Active smokers should not be denied access to lung transplantation

International society consensus statements, health insurance policies, and individual transplant programs almost uniformly consider active cigarette smoking an absolute contraindication to lung transplant. This denial is typically supported on utilitarian grounds-active smokers are prohibitively high-risk because of anticipated poor long-term survival-or nonutilitarian grounds related to fairness in resource allocation to smokers. However, the available literature on lung transplant recipients who resume smoking posttransplant does not demonstrate increased mortality. At the same time, other conditions that carry significant short and long-term posttransplant mortality, such as retransplantation, are considered relative contraindications. I also suggest that arguments regarding responsibility and fairness do not support the exclusion of active smokers. Patients with lung disease from other ongoing inhalational exposures, including avian antigens in chronic hypersensitivity pneumonitis, are not automatically excluded from transplant. I argue that active smokers are stigmatized, leading smoking to be treated as an inappropriate proxy for nonadherence. I suggest that the lung transplant community should treat active smoking as a relative, not absolute, contraindication to transplant. Transplant program policy should be revised to improve access for active smokers, particularly those who are in urgent need of a transplant and who will not survive long enough to demonstrate smoking abstinence.