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Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.

All rapid responses

Displaying 1-10 out of 95173 published

Re: The role of NHS gatekeeping in delayed diagnosis. Nigel Hawkes. 348:doi:10.1136/bmj.g2633

Sir
Nigel Hawkes subtitles his piece "How can people who need specialist care get it more quickly?" and then answers the different question "How can people with money who want specialist care get it more quickly?"
Briefly skating over the virtue of gatekeeping in controlling costs, he suggests that this barrier to care can be circumvented by paying for it. What is not made explicit is that for most people paying to access specialist care is beyond their means, and it is precisely because of this paucity of moneyed elite that he can buy his way round the gatekeeper.
If more people could buy this access then specialists would quickly be swamped by demand where priority was set by bank balance and not by clinical need and health care would become a bidding war. The role of the gatekeeper is to stop the whole tottering edifice of care according to need, not want, from falling over.
Faster access to specialists for all requires additional specialists and wider gates, but unless MPs think people are prepared to see more of their taxes spent on the NHS, Nigel Hawkes is simply advocating buying a seat on the lifeboat ahead of the poor who cannot swim.

Competing interests: NHS Gatekeeper

Gareth D H Richards, GP

Saxmundham Health GP practice, Saxmundham Health, Lambsale Meadow, Saxmundham, Suffolk, IP17 1DY

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Re: Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. Tom Jefferson, Mark Jones, Peter Doshi, Elizabeth A Spencer, Igho Onakpoya, et al. 348:doi:10.1136/bmj.g2545

The comments colleagues and I made previously still stand: http://www.bmj.com/content/339/bmj.b2728

Early in the "containment phase" of the pandemic the health secretary promised that everybody with flu-like symptoms would be given antivirals.

The effect of this was that we were obliged to honour this promise. There were not the resources to do this in a timely fashion: most people, while I was involved, were delivered the antivirals a week after the onset of symptoms. We were unable to prioritise high-risk patients.

The government has claimed that the "containment phase" was effective; that the reduction in viral shedding that may plausibly have been a consequence of antiviral treatment slowed the spread of the pandemic.

There is no reason to believe that antivirals given more than 48 hours after the onset of symptoms had any other benefit; although respiratory physicians tell me they believe it may have had some benefit in the most seriously ill patients.

Competing interests: I was seconded to work in a flu response centre early in the 2009 pandemic

Peter M English, Public Health Physician

N/A (response made in a personal capacity), 260 Chessington Road, KT19 9XF

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Re: The role of NHS gatekeeping in delayed diagnosis. Nigel Hawkes. 348:doi:10.1136/bmj.g2633

I'm a GP and I do agree that the gatekeeping role can cause delays in diagnosis, but I don't believe that this is because we are bad gatekeepers, or that we are not really trying, but that we do not have sufficient resources to meet the demand for appointments, have adequate time with the patient, have adequate access to quick investigations or similarly quick access to hospital care. To blame all this on the gatekeeping role seems unfair. The language used in the article is disparaging towards GPs - we apparently 'put patients a poor second to staff' and we 'complain we are overburdened' and we are so medieval we should ' discover the 19th century invention of the telephone.'
I have been a GP for over 20 years and I can say we truly are overburdened.We are working harder, seeing more patients, conducting more telephone consultations and managing more complex conditions. We work very long days - our work does not end when the consulting ends, as we have to manage referrals, deal with results of investigations ordered, read and action hospital letters, deal with prescription requests and queries, as well as innumerable other unseen tasks that we do behind the scenes to help our patients, in addition to mandatory training, meetings and continuing personal development. We have to maintain a high level of concentration and accuracy, as to make a mistake can have grave consequences.

We are undoubtedly letting patients down; we have no spare capacity to offer additional appointments - we often add in extra emergencies and telephone calls to our normal list to do what we can, but this is still not enough. Short of working all the hours of the day, and never seeing my family, I still believe there are insufficient resources to offer enough appointments, as well as a serious lack of trained GPs who wish to do the job, which can still be an extremely rewarding one.

I do believe a better integration between primary and secondary care, having a more blurred interface, can help, but this can only be achieved with adequate resources. It is much cheaper to deal with patients in primary care so the investment should be directed here, and this would help to relieve the burden on secondary care. If we could offer patients appointments quickly, within a week, have easy and quick access to investigations and secondary care, the patient experience would be vastly improved. This needs to be supported by adequate investment in social care, as I cannot personally keep elderly patients out of hospital without this.

Nigel Hawkes says that the GP can see thousands of patients with headache and to divine the one true case out of thousands is asking for miracles. But short of asking a specialist to see every single person with headache, or carrying out an MRI scan on every patient with a headache, how is anybody going to be 100% accurate?

On the telephone issue, 20 years ago we did no telephone consultations; now this is an every day part of GP life, and has been for years. We have introduced booking of appointments online, prescription requests online. We could offer email advice, but at the moment there is no capacity to allow this, unless we offer fewer face-to-face/telephone consultaions.

Expanding emergency departments and employing GPs to see patients here is a possibility, but many patients want to be seen locally, and where are these GPs going to come from, since there is a chronic shortage of GPs? This only really moves the problem from one place to another. It would be easier to access investigations/specialists in a hospital setting, but only if the resources exist to fund them. Patients seen in emergency departments are often told to go back to see their GP to request (sometimes unnecessary) investigations and referrals. Hospitals do not want to fund this so ask the GP to do so. In the end, it is all just NHS money so blurring the funding boundaries between GP and hospital would be welcome, and would allow too, consultant-to-consultant referrals without needing to use the GP as a go-between, which creates more appointments, increased frustration and further delay in treatment for the patient.

His other 'solution', i.e. go private, to the vast majority of ordinary people, is not a realistic option. Even if they can afford an initial consultation, they may not be able to afford (sometimes unnecessary)investigations or treatment, and then it's back to trying to make an appointment with the GP.

Competing interests: None declared

Sandra Teare, GP

GP Practice, NW10

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Re: PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study. I C McManus, Richard Wakeford. 348:doi:10.1136/bmj.g2621

Dear Sir,
Prof. McManus and Mr Wakeford analysed data from PLAB and MRCP(UK) and MRCGP examinations and have shown that PLAB graduates do worse than UK graduates in post-graduate examinations [1].

I have a few questions for the authors, and would also like to make a few comments.

1) A significant proportion of foreign doctors passing the PLAB examination go on to enter surgical specialities. Did the authors consider including the surgical specialities? Were the surgical Royal Colleges contacted?

2) Of all the PLAB graduates, what proportion went on to sit the MRCGP examination?
The authors have divided the PLAB graduates into 12 equally spaced groups based on their PLAB performance. It would be interesting to know whether the doctors going on to appear for the MRCGP were equally distributed in the 12 groups? If not, in which part of the spectrum were they more likely to be in?

3) 65,115 candidates had taken at least one part of the MRCP(UK) and MRCGP examination between 2001 and 2012. Only 37329 (57%) had a GMC number. How can this be explained. Did the authors look at the large percentage of doctors who sat for the MRCP examination, but never apparently worked in the UK? Intuitively, these data do not appear correct. Did the MRCP(UK) organisers have an opinion on this?

4) Of 24851 PLAB graduates, 15323(61%) did not take either the MRCP(UK) or the MRCGP examination.
This study therefore looked at the career progression, of at most 40% of PLAB graduates. This point is important, as the study findings cannot be generalised for all foreign doctors and also across all specialities.

5) Demographics of candidates taking the MRCP(UK) and MRCGP examinations : There was a significant difference between the ages at which UK graduates and PLAB graduates took the various components of the MRCP(UK) and MRCGP examinations.
This difference (of more than 4 years) is not only statistically significant, but also (for lack of an alternative word) “clinically” significant. This age difference might simply explain the difference in the performance at the postgraduate examinations.
The raw database should be analysed for the performance of UK graduates at different age levels. It is very likely that even among UK graduates, those who sit the postgraduate examinations at a later age would be performing poorly compared to those sitting the examinations at an earlier age (i.e. nearer to the time of graduation).

6) The authors make an assumption that if UK and PLAB graduates are outcome equivalent then the simplest of predictions is that their mean scores on the MRCP(UK) and MRCGP assessments should be the same.
This is the fundamental assumption of this paper, but unfortunately this is wrong. The performance in any sequential examination would be determined largely by the training and education received in the 1-2 years before sitting that exam. Most of the UK graduates would have been in hospital posts, recognised for training by the local deanery, and with protected time for education. On the other hand, the vast majority of PLAB graduates would have been in non-training posts (e.g. Clinical Fellow jobs) without access to protected teaching time or formal education.
For this study to be at all meaningful, there should be data about the jobs performed by the PLAB graduates in the intervening period between passing PLAB and appearing for the various components of the MRCP(UK) and MRCGP examinations.

7)I would suggest that if you looked at a cohort of UK graduates who did non-training jobs after graduation or after their FY2 years, their performance would be significantly worse than those of UK graduates in “training” jobs. This would also prove the basic assumption on which this paper is based as wrong.
8) Table 4 shows the mean (and SD) marks of UK and PLAB graduates at their first attempts at the various parts of the MRCP(UK) and MRCGP examination. It would have been better if you had compared the scores of only those candidates who had passed the examination. Failure in these examination would be an impediment to future career progression, and therefore the candidates would have to re-sit the examination (after another period of studying), or give up their chosen career path. Therefore, the scores of candidates who have passed this examination should be compared. I suspect the differences would not be significant. That would act as a reassurance to the NHS and medical establishment, and would prevent the kind of media frenzy, that this paper has generated in some sections of the press [2].

9) This paper also brings out a very important and significant finding. The graduates of Cambridge and Oxford have performed significantly better at the postgraduate examinations, and this perhaps is a reflection of the kind of school leavers, these institutions attract, and also their teaching methods. There is a significant variation amongst the performance of graduates of different medical schools. Should the medical schools at the lower end of the spectrum raise their bar at the exit examinations, so that the graduates they produce are equivalent to those produced by Universities at the top end of the spectrum? If this has been proposed of the PLAB examination, surely the same should be considered for the UK Universities.

I have a few other comments related not specifically to your methodology and results, but generally about the International Medical Graduates (IMGs), or foreign doctors in the UK.

Most of the locum posts (short-term, unsocial hours, or geography) are filled by foreign doctors. In our department, (Cardiothoracic Surgery, Edinburgh), we are very reliant on locums in the middle-grade rota. In the last five years, I have not seen a single UK graduate available for these locum posts. They have all been foreign graduates. While I have come across many criticisms (some justified, some not) of locum doctors in the popular media, I have never seen any mention of gratitude for these doctors, who by actually turning up, allow for our services to exist (in a legally compliant fashion) and allow us to provide emergency services to the local populations.

Previous studies have shown that the performance of foreign doctors does not result in detectable differences in mortality. Like the UK, the US is also heavily reliant on foreign doctors. Similar concerns about the performance of foreign doctors have been raised in the US. In the clinical setting, however, there has been no evidence of patients suffering as a result of being cared for by foreign doctors. In fact one study showed that patients of foreign doctors had a lower mortality than those of US doctors (graduates of US medical schools) [3].

Along with a medical student, I analysed the publicly reported mortality outcomes of all cardiac surgeons in the UK in 2013. The outcomes of the International Medical Graduates (from outside Europe) were significantly better than those of UK graduates or European graduates. (This study has not yet been published, but I would be willing to send the paper to anyone interested). [4].

And finally there is another way to interpret this data. The PLAB test is set at a level which is equivalent to a UK graduate at the FY1 level. Therefore PLAB graduates and UK graduates are equivalent at that stage. Three to five years down the line, the performance of IMGs is significantly worse than that of UK graduates. This could be due to lack of proper training, and teaching opportunities in the UK, for the foreign doctors.

It is a well-recognised fact, that the NHS is very reliant on foreign doctors. Many departments (across many specialities, and across many regions) would have to shut down if a regular supply of foreign doctors was not available. And therefore it is the responsibility of the NHS to provide significant extra resources for the education and training of foreign doctors who pass PLAB and work in non-training jobs. The reason for doing this is just not to help the foreign doctors, but more importantly because the NHS hospitals and patients will be relying on these doctors in future years.

Yours sincerely,

Vipin Zamvar

zamvarv@hotmail.com

References:
1) PLAB and UK graduates’ performance on MRCP(UK) and MRCGP examinations: data linkage study. I C McManus, R Wakeford. BMJ 2014;348:g2621.
2) Half of foreign doctors are below British standards. www.telegraph.co.uk/health/nhs/10773857/ accessed 18 April 2014.
3) Evaluating the Quality of Care Provided by Graduates of International Medical Schools. Norcini JJ, Boulet JR, Dauphinee WD, Opalek A, Krantz ID, Anderson ST. Health Aff (Millwood). 2010;29:1461-8.
4) Cardiac Surgical Results in the UK: What do the numbers reveal? Yeung E, Zamvar V (Unpublished)

Competing interests: None declared

Vipin Zamvar, Consultant Cardiothoracic Surgeon

Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SU

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Re: Doctors should be taught to consider the cost of their practice. Bela Nand. 348:doi:10.1136/bmj.g2629

I agree with Bela Nand that doctors should be trained to think of the consequences of ordering expensive investigations (1) the impact patient care and what will be done with a positive result.

GMC guidance on shared decision making suggests that investigations should involve a discussion with the patient regarding what we are looking for with the test and the risks/benefits of undergoing it (2). It should also be considered that a positive test often leads to ordering another or intervention with further costs.

In the NHS environment doctors are primarily driven by service to the patient rather than service to an insurance company as in the US system where financial incentives are sometimes offered to clinicians by insurance companies to drive down costs. This has been shown to alter physician behaviour although the impact on patient outcome is unclear (3).

Increasing costs of healthcare are a result of the success of the NHS rather than its failure. Saving lives leads to longer life expectancy and an aging population, each new medical and technological development raises the acceptable standard of healthcare, leading to ever escalating costs.

It is high time that the British public accept that healthcare costs are going to continue to escalate regardless of how much funding is put into healthcare and this will involve a trade-off with funding to other services, unlimited access to one service will lead to limits elsewhere.

There has been much drive to improve efficiency and limit wastage of resources (4). This is not a realistic option and a risky strategy in an environment which deals with unpredictable systems; one cannot deny treatment when the outcome is uncertain on the basis that it might not work or cut resources on the basis of a short term reduction in demand. Staff working in the NHS will appreciate how unpredictable and variable the workload and caseload can be even on a day to day basis.

In the face of uncertainty about the future of the NHS and healthcare funding in the UK it would seem prudent to limit the use of expensive investigations. I would also argue that limits need to be placed on the development of technological advances which add limited value to an already acceptable standard of care, the business sector creates new markets for products which are seldom cost effective in terms of public spending.

The public need to accept that access to healthcare and disease care is not unlimited and is not cost-free. Politicians need to face the hard truths rather than applying risky strategies to apply the metaphorical sticking plaster to a gangrenous wound.

A culture of openness with regards to what can be achieved and the setting of reasonable limits on a sound ethical basis needs to be embraced if the NHS is to move forward and continue to provide a high standard of care.

References:
1. Nand, B. (2014) Doctors should be taught to consider the cost of their practice. BMJ 2014;348:g2629
2. http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp
3.Rice, T. (1997) Physician payment policies; impacts and implications. Annual review of public health 18:549-65
4. http://www.institute.nhs.uk/establishing_evidence/establishing_evidence/...

Competing interests: None declared

Serena R Strickland, Locum Medical SPR

Rishabha Deva Sharma

NHS, Yeovil District Hospital

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Re: Assessment and management of medically unexplained symptoms. Simon Hatcher, Bruce Arroll. 336:doi:10.1136/bmj.39554.592014.BE

In a a discussion in BMJ of 30-3-14 I provided a summary of an essay called The Matter of Framework which was published in the Australasian Nurses Journal in June 1980, where I presented my conclusion that poor posture was the cause of a wide diversity of previously unexplainable symptoms.

However, I looked in the mirror and my posture appeared to be reasonably good, but a few years later I decided to turn and look at my side view, and that was when I could see how significant the problem was.

My upper back was very curved in the forward direction, much more so than the normal slight curve, and my lower spine was arched forward, where the combination produced a very distinct S-shape in my spine from my neck to my hips.
My head was also upright, which in combination with the forward curve of my upper spine produced a significant backward curve in my neck.

I therefore became curious about why I had that shape when most people didn’t.

A few more years went by when I was cleaning out some cupboards and found an old photo album and decided to look through the pages.

I saw a photo of myself when I was about 3 years old, when my spine was upright and my physique and complexion were exceptionally good.

I then saw a photo when I was about 7 years old and I was thin, very round shouldered, and slouched, and wearing spectacles which made my left eye look larger than my right, so I then became curious about what happened during the intervening years.

I could recall being told that I had contracted measles at the age of five, and that it infected my left eye muscles in such a manner that it turned inwards and gave me a squint, or cross-eyed appearance, and that I had two operations to try and correct it but they were unsuccessful.

I was then given a patch to wear over my right eye, so that my weak left eye would be forced to function and return to normal strength, but it didn’t, so i was then prescribed with spectacles where the lens in the left side had greater magnification to equalise the vision in each eye.

That explained why my left eye appeared larger in my photo at age seven.

I also had hepatitis for several months at the age of six, which probably involved a lot of nausea, vomiting, and poor appetite, and consequent weight loss in which case my bones and muscles would have become thinner and weaker and my spine would have slumped and remained in that position.

One of the reasons for putting so much time into determining the cause was to get a clearer understanding of how to fix the problems, and the most obvious solution was to sit up straight.
However, when I did that I soon noticed that my back muscles were being strained, and it was unsustainable so I tended to slump again, so I needed to find out why.

As I continued to study the problem I found that when a child is young their bones are soft and pliable, like the trunk of a young tree which is easily bent, and it hardens toward adulthood, like the trunk of a fully grown tree.

Consequently I had been trying to straighten curved bones with muscle, which is why just sitting up straight wasn’t effective.

I was eventually able to develop the standing computer posture which was reasonably effective, and which I have also described in my comments in BMJ of 30-3-14.

Competing interests: None declared

Max Allan Banfield , Publisher

None, Unit 6 No.6 Hartman Ave., Modbury, South Australia, 5092

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Re: Medical education’s authenticity problem. Brian W Powers, Amol S Navathe, Sachin H Jain. 348:doi:10.1136/bmj.g2651

I have just read this article while preparing a presentation on psychological realism within low to medium fidelity simulations and I realise there are some shared concerns. The problem stems from training in one venue (the classroom, sim suite) and the application in another (the surgery, resus room etc) and the assumption might be that a curriculum in the former determines the behaviour in the latter. In other words, it is the script, rather than the understanding that makes the transition from one to the other.

My observation is that the narrower the experiential gap between learning and application, the more likely there will be higher level transfer. This is supported by two features: effective facilitation of the training event which aims for high levels of psychological realism; and secondly, well designed and effective feedback sessions which encourage self awareness and reflection, which the authors recognise as being essential ingredients of good practice. The curriculum, therefore, is not content based but dependent on an authentic process designed to encourage self-knowledge.

Competing interests: None declared

Mike Davis, Consultant in continuing medical education

Freelance, 36 Tarragon Drive, Blackpool FY2 0WJ

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Re: Vitamin D and risk of cause specific death: systematic review and meta-analysis of observational cohort and randomised intervention studies. Rajiv Chowdhury, Setor Kunutsor, Anna Vitezova, Clare Oliver-Williams, Susmita Chowdhury, et al. 348:doi:10.1136/bmj.g1903

Widely distribution of calcitriol receptors in the body has suggested extended roles for it beyond calcium homeostasis.Calcitriol affects maturation and differentiation of mononuclear cells and influences cytokine production (1). Calciteriol inhibits proliferation and differentiation of malignant cells (2, 3). Also calcitriol inhibits epidermal proliferation and promotes epidermal differentiation and therefore is a potential treatment for psoriasis vulgaris (4). It has been suggested that calcitriol also affects the function of skeletal muscle, brain and blood pressure (5-7).
Although the question is to what extent compensate of vitamin D deficiency in some diseases, including cancer can increase patient survival and suppress disease progression, or, how calcitriol administration in cardiovascular disease can be effective. Of course, as this article stated vitamin D deficiency can cause deterioration of the patient's condition. But cannot declare that correction of vitamin D deficiency cures the disease and increases patient survival, particularly in conditions such as cancer, because these diseases are associated with high mortality risk and cannot simply declare thatvitamin D deficiency is the only cause of death in these patients. The authors concluded that vitamin D3 can substantially reduce mortality rate in elderly people, but they stated that the exact dose and duration of vitamin D should be determined in future studies. Now the question is whether the effect of vitamin D has been determined in these patients so far. If not based on which data authors concluded that vitamin D can reduce mortality rate in elderly.

1. Luo J, Wen H, Guo H, Cai Q, Li S, Li X. 1,25-dihydroxyvitamin D3 inhibits the RANKL pathway and impacts on the production of pathway-associated cytokines in early rheumatoid arthritis. Biomed Res Int. 2013;2013:101805.
2. Salomón DG1, Fermento ME, Gandini NA, Ferronato MJ, Arévalo J, Blasco J, Andrés NC, Zenklusen JC, Curino AC, Facchinetti MM. Vitamin D receptor expression is associated with improved overall survival in human glioblastoma multiforme. J Neurooncol. 2014 Mar 1. [Epub ahead of print]
3. Pilon C, Urbanet R, Williams TA, Maekawa T, Vettore S, Sirianni R, Pezzi V, Mulatero P, Fassina A, Sasano H, Fallo F. 1α,25-Dihydroxyvitamin D₃ inhibits the human H295R cell proliferation by cell cycle arrest: a model for a protective role of vitamin D receptor against adrenocortical cancer. J Steroid Biochem Mol Biol. 2014 Mar;140:26-33.
4. Kragballe K, Iversen L. Calcipotriol. A new topical antipsoriatic. Dermatol Clin, 1993, 11:137–141.[PMID: 8435908] [Full Text]
5. Girgis CM, Clifton-Bligh RJ, Mokbel N, Cheng K, Gunton JE. Vitamin D signaling regulates proliferation, differentiation, and myotube size in C2C12 skeletal muscle cells. Endocrinology. 2014 Feb;155(2):347-57.
6. Keeney JT, Förster S, Sultana R, Brewer LD, Latimer CS, Cai J, Klein JB, Porter NM, Allan Butterfield D. Dietary vitamin D deficiency in rats from middle to old age leads to elevated tyrosine nitration and proteomics changes in levels of key proteins in brain: implications for low vitamin D-dependent age-related cognitive decline. Free Radic Biol Med. 2013 Dec;65:324-34.
7. Min B. Effects of Vitamin D on Blood Pressure and Endothelial Function. Korean J Physiol Pharmacol. 2013 Oct;17(5):385-392.

Competing interests: None declared

Alireza Abed, Pharmacologist

Golnaz Vaseghi, Azade Safaei

Applied physiology research center, Isfahan University of medical sciences, Isfahan, Iran

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Re: The poisonous “juice” in e-cigarettes. Douglas Kamerow. 348:doi:10.1136/bmj.g2504

This article is scaremongering of the type I would normally only expect to see from the likes of the Daily Mail. NRT replacement therapy has been shown to be ineffective for many smokers who are trying to quit but if nicotine itself were a known carcinogen or had other associated health risks it would not be available as a licensed medical quit aid for smokers. It is because it has hugely decreased risk when compared with smoking that it is available to be bought over the counter without the need for prescription. The same is also true for nicotine liquid used in e cigarettes (or vaping devices). There is plenty of evidence available that these devices do work as a substitute for smoking, there are no claims that they are a form of smoking cessation therapy. However for a committed smoker there can be no doubt that they provide a safer and healthier alternative than continued tobacco cigarette usage. There are also a large number of users who no longer smoke having entirely substituted the smoking habit for vaping. They may still be intaking nicotine on a permanent basis but are no longer subject to the thousands of other chemicals in cigarettes including at least 69 known carcinogens. How does Dr Kamerow justify his stance that those people should either continue smoking or use approved NRT products which do not work for them when here is an alternative that does for many of them? This smacks of writing from a position of vested interest and worries about loss of sales revenue for his pharmaceutical industry sponsors. I would also like very much to know where he gets his evidence from that e cigarettes may act as a gateway into tobacco smoking since as far as I am aware no such body of evidence exists. There may have been an increase in people using e cigarettes that have never smoked but that is a pretty big leap to his assertion that those people will then go on to smoking. There are also users of NRT that have never smoked but as far as I am aware there is no evidence of these people becoming smokers of tobacco products either. This article may have been written as an opinion piece rather than a scientific research article, however I would still expect that an author in a medical journal at least do some very basic research and back up any assertions they make with regards to the dangers or benefits of a product. If the best you can say from this research is that the risks or benefits are unknown then that should be all that you do say. Asserting that something is true simply because it is what you personally believe or wish to be the case is at best very poor journalism and at worst a deliberate attempt to mislead others due to vested interests in this matter.

Competing interests: None declared

nicola j eyles, personal care assistant

none, 60 bentinck street

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Re: E-cigarettes are to be regulated as medicines from 2016. Ingrid Torjesen. 346:doi:10.1136/bmj.f3859

This article is jumping the gun a little here. The legislation around e cigarette use in the UK is currently under review and no such move has been confirmed. As it stands current legislation of e cigarettes and other nicotine containing products will continue under consumer control law until at a cut off date in 2016 when the new EU legislation regarding nicotine containing products will come into effect. This new EU legislation regarding nicotine containing products allows liquids containing up to 20mg nicotine per ml to be sold as they currently are under normal consumer law and products containing higher concentrations of nicotine to be medically licensed should the pharmaceutical industry wish to do so (and you can bet your bottom dollar that they will).

Competing interests: None declared

nicola j eyles, personal care assistant

none, 60 bentinck street

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