An increasing number of NHS clinics that provide assisted reproduction technologies (ART) are denying treatment to women who smoke or have a partner who smokes. But is it appropriate for any lifestyle factors to be used to deny state-funded treatment? And where should the line be drawn between medical 'advice' and 'restrictions'?
Along with body mass index, smoking is just one of the lengthening list of additional criteria being applied as a condition for women accessing such services. Many clinics require evidence of smoking status, either in the form of carbon monoxide tests or written proof from the professional running their smoking cessation group to say the person has attended and given up smoking.
Despite the fact National Institute for Health and Clinical Excellence (NICE) guidance does not specify those undergoing IVF should be non-smokers, many PCTs now stipulate this as a requirement. This was highlighted in the All Parliamentary Group on Infertility report, 'Holding back the British IVF revolution' (1), published in June 2011. In Wales, the Health Commission stated in 2008 that both the woman and her partner must have stopped smoking at the time of treatment. The rationale given for such changes to the NHS provision of ART to non-smokers is the medical evidence that smoking significantly reduces the success rate of assisted reproduction. A useful meta-analysis of this research was published by Waylen and colleagues in 2009 (2), demonstrating that smoking in women has a significant negative effect on the clinical outcomes of ART. They conclude that this evidence should be presented to actively smoking women seeking any form of ART, with the clinical advice that the woman should quit smoking before treatment. However, the review found conflicting evidence on the effect of male smoking and clinical pregnancy rates, and no evidence of a significant effect upon either live birth rates or fertilisation rates.
But is the increasing application of smoking as a criterion for the provision of ART on the NHS due to the research evidence? There has been a proven relationship between the success of ART and women smoking for several years (3), yet the requirement of being a non-smoker has been increasingly applied throughout the NHS. Some might argue that the clinical findings are the rationale for such restrictions.
However, I feel that the extension of this evidence from medical 'advice' to a denial of services is being used as a pretext for the rationing of provision. Those deemed appropriate for treatment on the NHS are those seen as most deserving because they are prepared to improve their chances of success by changing their lifestyle or behaviour. The undeserving, who are not prepared to change their lifestyles forfeit their chance of having a child or expanding their family. A useful by-product of such criteria is the improvement in individual clinics' success statistics, which is always helpful in a climate where funding is in short supply.
The NHS Choices website states that 'the NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. That principle remains at its core. With the exception of charges for some prescriptions and optical and dental services, the NHS remains free at the point of use for anyone who is resident in the UK'. It seems that for ART, and an increasing number of other health services, if you smoke this is no longer true. Effectively this policy ensures that those in lower socioeconomic groups are more likely to be denied access to such treatments, as they have higher rates of smoking (4) and less means to use private providers when NHS funding is not forthcoming.
As research progresses, an increasing number of lifestyle factors are being identified as having an impact on the success of ART. For example, some studies have shown that the success of IVF can be profoundly affected by caffeine intake (5), and such influences are often discussed with couples in pre-treatment counselling. Whether these lifestyle factors become barriers to ART access on the NHS depends upon the prevailing moralism rather than the behaviour itself.
The most insidious aspect of implementing restrictions around smoking is the way that the relationship between health professionals and patients is distorted into one in which the practitioner has to 'police' the patient's lifestyle. It would be normal to expect a discussion about the possible impact of various lifestyle factors on the potential effectiveness of ART, and many women and couples eager to maximise the chances of having a baby would give up smoking. They may also welcome any support from NHS services, and engage in an honest and open discussion about how they might best achieve these goals.
By advising women and couples about the impact of smoking on ART and supporting those who wish to quit, health professionals make a positive contribution and could help them have a healthy child. However, a subtle but dangerous line is crossed when health practitioners are forced to go beyond advice by seeking to confirm that the 'desired behaviour' has been achieved before treatment is made available.