Nick Summerton On poor-health deterrents

Published: 27/05/2004, Volume II4, No. 5907 Page 29

Inflicting pain on people does not necessarily stop them smoking. In 1965, the Medical Research Council epidemiological research unit in Wales examined the effects of caning on smoking in a secondary modern school. No evidence was found that the punishment had any effect on smoking rates.

The use of overt deterrents has gradually fallen out of favour but there remains a negative view of smokers among many healthcare professionals. I have heard colleagues comment, 'If patients can afford to smoke, why should the NHS pay for their nicotine replacement therapy?' and, 'If a patient can't be bothered to stop smoking, why should I bother to check or treat their elevated cholesterol levels?'

There is now a growing appreciation that the factors encouraging the commencement, continuation and cessation of smoking are multiple and complex. For my part, it was only when working as a public health physician in a deprived inner city area that I began to appreciate that an occasional cigarette may be the only pleasure an individual gets; even food may be sacrificed in favour of cigarettes.

In recent years, there has also been a shift in thinking on the prevention of cardiovascular disease. The term hyperlipidaemia, for example, is quite misleading as there is no threshold below which the patient is at zero cardiovascular risk.

Importantly, randomised controlled trials have demonstrated that the mortality and morbidity benefits derived from statin treatment are related to the degree of cholesterol lowering rather than the individual's baseline cholesterol concentration.

It is now argued that intervening to change risk factors such as cholesterol should be determined by a person's total level of risk - combining age, their ratio of high-density to low-density lipoproteins (two types of cholesterol), smoking status, blood pressure, diabetic status and sex - not by the level of individual risk factors. The implication is that all reversible cardiovascular risk factors should be reduced in anyone at high risk, irrespective of the starting level of the individual variables. The bottom line is that a patient at high cardiovascular risk with a 'normal' cholesterol level, for example, would benefit from treatment with a statin.

If we are going to make any serious impact on cardiovascular disease, smokers should be empowered to stop, sedentary individuals should be persuaded to exercise and everyone should be encouraged to adopt a healthy diet.However, failing to exercise, continuing to smoke or consuming junk food should not be used as an excuse for health professionals to exercise their own prejudices.

All patients should now be treated according to the level of their total cardiovascular risk, irrespective of how that risk is accumulated. There also needs to be a greater emphasis on interventions of proven effectiveness, with more aggressive pharmacological approaches to lower blood pressure and cholesterol reduction.When statins become available without prescription, we must not punish those smokers who cannot afford to buy them.

Nick Summerton is a GP and primary care trust research lead, and heads Hull University's public health and primary care division.