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EDITOR'S CHOICE: Richard Smith No spitting, no smoking BMJ 2003; 327: 0-g [Full text]

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we will if we want to

susanne stevens, N/A   (11 July 2003)

The Spitting Image

Jeremy G Jones, LL572PW   (12 July 2003)

Individual smoking rights versus public health

Ediriweera B.R., Desapriya   (12 July 2003)

No Spitting, Fine 40/-

colin mailer, solo   (12 July 2003)

Smoking increases mercury exposure in hospital workers-13 July, 2003

Phillip J. Colquitt   (13 July 2003)

Fashion

Peter N Wilson   (18 July 2003)

we will if we want to 11 July 2003
susanne stevens, retired cardiff CF24 3pf, N/A Send response to journal: Re: we will if we want to	In the park near where I live spitting is indulged in mainly by teenage boys, whether playing sports or not, it is quite common - but certainly not on buses.Sneaky cigarette smoking goes on there.Teenage girls are the main smokers. It is partly a bonding thing. Spitting is not mentioned in the latest critical report on the health services in Wales but a finger wagging is aimed at users of health services - 'People must take more responsibility for their own health.' This is not as easy as it sounds in the report.For example in this area women have had invitations sent out of the blue by a breast screening service after their details have been passed on by GPs, regardless of whether they have already made a decision. There has been no high quality information offered,of the sort described by the respondent in this issue, they are simply expected to attend. This attitude is quite common.Unless health messages are put across in ways which respect peoples' need for information and their right to choose it is doubtful whether the directives everybody is bombarded with today will be taken all that seriously.People will also carry on going on experience and anecdotal 'evidence' eg relatives who live to a hundred,smoked twenty cigs a day,lived on chips, drunk like fishes, never excercised in their life and were extremely happy. What about appointing somebody responsible for not just producing public information but also ensuring it is disseminated? Whenever yet another report is produced aimed at improving the health of the nation, or most often certain groups in the nation ,'the poor',the social class this or that,there should be high quality honest information provided including what findings the message is based ,references to research and opposing opinions. Some will ignore it, some who are as old as Richard Smith have seen health fads come and go, may decide to carry on putting dripping on their bread - and all decisions in between - as he says we do live in a democracy - of a sort. Competing interests:   None declared
The Spitting Image 12 July 2003
Jeremy G Jones, Consultant Rheumatologist Ysbyty Gywnedd, Bangor, Gwynedd, LL572PW Send response to journal: Re: The Spitting Image	Editor Smith, now that he is older, no longer sees "No spitting" signs and concludes that spitting is a highly deviant activity. One could debate whether this is so in the street, but television shows us that the habit is rife among our footballers; role model to the youth of the nation. While the copious volumes of spittle which are propelled so stylishly onto our playing fields will these days but rarely be crawling with tubercule bacilli, we now know it may contain herpes, hepatitis viruses, HIV and other nasties which may be infectious. Perhaps were Editor Smith younger he would be aware of the way the habit of spitting has become part of the behaviour code of modern youth. We will have to wait and see whether its resurgence produces an increase in infectious diseases. If it does we shall have to dust off our "No Spitting" signs. In the meantime perhaps we should start making spittoons again so they can take the place of the ashtray. Jeremy G Jones Competing interests:   None declared
Individual smoking rights versus public health 12 July 2003
Ediriweera B.R., Desapriya, Research Associate Centre for Community Child Health Research, 4480 oak Street, L408 Vancouver, British Columbia V6H 3V Send response to journal: Re: Individual smoking rights versus public health	Individual smoking rights versus public health of citizens Recent editorial by Martin McKee and Anna Gilmore1 criticize a decision by the Royal Victoria Hospital in Belfast to build seven smoking rooms for patients and staff at a cost of £500,000, and argue that the money would have been better spent on implementing a smoking ban at the hospital, and developing smoking cessation initiatives. As Smith2 pointed out ‘second hand smoking effect public health’ and moreover ‘ambivalence about smoking is still embedded in British society’. However McKee et al; 3 have argued that we should maintain hospitals’ smoking privileges. Totally smoke-free workplaces are associated with reductions in prevalence of smoking of 3.8 %.4 The figures from the review are startling and would make workplace smoking bans by far the most effective short term cassation strategy available to any policy maker. Not only smoking should be ban in the hospitals but also it is hospital workers’ social responsibility to support for ongoing education programs on dangers of second hand smoke, and nicotine addiction; strong community-based programs concentrating on strict clean indoor air laws and countering pro-tobacco influences in the society. It seems that when dealing with this sensitive issue hospital administrators usually yield to the pressure or consideration of the current political and economic environment rather than scientific evidence. It should be understand that protect lives of patients/citizens and political interest cannot be achieved simultaneously. Smoking zones equipped with large air cleaners have become commonplace in public spaces in our societies as the growing awareness over the ill effects of second-hand smoke has prompted non-smokers to demand stricter segregation of smokers. But in contrast to many users’ expectations, public health experts know that such air purifiers, both at homes and public spaces, cannot filter out the majority of hazardous substances in tobacco smoke. However, this is not widely publicized, the devises sold as air purifiers have a major limitation as they only reduce particulate matter, not gaseous substances. This makes such products ideal for reducing pollen and other airborne particles, but not for much of the toxic chemicals in tobacco smoke, most of which are gaseous. 1. McKee M, Gilmore A, Novotny TE. Smoke free hospitals. BMJ 2003;326: 941-2. 2. Smith R., No spitting, no smoking. BMJ 2003;327: 3. McKee, W., et al; Smoke free hospitals-Challenge nee to be faced. BMJ 2003;327:104 4. Fichtenberg, C., Glantz, S.A., Effect of smoke free work places on smoking behavior: systematic review. BMJ 2002;325:188 Competing interests:   None declared
No Spitting, Fine 40/- 12 July 2003
colin mailer, Minor Procedures St Joseph's Ivey Institute of Ophthalmology London, Canada, solo Send response to journal: Re: No Spitting, Fine 40/-	Dear Richard: Editor's choice reminded me of post-war Glasgow where the fine for spitting in that city was 40/- (forty shillings=2 pounds). As a medical student in Edinburgh, I realized that these people had to spit because they had "productive" bronchitis secondary to smoking, in spite of the fine.The coughing was terrible (smokers' cough) and what looked like carbon granules were visible on the chest fluoroscopes of smokers who lived in Glasgow, where environmental air pollution was really high, not to mention the River Kelvin which stank on its way to the River Clyde through Kelvingrove Park. At Edinburgh med school 2nd year, I recall the supervisor__a tall thin gentleman__ in the Medical Reading Room indulging in a "civilised" cigarette when the MRR closed (at 10 PM), while at the Royal Medical Society(RMS) at 7 Melbourne Place, the President and First Secretary would smoke, as their privilege, during the proceedings. Noone else was permitted to smaike and all smoking in the RMS was banned when Doll and Bradford Hill's Articles describing the relationship with Lung Cancer appeared around 1955. I think we were lucky to hear the message at an impressionable age. The rest of the people are finally realizing that smoking is really dangerous and does shorten life. colin Mailer, ophthalmologist London,ON Competing interests:   None declared
Smoking increases mercury exposure in hospital workers-13 July, 2003 13 July 2003
Phillip J. Colquitt, Technical Advisor Self-employed Send response to journal: Re: Smoking increases mercury exposure in hospital workers-13 July, 2003	Roels at al [1], in 1982, found that smoking during the work shift increases mercury [Hg] vapour exposure for workers in traditional Hg using industries. There is no reason to expect otherwise is the case for health care workers in both medical and dental settings, as these workers are often casual about Hg handling hazards. Death of a 19-year-old student nurse was reported by Popper [2] in 1966, six years after unreported breakage of a Hg thermometer. Hg from the broken thermometer was accidentally implanted into the tissues of the left hand, as the thermometer was shaken down. The nurse was twice subjected to lung surgery during the six-year period, and mercury emboli were found in her lung tissue, though Hg was not seen on radiological exam. Despite this, LJ Goldwater, in his classic Hg text of 1972[3], made mere humour of Hg thermometer associated hazards, based purely on fictional satirical work [4]. Two decades after Popper, in an identical incident, which was both reported and monitored [5], a nurse was diagnosed with amyotrophic lateral sclerosis, and left tetraplegic seven years after accidentally implanting Hg into her left hand while shaking down a thermometer. Surgical removal of the Hg was unsuccessful. Soft tissue injury incidents via Hg thermometers are not rare [6], merely not reported. Frykholm [7], in 1957, showed that the dental nurse is far more exposed to mercury than is the dentist. Knapp [8], in 1963, warned of hazards of handling Hg for dental workers (giving special mention to smokers). Nevertheless, Cook and Yates [9], in 1969, reported the death from Hg poisoning of a dental assistant who’d worked for decades without symptoms. Choi-Lao et al [10], in 1979, identified sphygmomanometers and thermometers as the main source of Hg vapour in hospitals. Choi-Lao [11] subsequently and in the same year, relegated nurses to a role of managing Hg spills for the benefit of the “environment”. Nurses have virtually been omitted from rightful consideration in other investigations of Hg exposure of workers in the hospital environment [12]. This journal, as recently as 1999, described mercury poisoning of a child via a hospital supplied sphygmomanometer[13]. Two subsequent in- hospital Hg self-poisonings, both in mentally unwell patients, were caused by the unnecessary presence of Hg sphygmomanometers [14,15]. Hypertension experts have been influential in perpetuating the dreaded, leaky, unsafe, unlabelled Hg sphygmomanometer. But recent high ranking validation of an aneroid** device[16], together with the admission of Hg equivalence of aneroid blood pressure readings[17], means Hg exposure of hospital workers is now even less tolerable. The above information indicates a casual attitude to Hg containing instruments among hospital workers. Smoking, with it’s attendant inhalation of vapour from that which is transferred to the cigarette(Hg) via the individual’s Hg exposed hands, increases the existing exposure to Hg for workers using thermometers and sphygmomanometers. To offset Hg ingestion via hand to mouth route in smokers, "spitting rooms" are not the answer. Phillip J. Colquitt, Independent Technical Advisor, New Farm, Queensland, Australia. **Aneroid means “without water”(Greek), meaning without liquid Hg in the case of the aneroid device. PS. Please feel free to comment on any errors. References: [1] Roels H, Lauwerys R, Buchet JP, Bernard A, Barthels A, Oversteyns M, Gaussin J. Comparison of renal function and psychomotor performance in workers exposed to elemental mercury. Int Arch Occup Environ Health. 1982;50(1):77-93. [2] Popper L. [Death following injuries by a thermometer]. Wien Med Wochenschr. 1966 Sep 17;116(38):779-80. [Note: though this article is in German, non-German readers can find an English version of the article in Canad. Med. Ass. J. Jan. 14, 1967, vol 96 p8 Absract]. [3] Goldwater LJ. Mercury: a history of quicksilver. Baltimore : York Press 1972. [4] Hiebert PG. 1947. Sarah Binks – Sweet Songstress of Saskatchewan. Oxford University Press. [5] Schwarz S, Husstedt I, Bertram HP, Kuchelmeister K. Amyotrophic lateral sclerosis after accidental injection of mercury. J Neurol Neurosurg Psychiatry. 1996 Jun;60(6):698. [6] Rachman R. Soft-tissue injury by mercury from a broken thermometer. A case report and review of the literature. Am J Clin Pathol. 1974 Feb;61(2):296-300. [7] Frykholm KW. On mercury from dental amalgam. Its toxic and allergic effects and some comments on occupational hygiene. Acta Odontol Scand 1957;15(suppl 22):1-108. [8] Knapp DE. Hazards of handling mercury. JADA 1963; 67 July:59- 61. [9] Cook TA, Yates PO. Fatal mercury intoxication in a dental surgery assistant. Br Dent J. 1969 Dec 16;127(12):553-5. [Note: On 11 July 2003, this article was available free and full text online at http://www.geocities.com/ResearchTriangle/2888/dentalasst.html ] [10] Choi-Lao AT, Corte G, Dowd G, Lao RC. Mercury vapour as a contaminant of hospital environment. Sci Total Environ. 1979 Apr;11(3):287 -92. [11] Choi-Lao AT. The nurse's role in minimizing mercury vapour exposures in hospitals. Occup Health Nurs. 1979 May;27(5):24-6. [12] Colquitt PJ. Labelling All Sphygmomanometers. CMAJ eLetter responses; 13 January 2003. Available free online at:- http://www.cmaj.ca/cgi/eletters/168/1/78 Accessed on 12 July 2003. [13 ] Rennie AC, McGregor-Schuerman M, Dale IM, Robinson C, McWilliam R. Mercury poisoning after spillage at home from a sphygmomanometer on loan from hospital. BMJ. 1999 Aug 7;319(7206):366-7. [14] Shareeff M, Bhat YM, Adabala R, Raoof S. Shortness of breath after suicide attempt. Chest. 2000 Sep;118(3):837-8. [15] Baddi L, Ray D. An unusual nosocomial pneumonia.Chest. 2002 Sep;122(3):1077-9. [16] Reinders A, Jones CR, Cuckson AC, Shennan AH. The Maxi Stabil 3: validation of an aneroid device according to a modified British Hypertension Society protocol. Blood Press Monit. 2003 Apr;8(2):83-9. [17] Jones DW, Appel LJ, Sheps SG, Roccella EJ, Lenfant C. Measuring blood pressure accurately: new and persistent challenges. JAMA. 2003 Feb 26;289(8):1027-30. Competing interests:   Mercury exposure
Fashion 18 July 2003
Peter N Wilson, GP West London North End Medical Centre W14 9NP Send response to journal: Re: Fashion	A corollary of Richard Smith's joy in spotting long term trends with age is the old saying fashions come and fashions go. Alongside Richard's piece is another of the excellent POEMs. But wait a minute what does it say? The succesful suicide rate is 0.76 on tricyclics, 0.59 on SSRIs and just 0.45 on placebo. The "Bottom Line" is said to be that suicide rates are unaffected by choice of antidepressant. The authors "speculate" the low suicide rate on placebo is due to a short period of treatment. Well mightn't the headline in the Sun be "Antidepressants increase suicide rate by over 33% shock!"? And haven't we just heard talk that in preclinical testing SSRIs may have increased suicide feelings in even non-depressed patients, apparently in unpublished drug company trials? I seem to remember numerous articles recommending HRT as reducing heart disease and if there was any more breast cancer it was just easier to treat ones anyway. I thought it was funny when the pill seemed to be the opposite. And now it turns out it was bad for you afterall. The BMJ makes great claims with its no conflicting interests statements but it seems to me the greatest coflict if interset is simply to be working in the field. After all you arent going to get any research grants and your salary if you don't show anything new. Plus ca change.... Competing interests:   None declared