Correspondence
For more on the Independent Scientific Committee on Drugs see http://drugscience.org.uk
health is sometimes perceived as neocolonialist.5 Defending sovereignty remains a safe bet, offering both a defence against the narrow self-interest of global economic forces and an advantageous context for the struggle for health. We declare that we have no competing interests.
*Wim De Ceukelaire, Marc Johan Botenga [email protected] People’s Health Movement, Brussels 1210, Belgium (WDC); and Third World Health Aid, Brussels, Belgium (MJB) 1
2
3
4
5 For the European Council Decision see http://eur-lex. europa.eu/LexUriServ/ LexUriServ.do?uri= CELEX:32005D0387:EN:NOT
Frenk J, Gómez-Dantés O, Moon S. From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence. Lancet 2014; 383: 94–97. WHO. Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. Geneva, Switzerland: World Health Organization, Commission on Social Determinants of Health, 2008. De Ceukelaire W, De Vos P, Criel B. Political will for better health, a bottom-up process. Tropical Medicine & International Health 2011; 16: 1185–89. Gleeson D, Friel S. Emerging threats to public health from regional trade agreements. Lancet 2013; 381: 1507–09. Horton R. Offline: Is global health neocolonialist? Lancet 2013; 382: 1690.
Deaths from “legal highs”: a problem of definitions Commenting on a report1 from the National Programme on Substance Abuse Deaths, BBC’s Tulip Mazumdar recently reported2 that the number of UK deaths linked to so-called legal highs has risen to at least 68 in 2012. However, almost all of those substances are controlled drugs in the UK. The term “legal highs” is misleading; they are more precisely known as new psychoactive substances. Of those 68 deaths, 17 were linked to p-methoxyamphetamine (PMA) and three with p-methoxymethylamphetamine (PMMA). But PMA and PMMA have been controlled drugs in the UK since 1977. Furthermore, PMA was added to the 1971 UN Convention
952
on Psychotropic Substances in 1986, while PMMA is widely controlled in European countries. Therefore, it seems no more logical to say PMA and PMMA are new psychoactive substances than it is to regard 3,4-methylenedioxymethylamphetamine (MDMA) in that way. The National Programme on Substance Abuse Deaths’ report also includes deaths linked to khat, anabolic steroids, and 2,4-dinitrophenol (DNP), but khat is not a new psychoactive substance, whereas anabolic steroids and DNP are not even psychoactive. The National Programme on Substance Abuse Deaths’ report lists five deaths linked to phenazepam. This drug is an anxiolytic benzodiazepine that might be new in the UK, but it has been a prescription medicine in Russia for years. Its mentioning here reflects a current dispute between the UK Government and the European Commission concerning new psychoactive substances with commercial value. Among the hundreds of substances reported in Europe in recent years is a large group of medicinal products including phenazepam. European Council Decision 2005/387/JHA allows reporting of the misuse of medicinal products, but they are arguably not new psychoactive substances. The report 3 from the Office for National Statistics on deaths related to drug poisoning in England and Wales in 2012 noted that there were 52 deaths associated with new psychoactive substances. Following a Freedom of Information request (FOI 1881), 13 of these deaths were found to be associated with γ-hydroxybutyrate (GHB): a substance added to the Misuse of Drugs Act in 2003, in Schedule II of the 1971 UN Convention, and not a new psychoactive substance. There is thus no simple answer to how many deaths were associated, let alone caused, by new psychoactive substances or even “legal highs” in any given period. If we are to develop a sensible drugs policy, such failings of
data collection and presentation need to be rectified immediately. We declare that we have no competing interests.
*Leslie A King, David J Nutt, on behalf of the Independent Scientific Committee on Drugs [email protected] Retired, Basingstoke, UK (LAK); and Imperial College, London, UK (DJN) 1
2
3
Corkery J, Claridge H, Loi B, Goodair C, Schifano F. Drug-related deaths in the UK: January–December 2012. Annual Report 2013, National Programme on Substance Abuse Deaths (NPSAD), St George’s, University of London. http://www.sgul.ac.uk/research/ projects/icdp/our-work-programmes/pdfs/ National%20Programme%20on%20 Substance%20Abuse%20Deaths%20-%20 Annual%20Report%202013%20on%20Drugrelated%20Deaths%20in%20the%20UK%20 January-December%202012%20PDF.pdf (accessed Feb 14, 2014). Mazumdar T. Rise in deaths from ‘legal highs’ in the UK. http://www.bbc.co.uk/news/ health-26089126 (accessed Feb 14, 2014). Office for National Statistics. Deaths related to drug poisoning in England and Wales, 2012. http://www.ons.gov.uk/ons/dcp171778_ 320841.pdf (accessed Feb 14, 2014).
BBC must ensure commentators’ tobacco industry links are made public The tobacco industry has a long history of delaying regulatory action and obfuscating the evidence of the harmfulness of its products, which kill one in two long-term users. Because it has become an increasingly discredited participant in debates on public health, the industry employs third parties to convey its message.1 Leaked documents from the world’s largest transnational tobacco company, Philip Morris International, indicate that “broad third party media engagement”2 is key to its current campaign to derail the introduction of standardised tobacco packaging in the UK. Growing evidence suggests that standardised packaging is a necessary and crucial step in preventing the next generation of children from smoking.3 The leaked documents from Philip Morris International identify www.thelancet.com Vol 383 March 15, 2014
Correspondence
a number of organisations and individuals Philip Morris International aims to use as “media messengers” in its campaign.2 One such organisation is the think tank, the Institute of Economic Affairs.2 The Institute of Economic Affairs refuses to disclose publicly who funds it, but it has received funds (through membership fees) from the tobacco industry.4,5 Its director Mark Littlewood has appeared in videos 6 developed by tobacco industry-funded group Forest and at tobacco industry meetings7 to oppose standardised packaging. However, when Littlewood appeared on the BBC Radio 4 Today programme (Nov 28, 2013) as Director of the Institute of Economic Affairs to argue against the introduction of standardised packaging, the tobacco industry’s funding of the Institute of Economic Affairs was not mentioned. Similarly, on Jan 29, both Christopher Snowdon from the Institute of Economic Affairs, and Simon Clark of Forest appeared on Radio 5 Live to debate on smoking in cars with no mention made of either organisation’s tobacco industry funding. The BBC’s editorial guidelines require it to provide the credentials of contributors so that audiences can judge their status. In these recent instances, questions must be asked as to whether the guidelines were inadvertently broken and listeners misled because they were not told that the Institute of Economic Affairs and Forest had received money from the tobacco industry. The UK Government’s recently announced independent review of the evidence for standardised packaging reports at the end of March, 2014, and will inevitably prompt media coverage. Given the overwhelming evidence of the industry’s intended use of third parties,2 it is crucial that this media coverage is accurate and transparent. We therefore call on the BBC Trust to ensure its guidelines are fit for purpose and to give an undertaking that it will disclose the funding of commentators in smoking and health debates. www.thelancet.com Vol 383 March 15, 2014
AG receives funding from Cancer Research UK and Economic and Social Research Council for TobaccoTactics.org. JB and MM declare that they have no competing interests.
*Anna B Gilmore, John Britton, Martin McKee, on behalf of 17 signatories [email protected] University of Bath and UK Centre for Tobacco and Alcohol Studies, Claverton Down Road, Bath BA2 7AY, UK (ABG); University of Nottingham and UK Centre for Tobacco and Alcohol Studies, Nottingham, UK (JB); and London School of Hygiene & Tropical Medicine, London, UK (MM) 1
2
3
4
5
6
7
Savell E, Gilmore AB, Fooks G. How does the tobacco industry attempt to influence marketing regulations? A systematic review. PLoS One 2014; 9: e87389. Tobacco Tactics. PMI’s anti plain packaging media campaign. http://www.tobaccotactics. org/index.php/PMI%E2%80%99s_Anti-PP_ Media_Campaign (accessed Feb 25, 2014). Moodie C, Stead M, Bauld L, et al. Plain tobacco packaging: A systematic review. Report prepared for the Department of Health. Stirling: Centre for Tobacco Control Research, University of Stirling. http://phrc.lshtm.ac.uk/ papers/PHRC_006_Final_Report.pdf (accessed Dec 20, 2013). Doward J. Health groups dismayed by news ‘big tobacco’ funded rightwing thinktanks. http://www.theguardian.com/society/2013/ jun/01/thinktanks-big-tobacco-fundssmoking (accessed Dec 20, 2013). http://www.bat.com/group/sites/ uk__3mnfen.nsf/vwPagesWebLive/ DO726J59/$FILE/medMD98ZDCB.pdf (accessed Feb 25, 2014). Hands Off Our Packs. http://www.youtube. com/watch?v=azcDb2JneeQ (accessed Feb 25, 2014). Global Tobacco Networking Forum2013. Look Who’s Talking. http://gtnf-2013.com (accessed Feb 25, 2014).
Maternal and child mortality in China Maternal and child mortality is an important indicator of a country’s health and development. In 2000, 189 governments committed to eight development goals for 2015.1 The
target of Millennium Development Goal (MDG) 4 was to reduce mortality in children younger than 5 years by two-thirds between 1990 and 2015, and the target for MDG5 was to reduce the maternal mortality ratio by threequarters during the same period. In 2008, the Countdown to 2015 initiative identified 68 priority countries (including China) for accelerated action on maternal, newborn, and child health.2 During the past decades, China has made substantial progress in reducing maternal and child mortality.3,4 In June, 2013, China National Health and Family Planning Commission released the 2012 data from the National Maternal and Child Mortality Surveillance System.5 Mortality rates in pregnant women, neonates, postneonatal infants, and children younger than 5 years are shown in the table. These data suggest that China has achieved MDG4 ahead of schedule and is expected to achieve MDG5 in 2015. The dramatic reductions in maternal and child mortality rates are undisputedly attributed to China’s economy and health-care services. For 2012, national health expenditure was estimated to be ¥2·89 trillion, and health costs per head was about ¥2135·8. Effective interventions including antenatal care, hospital delivery, neonatal visits, and management of pregnant women and children younger than 3 years have greatly improved. Notably, in 1991, the rate of hospital births in China was only 50·6%, but raised 99·2% 20 years later.5 Since 2000, the Chinese Government adopted many measures to improve the health of women and children, such as the project All
Urban
Rural
1991 2012
1991 2012
1991
2012
Pregnant women (per 100 000 livebirths)
80·0
24·5
46·3
22·2
100·0
25·6
Neonates younger than 1 month (per 1000 livebirths)
33·1
6·9
12·5
3·9
37·9
8·1
Infants younger than 1 year (per 1000 livebirths)
50·2
10·3
17·3
5·2
58·0
12·4
Children younger than 5 years (per 1000 livebirths)
61·0
13·2
20·9
5·9
71·1
16·2
For more on Tobacco Tactics see http://www.tobaccotactics.org
See appendix for a full list of signatories
For the BBC Radio 4 Today programme see http://www. bbc.co.uk/programmes/ b03jdy3m/live
For the Radio 5 Live programme see http://www. bbc.co.uk/programmes/ b03s68c9 For BBC’s editorial guidelines see http://www.bbc.co.uk/ editorialguidelines/guidelines/
Table: Maternal and child mortality in China
953
For more on the Independent Scientific Committee on Drugs see http://drugscience.org.uk
health is sometimes perceived as neocolonialist.5 Defending sovereignty remains a safe bet, offering both a defence against the narrow self-interest of global economic forces and an advantageous context for the struggle for health. We declare that we have no competing interests.
*Wim De Ceukelaire, Marc Johan Botenga [email protected] People’s Health Movement, Brussels 1210, Belgium (WDC); and Third World Health Aid, Brussels, Belgium (MJB) 1
2
3
4
5 For the European Council Decision see http://eur-lex. europa.eu/LexUriServ/ LexUriServ.do?uri= CELEX:32005D0387:EN:NOT
Frenk J, Gómez-Dantés O, Moon S. From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence. Lancet 2014; 383: 94–97. WHO. Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. Geneva, Switzerland: World Health Organization, Commission on Social Determinants of Health, 2008. De Ceukelaire W, De Vos P, Criel B. Political will for better health, a bottom-up process. Tropical Medicine & International Health 2011; 16: 1185–89. Gleeson D, Friel S. Emerging threats to public health from regional trade agreements. Lancet 2013; 381: 1507–09. Horton R. Offline: Is global health neocolonialist? Lancet 2013; 382: 1690.
Deaths from “legal highs”: a problem of definitions Commenting on a report1 from the National Programme on Substance Abuse Deaths, BBC’s Tulip Mazumdar recently reported2 that the number of UK deaths linked to so-called legal highs has risen to at least 68 in 2012. However, almost all of those substances are controlled drugs in the UK. The term “legal highs” is misleading; they are more precisely known as new psychoactive substances. Of those 68 deaths, 17 were linked to p-methoxyamphetamine (PMA) and three with p-methoxymethylamphetamine (PMMA). But PMA and PMMA have been controlled drugs in the UK since 1977. Furthermore, PMA was added to the 1971 UN Convention
952
on Psychotropic Substances in 1986, while PMMA is widely controlled in European countries. Therefore, it seems no more logical to say PMA and PMMA are new psychoactive substances than it is to regard 3,4-methylenedioxymethylamphetamine (MDMA) in that way. The National Programme on Substance Abuse Deaths’ report also includes deaths linked to khat, anabolic steroids, and 2,4-dinitrophenol (DNP), but khat is not a new psychoactive substance, whereas anabolic steroids and DNP are not even psychoactive. The National Programme on Substance Abuse Deaths’ report lists five deaths linked to phenazepam. This drug is an anxiolytic benzodiazepine that might be new in the UK, but it has been a prescription medicine in Russia for years. Its mentioning here reflects a current dispute between the UK Government and the European Commission concerning new psychoactive substances with commercial value. Among the hundreds of substances reported in Europe in recent years is a large group of medicinal products including phenazepam. European Council Decision 2005/387/JHA allows reporting of the misuse of medicinal products, but they are arguably not new psychoactive substances. The report 3 from the Office for National Statistics on deaths related to drug poisoning in England and Wales in 2012 noted that there were 52 deaths associated with new psychoactive substances. Following a Freedom of Information request (FOI 1881), 13 of these deaths were found to be associated with γ-hydroxybutyrate (GHB): a substance added to the Misuse of Drugs Act in 2003, in Schedule II of the 1971 UN Convention, and not a new psychoactive substance. There is thus no simple answer to how many deaths were associated, let alone caused, by new psychoactive substances or even “legal highs” in any given period. If we are to develop a sensible drugs policy, such failings of
data collection and presentation need to be rectified immediately. We declare that we have no competing interests.
*Leslie A King, David J Nutt, on behalf of the Independent Scientific Committee on Drugs [email protected] Retired, Basingstoke, UK (LAK); and Imperial College, London, UK (DJN) 1
2
3
Corkery J, Claridge H, Loi B, Goodair C, Schifano F. Drug-related deaths in the UK: January–December 2012. Annual Report 2013, National Programme on Substance Abuse Deaths (NPSAD), St George’s, University of London. http://www.sgul.ac.uk/research/ projects/icdp/our-work-programmes/pdfs/ National%20Programme%20on%20 Substance%20Abuse%20Deaths%20-%20 Annual%20Report%202013%20on%20Drugrelated%20Deaths%20in%20the%20UK%20 January-December%202012%20PDF.pdf (accessed Feb 14, 2014). Mazumdar T. Rise in deaths from ‘legal highs’ in the UK. http://www.bbc.co.uk/news/ health-26089126 (accessed Feb 14, 2014). Office for National Statistics. Deaths related to drug poisoning in England and Wales, 2012. http://www.ons.gov.uk/ons/dcp171778_ 320841.pdf (accessed Feb 14, 2014).
BBC must ensure commentators’ tobacco industry links are made public The tobacco industry has a long history of delaying regulatory action and obfuscating the evidence of the harmfulness of its products, which kill one in two long-term users. Because it has become an increasingly discredited participant in debates on public health, the industry employs third parties to convey its message.1 Leaked documents from the world’s largest transnational tobacco company, Philip Morris International, indicate that “broad third party media engagement”2 is key to its current campaign to derail the introduction of standardised tobacco packaging in the UK. Growing evidence suggests that standardised packaging is a necessary and crucial step in preventing the next generation of children from smoking.3 The leaked documents from Philip Morris International identify www.thelancet.com Vol 383 March 15, 2014
Correspondence
a number of organisations and individuals Philip Morris International aims to use as “media messengers” in its campaign.2 One such organisation is the think tank, the Institute of Economic Affairs.2 The Institute of Economic Affairs refuses to disclose publicly who funds it, but it has received funds (through membership fees) from the tobacco industry.4,5 Its director Mark Littlewood has appeared in videos 6 developed by tobacco industry-funded group Forest and at tobacco industry meetings7 to oppose standardised packaging. However, when Littlewood appeared on the BBC Radio 4 Today programme (Nov 28, 2013) as Director of the Institute of Economic Affairs to argue against the introduction of standardised packaging, the tobacco industry’s funding of the Institute of Economic Affairs was not mentioned. Similarly, on Jan 29, both Christopher Snowdon from the Institute of Economic Affairs, and Simon Clark of Forest appeared on Radio 5 Live to debate on smoking in cars with no mention made of either organisation’s tobacco industry funding. The BBC’s editorial guidelines require it to provide the credentials of contributors so that audiences can judge their status. In these recent instances, questions must be asked as to whether the guidelines were inadvertently broken and listeners misled because they were not told that the Institute of Economic Affairs and Forest had received money from the tobacco industry. The UK Government’s recently announced independent review of the evidence for standardised packaging reports at the end of March, 2014, and will inevitably prompt media coverage. Given the overwhelming evidence of the industry’s intended use of third parties,2 it is crucial that this media coverage is accurate and transparent. We therefore call on the BBC Trust to ensure its guidelines are fit for purpose and to give an undertaking that it will disclose the funding of commentators in smoking and health debates. www.thelancet.com Vol 383 March 15, 2014
AG receives funding from Cancer Research UK and Economic and Social Research Council for TobaccoTactics.org. JB and MM declare that they have no competing interests.
*Anna B Gilmore, John Britton, Martin McKee, on behalf of 17 signatories [email protected] University of Bath and UK Centre for Tobacco and Alcohol Studies, Claverton Down Road, Bath BA2 7AY, UK (ABG); University of Nottingham and UK Centre for Tobacco and Alcohol Studies, Nottingham, UK (JB); and London School of Hygiene & Tropical Medicine, London, UK (MM) 1
2
3
4
5
6
7
Savell E, Gilmore AB, Fooks G. How does the tobacco industry attempt to influence marketing regulations? A systematic review. PLoS One 2014; 9: e87389. Tobacco Tactics. PMI’s anti plain packaging media campaign. http://www.tobaccotactics. org/index.php/PMI%E2%80%99s_Anti-PP_ Media_Campaign (accessed Feb 25, 2014). Moodie C, Stead M, Bauld L, et al. Plain tobacco packaging: A systematic review. Report prepared for the Department of Health. Stirling: Centre for Tobacco Control Research, University of Stirling. http://phrc.lshtm.ac.uk/ papers/PHRC_006_Final_Report.pdf (accessed Dec 20, 2013). Doward J. Health groups dismayed by news ‘big tobacco’ funded rightwing thinktanks. http://www.theguardian.com/society/2013/ jun/01/thinktanks-big-tobacco-fundssmoking (accessed Dec 20, 2013). http://www.bat.com/group/sites/ uk__3mnfen.nsf/vwPagesWebLive/ DO726J59/$FILE/medMD98ZDCB.pdf (accessed Feb 25, 2014). Hands Off Our Packs. http://www.youtube. com/watch?v=azcDb2JneeQ (accessed Feb 25, 2014). Global Tobacco Networking Forum2013. Look Who’s Talking. http://gtnf-2013.com (accessed Feb 25, 2014).
Maternal and child mortality in China Maternal and child mortality is an important indicator of a country’s health and development. In 2000, 189 governments committed to eight development goals for 2015.1 The
target of Millennium Development Goal (MDG) 4 was to reduce mortality in children younger than 5 years by two-thirds between 1990 and 2015, and the target for MDG5 was to reduce the maternal mortality ratio by threequarters during the same period. In 2008, the Countdown to 2015 initiative identified 68 priority countries (including China) for accelerated action on maternal, newborn, and child health.2 During the past decades, China has made substantial progress in reducing maternal and child mortality.3,4 In June, 2013, China National Health and Family Planning Commission released the 2012 data from the National Maternal and Child Mortality Surveillance System.5 Mortality rates in pregnant women, neonates, postneonatal infants, and children younger than 5 years are shown in the table. These data suggest that China has achieved MDG4 ahead of schedule and is expected to achieve MDG5 in 2015. The dramatic reductions in maternal and child mortality rates are undisputedly attributed to China’s economy and health-care services. For 2012, national health expenditure was estimated to be ¥2·89 trillion, and health costs per head was about ¥2135·8. Effective interventions including antenatal care, hospital delivery, neonatal visits, and management of pregnant women and children younger than 3 years have greatly improved. Notably, in 1991, the rate of hospital births in China was only 50·6%, but raised 99·2% 20 years later.5 Since 2000, the Chinese Government adopted many measures to improve the health of women and children, such as the project All
Urban
Rural
1991 2012
1991 2012
1991
2012
Pregnant women (per 100 000 livebirths)
80·0
24·5
46·3
22·2
100·0
25·6
Neonates younger than 1 month (per 1000 livebirths)
33·1
6·9
12·5
3·9
37·9
8·1
Infants younger than 1 year (per 1000 livebirths)
50·2
10·3
17·3
5·2
58·0
12·4
Children younger than 5 years (per 1000 livebirths)
61·0
13·2
20·9
5·9
71·1
16·2
For more on Tobacco Tactics see http://www.tobaccotactics.org
See appendix for a full list of signatories
For the BBC Radio 4 Today programme see http://www. bbc.co.uk/programmes/ b03jdy3m/live
For the Radio 5 Live programme see http://www. bbc.co.uk/programmes/ b03s68c9 For BBC’s editorial guidelines see http://www.bbc.co.uk/ editorialguidelines/guidelines/
Table: Maternal and child mortality in China
953
