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Lancaster General Health (LG Health) is the largest employer in Lancaster County, currently responsible for more than 7,000 employees. In January 2013, we took the bold step of implementing a new human resource policy, hiring only those applicants who test negative for tobacco use. Here is the story behind this controversial decision.

Targeting Tobacco

Our mission at LG Health is to improve the health and well-being of the communities we serve, and one of the ways we do this is by identifying and addressing community health priorities. Together with other members of the Lancaster Health Improvement Partnership (LHIP), the Mission and Community Benefit Committee of the LG Health Board of Trustees regularly analyzes federal, state, and local data to identify our community’s most pressing health concerns.

As a result of its carcinogenic and other deleterious systemic effects, cigarette smoking is the leading cause of preventable death and is linked to one of every five deaths in the United States. Cigarette smoking is costly as well. The CDC reports that in the years 2000–2004, smoking cost more than $193 billion—$97 billion of which was attributed to lost productivity, and $96 billion to healthcare expenditures.

As a healthcare organization, reducing the number of youth and adult smokers in Lancaster County must remain one of our priorities.

Putting our Money Where Our Mission Is

Over the years, LG Health has established policies and implemented programs to educate the community about the risks inherent in tobacco use and to support smoking cessation.
a) Through our Wellness Center, LG Health offers individual and group programs to help people quit smoking. We also offer counseling, education, and follow-up support to inpatients who are interested in quitting smoking.
b) LG Health co-founded, and currently serves as chair of, the Tobacco-Free Coalition of Lancaster County, a partnership of local health professionals and community leaders whose mission is to prevent young people from using tobacco; to provide resources for people to quit their use of tobacco; to eliminate tobacco-smoke pollution; and to advocate to protect and expand funding for tobacco cessation and prevention services.
c) In January 2008, LG Health unveiled BreatheWell, a comprehensive tobacco-free initiative designed to improve the health of our 7,000+ employees, as well as visitors to LG Health facilities. BreatheWell encompasses a variety of smoking cessation programs to help employees and their spouses quit smoking. Helping our employees obtain and maintain a tobacco-free life is important to the health of our organization and our community. The BreatheWell program included a dedicated counselor for tobacco dependence treatment for employees, and coverage for cessation medications. It also launched a system-wide transition to smoke-free campuses. As of 2008, the use of tobacco is no longer permitted at any of LG Health’s worksites.

Taking the Next Step

About 18 months ago, with support from the Mission and Community Benefit Committee, LG Health’s Human Resources Department began exploring a bold new initiative: changing our employment policy to ban the hiring of tobacco users. The new policy would not apply to current employees, who would be encouraged to take advantage of LG Health’s smoking cessation programs.

A task force was assembled to look at the tobacco use statistics, historical data, legal considerations, and potential employee concerns.

According to a recent survey by the PA Department of Health, approximately 13 percent of adults in Lancaster County smoke—a notable reduction from the 23 percent who reported themselves as smokers in 2002, but still a significant population. A Health Risk Assessment (HRA) completed by LG Health employees revealed 11 percent as tobacco users. While implementing smoke-free campuses was a critical step toward discouraging tobacco use, the leadership team at LG Health agreed that it was not enough.

To truly set an example for making smarter lifestyle choices about wellness, model healthy behavior, and create a safer environment for our employees, patients and visitors, it became clear that the right thing to do was to take this next step and allow only non-smokers to join our workforce in the future.

The Controversy

The issue has become a magnet for opposing viewpoints, with both sides presenting arguments in print media and online. There have also been legislative implications as 30 states currently have smoker-protection laws that prevent employers from discriminating against employees or job applicants because they smoke. However, Pennsylvania is not one of these states. In fact, four other health systems in our region implemented non-hiring policies for smokers prior to LG Health doing so. St. Luke’s Hospital, Geisinger Health System, Susquehanna Health System, and Ephrata Community Hospital have all banned smokers from being considered for new employment.

The New England Journal of Medicine recently ran dueling commentaries by two groups of ethicists and behavioral economists.^1,2

One set of authors spoke out in favor of non-hiring policies, stating that taking a strong interventional stance against tobacco use was a necessary step to change societal norms.¹ Regulations that ban smoking in the workplace or in many bars and restaurants were once viewed as controversial and even unconstitutional, but are now accepted as normal by most Americans. The authors recalled that smoking used to be permitted on airplanes—a reminder of how far our society has come in reducing its tolerance for public smoking.

The authors who spoke out against non-hiring policies pointed out that tobacco use is higher in poorer and less educated populations, so such policies place a disproportionate burden on groups that are already strained by high unemployment rates, poor job prospects, and job insecurity. Citing a 2012 poll by Harris International that found 65% of Americans opposed to policies of not hiring smokers, they concluded 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.²

Other opponents of such policies worry that initiatives like these intrude on the privacy of employees and create a slippery slope that could lead to discrimination based on obesity, alcohol use, or other health or behavioral issues. Another concern is that the policy could shrink the pool of available labor to fill critical positions.

Despite these concerns, more than 6,000 companies across the U.S. have adopted non-hiring policies for tobacco users, including the Cleveland Clinic, which was one of the first and largest medical centers to implement a no-smokers rule in 2007. Since that policy change, the Cleveland Clinic, with 42,000 employees, has reported that fears of a reduced labor pool were unfounded. Dr. Paul Terpeluk, medical director of Employee Health Services at Cleveland Clinic, in a recent opinion piece,³ stated that since the policy was instituted, “less than 2% of job offers—about 300 out of 20,000—have been rescinded due to positive nicotine tests.” Even more encouraging, smoking rates reportedly decreased from 28% to 18% in the immediate Ohio area after this policy change.

While these hiring practices remain controversial and draw a mix of perspectives, reactions, and outcomes, ultimately LG Health’s leaders believe that the potential benefits—to employees, patients, and the community—outweigh any other consequences.

LG Health’s New Policy

Effective January 1, 2013, Lancaster General Health adopted a policy that bans the hiring of tobacco users by all of its entities. All applicants are informed of this policy when applying for a job and must agree to comply with pre-employment screening for the presence of tobacco products. After receiving an offer of employment, all new hires must undergo a nicotine test, which is part of the urine drug screening process. The test detects all forms of tobacco or nicotine, which remains in the body for up to 30 days after use. Applicants who test positive for nicotine have their offer of employment rescinded. Those applicants will be offered tobacco cessation services and may re-apply for a position after a six-month waiting period. At that time, if an applicant is offered another position and again tests positive for nicotine, that individual will be considered ineligible for future employment at LG Health for a period of one year following the last positive test.

Leaders at LG Health stand by this new policy, stating that it is the right thing to do and aligns with our mission to improve the health and well-being of the communities we serve. They are hopeful that by hiring only non-tobacco users, it will create a culture of wellness and motivate incumbent employees who use tobacco to stop.

A Growing Trend

Banning the hiring of tobacco users is a trend that is becoming more mainstream in states where smokers’ rights are not protected by law. As of July 1, 2013, two of the largest and most influential healthcare organizations in Philadelphia adopted non-hiring policies; the University of Pennsylvania Health System and the Children’s Hospital of Philadelphia.

With the changes brought about by healthcare reform, organizations like LG Health have a responsibility to look at ways to improve health in our community, and to reduce the cost of healthcare. As long as smoking remains one of the leading causes of preventable illness and death, smoking cessation will remain a key priority for us.

Recently, our Community Health Needs Assessment Task Force conducted an updated analysis of health statistics in Lancaster County. While more than 45,000 adults reported being daily smokers, the report included some positive news. Significantly fewer Lancaster County adults were smoking in 2010 than 2001, and the decline in adult smoking has been faster for the county than the state.

Progress is being made. As Lancaster County’s leading employer and largest healthcare system, it is our duty to continuously set higher standards and stay the course.

Resources

1. Asch, D., Muller, R., and Volpp, K. Conflicts and Compromises in Not Hiring Smokers. N Engl J Med. 2013; 368: 1371-1373.

2. Schmidt, H., Voigt, K., and Emanuel, E. The Ethics of Not Hiring Smokers. N Engl J Med. 2013; 368:1369-1371.

3. Terpeluk, P. Opposing view: why we won’t hire smokers. USA Today. January 29, 2012