Intended for healthcare professionals


Should smokers be refused surgery?

BMJ 2007; 334 doi: (Published 04 January 2007) Cite this as: BMJ 2007;334:21
  1. Leonard Glantz, professor of health law, bioethics, and human rights
  1. 1Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
  1. lglantz{at}

    Last year a primary care trust announced it would take smokers off waiting lists for surgery in an attempt to contain costs. Matthew Peters argues that denying operations is justified for specific conditions but Leonard Glantz believes it is unacceptable discrimination

    One of the noblest things about the profession of medicine has been its single minded devotion to patients. Doctors routinely treat patients who are despised by the society in which they live—enemy troops, terrorists, murderers. Given this, it is astounding that doctors would question whether they should treat smokers. The issue for doctors is whether they will allow the current antismoking zeal in America, the United Kingdom, and western Europe to infect their practice and undermine the doctor-patient relationship.

    In a surprisingly short time smokers have gone from being the victims of tobacco companies to perpetrators of wrongs against others. Secondhand smoke used to be an annoyance but is now treated as a poisonous gas. Smokers' diseases were previously seen as the result of a heartless tobacco industry preying on the young and supplying drugs to those it addicted. Tobacco companies used to win every lawsuit brought against them by diseased smokers because they successfully argued that smokers knowingly and voluntarily assumed the risks of smoking—if smokers do not want to incur the well known risks of smoking they should simply stop.

    But the 1988 US Surgeon General's report on the addictive nature of cigarette smoking gave plaintiffs' lawyers a way to rebut this argument.1 Smokers could now be portrayed as enslaved by the tobacco companies and incapable of stopping smoking because of their addiction. As a result, smokers did not voluntarily incur the risk of smoking but rather did so involuntarily because of their addiction. It is not without some irony that surgeons who refuse to perform operations on patients unless they stop smoking make the same argument that cigarette companies used—if smokers don't want to incur the adverse effects of smoking, including refusal of surgery, they should quit.

    Individual decision

    Assuming we can accurately determine who falls into the class of smoker (is it someone who smokes 40 cigarettes a day, 10 a day, or the occasional cigar?), the idea of doctors treating all smokers the same way runs directly counter to the practice of medicine. This requires an individualised evaluation of each patient to determine the appropriateness of a treatment regimen. Evidence exists that smokers are at an increased risk of postsurgical complications compared with non-smokers, and when smokers stop smoking before surgery their risks of complications decrease.2 But those same data show that most smokers who have surgery have no complications, and a policy denying all smokers access to surgical procedures arbitrarily denies beneficial treatment to those who would have had no complications.

    Withholding surgery from smokers also distorts the modern doctor-patient relationship, which is based on partnership. Doctors determine the risks and benefits of treatment, inform the patients of these facts, and patients then decide whether to incur the risks to gain the benefits. This applies equally to smokers and non-smokers. Doctors should certainly inform patients that they might reduce their risks of postsurgical complications if they stop smoking eight weeks before the procedure. There is every reason to believe many patients would follow their doctors' advice. The question is, “Should the price of not following the doctor's advice be the denial of beneficial surgery?” Should someone who was crippled by arthritic knee pain be denied surgery because she would knowingly and willingly take an increased risk of incurring postsurgical complications? If the decision whether to take an increased risk is not left to patients, they are likely to lie to their doctors about their smoking. This deception, of course, will make us unable to help smokers who wish to stop but fear the repercussions of disclosing their smoking to their doctors.

    Cost arguments

    An argument made to support the discriminatory non-treatment of smokers is that increased complications lead to additional expenditures that could be avoided if smokers would simply stop smoking. But why focus our cost saving concerns on smokers in the context of surgery? Do patients have a general obligation to get healthy as a condition of receiving treatment? Patients are not required to visit fitness clubs for eight weeks, lose 25 pounds, or take drugs to lower blood pressure before surgery.

    Many non-smokers cost society large sums of money in health care because of activities they choose to take part in. “Baby boomers” in the United States lost 488 million days of productivity in 2002 because of sports injuries. From 1991-8 sports related injuries in this age group increased 33% and cost about $18.7bn (£9.6bn; €14bn) a year in medical costs alone.3 We could reduce healthcare expenditure by simply refusing to pay for treating any injuries related to voluntary participation in sports. Let them suffer their painful knee condition which is entirely their fault. Indeed, if we treat a sports injury that person is likely to risk incurring future costly sports injuries. But we don't even think this let alone suggest it.

    Discriminating against smokers has become an acceptable norm. Indeed, at least one group of authors who believe smokers should be refused surgery blithely admits that it is “overtly discriminatory.”4 The suggestion that we should deprive smokers of surgery indicates that the medical and public health communities have created an underclass of people against whom discrimination is not only tolerated but encouraged. When the World Health Organization announced that it would no longer employ anyone who smokes, public health and medical communities did not respond to this act of blatant bigotry.5 6 Similarly, it is shameful for doctors to be willing to treat everybody but smokers in a society that is supposed to be pluralistic and tolerant. Depriving smokers of surgery that would clearly enhance their wellbeing is not just wrong—it is mean.


    • Competing interests: None declared.