From time to time there have been debates in the press and in politics about the efficient use of money, and the allocation of funding, within the NHS in the UK. Smoking is often seen as a self-inflicted problem and thus some argue that smoking-related illness might not deserve to be treated free of charge by the NHS. In this article, I outline the problems associated with smoking and some of its scientific basis; I also discuss some of the arguments made for and against charging smokers for certain treatments. I describe some of the reasons why people start smoking and I conclude by making the case for improved smoking prevention and cessation resources as a preferable option to charging for treatment.
Currently free treatment on the National Health Service (NHS) is available for the entire population of the UK. The NHS was set up in 19481 under the Health Secretary Aneurin Bevan upon the principle that it was to provide healthcare for everyone based on need rather than on the ability to pay. However, with the economic pressures on the NHS growing, some people have started to question that premise. Moreover, with an estimated 13 million people smoking in the UK (in 2010), smoking cost the NHS more than five billion pounds a year in 2005-62 , according to an Oxford study, without taking into consideration indirect costs of smoking, such as reduced productivity and the costs of treating disease caused by passive smoking. The World Health Organisation (WHO) estimates that 100 million deaths worldwide over the 20th century were directly caused by tobacco.
Extensive research over the decades has proven that smoking is very harmful for the human body. Some of the earliest work was carried out by the Argentinean chemist, Angel Roffo3 . He undertook many experiments in the 1930s showing that cancers could be induced by exposure to tar from burned tobacco. In 1930 he published a paper showing that exposure of rabbit gums to tobacco led to the development of leukoplakia, which is a known precursor of oral cancers. Later experiments included painting solutions made from tobacco smoke, most famously using blonde tobacco, onto the ears of rabbits, resulting in a proportion of them developing local skin cancers. Moreover, in the 1950s Richard Doll4 published articles in the BMJ showing a close statistical link between lung cancer in humans and a history of tobacco use. This linkage between cancer and tobacco smoke was then proved by an American scientist, Dr Auerbach5 , via his infamous experiments on beagles (1967-1970), during which the animals inhaled tobacco smoke for many hours each day through a mask or tracheostomy tube; of 86 dogs, 12 later developed cancers.
Cancer Research UK6 claims that tobacco smoking causes 28% of cancer deaths in the UK and suggests that 86% of lung cancer cases in the UK are caused by smoking7 . It is an alarming fact that prior to the First World War, which is the time that smoking became increasingly popular in the UK, lung cancer was a very rare diagnosis that many clinicians would never see. By 1948 82% of men and 41% of women smoked. As the possible link between smoking and cancers became more widely accepted the numbers gradually reduced to 21% of men and 20% of women smoking by 2010.
Recently an article from the American Cancer Society8 on 13th February 2014 states that the smoke from burning tobacco contains seventy known carcinogens, including cyanide, benzene and acetylene. The carcinogenic products bind to deoxyribonucleic acid (DNA) and cause genetic mutations. Tobacco also contains nicotine, which is a highly addictive psychoactive drug that carries a high risk of physical and psychological dependence. Thus it is no surprise that smoking is linked very strongly to a wide range of cancers9 including larynx cancer, bladder cancer and lung cancer. These all carry a substantial cost for the NHS and thus indirectly to the taxpayers.
Moreover, smoking has also been linked to a wide range of different, non-cancerous, diseases9 including myocardial infarction, cerebrovascular disease, low birth weight babies, chronic obstructive pulmonary disease (COPD) and peripheral vascular disease. Again, these all carry costs for the NHS, especially as many of the diseases caused by smoking are chronic problems requiring treatment over a long period of time. For example, patients with COPD are usually given inhalers for the rest of their lives, and in extreme cases they require home oxygen therapy as well as additional medication. These individuals are also more likely to suffer from infective exacerbations, some of which will require several days’ admission to hospital.
In view of this strong linkage to many cancers and diseases, on 29th April 2012 “The Guardian”10reported a survey of UK doctors which found that 54% of those that took part thought the NHS should withhold non-emergency treatment from patients who do not lose weight or stop smoking. In fact, in some parts of England smokers and obese people are not allowed breast reconstructions, IVF (in-vitro fertilisation), artificial hip or knee replacements. In other areas, smokers have to undergo a compulsory smoking cessation course preoperatively.
Smoking has also been proved to carry significant risks for patients undergoing surgical procedures. In 2012 D Khullar11 in the Journal of American College of Surgeons published a collective review of studies into the impact of smoking on surgical outcomes. He showed that only 5% of smokers managed to stop smoking around the time of elective surgery, despite verbal advice from their surgeon. In addition, Alice Theadom et al12 (2006) reviewed 12 cohort studies into the risk of surgery in smokers and proved that they were at increased risk of postoperative complications when compared with non-smokers. This ultimately led to prolonged stays in hospital with diverse problems such as pneumonia, wound infections and very costly prolonged artificial ventilation support.
Another added reason for some people believing that smokers should contribute to some of the costs of their health treatment is that smokers can harm other people’s health too. This effect is known as passive smoking and it has been shown to be able to increase a non-smoker’s risk of developing lung cancer or heart disease by 25%. As a result of this smokers have already been banned from smoking in public buildings and currently politicians are debating over the possibility of banning smoking in cars in the presence of children.
However, one of the main arguments for keeping treatment free for smokers is that once you have made that first change, and for example made smokers contribute to the cost of their healthcare, where would you stop? Would the economic pressures on the NHS continue to rise, and so would other people also be excluded from free healthcare such as those that drink alcohol on a regular basis, those that are obese and those that participate in extreme sports.
One of the most commonly used arguments for making smokers pay for their treatment is that they are voluntarily harming their body and so do not deserve free healthcare. However, is it fair that due to a few early mistakes people should then have to be punished for the rest of their lives? In fact it is thought that many people start smoking for a diverse number of reasons including peer pressure when young, tobacco industry marketing suggesting it as glamorous and the desire to mimic “adult behaviour”. Furthermore, once someone has started smoking it is then very hard to stop6 because the smoke from cigarettes contains highly addictive nicotine that leads to a fast nicotine “hit” as it takes approximately just 10 seconds for nicotine to reach the brain. This leads to a faster heart rate and the release of dopamine which is a chemical in the brain associated with a feeling of pleasure. As a result, tobacco users rapidly associate having a smoke with “feeling good”. In addition, there are rapid withdrawal symptoms on stopping smoking leading to anxiety, irritability, craving, poor concentration and poor sleep quality. The sensation that smoking reduces “stress” simply comes from the fact that smoking another cigarette stops withdrawal symptoms that start to build up between each smoke.
Thus it is hardly surprising that smoking cessation is hard to achieve. Amongst smokers wishing to stop, only 4-7% manage to stop unsupported on their own with each attempt. However figures from the NHS show that 25% can stay non-smokers by 6 months if they have used medications and the addition of smoking cessation counselling boosts the figures further. The NHS Stop Smoking Services England13 , which offers a service combining counselling with medication, published very encouraging figures for April 2012- March 2013. During this time period 52% of those setting a quit date successfully stopped smoking. This was achieved with an expenditure of £87.7 million which amounted to an equivalent cost of around £235 for each person who stopped smoking.
In conclusion, there is strong proven linkage between smoking and ill-health in humans, leading to a huge drain on the NHS. For this reason many people believe that smokers should contribute to the cost of their health care. However many people start smoking at a young age and then find it very hard to stop, especially by themselves, due to the addictive nature of nicotine. Thus, perhaps instead of the NHS trying to relieve the economic pressure on itself by charging smokers, it should invest in trying to cut down the number of people who smoke through support services. This would make the population of the UK healthier and would be a more ethical method of dealing with the expenses and problems that smoking causes the NHS.
- 2009 “BBC Health” http://news.bbc.co.uk/1/hi/health/8086142.stm
- “The Carcinogenic Effects of Tobacco”, Porfessor Roffo, Monatsschrift fur Frebsbekampfung Vol8, 1940, Issue 5
- “Smoking and carcinoma of the lung” R. Doll, British Medical Journal, 30th September 1950
- “Effects of cigarette smoking on dogs. II. Pulmonary neoplasms.” Auerbach, Archives of environmental health 21:6 (1970)
- Cancer Research UK: Tobacco, smoking and cancer: the evidence
- Cancer Research UK: Lung cancer risks and causes
- American Cancer Society, What in tobacco smoke is harmful?
- “What are the health risks of smoking?”, NHS choices website, last updated 28th November 2013
- The Guardian newspaper, 29th April 2012
- Khullar D and Maa J. The impact of smoking on surgical outcomes. The Journal of American College of Surgeons 2012; Vol 215, Issue 3: 418-426
- Theadom A and Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intra-operative and postoperative complications in adult smokers: a systematic review. Tobacco Control. Oct 2006; 15(5): 352–358.
- Health and Social care Information Centre. Statistics on NHS stop smoking services: England, April 2012- March 2013, published 30th October 2013