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Rapid Responses: Rapid Responses published:
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Defective and misleading: authors know EBM but overlook Single Patient Based Medicine.
- Sergio Stagnaro (4 February 2005)
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COPD v Emphysema
- James F Malone (4 February 2005)
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Let us redirect our efforts
- Anand B Palamarthy, CF64 2XX (6 February 2005)
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Governments need to act on tobacco industry misinformation on second-hand smoke
- Nick Wilson (7 February 2005)
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Cuba: A new ban on smoking follows Vineis et al paper
- Pedro O Ordúñez-García, Alfredo Espinosa Brito, Yanelis La Rosa Linares (9 February 2005)
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Prevention strategies for environmental tobacco smoke related prominent problems in the world
- Ediriweera B.R., Desapriya, Dr. Ian Pike, Assistant Professor Department of Pediatrics (10 February 2005)
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The need for education and public policies for second-hand smoking
- Nickolas Collins, Darshika Christie-David and Chih-Hung Kuo (2 March 2005)
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Is environmental tobacco smoke the real problem?
- Adrian K Watson (4 April 2005)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8. 16037 Riva Trigoso (Genova) Italy
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Sirs, In my opinion, once again, in this large piece of research (1) there is a common fundamental bias, now-a-days present unfortunately in all clinical researches. In fact, the authors investigated the association between environmental tobacco smoke, plasma cotinine concentration, and respiratory cancer or death, without considering that enrolled individuals, 303 020 people from the EPIC cohort who had never smoked or who had stopped smoking for at least 10 years, 123 479 of whom provided information on exposure to environmental tobacco smoke, are not “all” positive for Oncological Terrain, with “real risk” for lung cancer (2, 3). Actually, apart from the well-known negative influences of tobacco on health, as regards the importance of whatever risk factor (e.g., passive smoking) we have to consider the genetic predisposition of the single subject. As a matter of fact, to develop lung cancer people must be affected both by oncological constitution (Oncological Terrain) “and” real risk for lung malignancy (2, 4) (See web site HONCode, www.semeioticabiofisica.it.). As a consequence, the paper’s conclusions, “This large prospective study, in which the smoking status was supported by cotinine measurements, confirms that environmental tobacco smoke is a risk factor for lung cancer and other respiratory diseases, particularly in ex- smokers”, are certainly defective and misleading, because the authors know only EBM, but ignore Single Patient Based Medicine (5) (See above-cited web site, and Network of Competent Authorities Health Europe: website http://www.epha.org/a/355, “Planning for the EU public Health Portal” URL: http://www.google.it/search?q=cache:U5A- DtWmRDsJ:europa.eu.int/comm/health/ph_information/documents /ev_20030710_co01_en.pdf+single+patient+based+medicine+and+ stagnaro&hl=it&ie=UTF -8 Pg 36). 1) Vineis P., Airoldi LP., Olgiati L., et al.Environmental tobacco smoke and risk of respiratory cancer and chronic obstructive pulmonary disease in former smokers and never smokers in the EPIC prospective study. BMJ 2005;330:277 (5 February), doi:10.1136/bmj.38327.648472.82 (published 28 January 2005) 2) Stagnaro S., Istangiopatia Congenita Acidosica Enzimo-Metabolica condizione necessaria non sufficiente della oncogenesi. XI Congr. Naz. Soc. It. di Microangiologia e Microcircolaz. Abstracts, pg 38, 28 Settembre-1 Ottobre, Bellagio 3) Stagnaro Sergio, Stagnaro-Neri Marina. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 4) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico- Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Ediz. Travel Factory, Roma, 2004. 5) Stagnaro S., Stagnaro-Neri M., Single Patient Based Medicine.La Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Travel Factory SRL., Roma, in press. Competing interests: None declared |
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James F Malone, Retired home M28 1HH
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The article states that "14 died from Chronic Obstructive Pulmonary Disease or emphysema" I have Emphysema and consider it to be under the COPD unmbrella. The article I submit is confusing at a time when PCT's and Hospitals around the country are trying to highten the profile of COPD and widen the understanding of this condition. Regards. Jim Malone 24 Wyre Drive, Worsley, Manchester M28 1HH Competing interests: None declared |
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Anand B Palamarthy, locum sho Llandough Hospital, Cardiff, CF64 2XX
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The photograph on the BMJ issue showing the innocent child closing his eyes and mouth as a response to the smoke reflects the natural dislike of human body towards smoke. This natural dislike reflected on the child`s face is added on by an extensive evidence on the health hazards of passive smoking.Sufficient data to implicate passive smoking as a cause of lung cancer and coronary heart disease exists and a growing data implicating passive smoking as a cause of stroke is accumulating. Hence the need is for global urgent preventive and palliative measures. Various communities working on these issues may very well consider on those lines. I strongly feel on the following points: 1) Educating children in schools on health hazards of tobacco smoke. 2) Developing an antidote or a detoxifying substance to tobacco smoke or a vaccine against ill-effects of tobacco smoke. 3) More aggressive and a regular publicity blitz on ill effects of passive/active smoking. 4) More aggressive research to make smoke once exhaled to detoxify immediately in air. 5) Ready availability of smoking cessation clinics to those who want to stop smoking. 6) Also modifying National guidelines in terms of using nicotine patches or inhalers who were unsuccessful in the past to stop smoking. Lot of time and energies are being spent on doing various studies on looking at ill effects of tobacco smoke on which a lot of convincing data already exists.But if the same energies could also address some of the above stated issues,it may be worth an energy spent. Medical community should encourage every smoker to quit smoking and it would be worth saying "NO success is final,no failure is fatal" for a smoker in his efforts to stop smoking. Competing interests: None declared |
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Nick Wilson, Senior Lecturer (Public Health) Wellington School of Medicine, Otago University
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The study by Vineis et al [1] adds to the very substantive existing scientific evidence around the hazard posed by second-hand smoke (SHS) to health. The public health case for widespread government action to enact restrictions against indoor second-hand smoke is now extremely strong. However, governments should also be applying consumer protection law to stop tobacco industry misinformation on SHS. In various settings the industry continues to mislead the public. Consider, for example, the following statements on a company website in February 2005 [2]: “we don’t believe that it [second-hand smoke] has been shown to cause chronic disease, such as lung cancer, cardiovascular disease or chronic obstructive pulmonary disease, in adult non-smokers.” “the studies on lung cancer to date suggest that if there is a risk, it is too small to measure with any certainty.” Furthermore, the information on this company website can be seen to trivialise the threat of second-hand smoke by framing it as a “comfort issue” rather than a serious threat to health. Governments may find it difficult to tackle the multinational tobacco industry on the SHS issue by applying their consumer protection laws (though there are successful precedents as in Australia [3]). So there is a need for governments to work collectively against the tobacco industry at an international level. Strengthening the Framework Convention on Tobacco Control would be a good place to start. References 1) Vineis P, Airoldi L, Veglia P, et al. Environmental tobacco smoke and risk of respiratory cancer and chronic obstructive pulmonary disease in former smokers and never smokers in the EPIC prospective study. BMJ 2005;330:277-80. http://bmj.com/cgi/content/full/330/7486/277?etoc 2) British American Tobacco New Zealand. Environmental tobacco smoke. Auckland: British American Tobacco New Zealand. Accessed 4 February, 2005. http://www.batnz.com/oneweb/sites/BAT_5LPJ9K.nsf/vwPagesWebLive/ 80256D0B004C1BC780256ABE005B6B21?opendocument&DTC=20040414 3) Chapman S, Woodward S. Australian court decision on passive smoking upheld on appeal. BMJ 1993;306:120-2. Competing interests: None declared |
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Pedro O Ordúñez-García, MD. General Director Hospital Gustavo ALdereguía, Cienfuegos 55 100. Cuba, Alfredo Espinosa Brito, Yanelis La Rosa Linares
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EDITOR— Any effort of Cuba in terms of tobacco reduction should be accepted as more challenging than in any other country worldwide. Cuba, the world's best known cigar-producing country, as BBC defined1, has a special historical relationship to tobacco and suffers from relatively high smoking rates. A new ban on smoking recently initiated is focused on smoke-free policy and was designed to curb damage to people's health and contribute to a change in public attitudes. A ban moves in the direction of the Vineis et al paper on BMJ2, where the authors confirm that environmental tobacco smoke is a risk factor for lung cancer and other respiratory diseases, particularly in ex-smokers. Although Cuban icon is Havanos Cigars, within the country, however, cigarettes are used by 95% of regular smokers. Current rates of daily tobacco use are 40% among men, peaking at 60% in middle-age. At younger ages women have similar rates as men, however, there is little increase with age and the average prevalence is around 25%. There is some evidence of a decline in the last decade - in the same city the rates in 1992 were 44% in men and 33% in women.3 Just a day after the ban on smoking the Cuban people is wondering how the rule will be accepted by smokers and how public transport, shops and other closed spaces would become smoke-free. Cigarette smoking represents the most urgent challenge for Cuba and these new campaigns need the enthusiasm and vigor which have made other health interventions so successful. References: 1. Cuba, the world's best known cigar-producing country, has announced a ban on smoking in some public places. BBC news UK edition. Wednesday, 19 January, 2005, 17:21 GMT 2. Vineis P, et al. Environmental tobacco smoke and risk of respiratory cancer and chronic obstructive pulmonary disease in former smokers and never smokers in the EPIC prospective study. BMJ 2005;330:277. 3. Cooper RS, Ordunez P, Iraola-Ferrer M, et al. Cardiovascular disease and associated risk factors in Cuba: Prospects for prevention and control. Am J Public Health. In press. Pedro Ordúñez-García, MD..
Department of Internal Medicine, Hospital Gustavo Aldereguía Lima, Cienfuegos 55 100. Cuba. Competing interests: None declared |
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Ediriweera B.R., Desapriya, Research Associate Department of Pediatrics,BC Injury Research and Prevention- University of British Columbia-V6H 3V4, Dr. Ian Pike, Assistant Professor Department of Pediatrics
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Environmental Tobacco Smoke (ETS) contains toxic substances, over 40 of which cause cancer. Some of these substances are in stronger concentrations in second-hand smoke than they are in the smoke that goes directly into smokers’ lungs. Environmental Tobacco Smoke is a real and substantial threat to child health, causing death and suffering throughout the world. (1) The vast majority of children exposed to tobacco smoke do not choose to be exposed. This involuntary and harmful exposure can be seen as a human rights violation, given the provisions of Article 6 and 24 of the 1989 United Nations Convention on the rights of the Child. (1) Preventing children’s exposure to tobacco smoke will lead to improved child, adolescent, and ultimately adult health, resulting in reduced mortality and substantial savings in long term/short term health care and other direct costs. New strong regulations are necessary to protect children from exposure to tobacco smoke. These regulations should aim to ensure the right of every child to grow up in an environment free of tobacco exposure. In Canada all children under the age of 15, some 2.8 million children, are exposed to second-hand smoke on a regular basis. (2) ETS exposure causes a wide variety of adverse health effects in children, including lower respiratory tract infections such a pneumonia and bronchitis, coughing and wheezing, worsening of asthma, and middle ear disease. Asthma is the most common chronic disease of childhood, and environmental factors play an important role in determining both onset and severity. Children’s exposure to ETS may also contribute to cardiovascular disease in adulthood and to neurobehavioral impairment. Maternal smoking during pregnancy is a major cause of sudden infant death syndrome (SIDS) and other well-documented health effects, including reduced birth weight and decreased lung function. ETS exposure among nonsmoking pregnant women can cause a decrease in birth weight and that infant exposure to ETS may contribute to the risk of SIDS. A British study found that SIDS deaths could be reduced by two thirds if parents did not smoke. (3) Maternal smoking doubles the risk of sudden infant death syndrome. The relationship is almost certainly causal. (4) The published literature reports a 20% to 30% smoking rate among pregnant women. (5, 6) Smoking during pregnancy is a significant public health problem worldwide. Strong medical and legal interventions must be adopted for the women to stop smoking before pregnancy. A major, preventable exposure remains for infants throughout the world and health care providers should redouble counseling efforts toward reducing this exposure. The low success rate of smoking cessation among pregnant women in the literature suggests that efforts to reduce the complications of pregnancy attributable to tobacco use by pregnant women should focus on preventing nicotine addiction among youth and adolescents. Despite support from professional organizations and federal government groups, many pediatricians and family physicians do not routinely engage in intensive efforts to reduce children's ETS exposure. Training in techniques for reducing tobacco dependence should be included in professional education programs. Public and private insurance should reimburse providers for efforts in this area. (7) As a result of an effective intervention by pediatrics and family physicians in Sweden, maternal smoking during pregnancy has decreased from 24% to 10% during 1994-2004. (8) References: (1). Desapriya, E.B.R and Nobutada I., Shimizu, S., Political economy of tobacco control policy on public health in Japan. Japanese Journal of Alcohol Studies & Drug Dependence 38(1):15-33(2003). (2) Health Canada Environmental Tobacco Smoke (ETS) in home environments, Health Canada-Ottawa-Canada (1996). (3). Peter B., et al; Smoking and the sudden infant death syndrome: results from 1993-5 case-control study for confidential inquiry in to stillbirths and deaths in infancy.BMJ 313:195-198 (1996) (4).Anderson HR, Cook DG: Passive smoking and sudden infant death syndrome: review of the epidemiological evidence. Thorax 52:1003- 1009(1997). (5). DiFranza JR, Lew RA: Effect of Maternal Cigarette Smoking on Pregnancy Complications and Sudden Infant Death Syndrome. J Family Practice 40(4):385-394(1995) (6). Cnattingius S, Haglund B, Meirik O: Cigarette smoking as risk factor for late fetal and early neonatal death. BMJ 297:258-261(1988). (7). Klerman L.Protecting children: reducing their environmental tobacco smoke exposure. Nicotine Tobacco Res. 6 Suppl 2:S239-53(2004). (8). Alm B, Wennergren G, Erdes L, Mollborg P, Pettersson R, Aberg N, Norvenius SG. [Parents have accepted the advice on how to prevent sudden infant death] Lakartidningen. 1; 101(14):1268-70 (2004). (Article in Swedish) Competing interests: None declared |
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Nickolas Collins, Staff Specialist MACS Campbelltown Hospital 2560, Darshika Christie-David and Chih-Hung Kuo
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Darshika Christie-David and Chih-Hung Kuo
In acknowledgement of Dr. Nick Collins, Staff Specialist, Macarthur Ambulatory Care Service, Campbelltown, NSW EDITOR – In response to the article by Vineis et al(1), the EPIC study provides further evidence for the real harm associated with passive smoking. While medical attention has been drawn to this issue the public needs to be further informed. Just as there are government and community campaigns aimed at smokers to warn them of the detrimental effect of smoking, there should similarly be warnings for non-smokers to increase their awareness of the harm they are susceptible to because of their smoker acquaintances. The introduction of legislative restrictions against smoking in environments where non-smokers are highly susceptible to harmful health effects is vital to this cause. Public policy should be adopted to address the issue of passive smoking by perhaps firstly directing attention to the hospitality industry. Recently, this movement has become evident in Australia where the New South Wales and Victoria governments have introduced a law to ban smoking in pubs and bars. Such policy should be based on scientific evidence of the harmful effect of passive smoking, reinforced by several peripheral studies supporting the change. For example, one study demonstrates that designated smoking areas only provide a false sense of security and does not protect the patrons in designated non-smoking areas from the harm(2). Furthermore, the public support for banning smoking in pubs and clubs in Australia has increased after the Sharp case(3) where a non-smoking employee successfully established in court that her cancer was linked to years of working in a smoky bar. Opposition to such policy includes the potential financial impact on the hospitality industry, loss of tax revenue from tobacco and the violation of smokers’ right to ‘self-determination’. However, one study showed that restaurants in Australia that prohibited smoking were not affected in their operations by the change(4), and there is no evidence yet to demonstrate that the impending hospitality industries will be affected. The loss of tax revenue from tobacco might be compensated by the reduction of health expenses related to secondary smoking and wellbeing of the workers in bars and pubs. Ethically, adopting appropriate bans on smoking in pubs and clubs can be justified in terms of non-maleficence to non-smoking patrons and staff. Though the decision to ban people from smoking when and where they desire would deny them of their right to free will and autonomy, it would provide ethical public policy and promote optimal community health. It may also promote changes to social culture that has made smoking common-place in these environments and with existing campaigns directed at smokers encourage them to quit(5). Considering the current evidence, the introduction of public campaigns regarding passive smoke via such measures as prohibitions against smoking in hospitality industries is quite legitimate. In addition, the public has misconceptions about the health safety of enjoying designated non-smoker areas and there should be increased awareness about the real harm smokers are actually imposing on their fellow citizen’s health. 1. Vineis P, Airoldi L, Veglia F et al. Environmental tobacco smoke and risk of respiratory cancer and chronic obstructive pulmonary disease in former smokers and never smokers in the EPIC prospective study. BMJ 2005; 330: 277-80 2. Cains T. Designated "no smoking" areas provide from partial to no protection from environmental tobacco smoke. Tobacco Control 2004; 13(1): 17-22 3. Tzelepis F, Walsh R, Paul C. Community attitudes towards environmental tobacco smoke in licensed premises: Follow-up study after the Sharp case. Australian and New Zealand Journal of Public Health 2003; 27(5): 539-542 4. Chapman S, Borland R, Lal A. Has the ban on smoking in New South Wales restaurants worked? A comparison of restaurants in Sydney and Melbourne. MJA 2001; 174: 512-515 5. Fichtenberg C.M., Glantz S.A. Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ 2002; 325: 188-91 Competing interests: None declared |
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Adrian K Watson, Ocupational Hygienist Workplace Advice & Support Ltd, SO31 6LB
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Having read the article and table 3 in particular I note that hazard ratios for never smokers was 1.02 (95% CI 0.63 to 1.66) for respiratory disease and 1.05 (95% CI 0.60 to 1.82) for lung cancer, whilst it was 2.32 (95% CI 1.07 to 5.01) and 2.32 (95% CI 0.94 to 5.71) respectively in former smokers. This suggests to me that whilst a smoking ban will have an effect, the real effect is with ex smokers. Therefore the true lesson is that whilst stopping smoking is beneficial, it would be better to not have smoked in the first place as any exposure to ETS will reduce the benefit of not smoking. I would be interested to know if it was possible to examine the data to determine the size of the effect for exposure to ETS at home and in the workplace, both additively and separately for those who have never smoked Competing interests: None declared |
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