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~ BRICISYl MEDICAL JOURNAL 5 JULY 1975 an aclte atdmitting hospital is seldom far this is not necessarily the statistical optimum) { away- But in the coming years of financial it has clearly not proved satisfaetory in this . stringency the population must ehoose be- respect. One is therefore also led to question t -rn this luxury of convenience and rather whether this method can be trusted to en- W for a streamlined, rationalized, and sure chat on average ehc tesni:ent groups icient service. For example, for every 5 are similar with respect to patient charac- acute hospitals at present open 24 hours a teristics correlated with the trial end-points, i day, in the future one hospital only in that a necessary condition for unbiased compari- ' district should be adequately staffed and son. In view of the ready avaIlabifltr of equipped to deal with all emergencies. At eminently satisfactory randomizing tech- i present there is great variation in work load niques using random numbers,s which can between hospitals of comparable staffing and be constrained to give equal group sizes if beds. Such a scheme would give junior staff required, it is unnecessan- to relc on other no less experience but a more concentrated techniques of _eossible dubiety such as ones training and indeed would assist in reducing based on dates of birth. tlle present very long periods of post- The unbalanced distribution of group oraduate medical training which have long sizes is in itself interesting. After al!o•,cing distinguished Britain from comparable for differing lengths of the months and nations. If you are on duty in the hospital, seasonality of birth rate the significance of at whatever grade, you might as well be the observed deviations increases, so the busyl explanation does not lie here. An explanation I am not advocating wholesale reduction in terms of admission procedure or simple in the -hours worked by juaior hospital staff, bad luck must iniually be preferred to the though some cuts could be achieved, but possibility of a real correlation between mor- rather raoher suggesting that nothing but good bidiry and month of birth. I am currently would stem from bringing planning and collecting examples of such correlations and order to what in some areas resembles noch- should be interested to hear from anyone ing less than chaos. Within the next 5 years with relevant dara in narrowly definxd irt is probable that less rather than more doc- disease areas rather than in a heterogeneous ¢ors will be available to staff our hospitals, situation.-I am, etc., . with an increase in the proportion of women . ]. A. LEwts trained who then either take part-time ap- pointmen[s or leave medicine for a large Imperial Chemiol Induscies Ltd., part of their life and with the Pharmaceu« d Divi,~ion, prospect of Macdcsfieu, Ghahire significant reductions in the numbers of foreign medical graduates entering the country. Consideration of these further rea- sons for likely diminishing skilled medical manpower adds substantial weight to a plea enhanced ef5ciencyd urely it should be possible for medical 6 through their local medical executive contmittees and district management xeams to put such proposals as outlined above to the relevant higher area and/or regional health authorities and refuse to take "no" for an answer. While I am not so naive as to ignore all the vested interests and petry little empires that over the years ~have grown up within the N.H.S., •sureiy the time has come for those whose eyes are open to let a "wind of change" blast all the muddled and ineffective dtinking from 211 those areas where they ran influence affairs. After all, it only needs common sense and resolution --falas, rare qualities indeed, especially in combination, in 1975.-I am, etc., Broadgeen Ho.pinl. Livc.-pool RICHARn W. GRIIFITHS Randomization SIR, In the controlled clinical trial reported by Mr. I. L. Rosenberg and oehers (22 March, p. 649) randomization to the three treatment groups was by month of bu-t,h, those born in the first four months of the year being allocated to one treatment, etc. The resulting group sizes were 73, 79, and 121 respectively, with 22 withdrawals. Prior to withdmwal the group sizes were 88, 85, and 122 respectivelc (Pollock AN., personal Aftmuaicadon) and this poor distribution _--s",roup stzes deviates significantly from etar.on ,T=0-015, X test). Assuminq that one aim of ths method of tandom!zadon wz~ the reasonable one of achic•:inq roughl•: cq'~^I grou:, ,.iecs (though 1.Srmitase, P.. Sra,iseival Methods in lfedical Re- sea ,, Oxford, Blzckwell. 1971. Safer Cigarettes StR,-In their somewhat heavv condemnation of your leading article (17 May, p. 354), Professor C. M. Fletcher and Dr. K. P. Ball (14 )mne, p. 613) seem [o reflect a sadly one- sided view. They "strongly deplore" the term "safer cigarettes" and favour referring to them as "less lethal cigaretres." Whether we rall them less leohal, less •harmful, less hazardous, or safer, the fact that such cig- are[ces already exist and are gradually being improved would seem to merit encourage- ment and welcome rather than sceptici.sm and disparagement. Our common aim surely is to reduce smoking-relared disease. Traditional methods of health education, antismoking propa- ganda, and treatment at antismoking clinics -have had a long run without conspicuous success. There have been cries for more money and more restrictions, but such in- tensification is unlikely to meet with much success so long as those irrvolved remain fixated on the goal of abolishing all smoking. In my view far more could be achieved by focusing more of this effort on the more realistic goal of safer smoking.' The switch to filter-tipped cigarettes (a form of safer smoking) has done more aa reduce smoking- related disease than have two decades of Lealth education and antismoking propa- ganda. The more recently developed ventilated filterrs enable tar, nicotine,- and carbon monoxide (CO) yields to be reduced to very lotv levels. This makes it possible for cig- arecoes' to become even less hazardous. But -there is a rub. Most smokers smoke to obtain nicotine and modify their smoking pattem to regulate nheir nicorine intakr. If the nica- tine concentration 4 the mainstream <,moke is 41 reduced the smoker compensates by taking more smoke into ~his lungs; and if the nico- tine yield is lowered so much (<03 mg) that an adequate nicotine intake is impossible despite this compensatory increase in• smok- ing the cigarette will simply lose accept- ability.=' Such evidence suggests that the safer cigarette will be the one with a very low tar yield and a very low CO yield but a medium (abou[ 10 mg) rather than very low nicotine yield. It is the ratio of the nicotine to tar and CO that matters. I do not claim that suoh cigarettes would be completely safe, for nicotine is unlikely to prove completely safe. But they would sub- stzntially reduce the risk of lung cancer, which is caused by the tar, and if Professor Fleteher and Dr. Ball are correct about CO rather than nicotine being the cause of smoking- related cardiovascular disease such cigarettes would reduce the risk of this as well. If people cannot stop smoking and smoke mainly to obtain nicotine there is no reason •vnhy cigarettes should not be made which allow them to Stave their nicotine without having it contaminated by excessive amounts of tar and CO. Finally, Professor Fletaher and Dr. Ball's letter contains an error. They claim that 160,000 people in Britain stopped smoking after two Thames Television prqgrammes in April and that this represents 2°'0 of the snokirng population. This would mean that the smoking population was only 8m But in the Uniced Kingdom in 1973 there were 192m. cigarette smokexs.'! I am, etc., Atldi¢ion Research Uniq Insotuce of Psychiany, Lon.lnn, S.E.S M. A. H. Rt1ssBI.L I R,sssell, M. A. H., Lanc¢t, 1971, 1, 254. a Rusull, M. A. Ii., es ul., Bneish Medical joumd, 1973, 4, 512. a Russell, hl. A. H„ er ul., British MedicN yossmaf, 1975. i. 414. + Tobeccu Research Coundl. SmtisHes of Smaking i the Unleed Kiusdom, 1913 Supplemem. Lon- don, T.R.C., 1974. Diagnosis in the Elderly SIx,-It is surprising that Dr. j. R Flampton and his colleagues in their thoug.ht- •provoking paper (31 May, p. 486) on the value of history, examination, and investiga- tion in reaching a diagnosis made no state- men[ on the ages of.ehe patients seen. It seems likely that old people did not form a large part of their sample. Never- theless, old people will continue to be seen in general medical clinics elsewhere in L1rge numbers. Clinical ezpetuence suggests that the observations made by Dr. Hampton and his colleagues are not applicable to old people. The frequenry with which spedfic illnesses present in non-specific ways in old people is well recognized by those dealing with t.hem. Concentration on the patient's own history without equal attention to the history from other sources, examination, and simple investigation may result in the failure to diagnose such conditions as pul- utonary tuberculosis, thyanid disorders, and vitamin Bt_ and iron deficiency anaemias, to mention just a few of the most easily treatable. It is already known that the incidence of diseases, their presentations, and the appro- priate forms of treatment in old people differ from these aspects in the under-65s. If it