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This week, Friday Feedback takes a look at a .

In communities across the country, officials have banned smoking in public places ranging from restaurants to stadiums. Some could argue that we've gotten as far as we can expect with bans toward a tobacco-free nation. Even now, there are hospital systems that no longer hire healthcare providers who smoke.

We reached out to a diverse group of healthcare professionals and experts via email with this question:

What are your thoughts about the efficacy of a tobacco-free campaign that ties smoking to employment opportunities whether it be healthcare professionals, teachers, or even soldiers?

The participants this week:

Mohini Banerjee, a research assistant at the Hastings Center in Garrison, N.Y., who has written for 麻豆传媒 about the ethics of post-experiment consent.

Ronald Bayer, PhD, professor and co-chair, Center for the History and Ethics of Public Health, Columbia University's Mailman School of Public Health

Neil Brooks, MD, a family physician in Vernon, Conn., and former president of the .

Harold Farber, MD, pediatric pulmonologist, Texas Children's Hospital and member, steering committee of the (provisional) section on tobacco control, American Academy of Pediatrics

Jason M. Hockenberry, PhD, military veteran and assistant professor of Health Policy and Management, Rollins School of Public Health at Emory University

David L. Katz, MD, MPH, director, Yale University Prevention Research Center

Jennifer McClure, PhD, director of research, faculty, and development, and senior investigator, Group Health Research Institute in Seattle.

Lance K. Stell, PhD, director, Medical Humanities Program, and professor of clinical ethics at Davidson College in Davidson, N.C., and clinical professor of internal medicine at Carolinas Medical Center

New Normal

: "Change is always difficult, because however little sense it truly makes, the status quo benefits from our familiarity with it. While it may seem radical to move our culture toward the total banishment of tobacco, let's imagine if the situation were the converse. Imagine we had no tobacco products, and were now considering introducing them for the first time -- but in full knowledge of their harms. Would we sanction the production, selling, and marketing of a product known to be addictive, carcinogenic, toxic to the lungs, and even harmful to innocent bystanders? I rather doubt it. In fact, far lesser toxins routinely inspire protests and petitions."

: "Policies enacted to prohibit smoking in open-air public settings, while often justified in terms of protecting nonsmokers from side stream smoke, in fact, have little to do with such protections. Rather they are part of a campaign to de-normalize smoking."

: "I believe the crux of this question is whether this will help promote nonsmoking. Based on our experience with public smoking bans, I expect the answer is Yes. For many, this will provide the incentive they need to finally stop smoking -- something that 70% of smokers say they want to do."

Professional Bans

Bayer: "Policies that ban smokers from certain jobs even when they do not smoke in the presence of their co-workers, while often justified in terms of healthcare costs, are also one more sign of the effort to push smokers to the margins of society."

: "For healthcare fields, there is an immediate connection between a staff dedicated to health and a smoke-free environment. For teachers, they may be seen as role models for young students, and the military may decide that smoking is not within the limits a life in the service requires. Altogether, employment-based initiatives allow organizations and governments to overcome one tradition of manipulating people's preferences for profit in favor of an alternative that is in the interests of health and well-being."

: "Prohibitions of smoking in public places and workplaces have shown great health benefits for both children and adults -- for smokers and for nonsmokers.

"Economic productivity is lower on average, and healthcare costs are greater for smokers. Tobacco smoke exposure is exceedingly well documented to be harmful to nonsmokers. As children have less choice about who they spend time with, the proportion of nonsmoking children with tobacco smoke exposure is much greater than that of nonsmoking adults. As children learn what they see, adult modeling of tobacco use influences our children."

McClure: "But smoking bans and smoking status-contingent employment policies alone won't help everyone stop smoking. Hopefully, in the case of employers, adequate assistance will be offered to existing employees to help them stop smoking or using other forms of tobacco or nicotine."

Farber: "The evidence of harm of tobacco smoke for the nonsmoker is so extensive that a recent U.S. Surgeon General's report concluded that there is NO safe level of tobacco smoke exposures. It does not seem reasonable that nonsmokers should be made to bear the increased economic and health costs of smokers."

Enforcement Issue

: "Controlling whether soldiers smoke on leave may prove difficult."

: "From an efficacy standpoint, it is not clear that such a policy is strictly enforceable. Even though it's legal to set a tobacco use restriction on employment, it would be quite costly to do so. Ensuring compliance when outside the workplace requires workers, potential or existing, to respond honestly about their tobacco use. While some will respond honestly, there is recent evidence that they might not.

"Alex Liber, a former Emory student, and multiple faculty recently co-authored a study in nicotine and tobacco research that suggests even making smokers pay higher health insurance premiums induces employees to falsify their own, or their family members', tobacco-free status. So, if it were a matter of even being able to obtain or retain a job, I would expect even more falsification of tobacco use status, as employees would have little to lose by lying if they could not keep or get the job as a tobacco user anyway."

Stell: "Urine tests can pick up tobacco use for as long 30 to 45 days."

Hockenberry: "The main low-cost test for tobacco use is a test for cotinine, the metabolite of nicotine. However, nicotine use is not equivalent to tobacco use, so this is problematic. Furthermore, the current research indicates that nicotine consumption is not itself a risk factor for disease. Other strategies are more expensive, and may run into other legal and ethical issues."

Over-Stepping Boundaries

Bayer: "While professional bans might well work to reduce smoking, an obvious threat to individual and public health, they raise important questions about how harsh we should go in pursuing the goal of reducing the prevalence of smoking. If denying people the right to smoke out of doors and the right to gainful employment does not cross the line, what would?"

Stell: "Continual surveillance communicates distrust and disrespect. Soldiers feel that they have a right to smoke. They will be resentful if smoking is restricted/banned."

Banerjee: "When anti-tobacco movements target workplaces it creates an apparent tension between individual freedom and making a living. Creating employment-based, tobacco-free policies will limit smoking and tobacco use, but the notion that freedom is being limited is overblown. Even cultural choices to smoke have been shaped from years of powerful lobbying and advertising of an addictive substance. New cultural values that resist tobacco use can be enacted through places of work as loci of change."

Stell: "Tobacco using soldiers are a minority in society and in the armed forces. Any minority is vulnerable to stigmatization and discrimination when society turns against them and their habits in pleasure-seeking."

Neil Brooks, MD: "I have always been a strong advocate of eliminating the use of all tobacco products, but this may be an exception to the rule. Imagine walking up to a scared soldier in Afghanistan who has just been in a fire fight and telling him to put out his cigarette because it's bad for his health. Afghanistan is really bad for his health, let him have the damn cigarette."

Smokeless Soldiers

Hockenberry: "Tobacco use has been banned for soldiers in basic training for some time, and even after their initial training, soldiers often occupy government owned housing and are in situations where monitoring tobacco consumption is easier than in the civilian workforce. Of course, there are still some, including members of Congress, opposed to such a measure."

Farber: "The New England Journal article is correct. Tobacco use has been well documented to increase costs of training and to decrease troop readiness. Reducing or eliminating tobacco in the military makes great sense from both an economic and a troop readiness perspective. The tobacco industry has a long history of promoting their highly addictive product through the military. The "free" cigarettes distributed as part of rations in World War I were an important part of what addicted a generation to tobacco. Deeply discounted tobacco helps to promote and to maintain the addiction."

Brooks: "Some of the statistics quoted are out of context. Think of officers as executives and the rate of smoking is likely no different then the civilian population. The regular soldiers most likely smoke at the same rate as their civilian counterparts when all issues of background and economics are taken into account."

Stell: "The military has an interest in avoiding the incremental health costs associated with tobacco smoking soldiers, not only during their stint of active duty but also long term for the VA. The military also has an interest in protecting the airway health of its nonsmokers.

The goal of a nonsmoking military could be non-coercively pursued by raising the educational level required of recruits and re-enlistees. Has the benefit of lower-monitoring costs and reduced need for disciplinary measures. Would probably increase costs of attracting enlistees from the ranks of the more highly educated."

Brooks: "Given what the military has to do and the risks they take I find it very difficult to say that they should have to give up smoking. Frankly, this is a decision which should be made by the military without civilian interference. If the generals think it is the right thing to do, so be it. They are aware of their mission and responsibilities."

Compassionate Care

Katz: "In the fullness of time and understanding, tobacco proves to be an appalling boondoggle and a public health calamity. It needs to be consigned to the dust bin of truly horrible ideas, and all societal actions that help sweep it there are reasonable in my view. The one proviso is that while working to ensure no one is ever again addicted to these products, we must render constructive and compassionate care to those who already are."

McClure: "Most smokers still require appropriate comprehensive treatment to help them break their nicotine addiction."

Stell: "Nonsmokers have little sympathy for smokers' distress resulting from mandatory smoking cessation. Nonsmokers commonly regard smokers' habits as disgusting, unpleasant, self-harmful, and socially costly. Courts reflect social attitudes. They are unlikely to protect as rights soldiers' unpopular liberties, especially when associated with social costs."

Farber: "Tobacco dependence, however, is a severe chronic illness. Effective treatments are available. Free help is available from the National Smoker's Helpline (through the National Cancer Institute) at 1-800-QUIT NOW."

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Friday Feedback is a feature that presents a sampling of opinions solicited by 麻豆传媒 in response to a healthcare issue, clinical controversy, or new finding reported that week. We always welcome new, thoughtful voices. If you'd like to participate in a Friday Feedback issue, reach out to e.chu@medpagetoday.com or .

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