Smoking and Older Chest Physicians

~

think that the persistence of the bronchodilating effect

observed by Noppen et aI could be explained by the lack of

comparison with serial FEV I measurements after placebo infusion. It is not surprising to observe a small spontaneous increase in FEVI' in asthmatic patien~ starting the observations at 8:00 AM. The data of Skobeloff et a13 (cited by Noppen et a1) on the persistence of the bronchodilating effect of magnesium infusion refer to PEF values. It is possible that the increase in PEF-which is greatly inJIuenced by muscular strength- partially depends on a persistent positive etJect of magnesium on respiratory muscular power. 4 Giovanni Rolla, M.D., F.C.C.l, and Caterina Bucca, M.D., CUnica Medica of University,

7brino, Italy

Reprint requests: Dr Rolla, Clinica Medica, Via Genova 3, 10126 1hrin, ItalY REFERENCES

1 Rolla G, Bucca C, Carla E, Arossa ~ Bugiarli M, CeSano L, et ale Acute effect of intravenous magnesium sulfate on airway obstruction of asthmatic patients. Ann Allergy 1988; 61:388-91 2 Okayama H, Aikawa T, Okayama M, Sasaki H, Mue S, Takishima T. Bronchodilating effect of intravenous magnesium sulfate in bronchial asthma. JAMA 1987; 2S1: 1076-78 3 Skobeloff EA, Spivey WH, McNamara RM, Greenspon L. Intravenous magnesium sulfate for the treatment of asthma in the emergency department. JAMA 1989; 262:1210-13 4 Molloy D~ Dhingra S, Solven F, Wilson A, McCarthy DS. Hypomagnesemia and respiratory muscle power. Am Rev Respir Dis 1984; 129:497-98

Smoking a~d

Older Chest Physicians

1b the EdItor:

I read with great interest the articles on the older smoker (Chest 1990; 97:517-18, 547-53). I carried out a survey of the smoking habits and attitudes toward smoking among all members of the Japan Society of Chest Diseases in September and October 1989. 1 I would like to present the Bndings focusing on the smoking characteristics of older persons in Japan. Of the 6,224 members of the Society who were sent a voluntary questionnaire, 3,640 (58.5 percent) responded. Of the 3,640 respondents (mean age, 44 years), 25 percent were smokers, 39 percent ex-smokers, and 36 percent DOnsmokers. The smoking prevalence among members aged 50 to 59 years (n=544) was 21 percent, while among those 60 years and older (n = 578) it was 24 percent. Although 39 percent of smokers aged 50 to 59 and 21 percent of smokers 60 years and older wanted to stop smoking, 27 and 48 percent of each age group, respective~ replied that they do not think they will quit. It is surprising that half of smokers aged 60 and over answered that they continue smoking. Have they never advised their patients to stop smoking? The proverb says it is a good doctor who follows his own directions. A physician should not break the rules of health. Hiroshi Kawane, M.D., F.C.C.l, Kawasald Medical School, Kurashilri City, Okayama, japan

Reprint reque8Js: Dr Kawane, Department of Medicine, Kawasaki Medical School, Kurashiki City, Okayama, japan 701-01 REFERENCE

1 Kawane H. Smoking among members of the Japan Society of Chest Diseases. Nippon Kyobu Shikkan Gakkai Zasshi 1990;

28:102

528

1b the Editor:

Dr Kawane provides data that reinforce concern about smoking in Asian countries and reBect a number of the issues raised in the article by Rimer et aI on smoking among older adults (Chest 1990; 97:547-53) and our accompanying editorial (Chest 1990; 97:517-18). A number of reports indicate high rates of smoking among professionals and other middle-class groups in Oriental countries. That 25 percent of members of the Japan Society of Chest Diseases who responded to a survey admitted smoking certainly alarms American readers who assume that smoking is decreasing in prevalence and is not widespread among physicians. More directly pertinent to the cited articles, 48 percent of those smokers who were over 60 years of age indicated little interest in quitting. As Rimer et aI noted, and as we pointed out in our editorial, older adults and their physicians may underestimate the utility of quitting. Apparently, Japanese chest specialists may also underestimate this utili~ It is hard to imagine that their misapprehension is not wittingly or unwittingly transmitted to their patients. Misunderstanding the risks ofsmoking and advantages of quitting among older adults is an example of a more general problem: although most Americans and professionals know that smoking is dangerous, they underestimate how uniquely dangerous it is. Many fail to recognize that smoking kills more from heart disease than from lung cancer and is responsible for the vast majority of cases of chronic lung disease. Many fail to grasp its enormous impact in terms of mortality, although it is responsible for about one of every six or seven deaths in the United States, according to the Surgeon General's 1989 report. According to the same report, smokers are less aware of this impact than nonsmokers. The enormity of the problem is especially great in Asia. According to Dr Judith Mackay of Hong Kong, 50 million children currently alive in the People's Republic of China will die of diseases attributable to smoking if current trends continue. Dr Kawane's data emphasize, again, the scope of the problem, its exacerbation in Asia, and the especially unfortunate misunderstanding of smoking cessation among older smokers-and their doctors! Edwin B. Fishel; Jr., Ph.D., St. lDuis; and

Robert D. Hill, Ph.D., Salt lake City

Right-to-Left Atrial Shunting 7b the EdItor: I read with interest the case report by Remy-Jardin et al of rightto-left shunting through a patent foramen ovale without pulmonary hypertension. I The authors implied that their case was the first such report in a patient without previous lung resection. We reported the case of a patient with cyanosis and a small atrial septal defect with normal right heart pressures and without prior pulmonary surgery in lQ831; the mechanism was a persistent eustachian valve. A clinical complaint such as platypnea-orthodeoxia, which has already been reported, 3 could be explained on the basis ofpositional m0di6cation of abnormal shunting. Assumption of the upright position could stretch the interatrial communication, be it a patent foramen ovale or a small atrial septal defect, thus allowing more streaming of venous blood Bow through the defect, especially with a persistent eustachian valve. Right atrial angiography or inferior venacavography was the only method for making this diagnosis until the advent of echocardiography. Contrast echocardiography-especially following a Valsalva maneuve...·5 -is a simple and reliable noninvasive means of documenting a right-to-Ieft interatrial shunt with normal right heart Communications to the Editor