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ih. Reply. -I t.,o x•ould exp~tmp phy±i- cian to preacnibe my medicetione based ealely on what h+enr she felt u•as best fbr me. However, detail men oft:en' etieeu out date to present to phyRiciane rhatt support the arirsment that their prod- uct is euperior•. Fl>.rth'ermore„ if the pharma>:•eutical compan3' provides an ih, eeetlW!e (economic or otherv:i$e) to use its panduct„a phyeiNan's deci±ion pro- cees mayy be inflhenced. I iagrse with Mr, Ha11*comunentF that medical echool# and residf ncy programs should train physicia.n, to evaluatephar= macetitibal product.e critacaily: This was tfte primary motivation behind the de- veloprnent of our recent seminar thatt dealt with interactions. &+ben P:.Fergu.mt.,}TD ~teYRt'$41l!( }i(Nt+It111 ~ fiartfont. C(rtn Tfw Texes of Sin: Do Snwher. Pay Their Wey? 7b TAe Editerr. -T?ie artiele by Man- ning erd` did not consider the external costa incurred when a pregnant w oman I smokes. I' believe the sampling tech- niquea of'the authors would not have included t}ie expenses incurred in thee mve of premature infants. I s uspect' the . oost of'neonatal intensive care and the' future extra educatione.I and medioal!, com would make rtlie tisxes of's&' paid bv'rtnokere Inadtquate. Pettr W. Rttneth; )ID 1(}9urn4, Slus L..MSq w'O, awYr La: ~..rbu.tJF.'S4et EM. W'.r- ntOMJ. 'TMtuY etfin.~ /0 et.itrf awd dsv~err ry :.bea .arraux xees~aaas-ISOS: fx RIp1~ -Dr Rufieth~ concern about the addit,ional costs ftomneonatal inten•, eibe tare units is *s-ell taken, By omitting,g maternity, coete from-our ca?culatione,, ws omitted the extra coata of neonatali care caused by womenk amoking during; preg;)aseya I{rntvever, the'magnitude of, the omiasion ie srrtall and' does not alter our overall conelu,ione on cigarette i taxes. Women who smoke during pregnancy, have babies whose birth weights aver- age 200 g lo>'o.r: and lemokxrs are twice as likely to have lovt•-birth-weight ba- bies as nonarnokere.` Low birth uPight is one of the strongest predictors of use d aineonatal!tntenBtqe care ttnit. A re- eetttreporton neonatal'intensi4'e eare" itxlicatee that' between 150 000 and Z00QOO infants are treated annuali-r in naonatal' Intensive care unite; 6t!~k to 80% are aow-b:rth!weight babies, at an' average eost of 112 000'to S3D OOa:.If' we use the midpoint of each reI the eatlma•,.ed cost fdr neonatal' care for low-birth-weight bahies is S2 f# billion. J4M4.Alr9uf! +6, 1909- vo' 2c'2, k5 7 Ir. 19$0, Americans p' Cch4;Fd Fln2 't61- lion,cigarettAR (StAtirtic!.: Alisttwct of the Chiteci;Sia.es,1Q5b. p 119'i. Accoi:ding, to the National Health Interview Survey (1'483), 3o% of ail women in the 20- to 29-year-old age range were current smoliers„ If'up-to one thindlof pregnantK•nmen persist in smoking and are twice as likely to hare lbsv-birth•treight babiex, then smoking may be responsible for up't'o one fourth of all neonatallintena^ve care unit costs for low-birth•weight babies: This urn plies that our estimates of the direr. dollar coats iof smokdng are tco low'by up to 2'cents per pack. In addition, the eurgeon gentral" esti- mates that there are 2600 infantdeat,hs due toemoki'ngduring pregnane,r-.:If we value these infant deaths' at the same 91.66 million that we used for adultt deatha in our article and assume that the smoking mothers ignore the riske to their infants+ then the resulting cx- ternal cost not considered by the smoker is 14 Icents per pack. Thum; by including these costs, the eetlmated' external costs of smoking range ftbm 31 to 52 cents per pack,, which is.of the same general magnitude as the average value of curner.t cigarette taxes. R9lr:anir;, *Lnnirta, PhD E mtnett B. Reder, PkD, 7nwph P. ht.howe. Phb Elizabtth3t Slotr<; PhD 7eHrr,y Wtiawnnett, PhD Th'e U+Jrtrlttr o0tkhi;..'t , SchooI orPU bltt H e.7thAnn A_'bor 1 ~.rJnry,,erd.Hrall~Alkye.t~twrc.;.~.Gi.•,.,!N.+~nt~a:ea,~.ItC, l:8 Dr,,q af iHrskk EB+ntmr . rnd ua+ tur a 7 m. A H[ w. Pn V:rtt,w (PH e)19..9!1!Ke. 3. A"OI MteaA'e,i•'cKJSr'tart,KA.epht.lw.yr.~. Carw:wd 6j(esm...r. Wtykn4'n. LM:O!!!.e d Traavnt- op Aneretax.W. L'a CA.ryre..: tW't~ fAi.!va•~r-.OTA. t.csae e. Ar1'+otptAtN-a(tRCatreI rJr+rekr.p:'.1 A•pert41 tAe Swprr.c....a(c.N.r+unN,t+. DCtsiny. d Ht.akaod:Rtteun Slrrlte.:.leMrDHHS.pADliactrn (rxs)aos+lt.. Cipropoxaoln Gvels When RecelvVn9 SucraltatiA ?b th.: Editor.-ClproSloxacin by oral' administration has recently gained considerable popularity, in the treat- meet of serioue deep-seated infections in clinica113• etable patients because cf its intense microbiolbgiaal actie-ity against nurst Eultru8ncli'iaaceae and PH~tni%r- mcnne: ar.rugttinoa orgnnisma and ita excellent bionvuilability, at, least ir healthy volunteere, There remnine, however, a paucity of h+oavaiiahilit.•. data on ciprnfloxacin andiother fl,iam- qpinoiones in' ill patients, partlcularly, those who are trceiving other dnapx. It harbeen demonstrated in normal voltln- teet2 that aluminum• and magnepium- containing compounds (eg, antacids) de- crerMe the mean peak concenu'ation• of e single 500-mg dose of'ciproiloxacin ' i fi1om 1t7 to 0.1 i.g1mL andlurine recov- ery from 24% to 2:1q'd. presumably be- ' cause ofchelate formation: h4orever, in ~, a recent report,' eucralfate, sn alumi- numicontaining comnound; significant- Ir reduced the bioavaitability of norfhox- icin. Here. we report on aix elderly patients who received 750 mg of cipro- floxacin by mouth, one of whom was also receiving I gnf sucralfatR four tiimes a, day, and'then had aerumisamplks ob- tained 1.0, 1.5, 2'0; 2.6; and18A hours after the fourth dose to determine the steady-et.te rpeak concentrations. ka shotrm in the Table; thero wae a markedlreduction in serum coneentra- tions of'oilmofloxacin,in the patient re- ceiring sucralfate: In all these pat'tents, there was no history ofgastrointestinal diaease or surgery, and none were re- ceiving other medica.3ona known to in- terfere with the bioavailability, of'orali 1luoroquinclbnea, With the increasing popularity of eu- cralfate and i fluoroquinolonEe In hoapi- talized patients, t'he clinician neede to be aware of the:potential!for unreliable ab- t;orption, which could'possibly 1ead,to therapeutic failure.lKore information is needed on the bioasailabiliby of the fiuoroquinolonea in patients ttndergping gaatrointestinal eutRery or in those re- ceiving, oral medicationa or liquids ei'. ther by mouth or b,v nasogastric or duo- denal tubes. Jae H. S-nilt; PherntD Cha1h N. N'ightinasle. PAD P-(ehud!Qu1nUlt.m,11D Fiartterd(Coen) MIwp4sl l. H~r=ac,strn.rK.crcwrD:etat.tt.erRar~!.n. .bra.pionafe'rPrrao~.nn r e.u. yrwkVX. efuttaekaE'v. J, Ctlr Hv+nbh7 IaRe I aN afbI sH.NwDY..Nr).,re...bLn.rt.l A..r.vk.rMuter!Maa.;rr~tW.e.lYtrOrpaq,efeer}lo~rern An- ~•Rr'..tNRYCAI..O{A.- 1L:A',}yJKlet.. Cb"opai..dn L.rNS (M.an 1 _ .90)'dn etc.rat4ntaRltcavrnp..7dn:manOSe'of C.prdteneon I cte+ono:ean Uwa. /r0U*t- br T/hte a'lw Ad-Ml.tratien ofC4roNOY6otn: h I No.d FWtWnt4 Aer) t.o, . ,~r. zo~ xeao 3 se:etS.e: x.57s!o3 tes_re4 a,oct.to •U=r.Ws:55-r7a 06.0 0.35 a 0.40 047 . o<f 0.44 -l/~i.nrt:rnr ..er Coneu.•h,1'Y~ne.!~~mp A Q af ~~e~.Hpe lCar, Vatet raur Mnnas a a.y ~B'rytrB ~QL I