Smokers now face another risk from their habit: It could cost them a shot at a job.

More hospitals and medical businesses in many states are adopting strict policies that make smoking a reason to turn away job applicants, saying they want to increase worker productivity, reduce health care costs and encourage healthier living.

The policies reflect a frustration that softer efforts — like banning smoking on company grounds, offering cessation programs and increasing health care premiums for smokers — have not been powerful-enough incentives to quit.

The new rules essentially treat cigarettes like an illegal narcotic. Applications now explicitly warn of “tobacco-free hiring,” job seekers must submit to urine tests for nicotine and new employees caught smoking face termination.

This shift — from smoke-free to smoker-free workplaces — has prompted sharp debate, even among anti-tobacco groups, over whether the policies establish a troubling precedent of employers intruding into private lives to ban a legal habit.

“If enough of these companies adopt theses policies and it really becomes difficult for smokers to find jobs, there are going to be consequences,” said Michael Siegel, a professor at the Boston University School of Public Health, who has written about the trend. “Unemployment is also bad for health.”

Smokers have been turned away for jobs in the past — prompting more than half the states to pass laws rejecting bans on smokers — but the recent growth in the number of companies adopting no-smoker rules has been driven by a surge of interest among health care providers, according to academics, human resources experts and anti-tobacco advocates.

There is no reliable data on how many businesses have adopted such policies. But people tracking the issue say there are enough examples to suggest the policies are becoming more mainstream.

For example, hospitals in Florida, Georgia, Massachusetts, Missouri, Ohio, Pennsylvania, Tennessee and Texas, among others, stopped hiring smokers in the past year and more are openly considering the option.

“We’ve had a number of inquiries over the last six to 12 months about how to do this,” said Paul Terpeluk, a director at Cleveland Clinic, which stopped hiring smokers in 2007 and has vigorously championed the policy. “The trend line is getting pretty steep, and I’d guess that in the next few years you’d see a lot of major hospitals go this way.”

A number of these organizations have justified the new policies as advancing their institutional missions of promoting personal well-being and finding ways to reduce the growth in health care costs.

About 1 in 5 Americans still smoke, which remains the leading cause of preventable deaths. And employees who smoke cost, on average, $3,391 more a year each in increased health care costs and lost productivity, according to federal estimates.

“We felt it was unfair for employees who maintained healthy lifestyles to have to subsidize those who do not,” Steven Bjelich, chief executive of St. Francis Medical Center in Cape Girardeau, Mo., which stopped hiring smokers last month. “Essentially that’s what happens.”

Two decades ago — after large companies like Alaska Airlines, Union Pacific and Turner Broadcasting adopted such policies — 29 states and the District of Columbia passed laws, with the strong backing of the tobacco lobby and the American Civil Liberties Union, that prohibit discrimination against smokers or those who use “lawful products.” Some of those states, like Missouri, make an exception for health care organizations. But in other states, courts have upheld the legality of refusing to employ smokers.

A spokesman for tobacco maker Philip Morris said the company was no longer actively working on the issue, although it remained strongly opposed to the policies.

Meghan Finegan, a spokeswoman for the Service Employees International Union, which represents 1.2 million health care workers, said the issue was “not on our radar yet.”

One concern voiced by groups like the National Workrights Institute is that such policies are a slippery slope — that if they prove successful in driving down health care costs, employers might be emboldened to crack down on other behavior by their workers, like drinking alcohol, eating fast food and participating in risky hobbies like motorcycle riding.  Indeed, the head of Cleveland Clinic was both praised and criticized when he mused in an interview two years ago that, were it not illegal, he would expand the hospital policy to refuse employment to obese people.

“There is nothing unique about smoking,” said Lewis Maltby, president of the Workrights Institute, who has lobbied vigorously against the practice. “The number of things that we all do privately that have negative impact on our health is endless. If it’s not smoking, it’s beer. If it’s not beer, it’s cheeseburgers. And what about your sex life?”

Many companies add their own wrinkle to the smoking ban. Some prohibit all tobacco use — not just cigarettes — including cigars, pipes, chewing tobacco and even nicotine patches. Some companies test urine for traces of nicotine, while others operate on the honor system.

While most of the companies applied their rules only to new employees, a few eventually mandated that existing employees must quit smoking or lose their jobs. There is also disagreement over whether to fire employees who are caught smoking after they are hired. The Truman Medical Centers in Kansas City, for example, will investigate accusations of tobacco use by employees. In one recent case a new employee returned from a lunch break smelling of smoke and, when confronted by his supervisor, admitted that he had been smoking, said Marcos DeLeon, head of human resources for the hospital. The employee was fired.

Even anti-smoking advocates have found the issue tricky to navigate. The American Lung Association, the American Cancer Society and the World Health Organization do not hire smokers, citing their own efforts to reduce smoking.

But the American Legacy Foundation, an anti-smoking nonprofit group, has warned that refusing to hire smokers who are otherwise qualified essentially punishes an addiction that is far more likely to afflict a janitor than a surgeon. (Indeed of the first 14 applicants rejected since the policy went into effect in October at the University Medical Center in El Paso, Texas, one was applying to be a nurse and the rest for support positions; none were doctors.)

“We want to be very supportive of smokers, and the best thing we can do is help them quit, not condition employment on whether they quit,” said Ellen Vargyas, chief counsel for the American Legacy Foundation. “Smokers are not the enemy.”

Taking a drag of her cigarette outside the University of Kansas School of Nursing, just beyond the sign warning that smoking is prohibited on campus, Mandy Carroll explained that she was well aware of the potential consequences of her pack-a-day habit: both her parents died of smoking-related illnesses.

But Carroll, a 26-year-old nursing student, said she strongly opposed any effort by hospitals to “discriminate” against her and other smokers.

“Obviously we know the effects of smoking; we see it every day in the hospital,” Carroll said. “It’s a stupid choice, but it’s a personal choice.”

Others do not mind the strict policy. John Stinson, 68, said he had been smoking for more than three decades when he decided to apply for a job at Cleveland Clinic, helping incoming patients, nearly three years ago.

It turned out to be the motivation he needed: He passed the urine test and has not had a cigarette since.

“It’s a good idea,” Stinson said.

© 2011 The New York Times Company