Research into smoking or nicotine and human cognitive performance: does the source of funding make a difference?

AIMS: To establish whether there is a relationship between tobacco industry support of basic research and the conclusions drawn by the authors of that research. DESIGN: A sample of 91 papers investigating the effects of tobacco or nicotine use upon cognitive performance was analyzed to see if the pattern of conclusions drawn by researchers acknowledging tobacco industry support differed from the pattern of conclusions drawn by researchers not acknowledging tobacco industry support. FINDINGS: Scientists acknowledging tobacco industry support reported typically that nicotine or smoking improved cognitive performance while researchers not reporting the financial support of the tobacco industry were more nearly split on their conclusions. CONCLUSIONS: While it is only possible to speculate on the possible reasons, the existence of a possible bias in the published literature according to funding source must be given serious consideration.     

The effectiveness of cost-effectiveness analysis in containing costs

OBJECTIVE: Although cost-effectiveness analyses (CEAs) have been advocated as a tool to critically appraise the value of health expenditures, it has been widely hoped that they might also help contain health care costs. To determine how often they discourage additional expenditures, we reviewed the conclusions of recently published CEAs. DATA SOURCES: A search of the Abridged Index Medicus (a subset of MEDLINE designed to afford rapid access to the literature of "immediate interest" to the practicing physician) between 1990 and 1996. STUDY SELECTION: We only included articles that reported an explicit cost-effectiveness (CE) ratio (a cost for some given health effect) in the abstract. DATA ABSTRACTION: From each abstract, we collected the value for the incremental CE ratio and the measure of health effect (life-years, quality-adjusted life-years [QALYs], other). We then categorized the authors' conclusion into one of three categories: supports strategy requiring additional expenditure, no firm conclusion, and supports low-cost alternative. Finally, we obtained the article and collected information on funding source. DATA SYNTHESIS: Among the 109 eligible articles, the authors' conclusion supported strategies requiring additional expenditure in 58 (53%) and supported the low-cost alternative in 28 (26%). We then focused on the 65 articles reporting either life-years or QALYs. Cost-effectiveness ratios ranged from $400 to $166,000 (per life-year or QALY) in the 39 articles (60%) in which authors supported additional expenditure, and ranged from $61,500 to $11,600,000 in the 13 articles (20%) in which authors supported the low-cost alternative. Despite identifying similar CE ratios, authors arrived at different conclusions in the overlapping range ($61,500 to $166,000). Of the 10 articles acknowledging industry funding, 9 supported a strategy requiring additional expenditure (p = .01 as compared with those without such funding). CONCLUSIONS: Authors of CEAs are more likely to support strategies requiring additional expenditure than the low-cost alternative. There is no obvious consensus about how small the CE ratio should be to warrant additional expenditure. Finally, concerns about funding source seem to be warranted.     

Tobacco advertising and coverage of smoking and health in women's magazines

This study examines the extent of tobacco advertising and the coverage of smoking and health in all Irish produced women's magazines for 1989-93. There were 805 pieces in 402 magazines of which 684 (85%) were tobacco advertisements, 48 (5.7%) were new briefs; 27 (3.4%) were advice columns; 16 (2%) were feature articles; 15 (1.9%) were health promotion advertisements dealing with smoking and pregnancy; 10 (1.2%) were letters and 5 (0.61%) were editorials. Topics covered by the 106 articles on smoking were: smoking cessation-43 (40.6%); general health issues 35 (33%); smoking in pregnancy-4 (3.8%) and passive smoking 17 (16%). Of the 106 articles, 4 were negative about measures to control smoking. Four cigarette brands accounted for 70% of the advertisements. No tobacco advertisement carried the warning that "Smoking when pregnant harms your baby" or "Smoking kills". The 385002 cm2 of space devoted to tobacco advertising and negative messages about the dangers of tobacco and health represents 1.95% of total magazine space and is 14.5 times greater than the 26575 cm2 of positive messages about the dangers of smoking. That these magazines advertise tobacco without adequately covering the harmful effects of tobacco would suggest a degree of hypocrisy in their stated concern for women's health and lends further strength to the principle of a total ban on all tobacco advertising.     

Attitudes toward smoking

OBJECTIVES: This article examines socio-demographic variations in attitudes about the health effects of smoking, second-hand smoke, and the importance of smoke-free environments. DATA SOURCE: The data are from the Health file of the 1996/97 cross-sectional provincial household component of the National Population Health Survey, conducted by Statistics Canada. The sample consists of 60,260 respondents aged 12 or older. ANALYTICAL TECHNIQUES: Three smoking attitudes scores were derived. Multivariate analyses were used to study how age, sex, educational attainment, province and smoking status were associated with attitude scores. MAIN RESULTS: Smokers placed less emphasis than non-smokers on the health risks associated with smoking. Older Canadians, particularly smokers aged 65 and older, tended to have more lenient attitudes toward smoking, compared with younger age groups. Respondents with high school education or less held more lenient attitudes, compared with those with a university degree. Quebec residents were more tolerant of tobacco use than were residents of other provinces.     

Passive smoking and risk of cancer

During the last two decades there have been frequent discussions as to whether passive smoking causes cancer, or not. It is difficult to carry out satisfactory studies on this issue, partially because any increased risk of cancer seems modest. The tobacco industry has not only attempted to make the public aware of studies which conclude that passive smoking is harmless, but it has also tried to keep alive the discussion as to whether exposure to passive smoking is harmful, or not. A large number of studies has been carried out on the possible impact passive smoking may have on the risk of lung cancer, and it seems justifiable to conclude that passive smoking does increase the risk of this type of cancer. For other types of cancer too few studies have been performed to draw any firm conclusions.     

Tobacco, youth, and sports

Cigarette smoking constitutes the single largest threat to the health and longevity of American youth. Each year, almost 400,000 people die prematurely from tobacco-related diseases. Moreover, 90% of adult smokers began using tobacco before their eighteenth birthday, and each day 3,000 children and adolescents begin smoking. Smokeless tobacco use is less prevalent than cigarette smoking but has similar deleterious health effects and is often also glamorized by sports figures. This article examines the relationship between tobacco and sports and offers specific steps that physicians (specifically orthopedic surgeons and sports medicine physicians, who interact with athletes at sporting events and in schools as well as at the clinic) can take to help prevent or minimize tobacco use. Although sports have been used by the tobacco industry to promote tobacco products to young people, the authors suggest new ways to prevent its success.     

Techniques to improve physicians' use of diagnostic tests: a new conceptual framework

OBJECTIVES: To review the published literature on interventions aimed at improving physicians' testing practices and propose methodologic standards for these studies and to review selected studies using the PRECEDE framework, a behavioral model that helps categorize interventions based on which behavioral factors are being affected. DATA SOURCES: MEDLINE, EMBASE, and HEALTHStar databases were searched for the years 1966 to January 1, 1998, for English-language articles pertaining to diagnostic testing behavior; bibliographies were scanned to identify articles of potential interest; and researchers in health services, health behavior, and behavior modification were contacted for proprietary and other unpublished articles. STUDY SELECTION: A total of 102 articles were identified that described the results of interventions aimed at changing physicians' testing practices. We included the 49 studies that compared diagnostic testing practices in intervention and control groups. DATA EXTRACTION: Two investigators independently reviewed each article in a blinded fashion using a standard data collection form to obtain a methodologic score and to abstract the key elements of each intervention. DATA SYNTHESIS: On a 38-point methodologic criteria scale, the mean +/- SD score was 13+/-4.4. The desired behavior change was reported in the intervention group in 37 (76%) of 49 studies. Twenty-four (86%) of 28 interventions targeted at many behavioral factors were successful, while 13 (62%) of 21 studies aimed at a single behavioral factor were successful (P=.12). CONCLUSIONS: A majority of interventions to improve physicians' testing practices reported in the literature claimed success, with interventions based on multiple behavioral factors trending toward being more successful. While methodologic flaws hamper drawing strong conclusions from this literature, application of a behavioral framework appears to be useful in explaining interventions that are successful and can facilitate interpretation of intervention results.     

Message from editors to authors: review articles. How can the scientific and educational results be improved?

Most biomedical journals include review articles that pretend to provide the readers with an updated, synthetic and critical appraisal of some important topic. These articles are usually written by experts in the topics reviewed. There are no conventional or universally accepted requisites for the formal organization of contents in a review article. This is in contrast with other kinds of original articles. Therefore, to guide the authors on how to improve the review articles to be submitted to Revista Medica de Chile, some recommendations are proposed. These recommendations were based in the editors' experience and in other pertinent publications: 1) The scope and purpose of the review article should be established in the introductory paragraphs; 2) The methodology used in the selection of the literature reviewed and the time span covered by the search, should also be specified; 3) The author of the review article should systematically appraise the validity of the methods employed in the papers reviewed. A similar attitude should be observed with regards to the results, discussions and conclusions. The limitations and inconsistencies found should be pointed out; 4) The author of the review article should state his (her) own conclusions, identifying the solid as well as the weakly established facts; 5) Whenever feasible, a proposal of future lines of research envisioned after reviewing the literature, is commendable; 6) The literary style of the article should be kept as interesting as possible, to motivate the prospective readers; 7) The scope of the specific journal where the author intends to submit the review article, should always be kept in mind.     

Symptomatic syndrome of inappropriate antidiuretic hormone secretion associated with azithromycin

OBJECTIVE: To report a case of symptomatic syndrome of inappropriate antidiuretic hormone (SIADH) secretion associated with azithromycin and review the literature related to this adverse drug reaction. DATA SOURCES: Review articles identified by a computerized (MEDLINE) (1966-April 1996) and manual (Index Medicus) search. DATA SYNTHESIS: Azithromycin is a well-tolerated broad-spectrum macrolide antibiotic. We report a symptomatic case of SIADH secretion associated with azithromycin. The patient received two doses of azithromycin before the development of sudden mental status changes associated with severe hyponatremia. All other potential causes were ruled out. No previous reports exist in the literature. CONCLUSIONS: Azithromycin may be associated with symptomatic SIADH secretion. Awareness and attention are required if patients develop mental status changes or hyponatremia while receiving azithromycin so that appropriate diagnostic and therapeutic actions can be implemented.     

Reviewing the reviews: the example of chronic fatigue syndrome

OBJECTIVE: To test the hypothesis that the selection of literature in review articles is unsystematic and is influenced by the authors' discipline and country of residence. DATA SOURCES: Reviews in English published between 1980 and March 1996 in MEDLINE, EMBASE (BIDS), PSYCHLIT, and Current Contents were searched. STUDY SELECTION: Reviews of chronic fatigue syndrome (CFS) were selected. Articles explicitly concerned with a specialty aspect of CFS and unattributed, unreferenced, or insufficiently referenced articles were discarded. DATA EXTRACTION: Record of data sources in each review was noted as was the departmental specialty of the first author and his or her country of residence. The references cited in each index paper were tabulated by assigning them to 6 specialty categories, by article title, and by assigning them to 8 categories, by country of journal publication. DATA SYNTHESIS: Of 89 reviews, 3 (3.4%) reported on literature search and described search method. Authors from laboratory-based disciplines preferentially cited laboratory references, while psychiatry-based disciplines preferentially cited psychiatric literature (P = .01). A total of 71.6% of references cited by US authors were from US journals, while 54.9% of references cited by United Kingdom authors were published in United Kingdom journals (P = .001). CONCLUSION: Citation of the literature is influenced by review authors' discipline and nationality.     

Are non-allergenic environmental factors important in asthma?

OBJECTIVE: To review the roles of viral respiratory tract infections, environmental tobacco smoke and air pollution in asthma. DATA SOURCES: MEDLINE (1992-1995) searches were conducted for publications on asthma, environmental tobacco smoke, ozone, nitrogen dioxide and particulates. STUDY SELECTION: Representative original experimental and epidemiological studies and reviews of viral infections in asthma. DATA SYNTHESIS: Respiratory virus infections are the most common and important trigger of asthma attacks in children and probably also in adults. Their role in promoting development of asthma is not so clear. Exposure to environmental tobacco smoke is almost certainly responsible for some cases of childhood asthma, and can also trigger symptoms of bronchoconstriction in adults with asthma. Exposure to ozone or nitrogen dioxide is associated with symptoms, impaired lung function, bronchial hyperresponsiveness and hospital presentations for asthma. These pollutants may also act as cofactors in the development of allergen-specific bronchial hyperresponsiveness. CONCLUSIONS: Research on preventing upper respiratory viral infections may reduce asthma morbidity. The move to non-smoking workplaces is welcome, but new interventions are needed to prevent young women taking up smoking and subsequently exposing their children. The ambient air quality guideline for ozone should be revised and a health-based guideline for respirable particulates introduced.     

The impact of unemployment on health: a review of the evidence

OBJECTIVE: To review the scientific evidence supporting an association between unemployment and adverse health outcomes and to assess the evidence on the basis of the epidemiologic criteria for causation. DATA SOURCES: MEDLINE was searched for all relevant articles with the use of the MeSH terms "unemployment," "employment," "job loss," "economy" and a range of mortality and morbidity outcomes. A secondary search was conducted for references from the primary search articles, review articles or published commentaries. Data and definitions of unemployment were drawn from Statistics Canada publications. STUDY SELECTION: Selection focused on articles published in the 1980s and 1990s. English-language reports of aggregate-level research (involving an entire population), such as time-series analyses, and studies of individual subjects, such as cross-sectional, case-control or cohort studies, were reviewed. In total, the authors reviewed 46 articles that described original studies. DATA EXTRACTION: Information was sought on the association (if any) between unemployment and health outcomes such as mortality rates, specific causes of death, incidence of physical and mental disorders and the use of health care services. Information was extracted on the nature of the association (positive or negative), measures of association (relative risk, odds ratio or standardized mortality ratio), and the direction of causation (whether unemployment caused ill health or vice versa). DATA SYNTHESIS: Most aggregate-level studies reported a positive association between national unemployment rates and rates of overall mortality and mortality due to cardiovascular disease and suicide. However, the relation between unemployment rates and motor-vehicle fatality rates may be inverse. Large, census-based cohort studies showed higher rates of overall mortality, death due to cardiovascular disease and suicide among unemployed men and women than among either employed people or the general population. Workers laid off because of factory closure have reported more symptoms and illnesses than employed people; some of these reports have been validated objectively. Unemployed people may be more likely than employed people to visit physicians, take medications or be admitted to general hospitals. A possible association between unemployment and rates of admission to psychiatric hospitals is complicated by other institutional and environmental factors. CONCLUSIONS: Evaluated on an epidemiologic basis, the evidence suggests a strong, positive association between unemployment and many adverse health outcomes. Whether unemployment causes these adverse outcomes is less straightforward, however, because there are likely many mediating and confounding factors, which may be social, economic or clinical. Many authors have suggested mechanisms of causation, but further research is needed to test these hypotheses.     

Damage from passive tobacco smoking

The author presents data on the biological casualties and consequences of tobacco-smoking. Smoking is the most dangerous addiction in the scale of the world and in Poland. It causes numerous premature decrease and tobacco-dependent sickness. The author characterises the spread of this addiction in Poland concentrating on the problem of the passive smoking harmfulness. Non-smokers, children and youth, embryo and foetus during the pregnancy are exposed to the passive smoking. The experimental examinations of animals and the analysis of the lateral stream of the tobacco smoke confirm not the least, but rather the greater damage of the passive smoking than the active one. The mechanisms of acting of the tobacco smoke on the passive smokers' body and the health consequences are discussed. The manners, means and activities that are useful for the health protection of non-smokers against the tobacco smoke and the ways of the smoking prevention are described.     

Palliative care in undergraduate medical education. Status report and future directions

OBJECTIVE: To describe the status of palliative care education in the undergraduate medical curriculum and to offer recommendations for improvement. DATA SOURCES: Review of literature on palliative care and of recently submitted grants on medical education for end-of-life care. STUDY SELECTION: English-language reports of educational programs targeted toward medical students were examined, as well as surveys of medical schools. DATA EXTRACTION: Studies were reviewed by the authors to assess the quality of the educational program, evaluation methodology, and conclusions. From over 9000 citations on palliative care and related topics that were retrieved from MEDLINE searches from 1980 through 1995, and from reviewing 14 palliative care journals published from 1985 through 1996, 310 articles were identified that addressed medical education for end-of-life care, and 180 were carefully examined. DATA SYNTHESIS: While nearly all medical schools offer some formal teaching about end-of-life care, there is considerable evidence that current training is inadequate, most strikingly in the clinical years. Teaching about palliative care is received favorably by students, positively influences student attitudes, and enhances communication skills. However, curricular offerings are not well integrated; the major teaching format is the lecture; formal teaching is predominantly preclinical; clinical experiences are mostly elective; there is little attention to home care, hospice, and nursing home care; role models are few; and students are not encouraged to examine their personal reactions to these clinical experiences. CONCLUSIONS: The increasing attention to palliative care education has created major opportunities for improving education about care at the end of life. Educational programs should be rigorously evaluated to identify best educational practices.     

The campaign to raise the tobacco tax in Massachusetts

OBJECTIVES: Question 1 raised the Massachusetts state tobacco tax to fund tobacco education programs. This paper examines the process of qualifying and passing Question 1. METHODS: Information was gathered from internal memoranda, meeting minutes, newspaper articles, internal documents, letters, newsletters, news and press releases, and personal interviews. Data about campaign contributions were obtained from the Massachusetts Office of Campaign and Political Finance. RESULTS: Three factors help explain why Question 1 passed: (1) the policy environment was favorable because of the social unacceptability of smoking; (2) the activists assembled a large coalition of supporters; and (3) the activists countered industry claims that the new tax would hurt small business and lower-income smokers and would be wasted by the legislature. The ballot initiative passed despite the industry's $7 million campaign to defeat it. CONCLUSIONS: The apparent influence of the tobacco industry on the legislature was the driving force behind the decision of public health activists to qualify Question 1. Moving policy-making out of the legislature into the public arena widened the scope of conflict and enabled public health activists to win.     

Acute leptin action on insulin blood level and liver insulin receptor in the rat

OBJECTIVE: Despite the proliferation of electronic information retrieval (IR) systems for physicians, their effectiveness has not been well assessed. The purpose of this review is to provide a conceptual framework and to apply the results of previous studies to this framework. DATA SOURCES: All sources of medical informatics and information science literature, including MEDLINE, along with bibliographies of textbooks in these areas, were searched from 1966 to January 1998. STUDY SELECTION: All articles presenting either classifications of evaluation studies or their results, with an emphasis on those studying use by physicians. DATA EXTRACTION: A framework for evaluation was developed, consisting of frequency of use, purpose of use, user satisfaction, searching utility, search failure, and outcomes. All studies were then assessed based on the framework. DATA SYNTHESIS: Due to the heterogeneity and simplistic study designs, no meta-analysis of studies could be done. General conclusions were drawn from data where appropriate. A total of 47 articles were found to include an evaluation component and were used to develop the framework. Of these, 21 articles met the inclusion criteria for 1 or more of the categories in the framework. Most use of IR systems by physicians still occurs with bibliographic rather than full-text databases. Overall use of IR systems occurs just 0.3 to 9 times per physician per month, whereas physicians have 2 unanswered questions for every 3 patients. CONCLUSIONS: Studies comparing IR systems with different searching features have not shown that advanced searching methods are significantly more effective than simple text word methods. Most searches retrieve only one fourth to one half of the relevant articles on a given topic and, once retrieved, little is known about how these articles are interpreted or applied. These studies imply that further research and development are needed to improve system utility and performance.     

Magnocellular and parvocellular visual pathways are both affected in a macaque monkey model of glaucoma

OBJECTIVE: To review the literature addressing the use of the pulmonary artery catheter (PAC) in patients with respiratory failure. DATA SOURCE: All pertinent English language articles dealing with pulmonary artery catheterization in patients with respiratory failure were retrieved from 1983 through 1996. STUDY SELECTION: Articles were chosen for review if the use of pulmonary artery catheterization in patients with respiratory failure was studied or reviewed. DATA EXTRACTION: From the articles selected, information was obtained about changes in therapy and changes in outcome associated with PAC use in patients with respiratory failure. DATA SYNTHESIS: Evidence exists to suggest that use of the PAC in patients with respiratory failure often results in a change in diagnosis and therapy. Inadequate evidence exists to accurately determine benefit or harm from PAC use in patients with respiratory failure. CONCLUSION: The optimal role of the PAC as a diagnostic and monitoring device in different types of respiratory failure has not been clearly defined. Research is needed to determine the role of the PAC in very carefully defined groups of patients with respiratory failure.