Releases Saturday 22 April 2000
No 7242 Volume 320
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(1) SMOKING DOES NOT PROTECT AGAINST
DEMENTIA OR ALZHEIMER'S DISEASE
(2) TOBACCO
MAY EXPLAIN SOME OF THE
DIFFERENCES
IN HEALTH INEQUALITIES
BETWEEN NORTH
AND SOUTH EUROPE
(3) PSYCHIATRISTS
FAIL TO ASK THEIR PATIENTS
ABOUT VIOLENT
INTENTIONS TO OTHERS
(4) ACTION
NEEDED NOW TO CURB BIOLOGICAL
WARFARE
(5) CURRENT
GUIDANCE DOESN'T HELP DOCTORS
TREAT YOUNG
PATIENTS AT RISK OF HEART
DISEASE
(1) SMOKING DOES
NOT PROTECT AGAINST
DEMENTIA OR ALZHEIMER'S DISEASE
(Smoking and dementia in male British
doctors: prospective
study)
http://bmj.com/cgi/content/full/320/7242/1097
(Smoking and the brain [Editorial])
http://bmj.com/cgi/content/full/320/7242/1087
Smoking does not protect against dementia
or Alzheimer's
disease, shows a study in this week's
BMJ, contradicting the
implications of some previous research.
Doll, Peto, and colleagues, from the Clinical
Trial Service
Unit and Epidemiological Studies Unit,
Radcliffe Infirmary
Oxford, report on observations of over
34,000 male UK
doctors whose smoking habits have been
reviewed every six
to 12 years since 1951, to determine the
impact on their
health. They also reviewed the published
data on the
associations between smoking and Alzheimer's
disease.
Over 24,000 of the doctors had died by
the end of 1998.
Dementia was mentioned on the death certificates
of 483.
Among 473 whose smoking habits were recorded
at least 10
years before their death, when they would
not have been
influenced by the start of the disease,
the prevalence of both
Alzheimer's disease (the predominant cause)
and of other
dementias was similar in both smokers
and non-smokers. If
anything, persistent smoking may increase
rather than
decrease the age specific onset rate of
dementia, conclude
the authors.
The previous suggestions that smoking might
be protective,
say the authors, came from studies that
were flawed because
they were too small, or had relied on
information about
smoking habits from people other than
the sufferers
themselves.
Carol Brayne from the Institute of Public
Health, Cambridge,
writes in an accompanying editorial that
a protective effect for
nicotine is biologically plausible. This
is because of the
boosting effect of the drug on neurotransmitter
systems in the
brain, which are damaged in Alzheimer's
disease, she says.
But adds that these effects are likely
to be short-lived. In the
long term, smoking increases the risk
of vascular dementia,
because it increases the risk of vascular
disease in general.
"The public health message is clear: at
the population level
there is no protective effect of smoking
in dementia."
Contacts:
(Paper) Professor Richard Doll, Clinical
Trial Service Unit
and Epidemiological Studies Unit, Radcliffe
Infirmary,
Oxford.
(Editorial) Dr Carol Brayne, Department
of Public Health and
Primary Care, Institute of Public Health,
Cambridge.
Email: carol.brayne{at}medschl.cam.ac.uk
(2) TOBACCO MAY
EXPLAIN SOME OF THE
DIFFERENCES IN HEALTH INEQUALITIES
BETWEEN NORTH AND SOUTH EUROPE
(Educational differences in smoking:
international comparison)
http://bmj.com/cgi/content/full/320/7242/1102
Smoking may explain some of the differences
in health
inequalities between Northern and Southern
European
countries, indicates research in this
week's issue of the BMJ.
But says the research, the North / South
gap is likely to close,
while the health gap between the rich
and the poor will widen
further as a result of smoking.
A pan-European team of researchers led
by Mackenbach of
the Erasmus University, Rotterdam, in
the Netherlands,
compared the socioeconomic differences
in smoking patterns
across 12 European countries. Health survey
data were
analysed for the years 1986 to 1990, and
separately for men
and women and the age groups 20 to 44
and 45 to 74.
Educational level was chosen to indicate
socioeconomic
status.
Smoking rates were highest among younger
people with low
levels of education in most countries.
There was a distinctive
North / South pattern. Higher rates of
smoking were found
among women with low levels of education
in the UK,
Norway, and Sweden; higher rates were
found in well
educated women in southern European countries.
The same
was true for older men, although to a
lesser extent, but not for
younger men.
The differences in smoking patterns, say
the authors, are
likely to be related to the stage countries
have reached in the
"smoking epidemic" - with the more affluent
starting and
giving up smoking first. These patterns
are also likely to be
partly responsible for the high rates
of death and disease from
heart disease seen among the less well
off in Northern
European countries compared with their
peers in the South.
But on the basis of current trends, the
South will catch up.
And, worryingly, say the authors, these
patterns suggest that
the health gaps from diseases associated
with smoking
between the rich and poor will continue
to grow.
Governments wanting to tackle the social
inequalities in health
need to think about antismoking policies
that are less
intellectually demanding, conclude the
authors.
Contact:
Professor Johan Mackenbach, Dept Public
Health, Erasmus
University, Rotterdam, The Netherlands.
Email: mackenbach{at}mgz.fgg.eur.nl
(3) PSYCHIATRISTS
FAIL TO ASK THEIR PATIENTS
ABOUT VIOLENT INTENTIONS TO OTHERS
(Assessment of aggression in psychiatric
admissions:
semistructured interview and case
note survey)
http://bmj.com/cgi/content/full/320/7242/1112
(Assessing the risk of violence in
patients)
http://bmj.com/cgi/content/full/320/7242/1088
Psychiatrists fail to ask their patients
about violent intentions
to others, and may therefore be putting
them and the public at
risk, suggests research in this week's
BMJ.
Milne and colleagues from St Luke's Hospital,
Middlesbrough, carried out semistructured
interviews with
114 people admitted to general psychiatry
wards at the
hospital over a period of three months.
Patients were asked
whether they had thought about suicide,
damaging property,
and violence towards another person in
the preceding week.
Comparisons were then made with the number
of patients
who had been asked about these thoughts
by the treating
team.
Almost half said that they had had suicidal
thoughts and a
quarter of the patients had entertained
violent thoughts about
specific people. Nearly one in 10 admitted
owning a weapon
and one in 20 to carrying one, both of
which are recognised
risk factors for violence. Over half of
the patients had a
history of violent behaviour. But although
the clinical team
almost always asked their patients about
suicidal thoughts,
only 2.5 per cent asked about damage to
property and only
13 per cent asked about thoughts of violence
towards others.
In an accompanying editorial, Shaw argues
that politicians
tend to assume that it is easier to predict
violence by
psychiatric patients than it actually
is. Nevertheless, it is
essential to ask patients about violent
thoughts, because
although not all of them will act on it,
some will; and enquiring
routinely about thoughts of violence to
others is as important
as enquiring about suicidal thoughts.
But she points out that
there is no legislation to help doctors
in this regard and that
they are faced with the dilemma of needing
to maintain patient
confidentiality while wanting to protect
the public.
Contacts:
(Paper) Dr Steven Milne, St Luke's Hospital,
Middlesbrough.
Caroline Parnell, PR Manager, Tees and
North East
Yorkshire NHS Trust.
(Editorial) Dr Jenny Shaw, Guild Community
Health Care
NHS Trust, Preston, Lancashire.
(4) ACTION NEEDED
NOW TO CURB BIOLOGICAL
WARFARE
(Fighting biological warfare)
http://bmj.com/cgi/content/full/320/7242/1089
Swift action is needed to curb the prospect
of disease being
deliberately applied for military or terrorist
purposes through
biological warfare, writes Stephen Pullinger,
director of the
International Security Information Service
in this week's
BMJ.
Potentially capable of inflicting casualties
on the scale of
nuclear weapons, biological warfare has
the added bonus of
being cheap and easy to produce. And the
widely held
assumption that the use of biological
agents is only minimally
effective in war is false, he contends.
Several countries have
already developed biological weapons,
and the biotechnology
revolution could speed up that process
and even offer the
possibility of genetic weapons targeted
at specific groups of
people, he cautions.
The Biological and Toxin Weapons Convention,
which
prohibits the use of such arms, came into
force 25 years ago,
but contains no provisions to ensure that
States are not
cheating on their undertakings. The Chemical
Weapons
Convention of 1993 does contain such provisions,
but
attempts to include the same in the Biological
and Toxin
Weapons Convention hinge on a legally
binding protocol over
which disagreements still remain.
A protocol alone cannot prevent the proliferation
of biological
weapons admits Dr Pullinger, but it can
strengthen the "web
of deterrence" and consolidate international
responses to
non-compliance. But concerted political
will is needed, and
needed now if such a legal framework is
to be swifly put in
place.
Contact:
Dr Stephen Pullinger, International Security
Information
Service, London.
Email: isis{at}isisuk.demon.co.uk
(5) CURRENT GUIDANCE
DOESN'T HELP DOCTORS
TREAT YOUNG PATIENTS AT RISK OF HEART
DISEASE
(What is the optimal age for starting
lipid lowering treatment?
A mathematical model)
http://bmj.com/cgi/content/full/320/7242/1134
Current guidelines on drug treatment for
heart disease don't
advise doctors on how to treat young patients
with a high risk
profile, reports research in this week's
BMJ. This is because
the guidelines are based on who to treat,
rather than on when
to treat, inevitably shifting treatment
to older age groups,
where absolute risk "the chance of having
an 'event' such as
a heart attack over a fixed period of
time" increases.
But say Vallance and colleagues from University
College,
London, the substantial proportion of
young people with high
blood pressure and high cholesterol levels
might have a low
absolute risk, but they have a high relative
risk. This means
that their chances of having an 'event'
are higher than
somone with normal blood pressure and
cholesterol levels.
And, say the authors, these are the people,
who, by the time
they have reached the age at which they
cross the official
threshold for treatment with the expensive
statin group of
drugs, will have already accumulated most
of their lifetime
risk.
To solve the conundrum, the authors supply
several
mathematical models, based on proven formulas,
which could
help doctors predict the optimal age at
which starting
treatment would maximise the health benefits
for each
individual patient, and also the cost
benefits to the NHS.
Reducing the age at which treatment begins
inevitably costs
more�an additional£4000 per patient
a year at the age of 40
and an additional £2000 per patient
a year at the age of 50.
But, say the authors, the additional costs
would be set against
the gains to be made from fewer hospital
admissions and
acute care and less time off work, to
say nothing of quality of life.
Contact:
Dr Aroon Hingorani, Centre for Clinical
Pharmacology and
Therapeutics, University College, London.
Email: a.hingorani{at}ucl.ac.uk
(Is infestation with the common bedbug
increasing?)
http://bmj.com/cgi/content/full/320/7242/1141
Bedbugs seem to be making something of
a comeback after a
prolonged absence, suggests a letter from
Brighton Public
Health Laboratory Service in this week's
BMJ.
Paul and Bates report that in 1998, specimens
from just one
bedbug infestation were submitted to Brighton
Public Health
Laboratory Service. None had been submitted
in the
preceding three years, but in 1999 four
infestations were
reported within the space of nine months.
In all four cases, the bedbugs were apparently
transferred in
luggage and furnishings brought over from
overseas, including
the United States and Australia. One of
the cases concerned
a healthcare worker whose home became
infested. The
worker had not travelled recently, nor
bought furniture, nor
been in close proximity to a source of
infestation in the local
vicinity. The bugs were successfully killed
off with
insecticides, but three months later the
worker's parents,
who lived elsewhere, were also bitten,
suggesting that the
bugs had been transferred in personal
effects, say the authors.
Bedbugs can survive for up to six months
without food, they
caution.
The authors say that many doctors wouldn't
recognise a
bedbug if it came up and bit them in the
face, and so might
misdiagnose patients who have itchy bites
and rashes
acquired during the night. The bugs, which
look like lentils,
are rather shy, feeding on their unsuspecting
victims during the
night and going into hiding during the
day, say the authors.
The increase in international trade and
travel may be
responsible for the reported increase,
they conclude.
Contacts:
Dr John Paul, Brighton Public Health Laboratory
Service,
Royal Sussex County Hospital, Brighton.
Email: tetrix{at}pavilion.co.uk
Dr Janice Bates, Department of Microbiology,
Worthing
Hospital, Worthing.
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