such frameworks in combination, in a joint reflection of an Ethics of Workplace Health Promotion.

The Medicalization of Health and Shared Responsibility

Public, occupational and environmental health are relatively novel disciplines compared to the ancient history of medicine. Their development, together with a more insightful knowledge of the human pathophysiology (this more usual term is the one used in the article itself), have progressively expanded the field of investigation of medicine to environmental, behavioural and genetic factors that favour the development of certain medical conditions. As a result we have developed numerous additional strategies to monitor health and prevent disease, including interventions in anticipation of diseases themselves when patients are still healthy or in a grey area of increased risk. New developments related to genomics and distributed point of care technologies will exacerbate a process of medicalization of health. This process is profoundly re-shaping how medicine interacts with the general population, states and policy makers and has implications for healthcare system design and individual health choices.

Health Care Organizations and Policy Leadership: Perspectives on Nonsmoker-Only Hiring Policies

PURPOSE

To explore employers' decisions to base hiring policies on tobacco or nicotine use and community perspectives on such policies, and analyze the implications for organizational identity, community engagement, and health promotion.

METHOD

From 2013 to 2016, 11 executives from six health care organizations and one non-health-care organization with nonsmoker-only hiring policies were interviewed about why and how their policies were created and implemented, concerns about the policies, and perceptions of employee and public reactions. Focus groups were conducted with community members (n = 51) who lived in or near cities where participating employers were based, exploring participants' opinions about why an employer would stop hiring smokers and their support (or not) for such a policy.

RESULTS

Most employers excluded from employment those using all forms of nicotine. Several explained their adoption of the policy as a natural extension of a smoke-free campus and as consistent with their identity as health care organizations. They regarded the policy as promoting health. No employer mentioned engaging in a community dialogue before adopting the policy or reported efforts to track the policy's impact on rejected applicants. Community members understood the cost-saving appeal of such policies, but most opposed them. They made few exceptions for health care organizations.

CONCLUSIONS

Policy decisions undertaken by health care organizations have influence beyond their immediate setting and may establish precedents that others follow. Nonsmoker-only hiring policies may fit with a health care organization's institutional identity but may not be congruent with community values or promote public health.

Should Employers Be Permitted not to Hire Smokers? A Review of US Legal Provisions

BACKGROUND

Increasingly, healthcare and non-healthcare employers prohibit or penalize the use of tobacco products among current and new employees in the United States. Despite this trend, and for a range of different reasons, around half of states currently legally protect employees from being denied positions, or having employment contracts terminated, due to tobacco use.

METHODS

We undertook a conceptual analysis of legal provisions in all 50 states.

RESULTS

We found ethically relevant variations in terms of how tobacco is defined, which employee populations are protected, and to what extent they are protected. Furthermore, the underlying ethical rationales for smoker protection differ, and can be grouped into two main categories: prevention of discrimination and protection of privacy.

CONCLUSION

We critically discuss these rationales and the role of their advocates and argue that enabling equality of opportunity is a more adequate overarching concept for preventing employers from disadvantaging smokers.

Smoking or My Job? US Media Coverage of Nonsmoker-Only Hiring Policies

OBJECTIVES

Media advocacy plays a critical role in tobacco control, shaping the content of news in ways that generate public support for tobacco control. We examined US media coverage of nonsmoker-only hiring policies, which have little US public support, exploring the extent to which tobacco control advocates and experts have engaged the media on this controversial issue.

METHODS

We searched online media databases (Lexis Nexis, Access World News, and Proquest) for articles published from 1995-2013, coding retrieved items through a collaborative, iterative process. We analyzed the volume, type, provenance, prominence, content and slant of coverage.

RESULTS

We found 1,159 media items on nonsmoker-only hiring policies, most published in local newspapers in regions where such policies were enacted. The most common reason given for implementing such policies was to reduce healthcare costs. Most news items offered reasons both to support and oppose such policies; thus, the slant of the majority of news items was neutral or mixed. Tobacco control advocates or experts were infrequently cited or quoted in news items, and rarely authored opinion pieces. Those who expressed opinions were more likely to support than oppose nonsmoker-only hiring policies, for economic and health reasons. Ethical concerns about the policies were seldom raised.

CONCLUSIONS

As presented in the media, nonsmoker-only hiring policies were primarily framed in terms of business cost savings and had little connection to health initiatives. Tobacco control advocates were rarely quoted and their positions were not consistent. Given their intrusiveness and the lack of strong evidence that such business policies actually do improve worker health, tobacco control advocates may feel that the status quo is preferable to engaging on a policy that the majority of Americans dislike.

Smoking Norms and the Regulation of E-Cigarettes

Electronic nicotine delivery systems (ENDS)-commonly called e-cigarettes-are at the center of a polarized debate. How should they be regulated? Central to this debate is the concern that e-cigarettes could lead to the renormalization of smoking and that the regulation of ENDS should therefore be modeled on the regulation of conventional cigarettes. I argue that arguments based on the renormalization of smoking can lend support to restrictions on marketing of ENDS, but that such arguments are problematic when used to justify restrictions on where ENDS can be used. The debate has been insufficiently sensitive to the ethical complexities of attempts to manipulate social norms to change health behaviors; these complexities must also inform the debate about ENDS and their regulation.

Managing manifest diseases, but not health risks, saved PepsiCo money over seven years

Workplace wellness programs are increasingly popular. Employers expect them to improve employee health and well-being, lower medical costs, increase productivity, and reduce absenteeism. To test whether such expectations are warranted, we evaluated the cost impact of the lifestyle and disease management components of PepsiCo's wellness program, Healthy Living. We found that seven years of continuous participation in one or both components was associated with an average reduction of $30 in health care cost per member per month. When we looked at each component individually, we found that the disease management component was associated with lower costs and that the lifestyle management component was not. We estimate disease management to reduce health care costs by $136 per member per month, driven by a 29 percent reduction in hospital admissions. Workplace wellness programs may reduce health risks, delay or avoid the onset of chronic diseases, and lower health care costs for employees with manifest chronic disease. But employers and policy makers should not take for granted that the lifestyle management component of such programs can reduce health care costs or even lead to net savings.

Interventional pulmonology approaches in the diagnosis and treatment of early stage non small cell lung cancer

Lung cancer management is complex and requires a multi-disciplinary approach to provide comprehensive care. Interventional pulmonology (IP) is an evolving field that utilizes minimally invasive modalities for the initial diagnosis and staging of suspected lung cancers. Endobronchial ultrasound guided sampling of mediastinal lymph nodes for staging and detection of driver mutations is instrumental for prognosis and treatment of early and later stage lung cancers. Advances in navigational bronchoscopy allow for histological sampling of suspicious peripheral lesions with minimal complication rates, as well as assisting with fiducial marker placements for stereotactic radiation therapy. Furthermore, IP can also offer palliation for inoperable cancers and those with late stage diseases. As the trend towards early lung cancer detection with low dose computed tomography is developing, it is paramount for the pulmonary physician with expertise in lung nodule management, minimally invasive sampling and staging to integrate into the paradigm of multi-specialty care.

How low should you go? Determining the optimal cutoff for exhaled carbon monoxide to confirm smoking abstinence when using cotinine as reference

INTRODUCTION

Confirming abstinence during smoking cessation clinical trials is critical for determining treatment effectiveness. Several biological methods exist for verifying abstinence (e.g., exhaled carbon monoxide [CO], cotinine), and while cotinine provides a longer window of detection, it is not easily used in trials involving nicotine replacement therapy. The Society for Research on Nicotine and Tobacco's Subcommittee on Biochemical Verification cite 8-10 parts per million (ppm) for CO as a viable cutoff to determine abstinence; however, recent literature suggests this cutoff is likely too high and may overestimate the efficacy of treatment.

METHODS

This study examined the relationship between CO and cotinine in a sample of 662 individuals participating in a smoking cessation clinical trial. A receiver operating characteristics curve was calculated to determine the percentage of false positives and false negatives at given CO levels when using cotinine as confirmation of abstinence. Differences were also examined across race and gender.

RESULTS

A CO cutoff of 3 ppm (97.1% correct classification) most accurately distinguished smokers from nonsmokers. This same cutoff was accurate for both racial and gender groups. The standard cutoffs of 8 ppm (14.0% misclassification of smokers as abstainers) and 10 ppm (20.6% misclassification of smokers as abstainers) produced very high false-negative rates and inaccurately identified a large part of the sample as being abstinent when their cotinine test identified them as still smoking.

CONCLUSIONS

It is recommended that researchers and clinicians adopt a more stringent CO cutoff in the range of 3-4 ppm when complete abstinence from smoking is the goal.

Banning the hiring of tobacco users: where's the fire?

This commentary addresses the article in this issue by Huddle and colleagues concerning the implementation of policies by the University of Alabama at Birmingham (UAB) School of Medicine and other academic health centers to not hire users of tobacco products. Huddle and colleagues explore the basis for such policies and find that even though institutions may be within their rights to implement such policies, the policies are inconsistent with the societal role of an academic health center as a caregiving institution. They see a potential for discrimination, as contemporary users of tobacco are more likely to have less education and lower incomes than nonusers.The authors of this commentary review the arguments for and against such policies and explore the complexities of the implementation of such a policy by a state institution. They express concern that a state institution has chosen not to hire state residents who use tobacco products, which are legal. The authors also explore the potentially discriminatory aspects of such policies and possible implications of these policies in the context of rights and legal frameworks.The academic medicine community must learn from the experience that will follow from such policies as well as from other state and nonstate institutions that have implemented similar employment policies. Huddle and colleagues have provided a thoughtful contribution to a complex and inevitably continuing discussion.

Denial of Treatment to Obese Patients-the Wrong Policy on Personal Responsibility for Health

In many countries around the world, including Iran, obesity is reaching epidemic proportions. Doctors have recently taken, or expressed support for, an extreme 'personal responsibility for health' policy against obesity: refusing services to obese patients. This policy may initially seem to improve patients' incentives to fight obesity. But turning access to medical services into a benefit dependent on health improvement is bad policy. It conditions the very aid that patients need in order to become healthier on success in becoming healthier. Whatever else we may think of personal responsibility for health policies, this particular one is absurd. Unfortunately, quite a few personal responsibility for health policies use similar absurd conditioning. They mistakenly use as 'carrots' or 'sticks' for adherence the basic means to the same health outcomes that they seek to promote. This perspective proposes the following rule of thumb: any conditional incentive for healthy choice should be in a currency other than the basic means to that healthy choice.

Estimating the cost of a smoking employee

OBJECTIVE

We attempted to estimate the excess annual costs that a US private employer may attribute to employing an individual who smokes tobacco as compared to a non-smoking employee.

DESIGN

Reviewing and synthesising previous literature estimating certain discrete costs associated with smoking employees, we developed a cost estimation approach that approximates the total of such costs for U.S. employers. We examined absenteeism, presenteesim, smoking breaks, healthcare costs and pension benefits for smokers.

RESULTS

Our best estimate of the annual excess cost to employ a smoker is $5816. This estimate should be taken as a general indicator of the extent of excess costs, not as a predictive point value.

CONCLUSIONS

Employees who smoke impose significant excess costs on private employers. The results of this study may help inform employer decisions about tobacco-related policies.