Denial of hepatic transplantation on the basis of smoking: is it ethical?

There is disagreement and inconsistency between liver transplant programs regarding the acceptance or rejection of smokers as candidates for transplantation. This article reviews the outcome data for transplanted smokers, the rate of maintained abstinence from cigarettes by smokers who have quit and the ethics of using tobacco use as a transplant selection criterion.

Consistent with earlier studies, recently published articles continue to demonstrate an increased risk of noncutaneous malignancies, higher rates of graft arterial thrombosis and a higher mortality rate in liver transplant patients who smoke as compared with nonsmokers. There is a significant rate of relapse to smoking after transplantation, and the rates are higher among patients with alcoholic liver disease. Recent studies have shown that 10-16% of patients with biochemical verification of active smoking deny their tobacco use when interviewed for transplant consideration. Although extensively, if not universally, used to exclude transplant candidates, a recent study of marijuana use showed no difference in mortality outcomes as compared with nonusers.

With the exception of one recent study, there is substantial literature to support increased morbidity and mortality among posthepatic transplant smokers.