Charging smokers is a slippery slope

 

Elle Lindsay confronts debate as to whether smokers should be granted NHS care if they develop lung cancer

The very existence of the NHS is dependent on a healthy British economy and intelligent decision-making at the hands of our country’s leaders: in other words, it is often in trouble through no fault of its own. When considering the challenges faced by the NHS and the constant political strain it must withstand, we must first acknowledge the undeniable worth of its services, and the privilege of British citizens in accessing free healthcare. Nonetheless, scrutiny of the service yields consistent complaints about waiting times, staff, accessibility and even performance, and these are continuously reflected by British media.

No one can deny that lack of funding is one of the biggest trials faced by the NHS. Likening the NHS to any other service provider, it is easy to see how costs associated with staff, buildings, maintenance and resources begin to add up; however, the NHS is put under increasing pressure each year whilst contending with the stochastic nature of the country’s financial cycles. Now, in a period of such economic uncertainty, measures must be put in place to ease the strain, but the possible ways this might be achieved are rarely agreed upon. Privatisation of care is one such hotly contested issue, as generally the British population supports the core values of the NHS wholeheartedly. Though some say that at least partial involvement of private companies within our healthcare service is seemingly inevitable, this polarising proposal continues to simultaneously worry and anger many people. Since the way in which the NHS is currently running appears unsustainable, uncomfortable questions begin to arise with regards to whether availability of free healthcare should be filtered. If access to free healthcare is a privilege, is it one that should come with caveats? One question you may hear posed is whether smokers should have to pay for their own treatment if diagnosed with an associated disorder, such as lung cancer.

I have never smoked, but I have always known smokers: I think of my mother who smoked her entire life and certainly could not have afforded treatment if necessary. I think of my father who smoked but quit when my elder sister came along. I can effortlessly recall a seemingly endless list of friends and family members who have smoked, and many who still do. From practical and clinical points of view, the solution might appear simple; after all, that is how it works in countries without tax-funded healthcare. At a human level however, the answer becomes murkier as we consider personal stories of loved ones and the new reality we may have to live through with regard to our healthcare.

Arguments will inevitably emerge stating that smoking is a lifestyle choice and therefore any health complications occurring as a result are the responsibility of the smoker, including any associated costs. Statistics show that lung disease is one of the costliest disease areas within the UK, along with heart disease (also often associated with smoking). We know that many health issues can arise with continued use of tobacco products: it says so right there on the packet, “Smoking Kills”. Nonetheless, concluding that a smoker should pay for their treatment should these health issues arise is at best an oversimplification. Nicotine, which acts on both dopamine and noradrenaline in the brain, is an addictive substance. Once a dependency is built, cessation of smoking becomes riddled with withdrawal symptoms. As with any other addiction, be it drugs, alcohol or exercise, the situation is never as simple as “just stopping”.

If the main issue is that smokers put an unnecessary financial strain on the NHS, then consideration must be given to the fact that those paying for tobacco inevitably contribute more to the economy as they are taxed heavily for it. Tobacco Duty is included in the price of cigarettes and other smoking products, the same as Alcohol Duty is included in the price of the alcohol we buy, along with a standard VAT rate of 20%. Different tobacco products have different rates of tax, but in general, you can expect to pay over £7 on a 30g packet of tobacco and 16.5% of the RRP + £4.57 on a packet of 20 cigarettes. Clearly, smoking is an expensive habit, and paying for care if it led to health complications would be yet another financial burden. It’s hard to predict the outcome should smokers be forced to foot the bill for their healthcare: would this cause an overall decrease in smoking, or perhaps even a class divide? Arguably, charging smokers for their treatment may act as a deterrent, but there are further complications.

The primary difficulty associated with expecting smokers to pay for treatment is the slippery slope society would find itself on if we began trying to apportion blame to various diseases. Yes, some may argue that no one forces a smoker to adopt the habit, so the financial responsibility of any medical consequences should lie with the patient, but if this were to be put into practice, where do we draw the line? Do we charge the person who threw the first punch to mend their broken bone, whilst allowing the NHS to foot the bill for the patient that fell off their bike through no fault of their own? We’d have to reconsider the way we look at all ailments, from heart disease, to mental health, to obesity. Inarguably, lifestyle plays a huge role in many diseases, but there are also genetics and environmental links to contend with, and the result of each is not always possible to quantify. If we began charging smokers for cancer care, then what about patients who developed cancer in part due to lifestyle factors, such as unhealthy eating, lack of exercise or even from simply living in a more highly industrialised area? We are currently faced with an obesity epidemic, which will lead to a huge financial burden on the NHS due to the associated health risks such as cancers, hypertension and type 2 diabetes. The country now spends more each year on obesity treatment than the police, fire service and judicial system combined. To charge smokers for treatment would leave little defence not to charge a myriad of other patients.

If disease associated with poor lifestyle choices could be isolated, then there may be scope for such a scheme; however, invariably it is impossible to say that someone is suffering purely as a consequence of that lifestyle choice. A plethora of factors feed into our physiology. In considering smokers alone, some may smoke for years and never manifest health complications, whilst others must contend with cancers or COPD (Chronic Obstructive Pulmonary Disorder). Then there are those suffering from diseases we usually associate with smoking, having never smoked a day in their life. Determining who “deserves” free treatment would be an unenviable task requiring analysis on a case-by-case basis – the time commitment alone would be insurmountable and that’s before considering the ethical implications. The truth is the capricious nature of human life means that there are no set of rules that could be followed for every individual: it’s just too complicated. What if a patient smoked 30 years ago, then quit, but now presents with emphysema? The presence of the NHS removes the curse of having to make these decisions – one cannot quantify a life by one disease.

At this stage, it is “one for all, and all for one”, meaning no one gets left behind and everyone is equally entitled to access free healthcare. Taxes are lost to much less-worthy causes than treating a patient for cancer – regardless of whether any “fault” could be directed towards them. The conversation needs a new direction. In an ideal world, the key would be focusing funds and efforts on prevention. If the NHS will always be strained due to illnesses that occur by chance, genetics or age, then society must take responsibility for its own wellbeing. We should be teaching children to have balanced, healthy lifestyles and preparing for an ever-ageing population. Developing schemes to reduce unnecessary strains on our NHS is paramount. Positively, Scotland aims to raise its own tobacco-free generation by 2034, highlighting that prevention may eventually stub out the need for such morally questionable extremes.