170 substitute can be provided for mankind’s gardens and fields. The manufacture, storage, and use of paraquat should be banned. Buchan Lodge,

Norham, Berwick-on-Tweed.

G. A. C. BINNIE.

SMOKING AND CORONARY HEART- DISEASE

SIR,-In their paper on the beneficial effects of giving up smoking on total and coronary mortality amongst the Framingham subjects (Dec. 7, p. 1345), Dr Gordon and her colleagues referred to the lack of any effect amongst those who were 65 years and over. They also referred to the previous experience in Framingham where the impact of cigarette smoking on coronary heart-disease incidence is virtually non-existent beyond 65 years. It is our experience as clinicians interested in the cigarette-smoking experience of our patients that smokers reaching the late 60s and 70s are very often non-inhalers. This may indeed account for their survival into older age and it may be a factor, and an important one, in the failure to detect a beneficial effect from stopping the habit at this stage. The authors state that, in terms of cardiovascular disease, the urgency of giving up cigarette smoking may be greater in men under 65 years. May it not be that, in such terms, the urgency to stop is amongst inhalers, irrespective of age ? The authors are surely more than unnecessarily cautious when, in attempting to identify the reason for the acknowledged deleterious effects of cigarette smoking as opposed to the pipe and cigar, they state that this may possibly be due to inhalation of the cigarettes. We would consider that, with all the evidence available, the factor is very probably, if not certainly, the inhalation of cigarettes. We are rather unhappy about the conclusion that smoking is related weakly, if at all, to angina pectoris. The weak relationship to angina may be the Framingham experience, but a significant relationship between cigarette smoking and angina has been reported by other workers1 and we feel that this matter is sub judice. We are also unable to accept without qualification the suggestion that cigarette smoking may not be an important factor in atherogenesis. They base their assumption on the fact that the coronary heart-disease incidence amongst ex-smokers is similar to that of non-smokers. In reaching this conclusion they ignore the experimental, clinical, epidemiological, and necropsy evidence which links cigarette smoking directly with atheromatosis and which has already been referred to by us.22 By implication, they also assume that atheroma is irreversible. Whilst the evidence in favour of resolution of atheroma in human arteries is still circumstantial, there is certainly no evidence whatever that, given the removal of all relevant risk factors, atheroma is not reversible. The Framingham findings on the effects of stopping smoking are interesting and important from the publichealth point of view. These findings reflect our own experience in the secondary prevention field, where we find that cigarette smokers who continue to smoke heavily after a first myocardial infarction have a significantly greater subsequent mortality from coronary heart-disease compared with non-smokers and those who stop or who considerably reduce their consumption.3 St. Vincent’s Hospital, Elm Park, Dublin 4. 1.

2. 3.

RISTEARD MULCAHY NOEL HICKEY.

Shapiro, S., Weinblatt, E., Frank, C. W., Sager, R. V. J. chron. Dis. 1965, 18, 527. Mulcahy, R., Hickey, N. Geriatrics, 1967, 22, 165. Mulcahy, R., Hickey, N., Graham, I., McKenzie, G. Br. Heart J. (in the press).

WHAT IS PARACETAMOL?

SiR,—You have lately published several important and interesting articles and letters regarding paracetamol overdosage and its treatment.1-8 However, we had never heard of paracetamol and most of the articles did not mention its chemical name or structure. Goodman and Gillman’s textbook 9 gives no reference to this drug. A random poll of twenty of our learned colleagues disclosed that only one knew that paracetamol was N-acetyl-p-aminophenol (in the United States known as acetaminophen). The Annual Review on Dialysis of Poisons and Drugs of the American Society for Artificial Internal Organs 10 references paracetamol and acetaminophen as separate drugs. A computerised literature search revealed that Clark, Borirakchanyavat, et al.ll,12 and Maclean et al.13 are among the rare authors in the literature who recognise the equivalence of the two agents. Presently in the United States, as in England, acetaminophen (paracetamol) is being used more extensively for analgesia in order to avoid the bleeding and clotting complications of salicylates. Accordingly, we are also seeing a higher incidence of its overdosage and your recent paracetamol articles are relevant to most American physicians. While our language is apparently identical, we do name many of our drugs differently. We hope this letter will correct the injustice that was done to the thousands of American subscribers to The Lancet who do not know the composition of paracetamol, and, in fact, would have difhculty ascertaining this fact. In the future, we hope you will ensure that Lancet articles concerning other medicines will be written so that readers outside of the United Kingdom can benefit from them. Veterans Administration Hospital, 3350 La Jolla Village Drive, La Jolla, California 92161, U.S.A.

JOEL GOLDEN RICHARD A. STONE.

% * We apologise and shall strive

to

do better.-ED. L.

DOPAMINE-BETA-HYDROXYLASE AND SYMPATHO-ADRENAL ACTIVITY SIR,-Mr Butler and his colleagues (Oct. 26, p. 1022) have suggested that, contrary to previously expressed views,14 measurement of plasma activity is not a good index

dopamine-&bgr;-hydroxylase (D.B.H.) of sympathetic nervous activity.

We have further evidence to support their view. We measured plasma-catecholamine levels by the radiometric method of Passon and Peuler 15 and plasma-D.B.H. levels by the double enzymic method of Horwitz et al.16 in 3 patients during insulin tolerance tests and in 2 patients

during glucagon-tolerance tests. During the insulin tolerance tests plasma-noradrenaline levels increased 3-6-fold and plasma-adrenaline levels increased 3-7-fold. By contrast, plasma-D.B.H. activity was 1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11.

Prescott, L. F., Necoton, R. W., Swainson, C. P., Wright N., Forrest, A. R. W., Matthew, H. Lancet, 1974, i, 588. McLean, A. E. ibid. p. 729. Dixon, M. F., Dixon, B., Aparicio, S. R. ibid. 1973, ii, 1387. Nakra, B. R. S., Lee, F. E., Gaind, R. ibid. ii, p. 451. Matthew, H. ibid. 1973, i, 674. Kerr, D. ibid. p. 158. Prescott, L. F. ibid. 1972, ii, 652. Farid, N. R., Glynn, J. P., Kerr, D. N. S. ibid. p. 396. Goodman, L. S., Gillman, A. The Pharmacological Basis of Therapeutics. New York, 1971. Schreiner, G. E., Teehan, B. P. Trans. Am. Soc. artif. intern. Org. 1972, 18, 563. Clark, R., Borirakchanyavat, V., et al. Gastroenterology, 1973, 65,

788. 12. Clark, R., Borirakchanyavat, V., et al. Lancet, 1973, i, 66. 13. Maclean, D. et al. ibid. 1968, ii, 849. 14. Planz, G., Palm, D., Eur. J. clin. Pharmac. 1973, 5, 255. 15. Passon, P. G., Peuler, J. D. Anal. Biochem. 1973, 51, 618. 16. Horwitz, D., Alexander, R. W., Lovenberg, W., Keiser, H. R. Circ. Res. 1973, 32, 594.

Letter: Smoking and coronary heart-disease.

170 substitute can be provided for mankind’s gardens and fields. The manufacture, storage, and use of paraquat should be banned. Buchan Lodge, Norham...
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