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PAPERS: Martin J Jarvis, Jane Wardle, Jo Waller, and Lesley Owen Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study BMJ 2003; 326: 1061 [Abstract] [Full text]

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Where do we put scarce resources?

Gerry Waldron   (17 May 2003)

Hardcore smokers:“Social and Psychological staging” as important as TMN?

Michael O Oko, IRC Swan, LJ Clark Consultant Otolaryngologists, Prof.G Stansby,Professor of Vascular Surgery   (29 May 2003)

Where do we put scarce resources? 17 May 2003
Gerry Waldron, Cosultant in Public Health Medicine Northern Health & Social Services Board, County Hall, Ballymena, BT42 1QB Send response to journal: Re: Where do we put scarce resources?	Martin J Jarvis and colleagues have highlighted the interesting concept of "hardcore smokers". It is disturbing to note that, at 16% of all smokers studied, the prevalence of hardcore smoking in Britain is markedly higher than the 6% found in California. This must certainly be taken into account in devising and evaluating health promotion and smoking cessation programmes. However, I am not comfortable with Jarvis and colleagues' conclusion that "the current tendency to be more concerned about cessation in young rather than older smokers is misplaced". (This statement is somewhat stronger than the conclusion appearing in the paper version). Unless there is an evidence based intervention which will enable these "recalcitrant" hadcore smokers to quit in significant numbers (and neither the electronic nor paper version cites such an intervention)we would be advised to continue to target our efforts on the "non-hardcore" majority of smokers. In the present study 2 in 5 of these smokers had attempted to quit in the past year. It would be bordering on the perverse to shift scarce resources away from these people. Although this is probably not the authors' intent, it would be the logical conclusion of their proposed change in focus of smoking cessation policy. Competing interests:   None declared
Hardcore smokers:“Social and Psychological staging” as important as TMN? 29 May 2003
Michael O Oko, SpR Otolaryngology Southern General Hospital , Govan Glasgow, IRC Swan, LJ Clark Consultant Otolaryngologists, Prof.G Stansby,Professor of Vascular Surgery Send response to journal: Re: Hardcore smokers:“Social and Psychological staging” as important as TMN?	Response to: Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study (1) Dear Editor We would like to thank Jarvis et al for their interesting article that highlights some of the hardcore attitudes that many mature smokers have. We believe however, that the figure of 16% may be a significant underestimation of the size of the clinical problem, as many smokers will respond one way to questions at interview but in practice do the opposite. We think that this same group of hardcore smokers are the ones that present to us in Glasgow with late head and neck squamous cell carcinoma (T3-4) (2), have poor compliance with treatments, poor social conditions to return to after treatment, continue to smoke and hence increase their chance of recurrence. Identifying these patients, targeted screening, education and rehabilitation may well have a profound effect if this can lead to them presenting with early disease (T1-2) which has much better 5 year survival and cure rates. This is likely to have a significant effect on the overall five-year survival (which has remained unchanged in the last 25 years) while we await further improvements in cancer treatments. Currently we are validating a tool that we hope might help healthcare workers to quickly quantify a smoker into low, medium and high-risk categories. This would potentially allow a clear numerical identification of hardcore smokers as well as patients who are approaching this definition. This may be helpful for patients to modify their behaviour to reduce the risk from their habit. It may be possible in future to look at such “Social and Psychological staging” systems in addition to TNM staging to predict treatment outcomes and channel resources appropriately. Other clinicians dealing with the cardiovascular and pulmonary complications of long-term smoking will instantly recognise this group and their uniformly poor outcomes. 1. M. J Jarvis, J. Wardle, J. Waller, and L. Owen Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study. BMJ, May 15, 2003; 326(7398): 1061. 2. Vernham GA. Crowther JA. Head and neck carcinoma-stage at presentation.Clinical Otolaryngology & Allied Sciences. 19(2):120-4, 1994 Apr. Competing interests:   None declared