- Email: [email protected]
Assessing drug-related harm – Authors' reply
Correspondence
indeed rationality of a system that ranks tobacco ninth in terms of potential for harm. The likely reason for their conclusion is that their scoring system aggregates data into a simple arithmetic mean of the nine points rated. For tobacco, the score for chronic harm resulting from killing more than 100 000 people each year in the UK2 is more than offset by low scores for acute harm and intravenous use. Nutt and colleagues acknowledge that their score might not be ideal. We agree. They mention the need for further assessment to validate the entire system independently. It might have been wise to pursue this before publication. Nutt and colleagues also suggest that harm caused by tobacco is offset by the tax revenue it generates. This is a misrepresentation of taxes as a “benefit” to the economy, when they are in fact a transfer from one part of the economy to another. It is in any case wholly inappropriate to offset health costs against the tax take. National and international regulatory bodies seeking to reduce the toll of death and disability caused by drugs in society would be ill-advised to base tobacco policy on this study. RW does research and consultancy for, and has received hospitality and travel funds from, manufacturers of smoking cessation medications, and has a share of a patent for a novel nicotine delivery device. All other authors declare that they have no conflict of interest.
*John Britton, Ann McNeill, Deborah Arnott, Robert West, Christine Godfrey [email protected] University of Nottingham, Division of Epidemiology and Public Health, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK (JB, AM); Action on Smoking and Health, London, UK (DA); Cancer Research UK Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London, UK (RW); and Department of Health Sciences, University of York, York, UK (CG) 1
2
Nutt D, King L, Saulsbury W, Blakemore C. Development of a rational scale to assess the harm of drugs of potential misuse. Lancet 2007; 369: 1047–53. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004; 328: 1519–28.
www.thelancet.com Vol 369 June 2, 2007
Authors’ reply Philip Murphy and John Britton and colleagues raise important issues, which we acknowledged in our paper. The harms of ecstasy do indeed need reviewing in light of the growing research base. We argued for a rolling review of the evidence for all drugs, and for a system of classification that is easily modified. Opinion about the acute dangers of ecstasy has not really changed since the early years, and the risks are partly mitigated by harm-reduction interventions, such as chill-out rooms and free water in dance clubs. However, the question of longterm harm is yet to be resolved, and the papers cited by Murphy make a contribution here. He will be pleased to know that the Advisory Council on the Misuse of Drugs, in association with the Health Technology Assessment programme, is currently undertaking a systematic review of the evidence, which could inform a further harm assessment for ecstasy and related drugs. We were disappointed by Britton and colleagues’ accusation that we under-rated the harm of tobacco. We pointed out that “tobacco is estimated to cause up to 40% of all hospital illness and 60% of drugrelated fatalities” and that “tobacco is the most addictive commonly used drug”. Consequently, our estimate of chronic harm was “unsurprisingly, very high”. The fact that taxation on legal drugs partly offsets health-care costs cannot be ignored in any economic analysis, and heavy taxes on tobacco have influenced prevalence. But we most definitely did not “suggest that harm caused by tobacco is offset by the tax revenue”. This had no part at all in our analysis of harm. Our method focused on the intrinsic harm of substances, independent of prevalence, because, to guide investment in policing and education, we need to be able to assess substances when their use is low, but
which have the potential to become widespread. Even the simple consolidated harm score for tobacco was higher than that of several class A drugs. However, we fully acknowledged the main issue raised by Britton and colleagues, namely the disparity in scores across different categories of harm for certain drugs, especially tobacco. Multicriteria decision analysis might be useful but is unlikely to generate single harm scores appropriate for every aspect of policy. One advantage of having explicit scores for different aspects of harm is that they could be differently weighted to guide approaches to policing, strategies to reduce acute harm, sentencing, education, health-care provision, and public health interventions. Of course further consideration and refinement are needed, but we hope that our paper is a useful step towards evidence-based classification of drugs. We declare that we have no conflict of interest.
*David Nutt, Les King, William Saulsbury, Colin Blakemore [email protected] Psychopharmacology Unit, University of Bristol, Bristol BS1 3NY, UK (DN); Forensic Science Service, London, UK (LK); Police Foundation, London, UK (WS); Medical Research Council, London, UK (CB); and Department of Physiology, Anatomy and Genetics, Oxford, UK (CB)
Influenza vaccination for elderly people and their care workers We are not familiar with the supposedly Cochrane origin of the outcome definitions described by Nicole Smith and David Shay in their Comment (Nov 18, p 1752).1 Perusal of the Cochrane Reviewers’ Handbook2 does not support the interpretation of efficacy and effectiveness as being tied to any particular study design. We can also reassure Smith and Shay that the diversity of outcomes encountered in the preparation of our 1857
indeed rationality of a system that ranks tobacco ninth in terms of potential for harm. The likely reason for their conclusion is that their scoring system aggregates data into a simple arithmetic mean of the nine points rated. For tobacco, the score for chronic harm resulting from killing more than 100 000 people each year in the UK2 is more than offset by low scores for acute harm and intravenous use. Nutt and colleagues acknowledge that their score might not be ideal. We agree. They mention the need for further assessment to validate the entire system independently. It might have been wise to pursue this before publication. Nutt and colleagues also suggest that harm caused by tobacco is offset by the tax revenue it generates. This is a misrepresentation of taxes as a “benefit” to the economy, when they are in fact a transfer from one part of the economy to another. It is in any case wholly inappropriate to offset health costs against the tax take. National and international regulatory bodies seeking to reduce the toll of death and disability caused by drugs in society would be ill-advised to base tobacco policy on this study. RW does research and consultancy for, and has received hospitality and travel funds from, manufacturers of smoking cessation medications, and has a share of a patent for a novel nicotine delivery device. All other authors declare that they have no conflict of interest.
*John Britton, Ann McNeill, Deborah Arnott, Robert West, Christine Godfrey [email protected] University of Nottingham, Division of Epidemiology and Public Health, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK (JB, AM); Action on Smoking and Health, London, UK (DA); Cancer Research UK Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London, UK (RW); and Department of Health Sciences, University of York, York, UK (CG) 1
2
Nutt D, King L, Saulsbury W, Blakemore C. Development of a rational scale to assess the harm of drugs of potential misuse. Lancet 2007; 369: 1047–53. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004; 328: 1519–28.
www.thelancet.com Vol 369 June 2, 2007
Authors’ reply Philip Murphy and John Britton and colleagues raise important issues, which we acknowledged in our paper. The harms of ecstasy do indeed need reviewing in light of the growing research base. We argued for a rolling review of the evidence for all drugs, and for a system of classification that is easily modified. Opinion about the acute dangers of ecstasy has not really changed since the early years, and the risks are partly mitigated by harm-reduction interventions, such as chill-out rooms and free water in dance clubs. However, the question of longterm harm is yet to be resolved, and the papers cited by Murphy make a contribution here. He will be pleased to know that the Advisory Council on the Misuse of Drugs, in association with the Health Technology Assessment programme, is currently undertaking a systematic review of the evidence, which could inform a further harm assessment for ecstasy and related drugs. We were disappointed by Britton and colleagues’ accusation that we under-rated the harm of tobacco. We pointed out that “tobacco is estimated to cause up to 40% of all hospital illness and 60% of drugrelated fatalities” and that “tobacco is the most addictive commonly used drug”. Consequently, our estimate of chronic harm was “unsurprisingly, very high”. The fact that taxation on legal drugs partly offsets health-care costs cannot be ignored in any economic analysis, and heavy taxes on tobacco have influenced prevalence. But we most definitely did not “suggest that harm caused by tobacco is offset by the tax revenue”. This had no part at all in our analysis of harm. Our method focused on the intrinsic harm of substances, independent of prevalence, because, to guide investment in policing and education, we need to be able to assess substances when their use is low, but
which have the potential to become widespread. Even the simple consolidated harm score for tobacco was higher than that of several class A drugs. However, we fully acknowledged the main issue raised by Britton and colleagues, namely the disparity in scores across different categories of harm for certain drugs, especially tobacco. Multicriteria decision analysis might be useful but is unlikely to generate single harm scores appropriate for every aspect of policy. One advantage of having explicit scores for different aspects of harm is that they could be differently weighted to guide approaches to policing, strategies to reduce acute harm, sentencing, education, health-care provision, and public health interventions. Of course further consideration and refinement are needed, but we hope that our paper is a useful step towards evidence-based classification of drugs. We declare that we have no conflict of interest.
*David Nutt, Les King, William Saulsbury, Colin Blakemore [email protected] Psychopharmacology Unit, University of Bristol, Bristol BS1 3NY, UK (DN); Forensic Science Service, London, UK (LK); Police Foundation, London, UK (WS); Medical Research Council, London, UK (CB); and Department of Physiology, Anatomy and Genetics, Oxford, UK (CB)
Influenza vaccination for elderly people and their care workers We are not familiar with the supposedly Cochrane origin of the outcome definitions described by Nicole Smith and David Shay in their Comment (Nov 18, p 1752).1 Perusal of the Cochrane Reviewers’ Handbook2 does not support the interpretation of efficacy and effectiveness as being tied to any particular study design. We can also reassure Smith and Shay that the diversity of outcomes encountered in the preparation of our 1857