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To dream the impossible dream

BMJ 2014; 348 doi: (Published 13 February 2014) Cite this as: BMJ 2014;348:g1521
  1. Tony Delamothe, deputy editor
  1. 1BMJ
  1. tdelamothe{at}

Ciggies, booze, with a serving of breast cancer on the side—again. Sometimes the BMJ’s weekly offering can seem as boring and predictable as the menu of one of those pubs that didn’t survive the downturn. Yet, we make no apologies. Taken together, these three account for an enormous amount of suffering.

Tobacco’s status as the captain of the men of death remains secure. Smoking killed about 100 million people in the 20th century, and its annual toll is predicted to reach six million deaths about now (Tobacco Control doi:10.1136/tobaccocontrol-2011-050338). In the UK it is the leading cause of preventable death and early mortality, responsible for killing about 100 000 people a year. Yet a letter from Jamie Brown and Robert West brings grounds for quiet hope: the prevalence of smoking in England has fallen below 20% for the first time in 80 years (doi:10.1136/bmj.g1378). Last year the rate of decline quickened over its 40 year average. Can we start dreaming of zero prevalence yet?

Such an idea seemed frankly deranged a few years ago, but it has begun to capture the imagination of the worldwide tobacco control movement, as Ruth Malone and colleagues describe (doi:10.1136/bmj.g1453). “Endgame discourse centres on the idea that it is essential to extend our planning beyond a focus on tobacco control . . . towards planning a tobacco-free future.” Surveys done in a range of countries identify surprisingly high levels of public support for moves towards zero prevalence, they say.

Banning smoking in vehicles in which there are children enjoys support from about 80% of the UK population (and anecdotes suggest an even higher proportion of children). And earlier this week MPs huffed and puffed their way towards agreeing an amendment to the Children and Families Bill that would allow a new law (doi:10.1136/bmj.g1508). Reassuringly, the MPs’ register of interests revealed no relation between Big Tobacco and even the most vociferous of the amendment’s opponents.

How laws get made, or don’t get made, seems far murkier for alcohol. Earlier this year we published a major investigation by Jonathan Gornall into how the alcohol industry successfully lobbied the government against the introduction of a minimum unit price for alcohol (BMJ 2014;348:f7646, doi:10.1136/bmj.f7646). (You can read the industry’s response to his charges on page 22 and more from the BMJ investigation at

Central to the debate was work done by the Sheffield Alcohol Research Group on whether the minimum price proposal would target high risk drinkers, as intended. When a Home Office minister announced the shelving of action because of a lack of concrete evidence, he had in his possession an earlier version of the analyses published in full by the Lancet this week. As Jacqui Wise reports (doi:10.1136/bmj.g1450), Sheffield’s modelling study showed that a minimum unit price would produce the greatest behavioural change in harmful drinkers, with minimal effects on moderate drinkers, regardless of income.

From a public health perspective, deciding the right course of action over a minimum unit price for alcohol or over smoking in cars carrying children is easy—but not so the diagnosis and treatment of breast cancer, which continues to throw up knotty problems.

In a Canadian randomised screening trial, annual mammography detected a significant number of small non-palpable breast cancers but had no effect on breast cancer mortality (doi:10.1136/bmj.g366, doi:10.1136/bmj.g1403). And in a retrospective analysis, women with BRCA associated breast cancer treated with bilateral mastectomy were much less likely to die of breast cancer within 20 years than women treated with unilateral mastectomy (doi:10.1136/bmj.g226).


Cite this as: BMJ 2014;348:g1521


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