Gérard Dubois

Secondhand smoke is the most frequent cause of child maltreatment

Sir, Jud et al. recently published an interesting paper on characteristics associated with maltreatment types in children [1]. They are obviously quite experienced in the field of child maltreatment. Yet, to our surprise, they do not express any concern about the most frequent of all thinkable forms of physical harm namely exposure to secondhand tobacco smoking. Children are especially sensitive. When exposed to secondhand smoke, they have double the rate of respiratory and lung disorders and are more often absent from school, which affects their behaviour and learning abilities. Even if a child does not suffer from asthma but both parents smoke, he or she will have a 40% higher rate of being absent from school due to bronchitis, pneumonia or bronchiolitis. Lastly, a smoking mother doubles the risk of cot death [2]. A comparable failure to classify the harm of smoking as a type of child maltreatment occurs during pregnancy where smoking is the first avoidable cause of preterm birth and intrauterine growth retardation [3]. Similar to the other maltreatments described in the paper, smoking and low socioeconomic status are correlated. We do not hesitate to label smoking as child maltreatment despite the lack of intentionality of the child’s carers. Smoking is a disease; a very powerful addiction with the most devastating consequences. Healthcare providers and practitioners are not acting effectively about diagnosis and treatment (e.g. cognitive behavioural therapy, nicotine substitutes or varenicline). It is shameful that social security schemes fail to properly reimburse such treatments despite their high cost-effectiveness. It is predicted that 2 billion people will smoke in 2025 with a dramatic increase in lowand middle-income countries. Paediatricians must recognise smoking as child maltreatment to prevent one of the most dramatic modern epidemics.

Public health, politicians’ decisions, and the citizen

If prioritisation in healthcare is required, Werntof and dberg sadly observed that politicians will be afraid of disleasing voters, while physicians will be afraid of making edically incorrect decisions [1]. They proposed that the itizens must take part in the debate. The facts are clear, ut their proposal is far from enough. In June, French representatives of both Chambers voted major law to reform the healthcare system and improve ublic health. At the same time, they: (a) allowed adverising on the Internet for alcoholic beverages; (b) rejected proposal protecting children from advertising of foods igh in fat and sugar; (c) did not increase taxes on tobacco roducts (the last one was 5 years ago). Evidently, these decisions may be dangerous and ven worse are inconsistent. At a population level, conumption is driven by availability (price) and marketing. veryone knows the pivotal role of promoting and adverising these products in increasing consumption and arm. Politicians also have an open disrespect of the majority. ools indicated that 8 out of 10 citizens supported oppo-

Influence des politiques publiques de lutte contre le tabac

Le tabac, première cause évitable de décès dans le monde, avec 6 millions de décès annuels devrait être la priorité des politiques publiques de santé. La déclaration de Bellagio estime qu’un million de cigarettes vendues provoquent un décès prématuré et permet d’estimer les décès évités grâce aux politiques publiques, à partir des variations de ventes [1]. Cet éditorial vise à décrire la situation en France depuis 1950 pour analyser succès et échecs, car la politique de lutte contre le tabac est loin d’avoir été un processus continu. Les décisions en matière de lutte contre le tabac ont été marquées par quatre évènements principaux : la loi Veil en 1976, la loi Evin en 1991, le plan cancer I du président Chirac en 2003 puis le gel des taxes qui a succédé depuis 2004 (figure 1) [2,3]. En 1976, la loi Veil créée les avertissements sanitaires sur les paquets, limite la publicité et le parrainage d’événements sportifs et interdit de fumer dans les hôpitaux et les ascenseurs. Les ventes s’infléchissent jusqu’en 1991 sauvant 17 000 vies sur cette période. L’effet a été limité car l’industrie du tabac a réussi à contourner la loi et si les prix ont cessé de baisser, ils n’ont pas augmenté. En 1991, la loi Evin interdit toute publicité, sépare partiellement les fumeurs des non-fumeurs et retire le tabac du calcul de l’indice des prix. Grâce à des augmentations de prix dissuasives et répétées pendant six ans, pour la première fois les ventes de cigarettes diminuent, sauvant 14 000 vies sur cette période. Pendant les cinq années qui suivent, Bernard Kouchner étant ministre de la santé, les ventes restent stables car les augmentations de prix sont trop faibles pour être dissuasives. Il faut une augmentation de 10 % du prix pour entraîner une baisse de 4 % du nombre de fumeurs dans les pays développés [4]. Si la tendance observée de 1991 à 1997 avait été maintenue de 1997 à 2001, 10 000 décès auraient pu être évités sur cette période. À l’automne 2002, une augmentation de taxes accroît le prix de 12,5 % et précède le plan cancer I que le président Chirac inaugure par : « Je déclare la guerre contre le tabac » [5]. Trois nouvelles hausses de taxes en 12 mois augmentent le prix de 39 %. Les ventes chutent de 34 %, sauvant 25

Searching for an indicator of the influence of the tobacco lobby on politicians.

examinedtheimpactof cigarette pack design and pictorial health warningsused by governments to communicate directly to con-sumers. In its comprehensive policy, the FrameworkConvention on Tobacco Control (FCTC), which cameintoforcein2005,specificallycalledfortheimplementa-tionofhealthwarningsontobaccopackagingcoveringatleast 30% (ideally 50% or more) of the display areas thatmay include pictures or pictograms.

HEPATITIS B VACCINE AND THE RISK OF CNS INFLAMMATORY DEMYELINATION IN CHILDHOOD

Mikaeloff et al.1 assert that Engerix B vaccine appears to increase the risk of CNS inflammatory demyelination in childhood. This type of subgroup analysis and conclusion should be based on known mechanisms or made in response to previous findings. A subgroup analysis should also include the declaration of the number of analyses performed and adjustments …

Screening for prostate cancer: a public campaign, evidence-based-medicine and conflicting interests

Participation is a key process for the efficacy of cancer screening programs. However, concern for the assessment of the effectiveness of mass publicity campaigns seems to be lacking. Indeed, if you do a query on Pubmed with the following key words fewer than three dozen papers come up. In 2005, in France, the number of men who underwent prostate cancer screening was higher than the number of those who had colorectal cancer screening. And yet, the benefit from the former screening has not been proven despite numerous attempts over …

Prostate Specific Antigen (PSA), encore combien de dégâts ?

Screening for prostate cancer has been widely promoted since the early 1990s despite the lack of evidence of its efficacy. The US Preventive Services Task Force recommended against PSA screening because there is sufficient evidence that the harms of screening outweigh its benefits. Yet more than half of French doctors are in favor of screening and the use of PSA assays continue to grow, by 4.6% between 2009 and 2010. The sale of a rapid immunological test for PSA, intended for home use, can only aggravate a situation already out of control. The role of the French authorities in the present situation cannot be ignored.

Re: Fritz H. Schröder, Jonas Hugosson, Sigrid Carlsson, et al. Screening for Prostate Cancer Decreases the Risk of Developing Metastatic Disease: Findings from the European Randomized Study of Screening for Prostate Cancer (ERSPC). Eur Urol 2012;62:745–52

The report of an absolute risk reduction of metastatic disease of 3.1 per 1000 men randomized to screening in the European Randomized Study of Screening for Prostate Cancer (ERSPC) deserves caution [1]. First, this is a post hoc analysis of a secondary end point in a subgroup of the whole trial. Second, as observed in the methods section, the diagnosis of metastatic disease lacked rigor and was retrospective—‘‘patients with a PSA [prostate-specific antigen] value >100 ng/ml were considered to have metastatic disease if imaging studies were not reported’’— despite the European Society for Medical Oncology recommendation that radionuclide bone scans be performed at initial staging if patients have PSA levels>20 ng/ ml, chronic bone pain, or fractures [2]. Third, this report conflicts with the findings from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO), which had a longer follow-up (13 yr) and did not find significant effects of screening but, as expected, found an increase in stage IV prostate cancers in the screened group during the beginning of the follow-up [3,4]. In the screened populations, incidence of stage IV prostate cancers was 2.5 per 10 000 in the PLCO trial versus 3.3 for metastatic disease in the ERSPC trial. In contrast, figures were markedly different in the control populations: 2.8 versus 6.9, respectively. A significantly lower quality of prostate cancer treatment in the control group may explain the high rate of metastatic disease in the ERSPC trial [5].

Framework convention on tobacco control … in search of outcomes. The responsibility to protect

The WHO’s Framework Convention on Tobacco Control FCTC) is an international treaty designed to respond to the obacco pandemic. It specifies the measures that governents should implement (e.g. advertising bans, taxation, moke-free policy, health promotion, and cessation suport). Wipfli and Huang evaluated the FCTC as “effective, ven when the outcomes are unclear from the start” [1]. Sadly, the facts tragically belie this paradox. The FCTC ame into force in 2005, being the international treaty ratfied by the biggest number of countries at the quickest ate, and by 2008 at most 5% were implementing the meaures. Among countries in Europe, implementation is at est incomplete, and in most developing countries, impleentation is minimal [2]. Below, we develop the example of France to stress that treaty based upon policies but not on goals is fake which llows for concealment. In European Union, France was the first of the old Memer to ratify the FCTC treaty in October 2004. From 1991 to 005, mainly due to important and repeated increases in xcise tax, prices almost tripled and cigarettes sales nearly alved from 9.7 billion to 5.5 billion. Since 2005 cigarettes ales leveled off, being 5.5 for 2010 and the prevalence of moking even increased by 3% although several tobacco ontrol policies where implemented: (a) three successive ncreases in price. However, the increases in price were limted to 6% in retail price (a level known to be inefficient on ales in France) and concerned the manufacturer price, not axes; (b) the ban on smoking in public and workplaces was btained in 2006, implemented in 2007 for workplaces and 008 for public places. However, first well implemented, owadays this ban is flawed as the enforcement is lackng [3]; (c) pictures on packages were enforced in 2011. owever, France is only the 39th country to enforce this ecommendation and the size of the picture is limited to

Web-Based Intervention and Alcohol: Who is Upside Down?

In 2003, the Journal published the first web-based approach for screening and delivering brief intervention to obtain a reduction of hazardous drinking among young people (Kypri et al . 2003). Further research from these Australian authors confirmed that this promising approach was valid and efficient (Kypri et …