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Rapid Responses: Rapid Responses published:
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How is effectiveness of emergency pill measured?
- Trevor G Stammers (8 March 2005)
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Progesterone contraceptives increase STI rates.
- Ellen C G Grant (9 March 2005)
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Re: How is effectiveness of emergency pill measured?
- Jamie S Robertson (9 March 2005)
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Is the smoking cessation worth cheating with research?
- Vasiliy Vlassov (10 March 2005)
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Health promotion and adolescent gambling : A neglected area
- Mark D Griffiths (18 March 2005)
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Trevor G Stammers, Senior Tutor in General Practice St George's Hospital Medical School, London SW17 0RE
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I am surely not the only reader to be bemused by Viner and Macfarlane's suggestion, in an otherwise outstandingly good ABC series so far, that making the emergency pill available over the counter (OTC) is a good example of "by far the most effective" type of health promotion - namely that by society as whole. The latest provisional figures for 2003 show that the rate of pregnancies in under-18s in England and Wales is 42.7 per 1000(1). Since the rate in 2001, when Levonelle went on OTC sale was 42.7, and in 2002 it rose to 42.8(1) a clearly effective trend is not evident to me. The likelihood of the Teenage Pregnancy Unit's targets for teenage pregnancy reduction being reached is not high on the figures to date. However, since the introduction of OTC emergency pills, rates of STIs in teenagers have continued to rise rapidly (2) and though, of course, association is not proof of causation, I warned of the possibility and nature of a causal link when the measure was introduced. (3) If what has happened since the introduction of OTC emergency pills is considered a success, what hope is there of truly improving the sexual health of Britain's teenagers? 1.http://www.statistics.gov.uk/STATBASE/Expodata/Spreadsheets/D8901.xls 2.http://www.statistics.gov.uk/CCI/nugget.asp?ID=721&Pos=1&ColRank=2&Rank=576 3.Stammers T Emergency contraception from pharmacists misses opportunity BMJ, May 2001; 322: 1245 Competing interests: None declared |
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Ellen C G Grant, physician and medical gynaecologist kingston-upon-Thames, KT2 7JU,UK
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Progesterone contraceptive increases in cervical cancer with were first published in 1968. The RCGP Oral Contraception Study reported increases in over 60 conditions including viral, bacterial and fungal infections in 1974. These were systemic, like chicken pox and bronchitis, and genitourinary, like pyelitis, cervicitis (which increased with progestogen dose), vaginitis, vulvitis, moniliasis and trichomonas.1 Vulvitis, genital ulcer disease, vaginal discharge, and candida vaginitis are significantly associated with HIV-1 seroconversion. Progesterone-based contraceptives, younger age, and race had an independently increase the numbers of cervicovaginal inflammatory cells in women infected with HIV-1.2 Simian immunodeficiency virus genital infection in macques were enhanced by progesterone implants compared with the rate of vaginal transmission in the follicular phase and the and disease course was more rapid.3 Progesterone-treated mice developed extensive genital ulceration when exposed to HSV2. Progesterone contraceptives, like Depo-Provera, increase the risk of sexually transmitted infections including chlamydia and a more seriously double of the risk of HIV.4-7 At an international conference on Women’s Health last year, progesterones were described as being more powerfully immunosuppressive than cortisol. The use of emergency over-the-counter progesterones by young women is of considerable concern to me. 8-10 Progesterone use is potentially disastrous. 1 The Royal College of General Practitioners Oral Contraceptives and Health. Oral Contraceptives and Health. London: Pitman Medical, 1974 2 Ghanem KG, Shah N, Klein RS, et al. Influence of sex hormones, HIV status, and concomitant sexually transmitted infection on cervicovaginal inflammation. J Infect Dis. 2005; 191 :358-66. 3 Marx, P. A., A. I. Spira, A. Gettie, et al. 1996. Progesterone implants enhance SIV vaginal transmission and early virus load. Nat. Med. 2:1084-1089. 4 Baker DA , Plotkin SA. Enhancement of vaginal infection in mice by herpes simplex virus type II with progesterone. Proc. Soc. Exp. Biol. Med. 1978; 158:131-134. 5 Kaushic C, Ashkar AA, Reid LA, Rosenthal KL.Progesterone increases susceptibility and decreases immune responses to genital herpes infection. J Virol. 2003 Apr;77(8):4558-65. 6 Baeten JM, Nyange PM, Richardson BA, et al. Hormonal contraception and risk of sexually transmitted disease acquisition: results from a prospective study. Am J Obstet Gynecol. 2001;185: 380-5. 7 Kaushic, C., F. Zhou, A. D. Murdin, and C. R. Wira. 2000. Effect of estradiol and progesterone on susceptibility and immune responses to Chlamydia trachomatis infection in the female reproductive tract. Infec. Immun. 68: 4207-4216. 8 Grant ECG. Levonorgestrel is hazardous http://bmj.com/cgi/eletters/329/7459/182#70964, 14 Aug 2004 9 Grant ECG. Hormonal contraceptives should not be OTC http://bmj.com/cgi/eletters/329/7459/182#71252, 17 Aug 2004 10 Grant ECG. OTC progesterones are dangerous http://bmj.com/cgi/eletters/329/7459/182#72260, 27 Aug 2004 Competing interests: None declared |
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Jamie S Robertson, Intercalating medical student University of Glasgow, G12
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Hear, hear. Or, as the headline on a satirical US website put it, "SHOCK - telling children how to have sex without falling pregant makes them do it more" :O) I did laugh, but it is an important point in our country's sexual health strategy - providing an 'easy way out' through such measures as OTC pills can often prove to be anything but. Competing interests: None declared |
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Vasiliy Vlassov, Director Russian Branch of the Nordic Cochrane Centre
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Dear Editor, In the health promotion field the interventions against smoking are very important. Unfortunately most data about smoking are from case control and cohort studies. Two recently published RCTs attract my attention because of their relatively high quality and biased reporting. One is a 30-month long smoking cessation (SC) RCT in women with severe cardiovascular conditions[1]. Authors found that SC was more frequent in the intervention group (p=0.038), but did not show the rates in the abstract. It is clear – why: The effect size was negligible. Simple calculations show that the all cause mortality was increased in the intervention group (hazard ration 2.4; p=0.0001). This effect was not discussed by authors and not noted in the rich media coverage. Second is the 14.5 year long RCT recently published and harvested the enormous media attention[2]. Authors stated that while SC rates were 22% and 5% (control group), “All-cause mortality was significantly lower in the special intervention group than in the usual care group (8.83 per 1000 person-years vs. 10.38 per 1000 person-years; P=0.03)”. It is strange that in the respected journal the statistical significance is called “significance”, especially when effect size (difference of rates) is absolutely negligible. These two reports are daunting illustrations of the misuse of the scientific argument for the wrongly understood common good. The absence or negligible size of the health improvement after SC in RCT is a fact which needs to be clearly formulated, discussed in detail and lead to new research of great importance. Reference List (1) Sivarajan Froelicher ES, Miller NH, Christopherson DJ, Martin K, Parker KM, Amonetti M et al. High rates of sustained smoking cessation in women hospitalized with cardiovascular disease: the Women's Initiative for Nonsmoking (WINS). Circulation 2004; 109(5):587-593 (2) Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE. The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial. Ann Intern Med 2005; 142(4):233- 239. Competing interests: None declared |
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Mark D Griffiths, Professor of Gambling Studies Psychology Division, Nottingham Trent University, Burton Street, Nottingham, NG1 4BU, UK
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I was interested to read the paper by Viner and Macfarlane (1) on health promotion in adolescence but was disappointed that no reference had been made to adolescent gambling as one of their "major health promotion areas in adolescence (p.527)." However, given that gambling as a public health issue amongst adults is only just being taken more seriously (2), it is perhaps unsurprising that adolescent gambling has yet to be incorporated along with drug and alcohol education in schools. Adolescent gambling is a major problem in society today. Not only is it usually illegal, but it appears to be related other activities such as illicit drug taking and alcohol abuse (3), and delinquency (4). A number of studies in Europe, the USA, Canada and Australia have noted high levels of gambling among adolescents. In some cases this is legal such as slot machine gambling in the UK (5) whereas other forms are illegal for youth such as casino gambling, video lottery terminals, and lottery purchases (6). There is, of course, a problem with the identification of adolescent problem gamblers in that there is no observable sign or symptom like other addictions (e.g. alcoholism, heroin addiction etc.). Although there have been some reports of a personality change in young gamblers (7), many parents may attribute the change to adolescence itself (i.e., evasive behaviour, mood swings etc. are commonly associated with adolescence). This is also one of the reasons that problem gambling has been described as the "hidden addiction" (2). It has been noted that adolescents may be more susceptible to pathological gambling (5). In the UK, a figure of around 5% level of pathological gamblers among adolescent fruit machine gamblers has consistently been found (8). Further studies in the UK, Canada and USA have revealed a general pathological gambling rate of five to six percent amongst the under 18 years of age group. This figure is two to three times higher than that identified in the adult population (9). Other factors that have been linked with adolescent problem gambling include working class youth culture, delinquency, alcohol and substance abuse, poor school performance, theft and truancy (5,8). This is therefore an area that should be taken seriously as a health promotion issue. Gambling has not been traditionally viewed as a public health matter (2,10) and research into the health, social and economic impacts of gambling are still at an early stage. According to Korn (11), the goals of youth gambling intervention are to (i) prevent gambling-related problems, (ii) promote informed, balanced attitudes and choices, and (iii) protect vulnerable groups. The guiding principles for action on youth gambling are prevention, health promotion, harm reduction, and personal and social responsibility. If the goal is to prevent the development of problem gambling in young people, Ferland, Ladouceur and Vitaro (12) claim an important first step in prevention may be simply giving adolescents the facts about gambling. At present, adolescent attitudes and views about gambling may be predominantly formed by the advertisements for gambling depicted in the mass media that present gambling as exciting and alluring. Such media portrayals may lead adolescents to believe that gambling is fun and exciting, and that gambling is an easy way to make money. By providing adolescents with a more realistic view about gambling, it may be possible to limit their interest in gambling and restrict their participation. At present, there are admittedly, more questions than answers when it comes to designing and developing adolescent gambling health promotion and prevention programs. However, this does not mean that adolescent gambling should not be considered as one of the major areas for health promotion work. References (1) Viner R, Macfarlane, A. Health promotion. British Medical Journal 2005; 330: 527-529. (2) Griffiths MD. Betting your life on it : Problem gambling has clear health related consequences. British Medical Journal 2004; 329: 1055-1056. (3) Griffiths MD, Sutherland I. Adolescent gambling and drug use. Journal of Community and Applied Social Psychology 1998; 8: 423-427. (4) Yeoman T, Griffiths MD. Adolescent machine gambling and crime. Journal of Adolescence 1996; 19: 183-188. (5) Griffiths MD. Adolescent Gambling. London : Routledge, 1995. (6) Giacopassi D, Stitt BG, Vandiver M. An analysis of the relationship of alcohol to casino gambling among college students. Journal of Gambling Studies, 1998; 14: 135-149. (7) Griffiths MD. Gambling in children and adolescents. Journal of Gambling Behavior 1989; 5: 66-83. (8) Griffiths MD. Gambling and Gaming Addiction in Adolescence. Oxford : British Psychological Society/Blackwells, 2002. (9) Shaffer HJ, LaBrie R, Scanlon KM, Cummings TN. At risk, problem and pathological gambling among adolescents : Massechusetts Adolescent Gambling Screen (MAGS). Cambridge, MA : Harvard Medical School, 1993.. (10) Korn DA. Expansion of gambling in Canada : Implications for health and social policy. Canadian Medical Association Journal 2000; 163(1): 61-64. (11) Korn DA. TeenNet Gambling Project. Paper presented at Discovery 2002 Conference, Responsible Gambling Council, Niagara Falls, April 2002. (12) Ferland F, Ladouceur R, Vitaro F. Prevention of problem gambling: Modifying misconceptions and increasing knowledge. Journal of Gambling Studies 2002: 18: 19-29. Competing interests: None declared |
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