Press releases Monday 18 January to Friday 22 January 2010

Please remember to credit the BMJ as the source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) Are electronic cigarettes safe?
(2) Industry documents reveal the truth about alcohol advertising
(3) High vitamin D levels linked to lower risk of colon cancer
(4) Lung cancer patients who quit smoking double their survival chances
(5) Malnutrition higher in children born to child brides
(6) Experts advise caution over new incentive scheme for NHS hospitals

(1) Are electronic cigarettes safe?
(Personal view: Electronic cigarette: miracle or menace?)
http://www.bmj.com/cgi/doi/10.1136/bmj.bc311

More research is needed before consumers can be reassured that electronic cigarettes (e-cigarettes) are safe, say two experts on bmj.com today.

Andreas Flouris and Dimitris Oikonomou, from the Institute of Human Performance and Rehabilitation in Greece, say that "our knowledge on the acute and long term effects of e-cigarette use is, at best, very limited."

With anti-smoking policies becoming more common, the interest in alternative smoking products is on the increase. One of the most recently introduced products on the market are electronic cigarettes or e-cigarettes. These are battery operated devices that allow users to inhale a nicotine vapour. They are intended to replace normal cigarettes and/or help smokers quit.

The US Food and Drug Administration (FDA) had expressed serious concerns regarding the safety of e-cigarettes. Three reports have been undertaken on the product - one by the FDA, one by a private body called Health New Zealand (HNZ) and another by Demokritos, a publicly-funded Greek research institute.

The interpretations of the three reports vary considerably, say the authors. The FDA detected a number of toxins in e-cigarettes and "carefully raises caution on potential harmful effects of e-cigarettes." HNZ recommends e-cigarettes as they are safer than normal tobacco products and DRI takes a neutral position.

They conclude that while "alternative smoking strategies are always welcome in an effort to reduce the threat to public health caused by the tobacco epidemic," more research is required in order to inform consumers about the safety of these e-cigarettes.

Contact:

Dr Andreas Flouris, FAME Laboratory, Institute of Human Performance and Rehabilitation, Centre for Research and Technology Thessaly, Greece
Email: aflouris@cereteth.gr

Although the content of alcohol advertisements in the UK is restricted, an analysis of previously unseen industry documents published on bmj.com today, finds that advertisers are still managing to appeal to young people and promote drinking.

Professor Gerard Hastings and colleagues show that companies are "pushing the boundaries" of the advertising code of practice and warn that the UK system of self regulatory controls for alcohol advertising is failing.

Hastings and his team analysed a sample of internal marketing documents from four alcohol producers and their communications agencies. The documents were made available as part of the House of Commons Health Committee alcohol inquiry and included client briefs, media schedules, advertising budgets, and market research reports.

The alcohol industry spends around £800m (Euro 900m; $1.3bn) a year promoting alcohol in the UK.

The authors looked at four themes that are banned by the advertising code of practice, such as appealing to people under 18 and encouraging irresponsible drinking, as well as sponsorship and new media.

They found that market research data on 15 and 16 year olds is used to guide campaign development and deployment, while many references are made to the need to recruit new drinkers and establish their loyalty to a particular brand. WKD, for instance, wants to attract "new 18 year olds" and Carling takes a particular interest in the fact that the Carling Weekend is "the first choice for the festival virgin."

Despite a ban on encouraging drunkenness and excess, the authors also found many references to unwise and immoderate drinking, suggesting that increasing consumption is a key promotional aim.

Other documents suggest that brands can promote social success, masculinity or femininity, despite this also being banned under advertising codes. For example, Carling is described as a "social glue" by its promotion team, while the need to "communicate maleness and personality" is noted as a key communications objective for WKD.

Although the codes prohibit any link between alcohol and youth culture or sporting achievement in advertising, the documents discuss in detail sponsorship deals with football, lads' magazines, and music festivals. The use of new media, including social networking sites, is also a fast growing channel for alcohol advertising, say the authors.

Hastings and his team argue that the UK needs to tighten both the procedures and scope of the regulation of alcohol advertising.

They suggest that regulation should be independent of the alcohol and advertising industries and that all alcohol advertisements should be pre-vetted. And they call for sponsorship to be covered by the regulations, and much greater scrutiny for digital media. Particular efforts should also be made to protect children from alcohol advertising, they say, such as banning billboards and posters near schools and restricting TV, radio and cinema advertisements.

They believe that the current problems with UK alcohol promotion are reminiscent of those seen before tobacco advertising was banned, "when attempts to control content and adjust targeting simply resulted in more cryptic and imaginative campaigns."

"History suggests that alcohol advertisers are, appropriately enough, drinking in the last chance saloon," they conclude.

In an accompanying editorial, Trish Groves, BMJ deputy editor calls for a clamp down on alcohol promotion and a minimum price per unit of alcohol to prevent the rise of alcohol related ill health in the UK.

She points out that the government is spending £17.6m on alcohol education and information in 2009-10, but this is dwarfed by the UK drinks industry's£600-800m annual spend on promoting alcohol.

"It is time to put away the rhetoric, popular with the drinks industry, that alcohol misuse is largely an individual problem best avoided and managed through education, counselling, and medical treatment," she writes. "Instead, the UK needs to embrace the idea that the health and societal costs of alcohol misuse are best prevented through legislation on pricing and marketing."

But it's not just the money that keeps the industry a step ahead. A linked article explains how the alcohol industry and trade organisations such as the Portman Group are well placed in UK policy circles to defend their position, and asks, is the government under the influence of the drinks industry?

Contact:

Professor Gerard Hastings, Director, Institute for Social Marketing, University of Stirling, Scotland, UK
Email: gerard.hastings@stir.ac.uk

High blood levels of vitamin D are associated with a lower risk of colon cancer, finds a large European study published on bmj.com today. The risk was cut by as much as 40% in people with the highest levels compared with those in the lowest.

Several previous studies have already suggested a link between vitamin D and colorectal cancer, but the evidence has been inconclusive with limited information from European populations.

So, researchers from across Europe set out to examine the association between circulating vitamin D concentration as well as dietary intakes of vitamin D and calcium with colorectal cancer risk in Western European populations. Colorectal cancer is the combination of colon and rectal cancer cases.

Their findings are based on the European Prospective Investigation into Cancer Study (EPIC), a study of over 520,000 subjects from 10 Western European countries.

Between 1992 and 1998, participants completed detailed dietary and lifestyle questionnaires and blood samples were collected. The subjects were then tracked for several years, during which time 1,248 cases of colorectal cancer were diagnosed and these were matched to 1,248 healthy controls.

Participants with the highest levels of blood vitamin D concentration had a nearly 40% decrease in colorectal cancer risk when compared to those with the lowest levels.

However, some recent publications have suggested maintenance of blood vitamin D levels at 50 nmol/l or higher for colorectal cancer prevention. Thus, the authors also compared low and high levels of blood vitamin D concentration to a mid-level of 50-75 nmol/l. This comparison showed that while levels below the mid-level were associated with increased risk, those above 75 nmol/l were not associated with any additional reduction in colon cancer risk compared to the mid-level.

Although the results support a role for vitamin D in the etiology of colorectal cancer, the authors caution that very little is known about the association of vitamin D with other cancers and that the long term health effects of very high circulating vitamin D concentrations, potentially obtained by taking supplements and/or widespread fortification of some food products, have not been well studied.

With respect to colorectal cancer protection, it is still unclear whether inducing higher blood vitamin D concentration by supplementation is better than average levels that can be achieved with a balanced diet combined with regular and moderate exposure to outdoor sunlight, they say.

The findings of previous randomised trials have been inconsistent. As such, new trials should be carried out to evaluate whether increases in circulating vitamin D concentration can effectively reduce colorectal cancer risk without inducing serious adverse events, they conclude. Currently, the best recommendation to reduce ones risk of colorectal cancer is to stop smoking, increase physical activity, reduce obesity and abdominal fatness, and limit intakes of alcohol and red and processed meats.

Contact:

Mazda Jenab, Lifestyle, Environment and Cancer Group, International Agency for Research on Cancer, Lyon, France
Email: jenab@iarc.fr

People diagnosed with early stage lung cancer can double their chances of survival over five years if they stop smoking compared with those who continue to smoke, finds a study published on bmj.com today.

This is the first review of studies to measure the effects of continued smoking after diagnosis of lung cancer and suggests that it may be worthwhile to offer smoking cessation treatment to patients with early stage lung cancer.

Worldwide, lung cancer is the most commonly diagnosed form of cancer. In the UK, it is second only to breast cancer, accounting for around 39,000 new cancer diagnoses annually.

Smoking increases the risk of developing a primary lung cancer; lifelong smokers have a 20-fold increased risk compared with non-smokers. But it is not known whether quitting after a diagnosis of lung cancer has any benefit.

So researchers at the University of Birmingham analysed the results of 10 studies that measured the effect of quitting smoking after diagnosis of lung cancer on prognosis.

Differences in study design and quality were taken into account to minimise bias.

They found that people who continued to smoke after a diagnosis of early stage lung cancer had a substantially higher risk of death and a greater risk of the tumour returning compared with those who stopped smoking at that time. Data suggested that most of the increased risk of death was due to cancer progression.

Further analysis found a five year survival rate of 63-70% among quitters compared with 29-33% among those who continued to smoke. In other words, about twice as many quitters would survive for five years compared with continuing smokers.

These findings support the theory that continued smoking affects the behaviour of a lung tumour, say the authors. They also provide a strong case for offering smoking cessation treatment to patients with early stage lung cancer.

Further trials are needed to examine these questions, they conclude.

An accompanying editorial says this study adds more to the evidence that it is never too late for people to stop, even when they have lung cancer.

Contact:

Amanda Parsons, Research Fellow, UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, UK
Email: a.c.parsons@bham.ac.uk

Infants born to child brides in India (married before the age of 18) have a higher risk of malnutrition than children born to older mothers, according to research published on bmj.com today.

However, low birth weight and childhood mortality are not significantly linked with the age of the mother, concludes the research, and the child's malnutrition was not related to the mother's body mass index.

Despite significant economic growth in the past decade, India still has the highest number of under-five deaths in the world. Almost half (44.5%) of 20-24 year olds in India are married before they are 18 and almost a quarter (22%) of the same age group have given birth by the time they reach 18.

The authors, led by Associate Professor Anita Raj, from Boston University School of Public Health, investigated the relationship between early marriage and infant and children mortality-related infection in India.

Professor Raj and colleagues analysed the data of a representative sample of almost 125,000 Indian women between the ages of 15 to 49. The information was collected from the 2005-2006 National Family Health Survey.

The study was restricted to births that took place in the last five years to women who had been married between the ages of 15 to 24 – this included over 19,000 births to almost 13,500 mothers.

The results show that the majority of births (73%) were born to child brides. Among the currently living children, the majority (67%) were malnourished – meaning they were either underweight or suffering from wasted or stunted growth.

The authors argue that "in view of previous evidence that child brides often are more controlled by husbands and in-laws, it may be that women married as minors are unable to advocate for adequate nutrition for their children."

Professor Raj concludes that the findings "emphasise the value of delayed childbearing among adolescent wives. They also reveal the need for targeted intervention efforts to support children born to mothers married as minors, who may be more vulnerable to nutritional deprivation than others in the family."

Contact:

Anita Raj, Associate Professor, Department of Social and Behavioral Sciences, Boston University School of Public Health, Boston, MA, USA
Email: anitaraj@bu.edu

The English NHS should "proceed cautiously" in introducing payment for performance schemes aimed at improving the quality of care in hospitals, warn researchers from the University of York on bmj.com today.

They believe that the effects of incentive schemes on healthcare systems are still unclear and that the cost of implementing them may not be justified.

Following the quality and outcomes framework (QOF), which provides financial incentives to primary care teams, a new scheme is being introduced for NHS hospitals, explain Alan Maynard and Karen Bloor.

This scheme, known as the commissioning for quality and innovation framework (CQUIN), is modelled on a US pilot scheme. It will also offer rewards for meeting targets, but the incentives are aimed at hospital trusts rather than the clinical team.

The scheme is being piloted in the NHS North West region, where hospitals in the top two performing quartiles are offered 4% and 2% increases in tariff payments and there are no penalties for those with low scores.

But the authors argue that evidence of the effectiveness of the US incentive scheme is weak. They also point to possible problems, such as effects on motivation and increasing financial instability in a time of increasing financial constraint in the NHS.

Although early data show good clinical engagement with the scheme in the North West, there is still uncertainty about the impact of rolling out the new scheme for NHS hospitals, they say.

Clearly the costs and benefits of using rewards and penalties alone or in combination to induce clinical and organisational performance improvement needs to be evaluated, they write. This should include consideration of the possible problems of bias or gaming, as well as inadequate data collection.

"Finally, the lesson learnt from the quality and outcomes framework is that we need to find out what the opportunity costs are of implementing the new scheme," they conclude. "If clinicians and hospitals allocate scarce resources to incentive schemes aimed at improving a particular set of conditions, there is a risk that other clinical conditions and procedures will get less attention and their outcomes will not be improved."

Contact:

Professor Alan Maynard, Director, York Health Policy Group, Department of Health Sciences, University of York, UK
Email: akm3@york.ac.uk

FOR ACCREDITED JOURNALISTS

For more information please contact:

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
British Medical Association
BMA House, Tavistock Square, London WC1H 9JP

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
[[$FOOTER]] http://intranet.bmj.com/departments/dept-bmj/bmj-team-resources/web-team-resources/General_blogging_principles.doc