Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Personal View of Smoking
- Bhavesh C. Gohil (6 July 2007)
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"Managing smoking cessation" driven by commercial interests of pharmaceutical industry ?
- Manfred Neuberger (8 July 2007)
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Isn't prevention better than cure??
- Rajasree R pai, 695011 (10 July 2007)
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Spin is a poor Substitute for Science
- Andrew J Ashworth (11 July 2007)
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Smoking: Management of curtailing smoking by educating adolescents universally
- Urban J.A D'Souza (12 July 2007)
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Responses to correspondents
- Paul Aveyard, Robert West (18 July 2007)
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Tobacco and oral health
- Eduardo M. Curbeira Hernández MDD, Moisés A. Santos Peña MD, Enrique Castillo Betancourt MDD, Juana Hernández Fernández MsC (20 July 2007)
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Exclusion of Psychiatric Patients
- Mohammad S Rahman, Lola Aderogba, SpR in Psychiatry (22 July 2007)
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Bhavesh C. Gohil, Foundation Year 2 Queens Hospital, Rom Valley Way, Romford, RM7 OAG
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I returned back from Australia last August. On my return I felt I had been accustomed to the norm of the smoke free environment. I was delighted to hear about banning of smoking in public enclosures and work places which commenced on July 1st 2007. It will ensure that bars, cafes, pub and clubs have to comply with this rule. Public venues outdoors are exempt from this. The rest of the UK has already successfully implemented this over the last two years. It was clear the differences in bars/clubs/cafes in Australia whereby you would never have to endure the passive inhalation of these noxious fumes or suffer from the occasional accidental cigarette burn and not to mention the trail of cigarette smoke that lingers on all. It is interesting how the trends have changed over tome. How often on history taking from the elderly population do they reveal that they are ex -smokers and on further questioning – their response for why they initially took it up was ‘you weren’t deemed a man in those days if you didn’t’. The trends have considerably changed especially since the work of Sir Richard Doll and his work confirming the link with lung cancer in the 50’s and plus the banning of cigarette smoking on televisions in the 60’s. The 90’s saw the glamourising of smoking by ‘cool’ movie stars on film which arguably has been a negative influence on the younger generation. Hopefully this new law will be considered another milestone in years to come. There will be plenty of benefits which will be seen and clearly there will be a significant effect on reducing risk factors for ishaemic heart disease, various cancers and chronic obstructive heart disease. It will clearly also benefit those patients who regularly inform us that they no longer smoke except occasionally when in a bar. The other side of the argument would suggest that this is breaching ones civil liberties and where would this end – alcohol, fatty foods…. Interestingly some venues are attempting to tackle a decrease in forecasting takings by applying for licensing outdoors. My personal thoughts are why has it taken so long and 1st July 2007 could be a historic day for our nation’s health! Competing interests: None declared |
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Manfred Neuberger, professor, department of preventive medicine, medical university of Vienna Kinderspitalgasse 15, A-1095 Wien, Austria
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Aveyard & West state that the Allen Carr Easyway method showed abstinence rates similar to those expected from behavioural support alone, quoting (1) instead of the two cohort studies mentioned. They omit two studies which found persistent abstinence in half of the cohort, part of which had tried NRT before and failed (2,3). Even more serious is the omission of fetal risks from NRT during pregnancy which have been reviewed recently (4). 1) McRobbie H, Hajek P, Bullen C, Feigin V. Rapid review of non-NHS treatments for smoking cessation. 2 Feb 2007. http://guidance.nice.org.uk/page%20aspx?o=404436 2) Hutter HP et al. Smoking cessation at the workplace: one year success of short seminars. Int Arch Occup Environ Health 2006;79:42-8. 3) Moshammer H & Neuberger M. Long term success of short smoking cessation seminars supported by occupational health care. Addict Behav 2007;32:1486-93. 4) Ginzel KH et al. Nicotine for the Fetus, the Infant and the Adolescent? Journal of Health Psychology 2007;12:215-24. Competing interests: None declared |
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Rajasree R pai, Junior Resident Dr SMCSI MCH, 695011
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The article has made a good attempt to point out the benefits of quitting smoking and the problems associated with it. But why can't the governments think of banning smoking altogether rather than promopting manufacturers to display messages like smoking is injurious. We should strongly advice against marketting of cigarettes and ban smoking in all public places, trains, buses, hotels, educational institutions and offices. Anyone selling them also should be warned against it. Competing interests: None declared |
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Andrew J Ashworth, GP Davidson's Mains Medical Centre, EDINBURGH, EH4 5BP
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Smoking is a behaviour that is a consequence of Nicotine Addiction. Self-injection is a behaviour that is a consequence of Heroin Addiction. In the latter (less common and, arguably, less dangerous addiction) various strategies are used for treatment with harm reduction and maintenance therapies commonly available in addition to detoxification (1). Aveyard and West’s review, in common with most of the medical literature, considers nicotine cessation as being synonymous with smoking cessation. For Cardiovascular disease this is probably a reasonable assumption, but in respiratory disease where the evidence does not support an aetiological role for the nicotine component of cigarette smoke, smoking cessation and abstinence from nicotine are separate, if related entities. For patients with COPD who are unable to stop smoking there is a raft of evidence that continued smoking behaviour will hasten their demise but none to support or undermine the practice of prescribing nicotine substitution on a long term basis reflecting the practice of giving Methadone to those who cannot manage to avoid self-injection without prescribed opiates. It would appear that our professional approach to smoking behaviour is based on a political rather than a scientific thesis, as emphasised by the publication of figure 2 in this review. Though the word “if” appears in the subtext, the reference from the main text suggests making a “real” effect, as does the labelling of the axes as historic fact without any reference to evidence. That this figure has made it past the reviewers and the BMJ Editors indicates that, in the medical profession, anti-smoking spin has the edge on the science of addiction. 1. Drug Misuse and Dependence – guidelines on Clinical Management 1999. HMSO Competing interests: I have proposed that Addictions have a common psychological and neurochemical basis |
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Urban J.A D'Souza, Associate Professor School of Medicine, UMS Malaysia
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Every established smoker started his/her smoking habit at a very tender age in the teens. As mentioned by other authors, mostly this smoking habit is initiated as a fun or enjoyment practice in addition to life stress. Nicotine hunger can be quenched only by substantiating with nicotine and however a smoker tries to quit smoking, brain chemistry results in unpleasant physical symptoms and mood which further draws a smoker to end up in fulfilling the nicotine hunger by lighting a cigarette. Most of smokers take New Year resolution of quitting smoking but brain chemistry does not permit for the same. What is the solution? As per the WHO norms” Prevention is better than cure" for every health problems, it must be true for smoking. Since smoking starts at an adolescent age in every individual, stern action must be taken against the teen-practice of smoking internationally. Instead of becoming a life long smoker, stern action as well as education to the society may bring down the percent of future smokers in the world. Impact of educational videos and films with smokers suffering in a broad way may create awareness among the teen children and help in stopping any smoking practice. This needs a universal policy by the government to implement educational series on bad habits of smoking in every school. Competing interests: None declared |
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Paul Aveyard, NIHR Career Scientist Department of Primary Care, University of Birmingham, Birmingham B15 2TT, UK, Robert West
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Pai and D’Souza ask if prevention is better than cure. This is a false dichotomy. If health care professionals can help smokers stop, this will save many millions of lives around the world in the next forty years. If public health interventions can prevent smoking uptake, this will save many lives in the latter half of this century. The evidence that specific preventative interventions for adolescent smoking are effective is weak, however1-3. Encouragingly, there is reasonable observational evidence that young people respond by giving up or not taking up smoking when adults around them stop4;5. It may be that cessation acts as a form of prevention. Neuberger questions our conclusions on the Allen Carr Easyway. As he points out, the observational data on abstinence rates are contradictory. This illustrates the difficulty of judging the efficacy of interventions without clinical trial data. Drug companies would not be permitted to make the claims of effectiveness made by Allen Carr Easyway without having funded independent clinical trials. Allen Carr Easyway should fund such trials. Neuberger also suggests that we ignore evidence of the harm from nicotine replacement therapy (NRT) in pregnancy. We believe the literature is insufficient to show whether NRT is completely safe and there is still insufficient evidence of its efficacy in pregnancy to confidently recommend it. However, based on clear evidence of its efficacy in non-pregnant populations6, and based on clinical reasoning that a lower dose of nicotine from NRT7 is safer than a higher dose with additional toxins from cigarettes, there should be a presumption of use in pregnancy. The UK drug regulatory authority also concluded this. Ashworth emphasises the value of long-term replacement of cigarettes by clean nicotine. Around a quarter of all long-term abstainers from cigarettes continue to use NRT for at least a year8, and in clinical practice you see people who have used it for many years. Furthermore, there is evidence that long-term use is more likely with the most rapid acting and therefore probably most rewarding products8, and that long-term use is more likely in those who, at baseline, were assessed as the most dependent upon cigarettes8. In a randomised trial of active versus placebo nicotine gum, long-term use was much more common in those given active gum9. This is strong circumstantial evidence to support Ashworth’s contention that long-term nicotine maintenance therapy is beneficial. Unlike Ashworth, we see no reason to be cautious about this in patients with stable cardiovascular disease, and the UK drug regulator agrees. However, there is scant evidence from clinical trials that long-term use of NRT is effective in preventing relapse10, which is why we could not recommend practitioners to consider this as a routine strategy. Our personal advice to abstinent smokers who feel they would resume smoking without long-term NRT is to continue NRT. We therefore suggested research to substantiate the efficacy of long-term NRT as a priority. We could not fully understand Ashworth’s point about spin. Nearly half of all smokers attempt to stop each year and the large majority fail. Very few use optimum treatment combinations. If doctors and others supported these attempts, more would succeed and sooner than otherwise and the majority of one-time smokers would cease. We feel we provided a strong scientific case for this. We recognise clinically that there may be some smokers who cannot stop, despite repeated efforts with best treatments. For these smokers, science has little to offer at the moment, which is why we recommended harm reduction as a research priority. Reference List (1) Sowden A, Stead L. Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews: Reviews 2003 Issue 1 John Wiley & Sons, Ltd Chichester, UK DOI: 10 1002/14651858 CD001291 2003;(1). (2) Thomas RE, Baker P, Lorenzetti D. Family-based programmes for preventing smoking by children and adolescents. Family based programmes for preventing smoking by children and adolescents Cochrane Database of Systematic Reviews: Reviews 2007 Issue 1 John Wiley & Sons, Ltd Chichester, UK DOI: 10 1002/14651858 CD004493 pub2 2007;(1). (3) Thomas R, Perera R. School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews: Reviews 2006 Issue 3 John Wiley & Sons, Ltd Chichester, UK DOI: 10 1002/14651858 CD001293 pub2 2006;(3). (4) Alamar B, Glantz SA. Effect of increased social unacceptability of cigarette smoking on reduction in cigarette consumption. Am J Public Health 2006; 96(8):1359-1363. (5) Bricker JB, Peterson AV, Robyn AM, Leroux BG, Bharat RK, Sarason IG. Close friends', parents', and older siblings' smoking: reevaluating their influence on children's smoking. Nicotine Tob Res 2006; 8(2):217- 226. (6) Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Nicotine replacement therapy for smoking cessation Cochrane Database of Systematic Reviews: Reviews 2004 Issue 3 John Wiley & Sons, Ltd Chichester, UK DOI: 10 1002/14651858 CD000146 pub2 2004;(3). (7) Benowitz NL. Pharmacology of Nicotine: Addiction and Therapeutics. Annu Rev Pharmacol Toxicol 1996; 36(1):597-613. (8) Hajek P, McRobbie H, Gillison F. Dependence potential of nicotine replacement treatments: effects of product type, patient characteristics, and cost to user. Prev Med 230;(3):2007. (9) Hughes JR, Gust SW, Keenan R, Fenwick JW, Skoog K, Higgins ST. Long-term use of nicotine vs placebo gum. Arch Intern Med 1993;(10):1991. (10) Hajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database of Systematic Reviews: Reviews 2005 Issue 1 John Wiley & Sons, Ltd Chichester, UK DOI: 10 1002/14651858 CD003999 pub2 2005. Competing interests: These are the same as those listed in the article |
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Eduardo M. Curbeira Hernández MDD, Dentistry and Epidemiology Departments Gustavo Aldereguía Lima University Hospital. Cienfuegos, Cuba, Moisés A. Santos Peña MD, Enrique Castillo Betancourt MDD, Juana Hernández Fernández MsC
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It is easy to recognize heavy smokers by the simple visual examination of their oral cavity: their teeth appear stained, the soft tissues can be reddish, and in general they offer a bad oral hygiene that affects their oral cavity, causing therefore lesions in the oral mucosa. Teeth are tattoed as a result of the tar of the smoke, they dissolve in the saliva and penetrate within it through the enamel, reaching the dentine where the stain appears. 1, 2
The lips, tongue and gums and the inner mucosa of the mouth can suffer from lesions due to the tobacco smoke. The cells of these tissues become irritated with the smoke components and different changes can occur in a normal cell that can make it malignant.
Clinical leukoplasia is a whitish stain in the oral mucous membrane that is mainly located in the extreme parts of the upper and lower lips, forming what is called the “leukoplastic angle of the smoker”.This lesion presents as a whitish aspect, which in heavy smokers darkens getting a dark brown color, and when touching it, it has a wrinkled aspect but it doesn’t hurt. Its appearance in the mouth is an alarming sign that shows the incapacity of the mucosa to continue its resistance to tobacco smoke. Leukoplasia, a pre-malignant lesion, is still curable. In many cases it disappears spontaneously only when the patient quits smoking. Oral cancer, constitutes about 3 to 5 % of all malignant tumors that appear in men, and 1% of those in women. It appears as a scab or ulcer that does not heal. It presents with few symptoms. Cancer of the lips is specially frequent in pipe and cigar smokers, although it can also appear in cigarette smokers. On diagnosis the advantage is that all these lesions of the lips and mouth can be observed since their onset and tratment can be applied before any other treatment of inner lesions of difficult location. 2 Their treatment is dificult and requires the combination of surgery and chemotherapy. The best results appear in cases of early diagnosed tumors. Good oral health is not compatible with any of the ways of smoking. Whitish teeth, healthy tissues, and a clean and fresh breath are some of the advantages for all those who have quit smoking. 3 References: 1. Aveyard P, West R. Managing smoking cessation. BMJ 2007;335:37-41 2. Silagy C. Consejo médico para dejar de fumar (Revisión Cochrane). [Internet]. En: La Cochrane Library Plus, Número 2, 2002. Oxford: Update Software. [Consulta 3 de Julio de 2002]. Disponible en: http://www.cochrane.org/cochrane/revabstr/g160index.htm 3. Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. [Internet]. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000. [Consulta 3 de Julio de 2002]. Disponible en: http://www.surgeongeneral.gov/tobacco/tobaqrg.htm Competing interests: None declared |
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Mohammad S Rahman, SHO in Psychiatry Rathbone Low Secure Unit, Mill Lane, Liverpool, L13 4AW, Lola Aderogba, SpR in Psychiatry
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Dear Editor, Smoking is common(1) amongst people with mental illness. There is also an increased mortality rate in this group of people(2). Therefore, effective intervention to reduce smoking is a priority for people with mental illness. However, we note that in their review of management of smoking cessation(3) Aveyard and West failed to include this important group of people. Patients with mental illness already suffer from significant stigma and exclusion from various sectors of society. As members of the medical profession, we should attempt to minimize this and consider a more inclusive approach. (1) Osborn D.P.J, Nazareth I, King M. B: Risk for coronary heart disease in people with severe mental illness The British Journal of Psychiatry (2006) 188: 271-277 (2) Kisely S, Smith M, Lawrence D, Maaten S: Mortality in individuals who have had psychiatric treatment. The British Journal of Psychiatry (2005) 187: 552-558 (3) Aveyard P, West R. Managing smoking cessation. BMJ 2007;335:37-41 Competing interests: None declared |
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