Epidemiological studies have identified links between smoking and a wide range of medical conditions, from heart disease to male impotence. There is a vast array of information available on the harm that smoking causes and it is easily available. Indeed, in many countries, health warnings are printed on all tobacco products. High profile and costly court settlements from tobacco companies -- in the US particularly -- have highlighted the (almost) universal acceptance that smoking causes many grave and fatal medical conditions It is therefore reasonable to assume that smokers are aware of the effects that smoking has on their health.
There is a debate about whether smokers should be entitled to the same level of access to public healthcare as non-smokers, given that they are knowingly harming themselves. This debate is one that has taken place in Parliaments and Universities, as well as cafes and living rooms. For example, in 2006, a UK primary care trust announced that it would remove smokers from its surgery waiting lists to cut costs1, provoking controversy and bipartisanship throughout the country.
Advocates for limiting healthcare access for smokers argue that surgery is less likely to help smokers and that they are unfairly clogging up hospitals by inflicting diseases upon themselves. Many defend smokers however. They argue that healthcare is a fundamental human right and smokers cannot be victimized for doing something perfectly legal. Moreover, they question who would be defined as a "smoker" and how anyone could prove that somebody fitted such a definition.
1 Daily Mail, Give up or we won't operate, smokers told.
There are realistic ways a policy of denying healthcare access to smokers could be carried out. Insurance companies already ask lots of health-related questions, often including whether their client is a smoker, when assessing life insurance premiums. In these cases, you are required to give details of your lifestyle by law. Of course, some people do not, however this is to be expected since no law is one hundred per cent effective. Sanctions exist to discourage dishonest behaviour. A similar model could be put in place requiring a declaration of smoker status to the health authority. Indeed, many doctors already enquire about their patients' smoking statuses on an informal basis.
It is also particularly hard to lie about being a smoker for two reasons. First, other people inevitably see you smoking. This means an abundance of witnesses in the case of a dispute, and thus a disincentive to lie. Second, people require doctors to undertake detailed examinations for treatment purposes, thereby allowing them to see obvious outward signs of smoking: tar deposits, tar in cough, yellowed fingernails, etc.
Denying, or even reducing, access to healthcare for smokers is impractical, and therefore an unrealistic policy goal. First, the extent to which care is denied is questionable. Does the proposition model include denying palliative care? If it does, this literally means leaving people to suffer agonising pain in emergencies while they try to locate private prescription painkillers, if they can afford them. Further, does it include denying emergency procedures such as resuscitation in the case of a heart attack? If it does, where are patients supposed to go? Private emergency rooms are few and far between, or non-existent, in many countries – never mind private ambulances. Second, in order to encourage smokers to stop smoking, the process needs to involve reactivating access to healthcare if smokers quit. But any cut-off point at which the right is re-activated will necessarily be arbitrary. Some studies have suggested that, for instance, teenagers do irreparable damage to their respiratory systems even if they stop smoking young. If all citizens make an informed decision to smoke, as the proposition argues, isn’t it the case that teenagers make an informed decision to do inordinate damage to their bodies? If it is, then why should there be an absolute cut-off point at which one reassumes healthcare rights? Should there be a relative scale? Wouldn’t this be impossible to construct on a scientific basis?
Smokers contribute a disproportionately large amount to the cost of healthcare. They are a drain on resources. In the UK it is estimated that up to 9,500 beds are blocked daily by smokers, and that up to eight million doctor consultations are required on their behalf each year. A well-informed smoker, unable or unwilling to quit, might assume an increased risk for himself but he would also be indirectly increasing the likelihood of others being unable to access necessary healthcare and this is not fair. Allowing smokers to take scarce beds or organs needed for transplants - that could otherwise go to those suffering from genuine misfortunes - is an unjust allocation of resources.
The added cost to public healthcare that comes as a result of diseases brought upon by smoking is vastly outweighed by the amount of money governments around the world receive in taxes on tobacco. The UK currently takes around 60% of the cost of a pack of cigarettes in tax duty. In 2008, the US took over $16 billion in tobacco tax revenue1. Such high tax duties and revenues can hardly be justified if smokers are not even to get healthcare for their money. And without the taxes, cigarettes would be much cheaper, encouraging more people to smoke. Moreover, because smokers tend to die earlier than non-smokers, per head the average health care costs are lower than those of non-smokers2.
1 Tax Policy Centre, US Tobacco Revenue Statistics,
2 USA Today, 15 Jul 11, Do smokers cost society money.. Accessed 15 Jul 11.
Many people have to wait for surgery when they have fallen ill or gotten injured through no fault of their own. Many of the people they are waiting behind have fallen ill out of choice. This includes smokers who have contracted diseases as a result of their habit. There is a vast array of information, easily available to smokers, on the dangers of cigarettes. If despite this, a person chooses to smoke anyway then it is unfair that others who have fallen ill out of genuine misfortune should have to wait in line behind them for healthcare. This problem is particularly in acute in states that have universal healthcare, where non-smokers are forced to wait in a queue for treatment behind those who have negligently made themselves ill smoking. In Britain for example, they have attempted to avoid this by establishing standards under which surgery is denied to obese patients1. Thomas Condliff, the patient, was denied gastric band surgery due to having a body mass index lower than the threshold under which they believed the surgery would be effective2. The priority in such cases is and should be with those who have made a conscious decision to develop an unhealthy habit.
1 BBC News, 11 Jul 11, Man appeals for NHS gastric bypass surgery. Accessed 14 Jul 11.
Many smokers do not choose to harm themselves, they simply can't help it. The 1988 US Surgeon General's report on the addictive nature of cigarette smoking provides proof of what is now widely accepted – smoking cigarettes is highly addictive. Moreover, there are high correlations between people smoking and being under stress or having parents that smoke. All of this suggests that people do not necessarily choose to smoke and may not be able to choose to give up. Given that smokers can therefore be portrayed as suffering from involuntary addiction, it would seem sensible to tackle this addiction alongside physical health issues, as oppose to dismissing smokers altogether.
Governments should do everything they can to discourage smoking. They already attempt to do so in a number of ways, such as through ensuring graphic health warnings are present on all tobacco packaging. Many states have also introduced legislation banning smoking indoors in an attempt to discourage the habit. However, smoking is still a massive problem - millions of people still do it. The refusal of medical treatment to smokers would surely be a massive deterrent to current/potential smokers from continuing/starting the habit. The safety net of modern healthcare being pulled from underneath them would be a powerful incentive to give up the habit, and reduce the estimated $100 billion that the White House believes smokers cost the economy annually through loss of productivity1.
1 USA Today, 15 Jul 11, Do smokers cost society money.. Accessed 15 Jul 11.
There is no evidence that limiting access to healthcare would act as a deterrent. In fact, in the developing world, where a smoker would on average have worse access to healthcare, tobacco consumption has increased significantly over the last decade.1
Furthermore, governments have indeed acted to discourage smoking through a variety of methods. These have included advertising campaigns and banning smoking in public places and they seem to have worked. Cigarette use in the developed world has declined over the last 50 years. In the UK, smoking rates have dropped by half between 1974 and 2009, from 45% down to 21%2. A majority 59% have never taken up the habit3.
1 World Health Organization, The Tobacco Atlas,
2 Daily Telegraph, 22 Jan 09, Lowest ever number of smokers after public ban and health campaigns.Accessed 14 Jul 2011.
3 Daily Telegraph, 22 Jan 09, Lowest ever number of smokers after public ban and health campaigns.Accessed 14 Jul 2011.
Failure to quit smoking before surgical procedures increases cardiac and pulmonary complications, impairs tissue healing, and is associated with more infections and other complications at the surgical site. For example, in a study of wound and other complications after hip or knee surgery, no smoker who quit beforehand developed a wound infection compared with 26% of ongoing smokers and 27% of those who only reduced tobacco use. Overall complications were reduced to 10% in those who quit smoking compared with 44% in those who continued1. This means that surgery costs more on average for smokers and is also less likely to be effective. Treating more smokers means devoting more resources for lower results. Therefore, prioritizing non-smokers, at least in certain areas of healthcare, would be beneficial to society as a whole.
1http Peters, M.J. (2007) Should smokers be refused surgery? British Medical Journal,
Smokers may have a higher chance of harm from surgery due to complications arising from their habit, but this is not a phenomenon specific to them. Cardiovascular disease, or heart disease to most people, is the number one killer of men and women in the United States1. It is caused by the build-up of fatty deposits that clog the vessels - those at risk are often smokers, but can just as often be those who are overweight, have diabetes or simply high blood pressure. As such, it is not justified to single out smokers when those with unhealthy diets can just as easily cause complications in their surgeries.
There are several reasons why limiting access to healthcare for smokers could prove impractical. Ultimately they surround the issue of how you define who is a smoker. One man might have chain smoked for 20 years but given up for a year, since a bill limiting access to healthcare for smokers was passed. Meanwhile, another might have been smoking cigarettes now and again just for the past year. Who would be prioritized if the two were on a waiting list for the same operation? If the law penalizes anyone who has ever smoked then it would not provide nearly as strong an incentive to stop smoking. But, if the law does not penalize anyone who has smoked, then choosing whom to punish would seem quite arbitrary.
Furthermore, what is stopping people from simply lying about how much/whether they smoke? They might not show any obvious signs of being a smoker. Even if they do, they could claim to have given up, work around fumes or be a victim of passive smoking.
There are realistic and practical ways in which the policy of denying healthcare to smokers could be carried out. Smoking is a habit that has clear and demonstrable physical effects, which often correlate with the regularity and longevity of the habit; doctors are trained to recognize such symptoms and do not need patient confirmation. Furthermore, if the bill made it quite clear that healthcare was to be denied to present smokers, the hypothetical presented by the opposition is easily negated. The goal of such a bill would to be to ensure that both smokers gave up the habit and non-smokers did not take up the habit. In this case, the man taking up smoking is in the wrong and is acting contrary to the law. He would have little room for complaint.
The denial of access to healthcare for smokers is a policy that will directly lead to the turning away of millions of people, merely for making one perfectly legal, if ill-advised lifestyle choice. In a state like France, where 20 per cent of the population, 12 million people, are smokers, such a policy would leave a large minority unable to access basic healthcare for issues that may be unrelated to their smoking habit . Furthermore, it may lead to the ridiculous situation whereby smokers are dying from preventable diseases despite hospitals being under-utilized, as a fifth of the population is no longer allowed in.
The opposition fails to recognize the impact that such a policy will have on smokers. Access will only be denied to smokers who continue to smoke once the bill is in place, if it is proven that they have given up, they will be free to access healthcare. Therefore, the only smokers who will be turned away, and who will potentially die from preventable illnesses are those who place their habit above that of their life.
Economically, the healthcare of the nation is important for maintaining a productive workforce. Do we really want to lose otherwise functional members of the workforce the first time they contract an aggravated throat infection and cannot afford, or delay for financial reasons, a simple course of antibiotics? Quite apart from productivity, as The Guardian notes, smokers in the United Kingdom also contribute over £10 billion to government coffers through the tobacco tax 1. To lose this source of revenue will do more to hurt national health services than the occasional complication in surgery granted to a smoker. Lastly, because smokers die younger than non-smokers, though they cost more per year, over their lifetime their average health costs are lower than those of longer-living, non-smokers.
Denying access to healthcare for smokers will not hurt the economy, for the health care costs of smokers are substantially larger than those of non-smokers. In fact, 'health care costs for smokers at a given age are as much as 40 percent higher than those for non-smokers' . Furthermore, though the opposition points out that because smokers die younger, average health costs are in fact lower than non-smokers, denying access to healthcare will have two effects which will cancel each other out: more people will give up smoking, increasing gross medical costs for the state, but those who don't will die younger for they won't get treatment, which will offset the previous rise.
The denial of healthcare, an established right, without the citizen doing anything either immoral or wrong is pure and simple victimization. Suppose you are a doctor and you have two patients waiting for a heart transplant. Patient A is 65. He does not exercise, has never had a job and has committed a series of crimes throughout his life. Patient B is in his 20s, with a first class degree from a good university. He is a trained doctor himself and wants to go and work in the developing world, to help people suffering from leprosy. But Patient B is a heavy smoker. Should you therefore prioritize patient A? It seems problematic to victimize smokers, particularly considering smoking is legal. If you are going to discriminate against smokers then surely you should discriminate against alcohol drinkers and people who do extreme sports as they are also knowingly endangering themselves. Smoking reduces life expectancy by 2.5 years for men, but obesity reduces life expectancy by 1.3 years and if high blood pressure is added to that by a total of 2.8 years all are preventable so why should only smoking be discriminated against?1 Maybe you should discriminate against people who choose to live in polluted cities. And then there are drug users. What about people who could afford private health care? Should age, occupation and past convictions be taken into account?
It seems arbitrary and unfair to single out smokers. Yet, if we start to take into account all the factors that determine who "deserves" to be prioritized for healthcare, then we are left with the unsavory, illiberal practice of Social Darwinism.
1 Harvard School of Public Health, "Four Preventable Risk Factors Reduce Life Expectancy in U.S. and Lead to Health Disparities", 22 March 2010, accessed 24 August 2010.
In practice, it is both viable and beneficial, in certain cases, to prioritize non-smokers for healthcare. Where there is more chance of a transplant being successful in a non-smoker for example. It is true that people can knowingly damage their health in other ways, such as drug taking or alcohol abuse and it may well be viable to limit access to healthcare in these cases also. This does not mean that every factor in a patient's life must be scrutinized in order to decide where they are placed on a doctor's waiting list. In public policy, the line must be drawn somewhere. Prioritizing non-smokers can mean that more people can be helped with same amount of resources and, where this is the case, it should be practiced.
Whether or not you believe it should be, smoking tobacco is legal. At the same time, healthcare is regarded as a fundamental human right, alongside rights to education, food and water. Denying someone healthcare is to impede upon his/her basic liberties and this cannot be justified when, in the eyes of the law, they have done nothing wrong. Criminals have the right to healthcare – it is often that you hear that the trial of a war criminal is being delayed while they receive treatment. Take the cases of Ratko Mladic or Slobodan Milosevic for example 1. If healthcare is given to men who have committed genocide then surely it should be given to smokers. Also, if a Government adopts the line that one's behavior determines the kind of health service one receives then what is to stop that Government applying such a mantra beyond smoking and controlling the practices of those they govern in any number of ways?
Goods provided by the state, like healthcare, are often, and necessarily, subject to certain provisions. For example, in order to get unemployment benefits, a person must prove that they are regularly looking for a job and a means to get themselves off benefits. Denying access to healthcare for smokers does not mean denying them healthcare access forever; they can regain unlimited access if they stop smoking. Therefore, prioritizing non-smokers for healthcare in certain cases is not impeding upon smokers' basic liberties but a recognition that those who care about their own health enough to not smoke should be prioritized.
Peters, M.J. (2007) Should smokers be refused surgery? British Medical Journal,
Glantz, L. (2007) Should smokers be refused surgery? British Medical Journal,
Barendregt, J. J. (1997) The Health Care Costs of Smoking. New England Journal of Medicine.
Statistics: Tax Policy Centre, US Tobacco Revenue Statistics,
World Health Organization, The Tobacco Atlas,
News Articles: BBC News, 11 Jul 11, Man appeals for NHS gastric bypass surgery. Accessed 14 Jul 11.
.Daily Mail, Give up or we won't operate, smokers told.
Daily News, 13 Jul 11, Cardiovascular disease: Defend yourself by lowering the risks.Accessed 14 Jul 11.
. Daily Telegraph, 22 Jan 09, Lowest ever number of smokers after public ban and health campaigns.Accessed 14 Jul 2011.
. Guardian, 30 Nov 10, Smokers should not be forced out of hospital.Accessed 14 Jul 2011.
. Harvard School of Public Health, "Four Preventable Risk Factors Reduce Life Expectancy in U.S. and Lead to Health Disparities", 22 March 2010, accessed 24 August 2010.
, New Scientist, 27 Jan 08, Do smokers deserve equal medical care? Accessed 14 Jul 11.
. New York Times, 3 Jan 08, Even France, Haven of Smokers, Is Clearing the Air. Accessed 14 July 11
. .The Times, 09 Dec 05, Should smokers and drinkers be denied medical treatment? Accessed 14 Jul 11.
. USA Today, 15 Jul 11, Do smokers cost society money.. Accessed 15 Jul 11.