Demystifying Medicine One Month at a Time

Thank You for Not Smoking Redux

Your employer can tell you to smoke outside. Can they tell you not to smoke at all?

As a doctor, I’m pretty happy that many states and institutions have banned indoor smoking. With the patients I treat, there’s a drastic difference between smokers and non-smokers in terms of suffering and longevity. Smokers get lots more of the former, less of the latter.

They don't call 'em death sticks for nothing.

I wrote previously about e-cigarettes and their growing ubiquity in the para-smoking world. I also blogged from the Cleveland Clinic’s 2010 Patient Experience Summit, where I learned that Mike Roizen, the Clinic’s Chief Wellness Officer, had successfully banned all smoking in employees.

“Kind of par for the course for a hospital,” I remember thinking at first blush. Then he repeated his statement: he’d banned smoking entirely.

Translation: if you smoke, they don’t hire you. If you start smoking, they fire you (at the time I heard him the policy was three years old; two employees had been fired to that point under the policy).

“How can they know what you do on your own time?” you ask. Well, like life insurers, the Clinic tests prospective employees for nicotine metabolites in the urine. You can fib on the questionnaire, but if you’ve recently smoked tobacco, you can’t escape the test.

Now the NY Times is reporting that hospitals in eight states have adopted similar policies. Many have been consulting the Clinic for guidance, where the policy has been in place since 2007.

I’ve always been slightly amused when I walk by clusters of nurses, transporters, environmental service workers (janitors) or patients clustered near the exits of our medical center, getting their fix, usually in shirt sleeves, before heading back into the building. Sometimes I wish the designated smoking areas were a couple of miles away from the exits–then we’d be less likely to inhale a train of smoke as we walk the gauntlet. At least the employees should know better, I often think, stunned to see respiratory therapists in the mix. The same therapists whose job it is to suction pus from the lungs of asthmatics and emphysemics.

Though I find the article’s trend-spotting interesting and in line with my professional values, I think it goes a bit too far in the personal privacy realm. After all, cigarettes, though vilified, are still legal for adults. Will employers start the practice of not hiring other “health-risky” employees (e.g. obese, hypertensive, or diabetic patients)?

What do you think about this?

Clever incentive to make workers at health care institutions walk the walk, or trampling of a civil liberty? Let me have your comments.



  1. Ann Sullivan-Larson

    This would be a trampling of civil rights if the criterion for hiring or firing were something over which the employee does not have any options to change, like race or sexual orientation or a physical disability like paraplegia. The difference is that smoking, while addictive as hell, is still voluntary. A hospital’s got a right to hire people qualified to fill its positions, and if one of the qualifications is something that’s achievable, with however much diffculty, then that’s something an employee is going to have to achieve to be employed. Seems to me a hospital should have standards that high.

    Also, whenever we go to the U of I for Mary’s follow-ups, even though the whole campus is supposed to be smoke-free, even in your car, the parking lot doorways are totally littered with butts, and people stand right next to the signs that say “smoke-free campus” all lit up. This flagrant ignoring of policy affects me, too, having to pass through that gauntlet with my child, and it irks me enormously. Without a tough policy, people will ignore it.

  2. Carolyn Thomas

    This reminds me of the kerfuffle in August 2009 when Dr. Delos Cosgrove, the CEO of Cleveland Clinic, first told the New York Times that if it were up to him, he would not only stop hiring smokers – he would also stop hiring obese people.

    Dr. Cosgrove, a cardiac surgeon, maintains that health professionals should be as proactive in addressing people’s weight issues as they are in pushing them to quit smoking. At the time, he was quoted in the Times:

    “Our anti-obesity efforts have none of the urgency of our anti-smoking efforts. We should declare obesity a disease, and say we’re going to help you get over it.”

    He also acknowledged that any effort to attack obesity would inevitably involve making value judgments and even limiting people’s choices – just as Western society has already done to smokers.

    While so far, Cleveland Clinic has not acted on Cosgrove’s bold hiring preferences for the non-obese, their administration certainly walks the talk for the 40,000+ people already on the payroll, including subsidized bariatric surgery, elimination of fried foods, soda and candy from their food service and vending machines, and subsidized Weight Watchers and fitness programs for its employees. More at: “Cardiologist’s Plan: “Fat People Need Not Apply For Jobs At Cleveland Clinic” –

  3. Jonathan Wishnick

    Hmm…So, I once smoked cigarettes. I am overweight, and somewhat unrepentant. Oh, and I may have done some drugs as a misguided youth…and I am repentant about this. Sometimes I love to drive too fast. I have a reasonably strong drink about 3 or 4 nights a week. I am married and do not cheat, but I could envision a different set of life choices that would have included lots of promiscuous sex. This isn’t China, but we have two children. I am not Christian, nor would I join a company prayer group.

    While I totally sympathize with not wanting to hire certain potential workers, where can we draw a line? Why should it be that people who are acting within the laws of our state and country can be discriminated against? Start with my having once smoked 2 packs a day of Camels from age 15 to age 30. Although I quit almost half a life ago, can that be held against me? It shouldn’t.

    If I were the CEO of the Cleveland Clinic (or any other organization) how much would you want me deciding about how you live your life? Hint: You may not agree with my decisions.

  4. dollarsdownthedrain

    So, our country’s president would not be where he is if this rule were enacted . He would have certainly failed the “nicotine” test.

    • pathdoc


  5. Siv

    “Third-hand” smoke is a real concern. Can hospitals argue that smokers are harming patients if they care for them after smoking?

  6. emmy

    I don’t smoke. I can grow rather large cancer tumors without that fertilization, thank you. I don’t even have a particular lot of patience with people who do smoke. But I do have an issue with your employer directing your life when you are not on the clock. The cardiologist who runs Cleveland Clinic should realize that weight is second only to height in heritability. You can choose your food, but not your genes. And that as it stands, long term weight loss has an abysmal record. There is simply not enough known about obesity to come up with a reasonable, workable solution. Hypertension and Diabetes also have a genetic link and unless you want to open up the can of the genetically superior race to begin hiring people, you’d better rethink your stance.

  7. pathdoc

    Each company should decide for itself. What’s good for the CC may not be good for all the others. I hate micromanagement.

  8. hgstern

    Grand Rounds is up, and your post is in it:

    Please let your readers know.


    Hank Stern

  9. Amanda

    Well I agree about not smoking near a hospital entrance…BUT, today my boss literally made me feel like he was going to fire me if I continued to smoke, ON MY OWN TIME. He talked down to me like I was a loser basically. I am a very hard worker, I dont drink, do drugs, etc. I have an addiction to smoking, and when I decide Im ready to quit, I will. I dont need some controlling man of a boss telling me what I can and cant do in my personal life. I pretty much told him that to. I started to get very upset, and cry. I was in a controlling relationship for 7 years and recently got out of it. He told me what to do, when to do it, etc. I feel like he has no right to tell me I cant smoke. He said he has a very sensitive nose and can smell it on me. Funny, cuz another lady at work said she wouldnt ever be able to tell if I as a smoker because I dont smell at all like it. I am a very clean person, I am a professional. I choose to smoke. SUE ME! What can I do?? He can fire me, and Ill sue him for violation of civil rights? Doubt that will work out for me since Maine is a hire at will, fire at will state. UGG!

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