National Health Service

“Smoking is the most preventable cause of ill health in Britain today” With reference to specific smoking related illnesses and ethical issues, discuss whether smokers should have the same access to the limited resources of the National Health Service. Tobacco is the only legally available consumer product that kills people when it is used entirely as intended. Killing about 300 people a day in the UK alone, this is like a plane crashing every day and killing all of its passengers, more than 13 people an hour. Currently smokers are entitled to the same treatment as non smokers but there is controversy about whether smokers should have to pay a premium to use the NHS because they are bringing the illnesses upon themselves and placing an unnecessary financial burden on the rest of society.

Approximately 3,000,000 people die worldwide each year as a result of smoking 1 . It is the cause of 30% of all cancer deaths and at least 80% of deaths from bronchitis and emphysema 2 . The rise in the occurrence of lung cancer has been closely linked to an increase in smoking. Lung cancer among males increased in the 1930’s following a marked increase in smoking during the 1st World War, and similarly an increase was noticed during the 2nd World War in the female population.

This is hardly surprising when we learn that tobacco contains over 4,000 chemicals, over 40 of which are known carcinogens3. Smoking has also been linked to cancer of the mouth, pharynx, larynx, bladder, pancreas, kidney and cervix. Cancer of the mouth and lungs etc are more closely linked because the smoke reaches these areas directly. Smoking kills twice as many people from other diseases as it kills from lung cancer. Up to 18% of coronary heart disease deaths are associated with smoking and it is linked with around 11% of stroke deaths.

The chemicals in cigarette smoke immobilise cilia in the bronchioles for several hours, and the smoke also stimulates mucus secretion 4 . As the cilia are now unable to carry the mucus away it blocks the airways, which in time can lead to bronchitis and emphysema. Emphysema is a disease where the lung tissue is permanently broken down due to an imbalance in the amounts of the enzyme elastase, which breaks down the protein that makes the lung tissue elastic, and the elastase inhibitor. This makes the lungs less able to force air out of the alveoli, and this residual air stops new, oxygen rich air from passing into the blood.

Smoking also impairs the function of the reproductive system. Ejaculation volume is reduced, sperm count decreases, sperm are less able to penetrate the ovum and the amount of shape abnormalities increases. In women fertility is 30% lower and the menopause can be up to 2 years early5. Smoking during pregnancy has been linked to increased fatal and perinatal mortality, low birth weight and premature labour.

Furthermore there is an increased risk to smokers of gum disease, angina, back pain, neck pain, cataract, Crohn’s disease, depression, osteoporosis, pneumonia, tuberculosis, skin wrinkling, diabetes, stomach ulcers and impotence. All the illnesses named above have to be treated, costing the NHS 1.5 billion a year 6 including hospital admissions, GP consultation and prescriptions. Many hospitals also find they do not have enough beds, when smokers occupy around 9,500 hospital beds every day 6. Smoking also costs the industry due to lost productivity caused by smoking breaks and an increase in days taken off sick. A Scottish study estimated the cost of smoking related absence to be 40 million per year 7. This is in addition to the �450 million of productivity losses. A Danish study concluded that smokers are more likely to take early retirement due to chronic disease.

All this money is being lost due to smokers when it could instead be used to improve the NHS by funding more research into diseases, buying more up to date equipment, building or extending more hospitals and training more doctors so waiting list decrease. Many people do not believe it is fair to spend money treating people who have smoking related illnesses as it is their choice to smoke and most are well aware of the risks they put themselves under. They therefore argue that smokers should pay a premium to use the NHS, so as not to put financial burden on the rest of society.

However, others argue that far from being a strain on the NHS, smokers pay their own way pretty handsomely. Currently in the UK, tobacco tax revenue stands at �7 billion a year 8, without the �3 billion lost from smuggling and cross channel shoppers. This is over 4.5 times the amount it costs the NHS. The idea that smokers should pay a premium goes against the founding principles that makes the NHS what it is. “To treat justly or to ensure equity in the provision of treatment and care is at the centre of the NHS. It means that no-one should be discriminated against because of their ability to pay, their social position, … , their lifestyle, or age. Indeed those whose needs are greatest, for whatever reason, even if their illnesses are to some extent self inflicted have the same rights as anyone else.”

If smokers should have to pay a premium then surely the same must go for anyone else who indulges in legal hobbies that are known to cause harm such as dangerous sports, drinking alcohol, promiscuous sex or simply eating unhealthy foods. In 1995 there were 20,727 admissions to the NHS for alcohol dependence and 2,076 for alcohol poisoning. 30,000 alcoholics are admitted for hospital treatment each year 10. This must also draw on NHS funding, but again it is each persons choice to consume alcohol, when they are aware of the risks.

In conclusion I believe that if it were found that smokers were a net burden on society, then it would be public right to put restrictions on smoking. But by the same reasoning any other activity, no matter how traditional, how honoured or how private, which was found to result in the danger of ill health significantly above average, would be equally open to control. Surely it is much more sensible to put extra money into anti smoking campaigns and measures to help people give up smoking. It has been shown that if a smoker believers they have a tobacco related illness they are much more likely to want to quit and have a greater interest in smoking cessation counselling 11, but this all relies on the facilities and support being available to them.


1. Cancer Medicine, 6th edition. Holland and Frei. Section 27: The Thorax



4. A New Introduction to Biology. Indge, Rowland and Baker.



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