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J.' Smoking-Re/ared Drs. I992: d(11; 1-2 EDITORIAL C a-1J'"O~, P"o s. G ive a dog-end * a bad name "Exposure to tobacco smoke and 'wellibeing and health' are incompatible. Discuss. " At first. glance, this hypothetical exarnination question poses no great intellectual challenge. Cause an6effect have been established beyond reasonable doubt, by means of well-designed'pro- and'retrospective epidemiological studies, between active cigarette smoking and a statistically significant increase in risk of, bronchial carcinoma and coronary heart disease (C HD). It has also been asserted that active smoking can increase morbidity and mortality from a host of other pathological conditions affecting almost all physiological systems. A quick glance down the index to our selected abstracts list will testify to that statement. Serious questions have, however, recently been raised' in this and other Journals on the reliability of some data seemingly establishing some of these causal relationships. In the previous issue Professor Ashford (J. Srnoking.Related' Dis. 1992; 3; 263-274) pointed to the very real probiems in assessing smoking-related mortality from all causes and suggested that, not infrequent!ly, a degree of interpretative licence appears to have been exercised in arriving at expected conclusions, If data on active smoking are being occasionally calli•d into question, there are even greate, problems concerning passive smoking and environmental tobacco smoke (ETS).. Cardiopulmonary disease, asthma,,athefogenesis, lung cancer, leukaemia, retarded growtn in children - in these and many more instances, a case has been made for ETS as a major aetiologicall factor. But assessing the impact ofi ETS is an, exercise rnadehazard'ousby confounding variables lurking around every statistical comer. In the case of CHD, for example, some 300 risk factors have at sorne time or other been identified - bywliat, means is it possible to unravel these dbta and point the finger with any degree of confidence at ETS per se as a major causative element? In this issue, Dr Armitage (pp27-36) tackles the question of ETS and CHD, and his analysis of 12 major epiderniological studies leads him to conclude thatthe relationship between ETS and increased risk of CHD "is not proven~" He has some cogent remarks to make on the suitability of meta-analyses in the assessment/evaluation of the effects of ETS and about publication bias, Paperswith a statistically significant result supporting the point of interestare more likely to be submitted and accepted f'or publication than are those covering larger numbers of subjects, but where there is a null finding. Further difficulties are encountered when determining inter- and intra-populationiquantitative exposure to ETS. Should domestic exposure alone be rneasured, or continual'but varying exposure over the course of tirrne? How do you compare groups from differentsized households both in terms of numbers of smokers and non-smokers and in the actual area of containment? Is exposure accurately determined by salivary or urinary cotinine concentrations? These are questions which urgently need tolbe addressed in a meticulous manner to.stem the flow of poorly researched or analysed data which could ultimately prove to be counter-productive to the overall'public health:task.. Inan article in the Viewpoint series in the L'ancet(1992, 340; 1208-1209) Dr Petr Skrabanek points out another fascinating stat+stical paradox arisinp frona anti-smoking campaigning over N the yeans, The number of deaths in the UK allegedly attributable to smoking has risen from 50,000 per annum in 1962 to 150,000 at present, However, the number of smokers has fallen O •Editor's note: For our Nnerican cousint, dog-end a burt. ~ ~ ~ 0

from 75% ofrnen and 50% ofiwomen in 1958 to 33% and 30%, respectively; 30 years later. What, one is tempted to enquire, is going on? Could it be that smoking is becoming an increasingly convenient scapegoat? In an illuminating;coupie of sentences, Skrabanek puts it into perspective, "Statements such as 'a hatfrbillion of'the world population will be killed by tobacco' are intended to horrify. They, tell us nothing about what to advise a 65-year-old widow with rheumatoid arthritis, who smokes 15 a day - and such information is nowhere to be found:" (My italics.) Subsequent correspondence (Lancet 1993; 341!; 58-59) under- scores the importance of resolving such clearly emotional questions. The Journal of Smoking-Related Disorders is firmly behind all efforts to prevent the young from starting to smoke and convincing older people to stop. But we can also see the dangers inherent in overkill and the use of unsubstantiated generalisations. Campaigners are by nature evangelical in their approach - but the scientific argument has to be built, on more solid foundations. To this end, the Editors of the JS-RD together with the publishers, Gardiner- Caldwell Communications (GCC Ltd), are actively canvassing support for an International Congress which will address some of the issues touched upon above. Anyone who wouldlike further information should contact the Managing Editor directly at GCC Ltd, Macclesfield. Returning to our examination question,- it does not, after all, elicit a clear-cut answer. For many; smoking is a pleasurable experience and to many more probably the only pleasurable one left without which their particular'well being and health' mightt we6lsuffer deleteriously. That is a fact which certainly the General Practitioner has to take on board when deaiing with the individual patient (relevant to the quotation from the Lancet article above). It does and should not in any manner detractfromthe mainthrust ofithe pathophysiological anti-smoking arguments which will be pursued with vigour in the pages of this Journal'. A.D.S. Caldwell Managing Editor Journal of Srnoking-Relared Disorders, Oxford, UK January 1993 2