Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Surgeons should help smokers quit not punish those who can't.
- Becky Freeman (5 January 2007)
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Smokers will lie about their habit
- Caroline Richmond (5 January 2007)
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Cotinine is validated
- Ian N Ross (5 January 2007)
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smokers and others ?
- Patrick SILVESTRE (6 January 2007)
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Separate Policies
- Randall Anderson (6 January 2007)
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Smokers do lie – but we have ways of identifying those who do and assisting them to quit
- Graham F. Cope (6 January 2007)
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Surgery of peripheral arteriosclerosis
- Finn Edler von Eyben, DK-6270 Toender (7 January 2007)
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No
- Andrew Montgomery (7 January 2007)
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An Incomplete Argument For Denying Treatment
- Mark Sheehan (8 January 2007)
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What about the passive smokers?
- Nicola N Noetic (8 January 2007)
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Three Hurrahs for Professor Glantz
- Evelyne Shuster (8 January 2007)
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An Incomplete Argument For Denying Treatment
- Matthew Peters (9 January 2007)
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Smoking is a disease
- D William Cameron, Ottawa, Canada K1H 8L6 (9 January 2007)
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Re: An Incomplete Argument For Denying Treatment
- L S Lewis (10 January 2007)
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Re: Separate Policies
- Walt Cody (11 January 2007)
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Utility vs. Autonomy
- Kiaran Asthana (11 January 2007)
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Re: Re: Separate Policies
- Randall Anderson (12 January 2007)
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Should smokers be refused surgery?
- Mohammad I Khalid (15 January 2007)
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Primum non nocere
- Jac Ciampolini (15 January 2007)
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Re: Re: Re: Separate Policies
- Walt Cody (17 January 2007)
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Smokers pay more taxes in the UK thus covering their extra care costs.
- Marise A McQueen (2 November 2007)
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Becky Freeman, Researcher - Future of Tobacco Control University of Sydney, NSW 2006
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Peters states that "as long as everything is done to help patients to stop" then smokers who don't quit should be given low priority for certain surgical procedures. A seemingly simple statement that is the crux of the issue – not everything is being done to help smokers quit. A few quick examples to illustrate: - An Australian study concluded that approximately one in six GPs indicated they "would not discuss" the patient's smoking status opportunistically.(1) - There was no mention of smoking cessation in the curriculum of 42% of UK medical schools. (2) Public health policy solutions that we know help smokers to quit have not been universally adopted: - Ban on the display of tobacco products at retail – it's hard to quit when there are attractive cigarette packs on display everywhere you shop - Ban on smoking in all workplaces, including bars and pubs - it's hard to quit if you’re a waitress and your customers are blowing smoke in your face Perhaps surgeons could focus their energies on improving the likelihood that smokers will quit (there is obviously plenty of room for improvement) instead of figuring out which smokers to deny access to surgery. 1. Young, Jane M, Ward, Jeanette E nfluence of physician and patient gender on provision of smoking cessation advice in general practice Tob Control 1998 7: 360-363 2. Roddy, E, Rubin, P, Britton, J A study of smoking and smoking cessation on the curricula of UK medical schools Tob Control 2004 13: 74-7 Competing interests: None declared |
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Caroline Richmond, Obituary writer SW3 5AQ
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This is a silly debate. Smokers can and will lie about their habit, and how are you going to detect the liars? And, if you can detect it, how are you going to confront them with your decision? Are there any smoker-detection tests, and how reliable are they? I have a friend who smokes but has told her GP she is a non-smoker. She justified this by telling me that she didn’t want to get an earful from her doctor, and anyway she is – she said – a light smoker. She may be typical of many people. She chain smokes when she is with me. If you refuse surgery to people who admit to smoking and allow it to those who don't, you will be punishing the truthful and rewarding the liars. Competing interests: Passionate non-smoker |
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Ian N Ross, Consultant Gastroenterologist Newark Hospital, NG23 5HQ
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Serum, salivary or urinary cotinine levels distinguish between non- smokers, light smokers and heavy smokers (>20 cigarettes/day). One could postpone elective surgery until the levels are in the non-smoking range. Not infrequently my alcoholic liver disease patients say their last drink was Xmas 2005. I don’t have any problem telling them that their blood sample contains ethanol, but I am not sure it makes them anymore honest the next time! Competing interests: None declared |
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Patrick SILVESTRE, General practitionner 60590 FRANCE
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I really agree with this analyse of the surgical care in smoker’s population… I propose also to study carefully the case of obese ones, who are guilty of their bad alimentation, of car or bike user, and their traffic injuries, or the pedestrian who would have to remain at home. Perhaps can we have productive thinking of cost effectiveness of care for the poor and unemployed or more simply, the other, the stranger? What a wonderful medicine, this medicine of the future! I am sorry, it’s not mine. (WMA Associate member) Competing interests: None declared |
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Randall Anderson, Systems Analyst Maricopa Community Colleges 85256
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I personally don't think they should be denied care however I would love to see smokers and overweight persons under separate insurance groups. For years I have watched as the costs of my HMO's and PPO's rise dramatically. I rarely, if ever, avail my self of those services, however I have seen the smokers and overweight people of my company seeking medical attention at what must be ten fold those of us who try to stay fit and health. It is a great effort for me to exercise, limit my food intake, and get the rest I need to stay healthy. Is it fair that others, who don't put fourth the same effort, have their medical costs subsidized by me? I think not. Competing interests: None declared |
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Graham F. Cope, Technical Director Mermaid Diagnostics Ltd
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The debate stimulated by the features published under the heading “Should smokers be refused surgery?”(1,2) is very welcome. The evidence that current smokers have less favourable outcomes, with regard to reduced wound healing, immune response and an increased risk of infections, is well established and convincing(3). However, with the pressures on modern healthcare, it is the cost implications of surgically treating smokers that is of increasing importance. It is clear that not all surgical procedures are affected in the same way, with plastic and constructive surgery being one of the most important. This has important legal implications to the surgical profession, with an increasing number of law suits against surgeons for failed operations, when the problems lies with the patient, who has failed both to divulge and stop their smoking. One factor that is important in this argument(1,2) is the verification of smoking habit. It was stated that “…they are likely to lie to their doctors about their smoking”(2). A study has addressed this issue by utilising a simple point-of-care urine test kit called SmokeScreen(4). This 5-minute test, which can be carried out in the clinic or surgery, measures nicotine breakdown products, including cotinine and provides instantaneous results. One hundred consecutive patients attending pre- assessment clinic who had reported their smoking habit on a self-completed questionnaire, were tested and 26% of declared non-smokers were found to have elevated cotinine levels indicating current smoking, with a further 50% significantly under reporting their cigarette consumption(5). A similar pattern emerged when the same test was used on patients attending vascular surgical outpatients, when 15% of non-smokers were found to have test results indicating active smoking(6). The immediate result allows feedback to be provided to the smoker, which has been shown to increase awareness of the need to stop smoking and improve smoking cessation(7). But once identified how should patients be treated? Every Health Authority in the UK provides a smoking cessation service, with the supply of free nicotine replacement therapy in many cases. There is anecdotal evidence that these services are under utilised by the medical profession, with most surgeons and physicians failing to refer their patients for help to stop smoking. With correct identification of smokers, increased understanding of the need to stop smoking by the patient together with a willingness to quit and the use of professional smoking cessation services there could be an improved surgical outcome in a large number of cases, with a concomitant reduction in costs. References 1.Peters MJ. Should smokers be refused surgery? BMJ 2007;334:20, doi:10.1136/bmj.39059.503495.68 2.Glantz L. Should smokers be refused surgery? BMJ 2007;334:21, doi:10.1136/bmj.39059.532095.68 3.Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review. Tob Cont 2006; 15: 352-358. 4.Cope G, Nayyar P, Holder R, Gibbons J, Bunce R. A simple near-patient test for nicotine and its metabolites in urine to assess smoking habit. Clin Chim Acta 1996; 256: 135-49. 5.Payne CE, Southern SJ. Urinary point-of-care test for smoking in the pre -operative assessment of patients undergoing elective plastic surgery. J Plast Reconstr Aesth Surg 2006; 59: 1156-1161. 6.Hobbs SD, Wilmink ABM, Adam DJ, Bradbury AWB. Assessment of smoking status in patients with peripheral arterial disease. J Vasc Surg 2005; 41: 451-456. 7.Cope GF, Nayyar P, Holder R. Feedback from a point of care test for nicotine intake to reduce smoking during pregnancy. Annals of Clinical Biochemistry 2003; 40: 674-679. Competing interests: The author is the inventor of the Smokescreen test and is employed by the current manufacturer. |
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Finn Edler von Eyben, consultant Medical Center Toender, Denmark, DK-6270 Toender
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I worked as a locum physician in Sweden last year. I admitted a smoker with peripheral arteriosclerosis and intermittent claudicatio with pain in the legs induced by walking for examinations for surgery. The patient was told to quit smoking and was told that surgery was only to be considered if the patient had stopped smoking and remained non-smoking for 12+ months. I find it reasonable that the hospital stressed for the patient the close link between smoking and cladicatio and stressed that a good outcome of surgery for this condition is strongly linked to longlasting smoking cessation. I think the hospital would have done harm for the patient if it had not stressed that the best outcome for the patient depended on the patient himself changed life style, not for blaming the past but for paving the way for the best future. Competing interests: None declared |
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Andrew Montgomery, locum auckland
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Smokers should be first in the queue for surgery because - 1. They have paid truckloads of money in tax which by some analyses more than covers the cost of their medical care.(unlike the obese) 2. The UK - in common with all nations - has had every opportunity to legislate cigarette smoking out of existence. It has failed to do so precisely because the tax revenue is too tempting and for fear of political backlash. 3. With regard to political backlash - this could easily be avoided as all politicians know - by simply raising year on year the age of legality to smoke - thus reducing new entrants to the addiction. 4. Smokers - having paid for the cost of their care via taxes, and with much shorter life expectancies deserve a quality last few years. I don't smoke and am not fat. I advise my patients (to their horror) that they would be better off medically to be addicted to heroin than experience addicition to nicotine or food. Competing interests: None declared |
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Mark Sheehan, James Martin Research Fellow Program on Ethics and the New Biosciences, Oxford University OX1 1PT
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The statistical evidence presented by Peters is quite impressive. Unfortunately he fails to address the ethical assumptions that underlie his argument. Had he done so he would have seen how difficult it is to make his case. As it stands, the argument moves from the claim that smoking makes procedures more expensive and less effective directly to the conclusion that smokers should be refused treatment until such time as they quit. There are a number of ways of bridging the gap in this argument. Cost-effectiveness is an obvious key to the argument but a moment’s reflection will show that always privileging cost-effectiveness is untenable. Palliative care and treatment for those over 70 would likely be very difficult to justify. There are presumably times when the cheapest, most effective treatment is appropriate and times when it is not. Why procedures on smokers are to be singled out among all of the other cost- ineffective procedures available is far from clear.1 A second attempt at bridging the gap in Peters’ argument is an appeal to fairness. This appeal claims that it is fair to prefer non-smokers to smokers for the limited number of procedures that we can provide. After all smokers have chosen to smoke and it is not the place of a resource- limited health service to pay for the lifestyle choices of each individual.2 But the story about free choice is far from simple.3 It may be that genetics and psychological predisposition play a significant role in so- called ‘choices’ to smoke. The connection between socio-economic status and smoking is well established and it would be no surprise if more fine- grained behavioural habits were heavily influenced by the close family context.4 This is not to say that the individual plays no role at all, only that it is much more difficult to attribute responsibility than Peters’ argument assumes. As important for Peters is an appeal to what is best for the patient. The effectiveness part of his claim can be understood to reflect this. But it is unclear that what is best according to the doctor should override the patient’s view of what is best. Rather than demanding compliance, properly educating the patient about the poorer outcomes seems a much better way of both getting at what is best all round and enabling the patient to take a fuller measure of responsibility. The statistics are all well and good but whether we should act on them in the way that Peters suggests will turn on what kind of response can be made to these ethical concerns. References: 1. Glantz L. Should smokers be refused surgery? BMJ 2007; 334:21, doi:10.1136/bmj.39059.532095.68 2. Wilkinson S. Smokers’ Rights to Health Care: Why the ‘Restoration Argument’ is a Moralising Wolf in a Liberal Sheep’s Clothing. Journal of Applied Philosophy 16; 3, 1999: 255-269. 3. Gillies J, Sheehan M. When should patients be held responsible for their lifestyle choices? BMJ, Feb 2006; 332: 279; doi:10.1136/bmj.332.7536.279 4. Edwards, R. The problem of tobacco smoking. BMJ, Jan 2004; 328: 217 - 219; doi:10.1136/bmj.328.7433.217 Competing interests: None declared |
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Nicola N Noetic, artist 97405
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I am surprised no one mentioned the possibility that passive smokers could get the rawest deal in this thinly veiled attempt to create a new set of second-class citizens!! Take the example of the abused wife of an unapologetic chain smoker who is afraid to speak out. I can just see it now: "Sure, you don't smoke ma'am! We've heard that line before! No surgery for you until you learn to tell the truth!" This is no exaggeration and it could VERY easily happen. As an adult who has painful childhood memories of being raised by abusive smokers, I know how easy it is for the guilty to get away with murder while the innocent get the blame. This is so Orwellian and a half, I want to puke! The possibility of abuse of newly established power is too great! Stop all types of second class citizenship treatment because you could be next on the list!- Nicola Competing interests: None declared |
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Evelyne Shuster, Medical Ethicist VA Medical Center, University and Woodland Avenue Philadelphia,PA 19104, USA
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Although as a matter of principle I fully support Professor Leonard Glantz 's position that depriving smokers of surgery is simply wrong, his careful and meticulous analysis fails to address a critical point in the debate, i.e. we are talking about "elective," not life-saving or life- sustaining surgery as Professor Glantz seems to suggest. Indeed, Dr. Matthew Peters rightly emphasized, that if reconstructive surgery is not required as part of essential surgery for head and neck cancer, for example, it would be medically justifiable not to offer elective reconstruction until the patient has stopped smoking. Such intervention would make the patient worse off by delaying possibly necessary adjuvant chemotherapy or radiotherapy because of wound infection or flap necrosis caused by smoking. The problem with smoking ( as it has become with obesity) is that we, as nations, have decided to make smoking a moral scourge, and thus a "pretext for a smoking inquisition" followed by deprivation of the smokers'liberty to make health decision. The single critical lesson to learn from this debate is in the protest (implied in Professor Glantz's statement) that consciousness is private and not a public domain to be manipulated by agents of the state, or any members of professional organizations. Competing interests: None declared |
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Matthew Peters, Respiratory Physician Concord Hospital, Sydney Australia 2139
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A punitive policy developed and implemented on the incorrect basis that smokers choose to smoke or that this is ther lifestyle choice would be unfair and unethical. This is no part of the argument I put forward in this debate. It is simplistic to make ethical arguments that end with an individual patient when judgements made at that level clearly impact on others who may have lesser access to services. Cost-effectiveness comparisons between very different forms of health care services are always vexed but here the comparisons, choices and differences in outcomes are somewhat clearer. Competing interests: None declared |
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D William Cameron, Professor of Medicine University of Ottawa at The Ottawa Hospital, Ottawa, Canada K1H 8L6
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Smoking is a disease by many definitions. So is obesity, and alcoholism, and each is driven by behavioural factors sometimes referred to as choice.
The role of the physician whose proper client is his patient is to act in that individual person's best interests. Otherwise, the physician should confess the competing interest (like some notion of the public purse) to his patient, and if conflicted, refer the patient to an unbiased provider. If a person or his disease is distasteful to a physician, he should confess and refer, rather than construct arguments that rationalize, or worse impose the prejudice by policy in disfavouring one person for another. All persons should be considered equal in dignity and rights, and triage for access to limited resources should be according to need, not by social or any other lottery. If it is the mission of a well-meaning physician to 'fight smoking' then he should address smoking, not the smokers, and surely not in the face of illness and a need for care. If it is the wish of society to save money by restricting healthcare, then the societal gain by taxation of tobacco consumption, and complicity in subsidising tobacco production must also be considered - as well as wasteful and harmful government practices which compete with healthcare for resources. Striking at the root of the problem, which is the tobacco industry and the smoking behaviour is the appropriate response. Discrimination in medical management or healthcare policy against those suffering disease is not only disrespectful and harmful to the patient, but to the medical profession. Competing interests: I no longer smoke. |
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L S Lewis, GP Surgery, Newport, Pembrokeshire SA42 0TJ
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Well said Mark Sheehan - you beat me to it. The hidden criterion here seems to be that smokers 'make a lifestyle choice' and hence bring disfavour upon themselves. If one doubts my claim that this unspoken criterion operates in Peters' argument , then one need simply substitute 'lower social class', or 'ethnic minority' , or 'elderly', or 'more seriously advanced disease' wherever he uses the word 'smoker'. But smokers do not have an entirley free choice, such is the nature of their addiction. And, of course, to those who have argued the case for insuring risks appropriately, smokers DO pay extra premiums in tax. Dr Sam Lewis Competing interests: a doctor and a smoker |
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Walt Cody, writer New York City
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Indeed, Mr Anderson. And, expanding on your grouch, why should the childless have to subsidize the pregnancies, deliveries, and subsequent pediatric services for those who choose to breed? Why should the celibate underwrite the escalating costs of STDs? Or teetotalers, of accidents and diseases caused by alcohol? Or couch potatoes, of skiers (and vice verse)? No end to the ways we can Balkanize medicine and rip the social contract if we follow your advice. Competing interests: None declared |
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Kiaran Asthana, GP Lakeside Medical Centre, Perton, Wolverhampton WV6 7PD
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Who does the most good? The paternalist who denies non-essential treatment until the patient stops smoking, with the potential gain of a lifetime of benefit to the patient? Or the idealist, championing individual freedom at the common expense? And how much should we pay to defend choice? Perhaps a controlled trial comparing clinical coercion (witholding surgery until the patient stops smoking) with a more laissez-faire approach would shed some light on these questions. And take out some of the heat. Competing interests: None declared |
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Randall Anderson, Systems Analyst 85256
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Yes, Walt I understand your point but I don't think you see mine. I was negligent in not mentioning alcohol abuse and other forms of high risk behavior. And even low risk behaviors a.k.a. couch potato. Though I would dare say it is not my advice nor do I see it as destroying the 'social contract'. It is not my idea/advice, if we look at Massachusetts in the United States which has implemented mandatory health insurance requiring all residents to purchase health insurance or face legal penalties. They have 'Balkanized' by allowing youths 18-25 to be part of a special group, with lower fees, because they are young, strong and don't get sick a lot. Now California is soon to follow. The logic of these 'Balkanized' groups is sound and if a liberal states like Massachusetts and California don’t see it as ripping up the social contact who am I to argue. I would say that 'Balkanizing' health care is strengthening the 'social contract' by holding people responsible for and paying for their own behavior. That in turns lets the rest of us know they are holding up their end of the 'social contract'. And just what is an individual's responsibility to the 'social contract'? I do like your analogy of skiers vs. couch potato. I have always asked myself why do we feel we must rescue or repair people who make a choice to indulge in unnecessary risks? Maybe smokers don't have a choice as addicts or maybe they do. Again, I don't believe smokers or anyone else for that matter should be denied health care but they should have to pay the extra costs for their behavior. Competing interests: None declared |
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Mohammad I Khalid, Locum Consultant Cardiologist Fairfield General Hospital, Bury BL9 7TD
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MJ Peters believes that smokers who fail to quit smoking should not be considered for elective surgery (1). His argument is based on his belief that the costs are increased and outcomes are worse in smokers than non-smokers. This theme is not new and the readers of the BMJ may remember the controversy caused by the article published in 1994(2). In that article M J Underwood and J S Bailey stated that the smokers should not be offered coronary artery surgery because in their opinion "subjecting patients to the increased risk of surgery in the face of a remediable cause is not justified.” In responding to their article I had argued that the NHS professionals tend to ignore the fact that they are appointed to provide service to the patients on the basis of their clinical needs irrespective of their shortcomings and degree of culpability(3). I would like to reiterate my argument that the surgeons are trained by the tax of both smokers and non-smokers and, in return, the tax payers expect them to provide prompt and efficient service when required. I am sure that no surgeons would refuse to operate on a smoker if he or she was paying a handsome fee as a private patient. I would also like to draw his attention to the paragraph 7 of 'Good medical Practice' published by the GMC. It states that 'The investigations or treatment you provide or arrange must be based on the assessment you and the patient make of their needs and priorities, and on your clinical judgement about the likely effectiveness of the treatment options. You must not refuse or delay treatment because you believe that a patient's actions have contributed to their condition. You must treat your patients with respect whatever their life choices and beliefs. You must not unfairly discriminate against them by allowing your personal views* to affect adversely your professional relationship with them or the treatment you provide or arrange. You should challenge colleagues if their behaviour does not comply with this guidance.” I believe that we should all feel privileged to be in a position to make decisions affecting the lives and livelihoods of our fellow beings and resist the temptation to abuse our authority. Gentle persuasion and counselling are the only decent ways of changing patient’s lifelong habit. (1) Peters M J. Should smokers be refused surgery. BMJ 2007;334:1 (6 January) (2) Underwood M J, Bailey JS, Shiu M, Higgs R, Garfield J. Should smokers be offered coronary artery surgery? BMJ 1993;306:1047-50 (17 April) (3) Khalid MI. Access to heart surgery for smokers. BMJ 1993;306:1408 (22 May) Competing interests: None declared |
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Jac Ciampolini, Consultant Orthopaedic Surgeon Peninsula Orthopaedic Treatment Centre, Brest Road, Plymouth, PL6 5XP
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I am an orthopaedic surgeon, and welcome the debate on smoking and elective surgery. My main activity is joint replacement: while most of my patients will do well, a small minority will not. Of those who have a complication,a tiny number will end up with an absolute catastrophe, complete and utter disaster. Infected knee replacement is a typical example (1,2). Orthopaedic surgery can radically change people’s lives, but not always for the best. It can restore mobility and quality of life to a lady whose knee replacement is uncomplicated. It can also ruin the last years of another lady whose knee replacement is complicated by a deep infection. There is in fact no doubt that no surgery is better than failed surgery. There has been good evidence in the literature for many years that the outcome of spinal surgery was adversely affected by cigarette smoking (3-5). We now also have conclusive scientific evidence that the same applies to joint replacement (6). If we really want to have a modern evidence-based practice, we cannot ignore the results of this powerful Swedish epidemiological study. First: do no harm. By performing elective orthopaedic surgery in smokers, we could make them far worse than when they first came to see us in clinic. A good surgeon knows when not to operate. It is our duty to protect cigarette smokers from the harmful effects of our scalpel.
1) Barrack RL, Engh G, Rorabeck C, Sawhney J, Woolfrey M. Patient satisfaction and outcome after septic versus aseptic revision total knee arthroplasty. J Arthroplasty.2000; 15:990 -3 2) Blom AW, Brown J, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Infection after total knee arthroplasty. J Bone Joint Surg Br. 2004 Jul;86(5):688-91 3) Brown CW; Orme TJ; and Richardson HD: The rate of pseudarthrosis (surgical nonunion) in patients who are smokers and patients who are nonsmokers: a comparison study. Spine, 1986.11: 942-3 4) Hadley MN, and Reddy SV: Smoking and the human vertebral column: a review of the impact of cigarette use on vertebral bone metabolism and spinal fusion. Neurosurgery, 1997.41: 116-24 5) Hanley EN, and Levy JA: Surgical treatment of isthmic lumbosacral spondylolisthesis. Analysis of variables influencing results. Spine, 1989.14: 48-50 6) Sadr Azodi O, Bellocco R, Eriksson K, Adami J. The impact of tobacco use and body mass index on the length of stay in hospital and the risk of post-operative complications among patients undergoing total hip replacement. J Bone Joint Surg Br. 2006 Oct;88(10):1316-20 Competing interests: None declared |
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Walt Cody, writer New York City
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Ah Randall, I fear you took me literally. No, my point was we all, in our own ways, do something that someone considers "risky" or at least expensive. It's vaguely called "living" and we're all in it together. Better we indulge each other's humanity, in the philosophical knowlege that it all evens out, than succomb to "the narcissism of small differences." Competing interests: None declared |
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Marise A McQueen, Staff grade Glasgow G11 6NT
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The complaint that smokers will generate extra care costs after surgery perhaps does not take the cost of taxation into account. Cigarettes cost about £5 per 20. Tax must be about £4 per pack. A smoker on 100 cigarettes per week is therefore paying £20 per week more tax than a non smoker per week - on previously taxed income. Thus £1120 per year extra. Over 30 years smoking: £33600 at todays prices. Surely this covers the extra complication rate? Competing interests: Smoker |
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