- Email: [email protected]
GOVERNMENT WARNING ON CIGARETTE PACKAGES
560
caption reading, " A lot of young men stop smoking suddenly ". We understand that a similar live sequence, also produced by the Scottish Health Education Unit, has been shown on television. The projected cause of death is cardiovascular (the poster tells us this), and we assume that this is one way of expressing the link between cigarette smoking and ischxmic heart-disease.1,2 As medical practitioners who appreciate the contribution of physical fitness to good health and possibly even recognise a prophylactic role for it in ischoemic heart-disease,3
a
Letters
to
the Editor
THE VULNERABLE MYOCARDIUM
SIR,-That the myocardium of some individuals with coronary-artery disease is more vulnerable than others cannot be contended in view of the poor relationship between the extent of myocardial fibrotic scarring and occlusive arterial diseaseand the fact that sudden death is equally common whether two, three, or four major coronary arteries are involved.What makes some ischaemic myocardia more vulnerable than others is one of the most challenging subjects for research in this field. It is all the more vital now we know that the immediate and longterm prognosis of patients resuscitated from primary ventricular fibrillation is as good as those who never had ventricular fibrillation3 and that, if treated early enough, many do not develop myocardial infarction or damage. Of the many immediate metabolic changes which accompany acute myocardial ischaemia, release of stored noradrenaline occurs within a minute of its experimental induction.4 One effect of this is the activation of an adenyl cyclase-dependent lipase leading to increased hydrolysis of triglyceride.5 It can be argued that excess storage of myocardial triglyceride prior to the onset of ischaemia might lead to a vulnerable state, since increased lipolysis could lead to immediate intracellular accumulation of free fatty acids with the many adverse effects thought to be conse7 quent on this. 6, Professor Anderson (Aug. 11, p. 298) suggests by analogy with animal muscular dystrophy that unsaturated fatty acids, if inadequately protected by antioxidants, could lead This proposal is consistent with the to heart attacks. accumulating evidence concerning the uptake of fatty acids by the ischsemic myocardium, unsaturated being taken up more readily than saturated,8 and could lead to increased triglyceride deposition with the vulnerability discussed above, although the evidence that lipid peroxidase formation is important is tenuous. Dr Barbara and Dr J. R. Chipperfield (Aug. 11, p. 293) may be witnessing a related occurrence with their observation that there are smaller concentrations of magnesium in the heart muscle of patients who die suddenly from coronary thrombosis compared with subjects who die from other causes. If the vulnerability of the myocardium is related in part to excess storage of lipid, and this has been reported in ischxmic and infarcted zones,9 then methods of reducing it become critical in importance: glucose-insulin solutions and blockade of hormone-sensitive lipolysis are two which require greater study. Department of Cardiology, Royal Infirmary, M. F. OLIVER. Edinburgh EH3 9YW.
SMOKING AND SQUASH SIR,-We were interested to see in our hospital and other nearby public buildings a poster depicting a young man lying on the floor of a squash court, apparently dead, with 1. Morris, J. N., Crawford, M. D. Br. med. J. 1958, ii, 1485. 2. Kuller, L., Cooper, M., Perper, J. Archs intern. Med. 1972, 129, 174. 3. McNamee, B. T., Robinson, T. J., Adgey, A. A. J., Scott, M. E., Geddes, J. S., Pantridge, J. F. Br. med. J. 1970, iii, 204. 4. Staszawska-Barczak, J., Ceremuzynski, L. Clin. Sci. 1968, 34, 531. 5. Kruger, F. A., Leighty, I. G., Weissler, A. M. J. clin. Invest. 1967, 46, 1080. 6. Kurien, V. A., Oliver, M. F. Lancet, 1970, i, 813. 7. Oliver, M. F. Circulation, 1972, 45, 491. 8. Spector, A. A. Ann. N.Y. Acad. Sci. 1968, 149, 768. 9. Wartman, W. B. in Ætiology of Myocardial Infarction (edited by T. M. James and J. W. Keyes); p. 115. London, 1963.
disturbed to see sudden death and physical exercise linked in this dramatic form. As far as we are aware the bulk of the evidence now suggests that physical exercise protects the individual from ischxmic heart-disease, and there is recent evidence to suggest that " vigorous exercise " 4 may be most important in this respect. We feel that popular appreciation of the positive contribution which physical exercise can make to health is still grossly deficient, and suspect that this poster may be a retrograde step. Will a smoking squash player give up his smoking or his squash ? We would have been happier with sudden death in a bus or a crowded restaurant or slumped over the wheel of a car-this would at least recognise the possible interaction of smoking, lack of exercise, and diet in the astiology of ischaemic heart-disease. Perhaps the Scottish Health Education Unit will think more carefully next time. we were
Department of Medicine, Royal Infirmary, Edinburgh EH3 9YW.
A. GORDON LEITCH B. J. KIRBY.
GOVERNMENT WARNING ON CIGARETTE PACKAGES
SIR,—The Government warning
on
cigarette packages,
health " (italics mine), indicates that the Government has doubts on this vital point. Yet there is no doubt that smoking does damage The self-administration in smoke of nicotine, health. carbon monoxide, and tar must damage the health of smokers in proportion to the amounts administered. Indecisive warnings tend to produce indecisive responsesin this case, indecisive attempts to stop smoking, which seldom succeed. Unsuccessful attempts to stop tend to induce defeatism about future success in stopping, and, with this, inaccessibility to the grave facts. That the Government’s indecisive warning may have done more harm than good is suggested by the fact that cigarette sales during 1972 actually rose-by 5°,0. I suggest that the present Government warning be " replaced by Cigarettes are our biggest killers ".
" Smoking
may
damage
your
9 Julian Road, Willaston, Douglas,
Isle of Man.
LENNOX
JOHNSTON.
WHAT’S IN A BLOOD BAG ?
SIR,-Your editorial,5 together with prior suspicion of toxic effects due to the dispensing of media through a specific brand of plastic tubing used in intravenous donor sets, prompted me to assess the effect of di-2-ethyl hexyl phthalate (D.E.H.P.) on blood lymphocyte cultures for
cytogenetic analysis. 1. 2.
3. 4.
Smoking and Health. Royal College of Physicians of London, 1962. Smoking and Health: Report of the Advisory Committee to the Surgeon-General of the Public Health Service. U.S. Department of Health, Education and Welfare, 1964. Morris, J. N. Uses of Epidemiology; pp. 172, 188. Edinburgh, 1970. Morris, J. N., Chave, S. P. W., Adam, C., Sirey, C., Epstein, L., Sheehan, D. J. Lancet, 1973, i, 333. p. 28.
5. ibid.
caption reading, " A lot of young men stop smoking suddenly ". We understand that a similar live sequence, also produced by the Scottish Health Education Unit, has been shown on television. The projected cause of death is cardiovascular (the poster tells us this), and we assume that this is one way of expressing the link between cigarette smoking and ischxmic heart-disease.1,2 As medical practitioners who appreciate the contribution of physical fitness to good health and possibly even recognise a prophylactic role for it in ischoemic heart-disease,3
a
Letters
to
the Editor
THE VULNERABLE MYOCARDIUM
SIR,-That the myocardium of some individuals with coronary-artery disease is more vulnerable than others cannot be contended in view of the poor relationship between the extent of myocardial fibrotic scarring and occlusive arterial diseaseand the fact that sudden death is equally common whether two, three, or four major coronary arteries are involved.What makes some ischaemic myocardia more vulnerable than others is one of the most challenging subjects for research in this field. It is all the more vital now we know that the immediate and longterm prognosis of patients resuscitated from primary ventricular fibrillation is as good as those who never had ventricular fibrillation3 and that, if treated early enough, many do not develop myocardial infarction or damage. Of the many immediate metabolic changes which accompany acute myocardial ischaemia, release of stored noradrenaline occurs within a minute of its experimental induction.4 One effect of this is the activation of an adenyl cyclase-dependent lipase leading to increased hydrolysis of triglyceride.5 It can be argued that excess storage of myocardial triglyceride prior to the onset of ischaemia might lead to a vulnerable state, since increased lipolysis could lead to immediate intracellular accumulation of free fatty acids with the many adverse effects thought to be conse7 quent on this. 6, Professor Anderson (Aug. 11, p. 298) suggests by analogy with animal muscular dystrophy that unsaturated fatty acids, if inadequately protected by antioxidants, could lead This proposal is consistent with the to heart attacks. accumulating evidence concerning the uptake of fatty acids by the ischsemic myocardium, unsaturated being taken up more readily than saturated,8 and could lead to increased triglyceride deposition with the vulnerability discussed above, although the evidence that lipid peroxidase formation is important is tenuous. Dr Barbara and Dr J. R. Chipperfield (Aug. 11, p. 293) may be witnessing a related occurrence with their observation that there are smaller concentrations of magnesium in the heart muscle of patients who die suddenly from coronary thrombosis compared with subjects who die from other causes. If the vulnerability of the myocardium is related in part to excess storage of lipid, and this has been reported in ischxmic and infarcted zones,9 then methods of reducing it become critical in importance: glucose-insulin solutions and blockade of hormone-sensitive lipolysis are two which require greater study. Department of Cardiology, Royal Infirmary, M. F. OLIVER. Edinburgh EH3 9YW.
SMOKING AND SQUASH SIR,-We were interested to see in our hospital and other nearby public buildings a poster depicting a young man lying on the floor of a squash court, apparently dead, with 1. Morris, J. N., Crawford, M. D. Br. med. J. 1958, ii, 1485. 2. Kuller, L., Cooper, M., Perper, J. Archs intern. Med. 1972, 129, 174. 3. McNamee, B. T., Robinson, T. J., Adgey, A. A. J., Scott, M. E., Geddes, J. S., Pantridge, J. F. Br. med. J. 1970, iii, 204. 4. Staszawska-Barczak, J., Ceremuzynski, L. Clin. Sci. 1968, 34, 531. 5. Kruger, F. A., Leighty, I. G., Weissler, A. M. J. clin. Invest. 1967, 46, 1080. 6. Kurien, V. A., Oliver, M. F. Lancet, 1970, i, 813. 7. Oliver, M. F. Circulation, 1972, 45, 491. 8. Spector, A. A. Ann. N.Y. Acad. Sci. 1968, 149, 768. 9. Wartman, W. B. in Ætiology of Myocardial Infarction (edited by T. M. James and J. W. Keyes); p. 115. London, 1963.
disturbed to see sudden death and physical exercise linked in this dramatic form. As far as we are aware the bulk of the evidence now suggests that physical exercise protects the individual from ischxmic heart-disease, and there is recent evidence to suggest that " vigorous exercise " 4 may be most important in this respect. We feel that popular appreciation of the positive contribution which physical exercise can make to health is still grossly deficient, and suspect that this poster may be a retrograde step. Will a smoking squash player give up his smoking or his squash ? We would have been happier with sudden death in a bus or a crowded restaurant or slumped over the wheel of a car-this would at least recognise the possible interaction of smoking, lack of exercise, and diet in the astiology of ischaemic heart-disease. Perhaps the Scottish Health Education Unit will think more carefully next time. we were
Department of Medicine, Royal Infirmary, Edinburgh EH3 9YW.
A. GORDON LEITCH B. J. KIRBY.
GOVERNMENT WARNING ON CIGARETTE PACKAGES
SIR,—The Government warning
on
cigarette packages,
health " (italics mine), indicates that the Government has doubts on this vital point. Yet there is no doubt that smoking does damage The self-administration in smoke of nicotine, health. carbon monoxide, and tar must damage the health of smokers in proportion to the amounts administered. Indecisive warnings tend to produce indecisive responsesin this case, indecisive attempts to stop smoking, which seldom succeed. Unsuccessful attempts to stop tend to induce defeatism about future success in stopping, and, with this, inaccessibility to the grave facts. That the Government’s indecisive warning may have done more harm than good is suggested by the fact that cigarette sales during 1972 actually rose-by 5°,0. I suggest that the present Government warning be " replaced by Cigarettes are our biggest killers ".
" Smoking
may
damage
your
9 Julian Road, Willaston, Douglas,
Isle of Man.
LENNOX
JOHNSTON.
WHAT’S IN A BLOOD BAG ?
SIR,-Your editorial,5 together with prior suspicion of toxic effects due to the dispensing of media through a specific brand of plastic tubing used in intravenous donor sets, prompted me to assess the effect of di-2-ethyl hexyl phthalate (D.E.H.P.) on blood lymphocyte cultures for
cytogenetic analysis. 1. 2.
3. 4.
Smoking and Health. Royal College of Physicians of London, 1962. Smoking and Health: Report of the Advisory Committee to the Surgeon-General of the Public Health Service. U.S. Department of Health, Education and Welfare, 1964. Morris, J. N. Uses of Epidemiology; pp. 172, 188. Edinburgh, 1970. Morris, J. N., Chave, S. P. W., Adam, C., Sirey, C., Epstein, L., Sheehan, D. J. Lancet, 1973, i, 333. p. 28.
5. ibid.