To the Editor: I would like to congratulate Peters et al on their strong stance against elective surgery in patients who smoke.1 The plastic surgery community became aware in the last two decades of the problems of healing in smokers. When patients claimed that they gave up cigarette smoking before surgery, we often found that the serum cotinine levels on testing were elevated, indicating that they had not given up smoking.

Patients who are smokers and who develop a healing complication, in breast reduction, mastopexy, abdominoplasty or a facelift, often attribute the complication to the surgical technique rather than their own habit. Many of these patients have gone on to litigate successfully. Voracious plaintiff lawyers attribute only a small amount of blame to the patient whose smoking has, in fact, contributed significantly to their complication.

In our plastic surgery practice, we have a non-smoking policy, and my malpractice insurer will not cover me for patients on whom I operate and who develop a complication associated with smoking. Hence, all patients who are smokers who wish to have elective surgery are referred to a smoking-cessation program and have to have given up smoking for at least 2 to 4 weeks before surgery. I prefer not to operate on smokers at all, as serum cotinine tests often confirm that their cessation attempt has been incomplete.

In the United States, where patients pay for their own health insurance, their premiums are adjusted for lifestyle. In Virginia, in the 1990s, a “Healthy Virginian policy” existed where premiums were reduced for non-smokers. My suggestion would be that the Medicare levy also be either reduced for individuals who do not smoke or increased for those who do.

To the Editor: Some time ago, I was approached by a general practitioner who had been trying for more than 12 months to arrange surgery for a patient who was suffering from intermittent claudication. The indications for surgery seemed compelling. The man was in great pain and disabled by the condition. The vascular unit at a major metropolitan hospital refused to operate on him while he remained a smoker. The man had been an alcoholic, but had managed to beat that addiction and had been “dry” for the entire 12 months.

With the patient’s permission, and at the request of the GP, I contacted the surgeon. The surgeon explained to me that his refusal to provide elective surgery was on the grounds that the patient smoked, which would increase recovery time and the risk of complications. After discussion of the ethical and legal situation, an early appointment for surgery was arranged with the patient.

Peters and colleagues, authors of a recent editorial on smoking cessation and elective surgery,1 would do well to attend to the terms of the Commonwealth Disability Discrimination Act 1992. It is unlawful for a person who provides services, or makes facilities available, to discriminate against another person on the grounds of the other person’s disability.

It seems legitimate to consider the effects of smoking on success rates as part of deciding whether elective surgery is likely to be safe and effective for an individual patient. However, the editorial suggests that patients be denied surgery, such as joint reconstruction, as a resource-allocation decision, even if the surgery would be in their interests.

It is important that smoking is recognised as an addiction. Some groups, such as the mentally ill, are particularly prone to it. A study by the Harvard medical school found that people with mental illness are twice as likely to be smokers, and nearly 45% of all smokers in the United States are people with a “mental disorder”.2 To the extent that it is an addiction, smoking needs to be considered as a medical condition in much the same way as alcoholism is referred to as a medical condition.

A doctor who did not provide a needed treatment to a smoker on the grounds that the patient was a smoker would be in violation of that person’s fundamental human right to healthcare and his or her right not to be discriminated against because of a disability. In fact, the doctor would be in breach not only of the Hippocratic oath, but of the Australian Medical Association’s Code of Ethics 2004,3 which states “. . . refrain from denying treatment to your patient because of a judgement based on discrimination”.

In reply: The rigid way in which Hodgkinson has addressed risk reduction in plastic surgery seems reasonable, as long as there is open disclosure and access to smoking-cessation services is assured.

It is an unfortunate fact that our healthcare system cannot provide everyone with what they want, or need, in a clinically appropriate timeframe. Resources are finite. In his own case example, and without considering the legal or ethical basis of his intervention, once Tonti-Filippini arranged for a patient at high risk of complications to have surgery, someone else was immediately prevented from having hospital care that was necessary for them. If complications developed, extending hospital stay, more than one patient might have been adversely affected.

Let me extend Tonti-Filippini’s case a little and imagine that a similar patient with peripheral vascular disease who was moved further down the vascular surgery waiting list as a result of the smoker’s surgery being expedited was an ex-smoker who had taken advice and ceased smoking to reduce risks and improve the surgical outcome. Then, in the period of surgical delay, the affected leg became acutely ischaemic and amputation (rather than vascular reconstruction) was required. Are there not ethical implications that follow? Reading more deeply into the Australian Medical Association’s Code of Ethics, one finds that we should work to increase standards and the quality of and access to medical services in the community, and make available our special knowledge and skills to assist those responsible for allocating healthcare resources. These are important obligations.

Most smokers are addicted, and this is a medical problem that needs to be consistently identified and addressed; the issue of smokers with mental illness was highlighted in the editorial. If a clinical decision is made not to perform surgery in the context of continued smoking, it is not made because the person is a smoker, or because they have an addiction, but because the ongoing smoking has major, adverse consequences that we are unwise to ignore. The distinction is subtle but important.