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SUBSTITUTE SMOKING MATERIALS
275
Letters
to
the Editor
PSYCHOGERIATRIC CARE the assessment of psychogeriatric cases SIR,-" could be carried out in any hospital with adequate accommodation, staff, and resources ... ". It is refreshing to read these words in your editorial of July 8 (p. 73): the workingparty are to be commended for breaking away from the ...
oft-repeated assumption that assessment can only be done in a special unit. Surely this is a shibboleth. Any mental hospital worthy of the name has the resources needed: any self-respecting psychogeriatric team prides itself on its competence to assess as a central part of its normal work, and to maintain liaison with its geriatric colleagues. The removal of acute psychiatry from the psychiatric hospital is already with us: if psychogeriatric assessment is also to go, what is left to attract young medical and nursing staff to our psychiatric hospitals ? The gravest obstacle to psychogeriatric care, as the planners must know, is the regrettable lack of interest shown by the majority of the younger hospital doctors in this branch of psychiatry. There is, moreover, one great advantage in carrying out assessment in the psychogeriatric unit of an ordinary mental hospital-namely, the facility to select the type of ward best suited to the individual patient during his or her assessment. Nothing is more inhuman than to admit a marginally confused person into a ward of severely demented patients. The rigid belief in special assessment units is a theoretical concept handed on from committee to committee. I think that if the planners came down from their heights to talk to those of us who work in ordinary mental hospitals, they might modify their views. Knowle Hospital,
Fareham, Hants.
C. F. J. CROPPER.
SUBSTITUTE SMOKING MATERIALS
SIR,-Many members of the medical profession will have seen recent press reports of " substitute smoking materials ". Earlier this year, for example, statements by the chairman and the director of research of Imperial Chemical Industries revealed that I.C.I. and the Imperial Tobacco Group are approaching the point of decision whether jointly to invest substantial sums in a plant to produce a synthetic, man-made smoking material. This is described as " at least ten times as safe as natural tobacco "1 for blending into cigarettes " to reduce health hazards 11.2Z Other groups, in the United States and Europe, are said to be active in the same field. Clearly, the introduction of such a material poses problems of conscience and ethics not only for the manufacturers but also for the medical profession generally. For the manufacturers, the question is whether to make available at the earliest possible moment a material which laboratory experience suggests might substantially reduce the known risks of tobacco-smoking, but which, without clinical or epidemiological experience with human smokers, must remain unquantified in terms of health risk. For the medical profession, the question is whether, in seeking to reduce the health risk for those already addicted, it should endorse a substitute material notwithstanding the fact that neither its absolute safety nor its comparative risk can be accurately determined in advance of its commercial introduction on a substantial scale. Nevertheless, I believe that the medical profession has a 1. Financial Times, Feb. 25, 1972. 2. Times, March 1, 1972.
and a role in this matter which it should not seek to avoid. First, we should be willing to cooperate in the development of a synthetic material by reviewing. the test methodology and standards of judgment in the light of health hazards known to be associated with smoking. Second, we should be prepared to review the material in the light of hazards not perhaps at present associated with smoking, but which, given the nature of the material, must be taken into account before its release to the general public. Finally, we should consider what clinical or small-scale consumer trials might be appropriate before cigarettes containing the new material are offered for sale. The Secretary of State for Health and Social Services. announced in the House of Commons last year3 his intention to establish an advisory committee, which would include representatives of the tobacco industry, to. start considering some of the basic issues in this most difficult area of judgment. If the committee can recommend an appropriate programme of testing, it is surely up to us9 whether politicians or doctors, to support its methodology.
responsibility
House of Commons.
TOM STUTTAFORD.
SMOKING AND HEALTH SIR,-Professor Burch4 has made a cogent argument for testing the constitutional hypothesis versus the causal hypothesis relative to smoking and early death by further studies like those of Friberg et al. of monozygotic twins. discordant for smoking habits. Interestingly, there is such a study in progress based on. the Danish twin register. Hauge et a1.5 made a brief report of preliminary figures in 1970: A series of 762 monozygotic and same-sexed dyzygotic twin pairs, which had their smoking habits mapped in 1959, has been followed continuously, and the mortality which has occurred in this group has been analyzed in relation to tobacco consumption. Neither monozygotic nor dyzygotic pairs showed any tendency to increased mortality in the heavier smoking co-twins. When the material was subdivided according to cause of death, no conspicuous exception from the general pattern was found, but the subgroups were relatively small." In a second series of 1584 twin pairs followed since 196& "
monozygotic pairs where only one twin had a coronary occlusion, he was equally often the light-smoking or nonsmoking one as the heavier smoking one. Presumably further results on comparative mortality are available bynow from this ongoing study. In the United States a large series of twins has been traced under the auspices of the National Academy of’ Sciences-National Research Council and their zygosityand smoking habits are known.6 If a survey of their mortality were to be made, these data together with those of theSwedish and Danish twin registers would constitute a respectable beginning toward the world-wide survey suggested by Professor Burch. It is disturbing that twin data in relation to smoking and mortality have been virtually ignored in major smoking and health reports such as those of the Royal College of Physicians and the U.S. Public Health Service. Although in
the present data base is small and results to date must be considered tentative, the twin data seem to weaken the inference of a causal connection between smoking and earlydeath which has been drawn from the conventional. epidemiological studies. The use of monozygotic twins who are discordant for some environmental or sociological attribute under investi-. gation in an epidemiological study provides an especially 3. Hansard, March 16, 1971, col. 1190. 4. Burch, P. R. J. Lancet, 1972, i, 1283. 5. Acta Genet. med. Gemell. 1970, 19, 248. 6. Jablon, S. Am. J. hum. Genet. 1967, 19, 133.
Letters
to
the Editor
PSYCHOGERIATRIC CARE the assessment of psychogeriatric cases SIR,-" could be carried out in any hospital with adequate accommodation, staff, and resources ... ". It is refreshing to read these words in your editorial of July 8 (p. 73): the workingparty are to be commended for breaking away from the ...
oft-repeated assumption that assessment can only be done in a special unit. Surely this is a shibboleth. Any mental hospital worthy of the name has the resources needed: any self-respecting psychogeriatric team prides itself on its competence to assess as a central part of its normal work, and to maintain liaison with its geriatric colleagues. The removal of acute psychiatry from the psychiatric hospital is already with us: if psychogeriatric assessment is also to go, what is left to attract young medical and nursing staff to our psychiatric hospitals ? The gravest obstacle to psychogeriatric care, as the planners must know, is the regrettable lack of interest shown by the majority of the younger hospital doctors in this branch of psychiatry. There is, moreover, one great advantage in carrying out assessment in the psychogeriatric unit of an ordinary mental hospital-namely, the facility to select the type of ward best suited to the individual patient during his or her assessment. Nothing is more inhuman than to admit a marginally confused person into a ward of severely demented patients. The rigid belief in special assessment units is a theoretical concept handed on from committee to committee. I think that if the planners came down from their heights to talk to those of us who work in ordinary mental hospitals, they might modify their views. Knowle Hospital,
Fareham, Hants.
C. F. J. CROPPER.
SUBSTITUTE SMOKING MATERIALS
SIR,-Many members of the medical profession will have seen recent press reports of " substitute smoking materials ". Earlier this year, for example, statements by the chairman and the director of research of Imperial Chemical Industries revealed that I.C.I. and the Imperial Tobacco Group are approaching the point of decision whether jointly to invest substantial sums in a plant to produce a synthetic, man-made smoking material. This is described as " at least ten times as safe as natural tobacco "1 for blending into cigarettes " to reduce health hazards 11.2Z Other groups, in the United States and Europe, are said to be active in the same field. Clearly, the introduction of such a material poses problems of conscience and ethics not only for the manufacturers but also for the medical profession generally. For the manufacturers, the question is whether to make available at the earliest possible moment a material which laboratory experience suggests might substantially reduce the known risks of tobacco-smoking, but which, without clinical or epidemiological experience with human smokers, must remain unquantified in terms of health risk. For the medical profession, the question is whether, in seeking to reduce the health risk for those already addicted, it should endorse a substitute material notwithstanding the fact that neither its absolute safety nor its comparative risk can be accurately determined in advance of its commercial introduction on a substantial scale. Nevertheless, I believe that the medical profession has a 1. Financial Times, Feb. 25, 1972. 2. Times, March 1, 1972.
and a role in this matter which it should not seek to avoid. First, we should be willing to cooperate in the development of a synthetic material by reviewing. the test methodology and standards of judgment in the light of health hazards known to be associated with smoking. Second, we should be prepared to review the material in the light of hazards not perhaps at present associated with smoking, but which, given the nature of the material, must be taken into account before its release to the general public. Finally, we should consider what clinical or small-scale consumer trials might be appropriate before cigarettes containing the new material are offered for sale. The Secretary of State for Health and Social Services. announced in the House of Commons last year3 his intention to establish an advisory committee, which would include representatives of the tobacco industry, to. start considering some of the basic issues in this most difficult area of judgment. If the committee can recommend an appropriate programme of testing, it is surely up to us9 whether politicians or doctors, to support its methodology.
responsibility
House of Commons.
TOM STUTTAFORD.
SMOKING AND HEALTH SIR,-Professor Burch4 has made a cogent argument for testing the constitutional hypothesis versus the causal hypothesis relative to smoking and early death by further studies like those of Friberg et al. of monozygotic twins. discordant for smoking habits. Interestingly, there is such a study in progress based on. the Danish twin register. Hauge et a1.5 made a brief report of preliminary figures in 1970: A series of 762 monozygotic and same-sexed dyzygotic twin pairs, which had their smoking habits mapped in 1959, has been followed continuously, and the mortality which has occurred in this group has been analyzed in relation to tobacco consumption. Neither monozygotic nor dyzygotic pairs showed any tendency to increased mortality in the heavier smoking co-twins. When the material was subdivided according to cause of death, no conspicuous exception from the general pattern was found, but the subgroups were relatively small." In a second series of 1584 twin pairs followed since 196& "
monozygotic pairs where only one twin had a coronary occlusion, he was equally often the light-smoking or nonsmoking one as the heavier smoking one. Presumably further results on comparative mortality are available bynow from this ongoing study. In the United States a large series of twins has been traced under the auspices of the National Academy of’ Sciences-National Research Council and their zygosityand smoking habits are known.6 If a survey of their mortality were to be made, these data together with those of theSwedish and Danish twin registers would constitute a respectable beginning toward the world-wide survey suggested by Professor Burch. It is disturbing that twin data in relation to smoking and mortality have been virtually ignored in major smoking and health reports such as those of the Royal College of Physicians and the U.S. Public Health Service. Although in
the present data base is small and results to date must be considered tentative, the twin data seem to weaken the inference of a causal connection between smoking and earlydeath which has been drawn from the conventional. epidemiological studies. The use of monozygotic twins who are discordant for some environmental or sociological attribute under investi-. gation in an epidemiological study provides an especially 3. Hansard, March 16, 1971, col. 1190. 4. Burch, P. R. J. Lancet, 1972, i, 1283. 5. Acta Genet. med. Gemell. 1970, 19, 248. 6. Jablon, S. Am. J. hum. Genet. 1967, 19, 133.