1.What are employer' rights regarding employee lifestyle choices?

2.What are the employee' rights regarding lifestyle choices?

Based in this article

Finding employment is becoming increasingly dificult for smokers. Twenty-nine U.S. states have passed legislation prohibiting employers from refusing to hire job ause they smoke, but 21 states have no such restrictions. Many ealth 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 percent of Americans, according to a 2012 poll by Harris International. 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 bec effectively promote smoking cessation. One justification for not employing smokers, used primar- ly 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 organizations with similar policies have argued that their mployees must serve as role models for patients and that only care 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. Accord- ingly, 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 unpro- tected 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 degre of responsibility for their own ill health, they should not discriminate against qualified job candidates on the basis of health-related behavior. The broader claim that it is fair to exclude smokers because they are responsible for raising health care costs is too simplis- tic. It ignores the fact that smoking is addictive and therefore not completely voluntary. Among adult daily smokers, 88 per- cent began smoking by the time they were 18,1 before society would consider them fully responsible for their actions. Much of this early smoking is subtly and not so subtly encouraged by cigarette companies. As many as 69 percent of smokers want to quit, but the addictive properties of tobacco make that exceed- ingly difficult: only 3 to 5 percent of unaided cessation attempts succeed.3 It is therefore wrong to treat smoking as something fully under an individual's control

In addition, all other diseases-and many healthful behaviors-also result in additional health care costs. Peo- ple with cancer burden their fellow workers through higher health care costs and absenteeism. People who engage in risky sports may have accidents or experience trauma rou tinely and burden coworkers with additional costs. Having babies increases premiums for fellow employees who have Many of these costs result from seemingly innocent, everyday lifestyle choices; some choices, such as those regarding diet and exercise, may affect cancer incidence as well as rates of diabetes and heart disease We as a society have rejected the notion that individuals should be fully responsible for their own health care costs. In instituting health insurance, we acknowledge the fragility of health and the costliness of restoring it, and we minimize cata- strophic consequences. The United States has chosen to pool risk predominantly through employers rather than the govern ment. Consequently, U.S. law requires firms with more than 50 employees to provide risk-pooled insurance. Finally, although less than one fifth of Americans currently smoke, rates of tobacco use vary markedly among sociodemo- graphic groups, with higher rates in poorer and less-educated populations. Some 42 percent of American Indian or Alaska Native adults smoke, but only 8 percent of Asian women do. Among adults with less than a high school education, 32 per cent are smokers; among college graduates, smoking rates are just over 13 percent. More than 36 percent of Americans living low the federal poverty line are smokers, as compared with 22.5 percent of those with incomes above that level. Crucially, policies against hiring smokers result in a "double whammy" r many unemployed people, among whom smoking rates are nearly 45 percent (as compared with 28 percent among Ameri- cans with full-time employment).4 These policies therefore roportionately and unfairly affect groups that are already burdened by high unemployment rates, poor job prospects, and job insecurity what should employers do? We believe that offering sup- port for healthful behaviors is the best approach. Central in this regard is assisting employees by providing evidence-based smoking-cessation programs, removing cost barriers, facilitat- ing access, and providing necessary psychological counseling nd other support. For example, many employers, such as Wal- greens, provide free nicotine-replacement therapy and smoking sation counseling to employees

Recent research also indicates that financial incentives can effectively promote smoking cessation. For example, a ran- domized, controlled trial involving employees of General Elec- tric showed that a combination of incentives amounting to $750 led to cessation rates three times those achieved through information- only approaches (14.7% vs. 5.0 %)

But General Electric's experience also reflects the politi. cal challenges of instituting policies regarding smokers. When the company decided to provide the program to all employees. nonsmokers objected to losing out on what would effectively be lower insurance premiums for their smoker colleagues. In response, the company replaced the $750 reduction with a $62;5 surcharge for smokers. Just like policies of not hiring smokers, penalties imposed on smokers raise serious ethical and policy concerns. The Department of Labor is considering whether to permit employ- ers to penalize smokers with a surcharge of up to 50 percent of the cost of their health insurance coverage (typically than $2,000 per employee per year). Yet even rewards for quit- ting are hard to sell to nonsmokers, who might also object to free smoking-cessation programs they through their insurance premiums. Underlying such opposition a distorted notion of personal responsibility and deserved- ness, according to which refraining from smoking results from willpower and active choice alone. Although some employees may be nonsmokers through such efforts, most should have the to recognize that "there but for the grace of God go they

Given nonsmokers resistance, it would be helpful if employers providing smoking cessation support engaged in early out reach emphasizing that helping smokers to quit adheres to the principle of risk pooling underlying health insurance. Success- ful cessation programs could lead to higher productivity and lower insurance contributions for nonsmokers, thereby benefit- diven nonsmokers' resistance, it would be helpful if employ. ing all employees. The goal of reducing smoking rates is important. Although smoking rates among U.S. adults have decreased from 42 percent in 1965 to 19 percent today,5 more remains to be done, particu- larly for low-income and unemployed populations. Promoting public health is a shared responsibility, and employers have a social obligation to contribute to the public health mission out- lined by the Institute of Medicine: "fulfill ing] society's interest in assuring conditions in which people can be healthy. By cherry- picking "low-risk" employees and denying employment to smokers, employers neglect this obligation, risk hurting vulnerable groups, and behave unethically. The same goes for imposing high penalties on smokers under the guise of providing wellness incentives. We believe that employers should consider more construc- tive approaches than punishing smokers. In hiring decisions, they should focus on whether candidates meet the job require- ments; then they should provide genuine support to employ ees who wish to quit smoking. And health care organizations in particular should show compassion for their workers. This roach may even be a win-win economic solution, sinc employees who feel supported will probably be more produc ap tive than will those who live in fear of penalties.