Canadian Medical Association Journal 1996; 154: 228-229
In the 25 years since I entered medical practice, I have tried to understand what drives tobacco addiction in individual patients and to comprehend the larger picture. A few years ago I wrote to the premier of New Brunswick, proposing a study to determine whether the sale of tobacco represented an overall financial gain or loss to society. He replied that we study things to death, and since smoking is bad we should simply get on with the job of dealing with the problem.
Another time I asked a national medical organization to which I belong to make a public position statement on the sale of tobacco to Canadians, but the idea died on the table.
What issues do we need to debate? Not that smoking tobacco will cause disease and death -- we already know this. And not that second-hand smoke is bad -- we know this too. Most current smokers would like to quit if they could -- this too is obvious. In fact, when talking to a patient a physician only has to say: "I presume you know how bad smoking is for you." Almost all patients will reply in the affirmative.
So the questions we have to come to grips with do not concern the impact of smoking on health -- what we need to deal with are questions about the role of tobacco in the economy, about the pursuit of pleasure, and about the concept of shared versus individual responsibility for the consequences of nicotine addiction.
Recently a younger colleague asked me whether he should send a heavy smoker, who had vowed that he would never quit smoking, for bypass surgery. (The question likely was prompted by media reports of British cardiac surgeons who denied such surgery to patients unless they would quit smoking.) The answer was yes, he should send the patient -- not because it would offer any long-lasting benefit to a patient who continued to smoke, but because in our publicly funded health care system there are no constraints on the medical services a Canadian should receive.
The unwritten policy, if it can be called that, seems to be that as long as smoking is legal and sanctioned by the government, no restrictions will apply to the provision of costly medical services of limited benefit to smokers.
Here is what I think our society says to Canadians: "You can do anything to your body that you like, for we have an open-ended health care system with no constraints on expenditures on the individual patient. Why not go ahead and see just how sick you can make yourself, and then come to us to be put back together. And if we can't restore you to health, then the state will look after you and you will never have to worry again."
I wonder what message Canadians received when the Supreme Court recently ruled that advertising provisions of the Tobacco Products Control Act were unconstitutional. Or when the tax on tobacco products was rolled back in an effort to stop smuggling by making cigarettes more affordable. Or when, at the end of November, Health Minister Diane Marleau refused to consider regulating tobacco under the Hazardous Products Act, even though it kills 45 000 Canadians a year.
Perhaps we need a reality check on our largesse concerning smoking-related diseases. Might not a little tough love be in order, as Dr. Allan Taylor suggested in a widely publicized letter to CMAJ several years ago (Taylor GA: Tobacco bill in jeopardy without MD support. CMAJ 1988; 138: 98)? Or maybe we simply need more public determination to strengthen antitobacco measures and reduce the smoking rate.
For many years I thought that when the cost of providing health care to smoking victims was taken into account, tobacco sales were a net financial drain on the economy. However, a recent estimate suggests that because smokers die earlier, the pension obligation of industry and the state is reduced and thus cancels out any increased cost of health care services related to smoking, thus making tobacco use a revenue-neutral issue for government.
If this is true, one cannot make a financial argument against the sale of tobacco. It does not take a cynic to recognize the number of people in agriculture, manufacturing, sales, the health care industry and the funeral business who benefit from the sale of tobacco.
But as our health care system comes apart, other questions come to mind. Can we continue to offer unlimited and shared liability for the consequences of tobacco addiction? Is it fair for those who have never smoked to shoulder the ever-increasing cost of caring for those afflicted with diseases caused solely by their addiction?
Perhaps we are not yet ready for such questions, but given the concerns about our finances and the future of health care, such questions will soon have to be aired in a public forum.
This month's National Non-Smoking Week is a laudable endeavour, but even though it has been observed for many years it has done little to solve the problem of tobacco use -- a problem that is growing among our young people. Perhaps we should use this time not just for boosterism, but also for contemplation and reflection. Maybe there is someone in some corridor of power who will have a bright idea that initiates some new thinking about the role of tobacco in society.
Certainly some Americans seem to be taking the lead in the offensive against the tobacco industry, which they are trying to challenge over the death and destruction caused by the sale of tobacco (see Class-action suit targets tobacco companies. CMAJ 1995; 153: 1632).
In Canada, unfortunately, our ambivalence toward the problem and our tolerance of the status quo are embarrassing national traits.
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