this week OPIOIDS ON SESAME STREET page 87 • VAPING HARM page 88 • VACCINATIONS page 90

North Wales

 

East Midlands

Unfilled vacancies Fewer trainees fewer ads fewer

Hospital trusts have cut back on advertising For example, North Wales had the highest Andrew Goddard (left), of the for consultant physicians despite the large proportion of unsuccessful appointments, Royal College of Physicians, number of vacancies, a report has warned. at %, and the East Midlands failed to fi ll and the BMA’s Rob Harwood have urged the government to The  annual census of consultant % of advertised posts. tackle workforce shortages and higher specialty trainee physicians Physicians were asked about their found that, as in previous years, a high working environments. A third ( %) of number of advertised consultant trainees said their morale was worse than posts in England and Wales were unfi lled a year ago. Reducing rota gaps, fi lling (%). This was usually due to a lack of vacant consultant posts, and improving any applicants at all (%) or any suitable experiences of general internal applicants (%). were crucial to improving working lives, However, the report on the census said the report said. LATEST ONLINE that this year there was a big reduction Andrew Goddard, president of the Royal (%) in the number of consultant posts College of Physicians of London, said the GP who estimated being advertised. “A number of factors results refl ected a wider crisis in the NHS. patients’ vital signs may have contributed to this fall, including “There simply aren’t enough doctors to treat without measuring the lack of trained HSTs [higher specialty the number of patients in need,” he said. them is struck off trainees] to meet the demand in shortage “We’re calling on the next government US hospital is specialties and the deteriorating fi nancial to double the number of medical students accused of keeping situation within the NHS, but this is a and to better support eff orts to retain current vegetative patient worrying pattern,” the report said. staff . Only then will we be able to provide alive to boost its transplant The census, conducted on behalf of all the sustainable and eff ective healthcare.” survival rate UK physician colleges, was sent to   Rob Harwood, chair of the BMA’s consultant physicians, from whom  Consultants Committee, said the survey US jury orders Johnson & eligible responses were received (%). showed the eff ect of shortages on doctors’ Johnson to It was also sent to  higher specialty wellbeing. He said, “The NHS must foster a pay bn to trainees, of whom  responded (%). supportive culture. Only if doctors are looked man with It found that areas in the UK with fewer after can they care properly for patients.” gynaecomastia consultants per patient population were Abi Rimmer, The BMJ linked to risperidone also the most likely to struggle to fi ll posts. Cite this as: BMJ ;:l the bmj | 19 October 2019 85 SEVEN DAYS IN Care gaps leave chronically ill prisoners at risk of transfer without medication Every day around 120 prisoners with chronic conditions are moved between prisons in England, but gaps in care mean many risk being denied medication, says a report. In its report the Healthcare Safety Investigation Branch (HSIB)—an independent, government funded organisation—cited the case of an inmate who had many seizures after his epilepsy drugs were not transferred with him. This was “just one example of a serious outcome when medication was missed.” The branch has called for changes to improve prisoner care, including integrating the prison service’s two IT systems—one for healthcare and one for operational needs—and changing the Care Quality Commission inspection process. Currently inspections by the CQC and the prison inspectorate focus on prisoners being released, rather than on routine transfers. The report also found that some prison health departments have only one authorised prescriber on site when transfers occur, creating “single points of failure.” Eamonn O’Moore, England’s health and justice lead, said, “The report provides valuable insights which will guide the work of partner organisations.”

GETTY IMAGES Elisabeth Mahase, The BMJ Cite this as: BMJ 2019;367:l6003

Interstitial cystitis a moral responsibility” to uphold scenarios. “This capacity is an NICE recommends drug for children’s rights, which included important part of our members’ chronic bladder condition being healthy, she said. preparations,” he said. NICE has reversed its decision “Stockpiles are also in place, and not to recommend the drug Severe obesity in primary some companies have already pentosan polysulfate sodium school leavers hits new high sourced alternative ferry routes.” for treating bladder pain New data showed that 4.4% of syndrome with glomerulations year 6 schoolchildren in England Tuberculosis or Hunner’s lesions in adults were classified as severely obese, J&J is urged to cut (49%; 17 052) involved children who have not responded to other the highest rate on record. Figures bedaquiline price who had been scalded by hot treatments, after negotiating a from NHS Digital showed that the People protested outside Johnson food or liquid, the International confidential price discount with rate of severe obesity in 10-11 & Johnson’s offices in cities Burn Injury Database showed. the manufacturer. Pentosan year olds had increased for the around the world to put pressure Over half of admissions in 2018 polysulfate sodium may be better fourth consecutive year, up from on the company to lower the price (51%; 1576) involved children than pregabalin, gabapentin, and 3.7% in 2014-15. The prevalence of bedaquiline, which is used to aged 0-2 years. As part of a “safe bladder instillations, although of obesity also increased in treat drug resistant tuberculosis. tea campaign” the Royal College the evidence is not high quality, reception year children (ages The drug costs nearly $1200 of Surgeons of England and the said NICE. Pentosan polysulfate 4-5), rising from 9.5% in 2017-18 (£957) for a course of treatment British Burn Association urged sodium should be used in to 9.7% in 2018-19. through the Global Drug Facility, the public not to drink hot drinks secondary care, it said, and could a UN scheme to keep drug costs while nursing a child, to test the benefit 1000 people a year. Brexit down for poorer countries. But water before putting a child in the Government announces researchers have said it can be bath, and not to leave children Child obesity extra drug freight capacity produced for a quarter of the unattended in the kitchen. Government has moral The Association of the British price. The charity Médecins Sans duty to act, says ex-CMO Pharmaceutical Industry (ABPI) Frontières has called for the price Workforce The UK government is falling short welcomed the government’s to be halved to scale up treatment Boosting staff wellbeing in its efforts to curb childhood announcement that it had signed and save lives. helped trusts’ CQC ratings obesity and must introduce extra freight capacity contracts Initiatives to increase staff tougher legislation to protect to help ensure that drugs still Childhood burns engagement and make children’s health, said England’s enter the UK after Brexit. Surgeons warn of leadership teams approachable former chief medical officer, Sally Mike Thompson (right), lifelong effects helped to improve NHS trusts’ Davies. In a hard hitting report, ABPI chief executive, said Almost half of child ratings from the Care Quality her last after nine years in the the industry would admissions to Commission, a report by NHS role, she warned the government do everything it specialised NHS Providers found. Improvements was currently “nowhere near” could to ensure burn services were remarkable given the achieving its ambition to halve people get their in England and challenging environment, childhood obesity by 2030. The Wales in the said the organisation, which government had “a duty as well as in all Brexit past five years represents NHS trusts.

86 19 October 2019 | the bmj SIXTY SECONDS MEDICINE ON . . . SESAME Environment Plastic straws and cups STREET AND Single use plastics will are to be phased out OPIOIDS be cut in NHS hospitals of England’s hospitals High street names and suppliers TODAY’S SHOW IS BROUGHT TO YOU BY including Marks & Spencer and THE LETTER    ? W H Smith are backing a call by “O” for opioid and the number 5.7 million. NHS England’s chief executive, Shockingly, that’s the estimated number of Simon Stevens, to reduce single US children under the age of 11 who live in households with a parent with a substance use plastics in hospitals. They use disorder. plan to cut the use of plastic straws and stirrers from next April, BUT WHERE DO MUPPETS COME IN? and plastic cutlery, plates, and Mental health America’s opioid crisis has inspired the cups will be phased out over the Queen’s speech promises BETTING long-running children’s TV show Sesame following year. Stevens also urged white paper this year In the past 12 Street to introduce a character whose mother catering departments to act: if The government pledged to is battling addiction. A series of videos, the NHS halved its use of catering publish a mental health white months, 41% activities, and articles take us through the backstory of Karli (below), a “bright green, plastic it could mean more than paper by the end of 2019 setting of children yellow haired” friend of Elmo who appears 100 million fewer items each year out its response to proposed aged 11-16 have with a young girl whose parents are addicts ending up in oceans or landfill. reforms to the Mental Health participated in Act. The announcement, made in recovery. some form of Promote plant based diets in the Queen’s speech on 14 IS THIS REALLY THE RIGHT TOPIC gambling more, says report October, was welcomed by FOR CHILDREN’S TV? Simon Wessely, who chaired The government should do [Cardiff Sesame Street has never been shy of tackling the independent review of more to promote vegan diets as University] big health and social matters such as autism, death, homelessness, and foster care. part of its efforts on the climate With an estimated 10.3 million US people crisis, a report for the Committee misusing prescribed opioids last year, it has on Climate Change urged. The now decided it’s time to explore addiction. paper by Richard Carmichael, an Imperial College London ARE CHILDREN OR ADULTS academic, advised that plant THE TARGET? based diets should be one of Both. Production company Sesame three big changes the UK should Workshop says it wants to help parents, the act. But he also called for healthcare providers, and teachers talk to make, alongside lowering parallel announcements that children about addiction by providing a transport and heating emissions. do not require legislation, “in viewpoint from young people that is rarely It called for regulations requiring particular the need for £800m of heard. “We are presenting the child’s true all public sector menus to offer a capital funding to modernise our perspective. At the same time, we are vegan option every day without inpatient settings, which would doing it in terms of how grownups can special request, as in Portugal. be totally unacceptable in any help,” Jeanette Betancourt, senior other part of the health service.” vice president for US social impact Acute care at Sesame Workshop, told health New toolkit will help staff Childbirth news website STAT. treat pregnant women Widespread mistreatment HAVE CLINICIANS BEEN INVOLVED? The Royal College of Physicians is found in poorer countries The children’s therapist Jerry Moe, and the Society for Acute Over a third of women in four low national director of the Hazelden Betty Medicine launched a new and middle income countries Ford Children’s Program, which toolkit to provide guidance experienced mistreatment around supports children with family for staff caring for pregnant the time of childbirth, a WHO members who have addictions, women with an urgent medical study found. The research, carried helped craft the segments. He said, problem such as chest or heart out in clinics in Ghana, Guinea, “These boys and girls are the fi rst to get pain, breathlessness, or severe Myanmar, and Nigeria, found that hurt and, unfortunately, the last to get headache. It aims to help staff women experienced physical or help. For them to see Karli and learn that unfamiliar with the normal verbal abuse or were not asked it’s not their fault and this stuff is hard to physiology of pregnancy not for consent for procedures such talk about and it’s OK to have these feelings, to miss signs or symptoms as caesarean section. that’s important. And that there’s hope.” that can appear differently in Gareth Iacobucci, The BMJ pregnant women. Cite this as: BMJ 2019;367:l6012 Cite this as: BMJ 2019;367:l5987

the bmj | 19 October 2019 87 Gender dysphoria researchers did not deviate from norms

The Health Research Authority has concluded that the team carrying out a controversial study offering puberty blockers to adolescents with gender dysphoria worked in accordance with recognised practice for health research and, in some areas, such as patient involvement and transparency, were ahead of normal practice at the time. It found no cause for the study to be reviewed further by a research ethics committee or to be Experts defend vaping’s considered for suspension or termination. Several concerns had been raised about the Tavistock and Portman NHS Foundation Trust’s safety after US deaths study. Started in 2011, it involved the use of gonadotrophin releasing hormone analogue to ung injuries in the US In the US there have been 1299 suppress puberty in 44 children aged between 11 among people using alleged cases and 26 deaths across 49 and 15. It has not yet been published. electronic cigarettes should states. In the UK only one victim has The HRA did not agree with criticism about the not deter UK smokers from been identified after nearly 10 years of lack of a control arm, saying that patients would be using them, a panel of e-cigarette use. Nor is there evidence unlikely to agree to having a placebo because the Lexperts told a briefing at the Science from the Medicines and Healthcare treatment was available in other countries. Nor did it Media Centre in London. The danger, Products Regulatory Agency’s yellow agree that rules were broken by the team in seeking they said, was less from vaping than card scheme of a hidden epidemic. approval from an ethics committee that critics said from the fear of vaping, which could The US Centres for Disease Control had links to the trust. discourage smokers from using the has now given the condition a name: A further criticism was that best available aid to quitting. EVALI (e-cigarette or vaping product the protocol was misleading in not providing information from a Dutch study indicating Trusts ask GPs to identify patients treatment would put patients on a path towards medical ineligible for free NHS treatment and, perhaps, surgical transition. The HRA found that the Dutch study was not published until after Hospital managers and GPs in regard to lies with the trust and the start of the UK study and that the UK’s study responsible for charging patients’ immigration never with a GP.” participants had already demonstrated persistence. overseas patients for status has been strained It also asked GPs Some of the concerns related to the clinical NHS care have asked GPs for years. In 2015 the to make it clear to service at the Gender Identity Development Service to help them identify BMA called for doctors prospective patients (GIDS), which is based at the Tavistock trust, but the patients ineligible for free to refuse to check the that questions regarding HRA said it did not have a remit to review clinical care, the BMA has said. status of patients seeking eligibility for free care on practices. Its report recommends the trust provide The newsletter from treatment, after a motion the GMS1 form did not more clarity on the boundaries between research the BMA’s General was passed at the annual have to be completed and clinical services and that clinical staff should Practitioners Committee representative meeting before registration. take care how they described treatments. warned GPs that overseas saying, “NHS staff do not GPs approached by A spokesperson, welcoming the findings, said the visitor managers had have any role in policing overseas visitor managers study involved nearly a decade of consultation with written to some London immigration.” And last with such requests international experts, adding, “The full study results practices and asked them year doctors and nurses should contact the BMA, will be published in a peer reviewed journal in line to note on referral letters protested against the it advised. with international best practice.” those patients who were Home Office’s use of NHS Michelle Drage, head of Jacqui Wise, London Cite this as: BMJ 2019;367:l6034 regarded as “overseas staff in enforcement. Londonwide LMCs, said, visitors.” The committee The newsletter “It’s important GPs make and Londonwide Local said that Department referrals based on clinical THE STUDY involved Medical Committees have of Health guidance judgment and need, the use of gonadotrophin releasing told GPs this was not their was “clear that the rather than perceived hormone analogue to suppress puberty responsibility. responsibility for eligibility.” The relationship determining a patient’s Elisabeth Mahase, The BMJ in 44 people aged between 11 and 15 between the government eligibility for NHS care Cite this as: BMJ 2019;367:l6002

88 19 October 2019 | the bmj use-associated lung injury). EVALI 0.9 percentage points a year,” Britton to use e-cigarettes—it’s the fl avours is so far corralled within the US, for said. “That’s twice as fast as in the US, that make them palatable.” Banning reasons that remain conjectural. and three times as fast as in Australia, fl avours might therefore prolong the CDC offi cials this week cautioned where e-cigarettes containing nicotine smoking habit for many. that symptoms may mimic those of are illegal. It’s also as fast a decline as And Britton added, “She [Davies] fl u or other respiratory viruses. “Any we have experienced in recent history.” fi rst expressed that fear several years given individual may have a lung Ann McNeill, professor of tobacco ago, saying more evidence was needed injury, they may have an infection, addiction at the Institute of on the safety of fl avours, but that It looks as if or they may have both,” said a CDC in London, said there was a small evidence is now clear.” it’s a cannabis medical offi cer. suggestion, in recent data from the UCL vaping Smoking Toolkit Study, of a rise in the Flavours used in food problem. It’s Cannabis products proportion of would be quitters trying This was echoed by Alan Boobis, Analysis of a subset of cases has to give up without any aids. That was emeritus professor of toxicology at not happening indicated that around three quarters of bad news, she said, as they are likely Imperial College London and chair of here. It’s a people aff ected had used e-cigarettes to fail. Fear of the supposed risks of the UK Committee on Toxicity, which US specific to inhale cannabis products. John vaping could be a cause of this trend. has examined e-cigarettes. “Most of problem Britton, director of the Centre for Surveys show, she said, that the fl avours are used in food, and at John Britton, Tobacco and Alcohol Studies at the smokers in the UK were uncertain the relatively low temperatures used Nottingham University of Nottingham, told the about the safety of e-cigarettes but, US in e-cigarettes they’re not going to give University briefi ng, “It looks as if it’s a cannabis experience apart, they had no grounds rise to hazardous byproducts,” he said. vaping problem. It’s not happening to be. “That’s our concern,” she said. Many of the US cases feature lipoid here. It’s a US specifi c problem.” “When asked about harms only 30% pneumonia, more usually seen in The US cases worry UK experts know the right answer, which is that people who inhale oil in industrial because of the risk of damage to the vaping is less harmful than smoking.” accidents. Britton believes the cases reputation of e-cigarettes, to which As for the former chief medical to be the result of inhaling cannabis they attribute a rapid fall in smoking at offi cer, Sally Davies, who favoured oils. But there are cases with diff erent a time when offi cial smoking cessation a ban on fl avoured e-cigarettes, the symptoms, and these could have a programmes are languishing. panel maintained she was wrong. diff erent cause, he said. “Between 2011 and 2018, smoking McNeill said, “Many adult smokers say Nigel Hawkes , London in the UK has fallen by an average of they need the fl avours if they’re going Cite this as: BMJ 2019;367:l6027

Mental health services: CQC warns of “perfect storm” A shortage of skilled staff, storm. We’ve seen since 2015 an them into special measures. Two AS AT 30 SEPTEMBER 2019 coupled with rising demand, 8% drop in the number of nurses have since improved, three have THE CQC REPORTED THAT has created a “perfect storm” who have a learning disability closed, and one is still registered for patients using mental health specialism. That’s meant, but with no resident patients. 10% of inpatient services and learning disability services, increasingly, mental health, Trenholm added, “The for people with learning England’s healthcare regulator learning disability, and autism ambitious plans to expand the has warned. services are being delivered mental health workforce to meet disabilities or autism were In its State of Care report by carers who lack the clinical an increase in demand must be rated inadequate, up from for 2018-19, the Care Quality support, skills and experience to accelerated.” in 2018 Commission said that although deliver really good care.” The report, which drew 1% quality ratings had been The report said the “shocking on inspections of almost maintained overall, it masked abuse” uncovered by the BBC at 32 000 services, also warned of child and “a real deterioration” in some Whorlton Hall (below) in County that performance in hospital 7% specialist inpatient services over Durham had put inpatient care in emergency departments adolescent inpatient the past 12 months. secure facilities into sharp focus. continues to worsen—with mental health services were Ian Trenholm, CQC chief Since October 2018 the CQC had “winter” pressures now inadequate, up from executive, said fewer specialist rated 14 independent mental commonplace all year round. 3% nurses, greater demand, and lack health hospitals that admit Chief inspector of hospitals, of timely access to community people with a learning disability Ted Baker, said, “For many care had accelerated the fall in or autism as inadequate and put patients going to A&E, it is not the 8% of acute care wards quality in these services and was best place for them, but it is the for adults of working age and of “significant concern.” only part of the system that has psychiatric intensive care Trenholm said, “We know open doors. We need changes in that increased demand and the way care is provided.” units were inadequate, up challenges around workforce are Gareth Iacobucci, The BMJ from 2% creating something of a perfect Cite this as: BMJ 2019;367:l6032 the bmj | 19 October 2019 89 NEWS ANALYSIS Mandatory childhood vaccination could cause “irreparable damage,” says expert panel

andatory vaccinations vaccinations for children aged under anywhere that [making it mandatory] works. for children could result 5 years has fallen in England over the past We could make things worse.” in “irreparable damage” year. In August the UK lost its World Health Helen Donovan, professional public health by turning the parental Organization measles free status. lead at the Royal College of Nursing, said, decision into a rights “The danger is it would become an issue of Missue, a panel of experts has argued. Unwanted harm rights and choice, rather than what is right In a debate at the Science Media Centre While the panellists acknowledged that for your child.” Donovan advises flu vaccine in London on 8 October, billed as being on action was needed to boost uptake rates, manufacturers, including Seqirus. mandatory vaccination, all speakers argued they warned compulsion was not based on The panellists also agreed that making against compulsion. They said the drop in UK evidence and could cause other problems. vaccination compulsory would undermine vaccination rates was mainly due to access Helen Bedford, professor of children’s confidence in the medical profession and problems, with vaccine hesitancy a smaller health at the Great Ormond Street Institute of ignored problems in the system that had part of the problem. Child Health, London, said, “There is a high contributed to the falling uptake. The panel was assembled in response level of public confidence in vaccines, and Bedford said, “Most people who are to a comment by the health secretary we need to build on that by making it easier under-immunised—it’s about the difficulty Matt Hancock at the Conservative Party for parents and by having well trained health accessing services. There are extreme conference last month that there was a “very professionals available to discuss questions, difficulties in accessing services for certain strong argument for having compulsory rather than running towards mandatory groups. It’s about making immunisation vaccinations for children.” A few weeks vaccinations as a solution, which could result more accessible for everybody. It’s about later England’s then chief medical officer, in irreparable damage.” offering vaccinations in places other than Sally Davis, speaking on BBC Radio 4’s David Elliman, a community child health general practices, places where families go Today programme, also said that mandatory consultant at Great Ormond Street Hospital, routinely.” She suggested places such as vaccination may become necessary. who is also a spokesman for the Royal supermarkets and children’s centres. The latest figures, from September College of Paediatrics and Child Health, said, Her comment echoed a message delivered 2019, show that uptake of all 13 routine “There really is no convincing evidence from at the first ever global vaccine summit We need to build Budget cuts There really is no on the high level have impacted convincing evidence of public confidence on immunisation that [making it in vaccines services mandatory] works Helen Bedford, Doug Brown, British David Elliman, Institute of Child Health Society for Great Ormond Street

C hronic Lyme disease is rare, say experts Lyme disease is present in People who have had Lyme Lyme disease in England and microbiologist for Hampshire 1.9% of ticks in the UK. disease rarely develop chronic Wales a year, with an estimated Hospitals NHS Trust and who has Their wider presence may be problems, experts have said, 2000 more cases treated in seen many cases of Lyme disease, attributed to climate change warning those who seek care primary care without positive “In most cases, patients with true abroad believing their symptoms blood tests, said experts at a Lyme do not develop chronic and changes in land use, but are a result of the infection may Science Media Centre briefi ng. symptoms.” more research is needed be putting themselves at risk. Of these patients, fewer than There are around 1000 one in 20 experience residual Infected ticks said that patients presenting laboratory confi rmed cases of symptoms. Those who have Lyme disease is contracted from with multisystem symptoms, confi rmed neurological Lyme infected ticks, most often spread which are often similar to disease—a late complication by small rodents and deer. chronic fatigue, should be wary present in about one in 10 cases— Dryden and others at the of seeking non-validated tests, have a higher rate of long term briefi ng warned that a rise many of which involve samples subjective symptoms, such as in awareness had led to being sent abroad. fatigue and poor concentration. misinformation, particularly Sarah Logan, a consultant But according to Matthew around “chronic” or “‘post- in the tropical diseases unit Dryden, consultant treatment” Lyme disease. They at University College London

90 19 October 2019 | the bmj Psychiatrist to quit NHS if his mother cannot stay in UK

A leading consultant child psychiatrist plans to leave the NHS and move to Australia unless the Home Office grants his widowed mother permission to stay in the UK by Christmas. Nishchint Warikoo, lead child psychiatrist for child and adolescent mental health services in Hampshire, told The BMJ he felt “hopeless, almost angry, and let down.” “Every day for the last two years my mother UPTAKE of all 13 routine childhood vaccinations for anxiously waits to see if there is a letter saying children aged under 5 years has fallen in England over the past year. she must leave within four weeks.” In August the UK lost its WHO measles free status He said he had spent years battling with the Home Office for his mother, Phoola, 71, who last month, co-hosted by the European how to overcome them. We need to see a was born in India, to be allowed to continue Commission and WHO, where leaders strategy that outlines this, the funding to go to live with him. He is her only child, and she said that access was still the main factor with it, to go back to the times when we had has no family in India to look after her. hindering coverage and must not be higher uptake rates. The more we can come overlooked in the fight to increase uptake. together as an evidence based community Worked in NHS for 15 years and work with the government to inform Warikoo, a British citizen who has worked in Fragmentation of the system any vaccine strategy and how that is the NHS for 15 years, has been offered a job in Doug Brown, chief executive of the British implemented, the more positive it will be.” Sydney with permanent residency for himself, Society for Immunology, whose members However, writing in The BMJ earlier this his wife, and 13 year old daughter and a visa include biomedical and biotechnology year, the sexual health doctor Eleanor for his mother. “For me it would be a career companies, said, “Austerity has played a Draeger argued that the UK needed to make move, with a pay rise. If my mother is turned role. With the fragmentation of the system vaccination mandatory because current down for leave to remain, we will have to pack since the 2012 Health and Social Care rates were not high enough to ensure herd our bags and leave within four weeks.” Act, public health budgets were moved immunity. Warikoo’s mother had been staying with to local authorities, who were then put The panel event was organised by the him on six month visitor visas, which she no under immense pressure. In some areas, Science Media Centre, which receives longer qualifies for since applying for leave budget cuts have particularly impacted on funding from pharmaceutical and other to remain. Her application was turned down immunisation services.” medical companies. last December. Brown added, “The good news is we Elisabeth Mahase, The BMJ Warikoo added, “They have behaved very know what the problems are and we know Cite this as: BMJ 2019;367:l5995 unprofessionally. They first took ages to decide, then said my mother was not in the country, when she was, then misplaced her Chronic Lyme disease is rare, say experts Hospital, said that long term places where Lyme disease passport, and then admitted they forgot to antibiotics for patients who is present, Tim Brooks, let us know their decision. In September they believe they have chronic Lyme clinical services director at said they would decide ‘imminently.’” disease can be more harmful than Public Health England’s rare and He has tweeted the prime minister and the disease itself. She recounted imported pathogens laboratory, the home secretary, asking for help: “I am the case of a patient who said, “You’re just as likely You’re just a British citizen, NHS consultant, and a contracted an infection from a to contract Lyme disease in as likely to researcher. Have cared for thousands of long term intravenous antibiotics your back garden as you are in children with mental health problems, saved line that had been fitted abroad. the countryside.” Awareness contract Lyme many young lives and helped Other patients have contracted campaigns should not stop disease from thousands of families in Clostridium difficile and drug people from enjoying outdoor ticks in your distress. Now my family is resistant infections from long activities, he said. garden as forced to leave the country. term antibiotic , she said. A recent innovation in the you are in the Help please.” The rise in UK cases may be Scottish Highlands, where Lyme countryside His plea follows a Royal because of better awareness and disease is present, is an app using Tim Brooks, Public College of Psychiatrists wider testing as well as an actual satellite and GP data to map the Health England survey that found a UK-wide rise in cases, the briefing heard. presence of ticks. shortage of psychiatrists. Asked whether people should Anna Harvey, The BMJ Clare Dyer, The BMJ avoid outdoor pursuits in Cite this as: BMJ 2019;367:l5975 Cite this as: BMJ 2019;367:l6000

the bmj | 19 October 2019 91 THE BIG PICTURE “We have an ethical duty”: doctors join climate protests

Doctors and other healthcare workers joined demonstrations by the climate crisis action group Extinction Rebellion in central London last week. They wore face masks to focus attention on the 180 excess deaths a week in London that are estimated to be the result of pollution. They also carried banners and placards to highlight the health effects of the climate emergency, including warning that “Climate change is a health emergency” and “Government inaction will cost countless lives.” Rita Issa, an academic GP, wrote in the Independent last week that she believed she had a “duty” to support Extinction Rebellion’s aims. “As a doctor, I’m bound by good clinical practice to hold human life with the utmost respect, to practise from a scientific evidence base, and to act promptly when patient safety may be compromised,” she wrote. “And I’m supporting Extinction Rebellion out of duty to this ethical code, and out of respect to the evidence that the climate crisis is, as the Lancet called it, ‘the greatest threat to human health of the 21st century.’” Issa is one of the co-founders of Doctors for Extinction Rebellion, which supports Extinction Rebellion’s key demands. These are that the government must declare a climate and ecological emergency, must act now to halt biodiversity loss and reduce greenhouse gas emissions to net zero by 2025, and must create a citizens’ assembly on climate and ecological justice. Tom Moberly, The BMJ Cite this as: BMJ 2019;367:l6037

92 19 October 2019 | the bmj DOMINIC LIPINSKI/PA DOMINIC

19 October 2019 | the bmj 93 EDITORIAL New safeguarding arrangements for England An important opportunity to improve child health

ow is it that if all infants a rising tide of exploitative violence born in the UK in and abuse. We have forgotten that 20171 had been born children should come first, and the call in Finland instead, for the NHS to do better has already perhaps 1500 more been made.6 Hwould have survived? That is one of the The key tenet of safeguarding questions that the newly established children is the principle, first laid out National Child Mortality Database, in the Children Act 1989, that “anyone set up under the Children and Social dealing with children or attending Work Act 2017, should start to answer. a person whose family includes The UK’s infant mortality rate of children, has a duty to make the child’s 3.9 deaths/1000 live births compares best interests paramount.”7 Increasing unfavourably with that of Finland or redirecting limited resources to (2/1000), Slovenia (2.1/1000), improve child wellbeing is consistent and Norway (2.3/1000).2 And for with this principle. Historically, any childhood health and wellbeing, the deficiencies in child health outcomes UK is ranked 15th among developed have not been seen as part of the child countries (Portugal is first). safeguarding agenda. But what does In this, the 30th anniversary year promoting the welfare of children of the United Nations Convention mean if it doesn’t translate into best on the Rights of the Child,3 reforms possible health? in England give us an important Health leaders now at the helm opportunity to improve children’s of new local child safeguarding lives. The UN convention committed partnerships must prioritise plans to ratifying nations to provide the best reverse declines in child wellbeing possible health for all children, but Local For example, the thresholds for that result from organic as well as the mechanism for promoting the approaches to intervention are now no longer just a social causes. Although some issues welfare of children has been led until mental health local authority decision. Furthermore, will benefit from regional or national recently by local authorities: health services and the new safeguarding partnerships efforts—such as the National Child and other partners were required only childhood are required to publish plans, set Mortality Database and initiatives to to cooperate with them. up scrutiny and dispute resolution deal with child exploitation—local obesity A review of local authority processes, and to publish an annual approaches to child and adolescent safeguarding boards in 2016 found should be part report on their activity. mental health services and childhood this system to be mostly ineffective.4 of the new The government has encouraged obesity should be part of the new local The review called for the boards to safeguarding new partnerships to be bold in their safeguarding plans. be replaced with local safeguarding plans vision, so new ways of working that If these principles are not followed partnerships—and this was given prioritise broader child welfare rather we will continue to see a deterioration effect in the 2017 Children and than just child protection are an of childhood, including worsening Social Work Act. In these new option. The health sector now has the wellbeing, health, and death rates. partnerships, leaders of clinical authority to influence this agenda. Not only would we be guilty of failing commissioning groups and the local to give a voice to those who have police now share legal responsibility Putting children first died and who deserved better, we for safeguarding children with local One major hurdle to overcome is would also have failed to invest in our authorities. This change, part of the the cultural perception that we are nation’s future. Litigation against the biggest reform to the system for more already spending plenty on children’s new tripartite partnerships, recently than three decades, came into full healthcare. The answer to this is an approved in the Supreme Court,9 is effect at the end of September. emphatic rebuttal. Clearly we aren’t already a possibility and will be all the Peter Green, The safeguarding ambitions of doing enough if infants are dying harder to defend if children in England designated doctor for protecting and promoting the welfare child safeguarding, in excessive numbers, children are continue to do so much worse than of all children in a local authority’s Children’s Department, increasingly affected by mental illness children in Finland and Portugal. area do not change, but new St George’s University and obesity, and we have outlier death Cite this as: BMJ 2019;367:l5813 statutory guidance allows structures Hospital, London rates from preventable conditions, Find the full version with references at and processes to be refashioned.5 [email protected] increasing rates of neonatal death, and http://dx.doi.org/10.1136/bmj.l5813

94 19 October 2019 | the bmj EDITORIAL HRT and breast cancer risk We must prevent another setback in women’s health

n the UK, most women go The safety through the menopause alert did not between the ages of 45 and mention 55. Around half of women benefits of experience some physical HRT, or that Ior emotional symptoms from the there was no decrease in ovarian function, including hot flushes, night sweats, increased risk low mood, anxiety, joint and muscle of death from pain, vaginal dryness, decreased sex breast cancer drive, and hip fractures in later life. or all causes. About one million women in the UK currently use hormone replacement therapy (HRT),2 the most commonly prescribed treatment for the symptoms of ovarian failure. HRT can bring many benefits, consumption, have a greater Public anxiety improving quality of life and offering effect on breast cancer risk than The alert has caused considerable protection against bone loss and HRT. For example, the extra risk anxiety, particularly in women who fragility fractures.2 of breast cancer associated with go through the menopause before being overweight or obese is six the age of 40 and have a higher risk New data times higher than the extra risk of early death and heart disease if Findings published in the Lancet associated with combined HRT, left untreated.7 The Lancet study in September provide data for both according to NICE.2 did not compare the risk of breast women and clinicians that could The new findings are consistent cancer for women taking HRT with help in discussions around the with NICE recommendations2 and that of women of the same age with use of HRT.3 However, this new should be viewed alongside the normal ovarian function and gives meta-analysis should be considered benefits of HRT,4 which for many a misleading presentation of the alongside the National Institute women considerably outweigh risk. Young women who stop HRT for Health and Care Excellence’s the risks. are likely to adversely affect their (NICE) 2015 guidance Menopause: The Lancet study did not address long term health and raise their risk Diagnosis and Management,2 mortality, only incidence of breast of death.8‑10 which considered all the available cancer, so findings must be weighed We all have a role in empowering evidence on benefits and risks of the against a recent systematic review that women to make the best choices different treatment options. showed that starting HRT close to the for their health by providing high The Lancet meta-analysis showed menopause may also reduce all-cause quality, unbiased evidence and that in the UK about 1 in 16 women mortality and cardiac death, with supporting them to make decisions. who have never taken HRT will no evidence of an increase in breast Women now live longer in the develop breast cancer between cancer mortality.5 postmenopausal period than in their the ages of 50 and 69. For women After the Lancet study was reproductive phase, and our focus with a normal body mass index published, the Medicines and must be on not merely extending who start HRT in their 40s or 50s, Healthcare Products Regulatory women’s lives but improving their the additional risk of breast cancer Janice Rymer, vice Agency (MHRA) issued a drug safety quality of life. After decades of associated with HRT was 1 in 200 president alert to all doctors to communicate misinformation and scaremongering janice.rymer@ for oestrogen-only HRT, 1 in 70 for the breast cancer risk to women headlines focusing on side effects kcl.ac.uk sequential HRT (oestrogen daily considering or taking HRT. It included of hormone treatment, we must Kate Brian, women’s and progestogen for part of each only the data from this publication all work together to avoid another voices lead month), and 1 in 50 for continuous and did not mention benefit in terms damaging setback in women’s Lesley Regan, combined HRT (oestrogen and president, of bone loss and providing protection health. We need to treat individual progestogen daily). Royal College of from cardiovascular disease. Nor women, not statistics. However, women should be Obstetricians and did it mention that there was no Cite this as: BMJ 2019;367:l5928 counselled that other factors, increased risk of death from breast Gynaecologists, Find the full version with references at including body weight and alcohol London cancer or all causes. http://dx.doi.org/10.1136/bmj.l5928 the bmj | 19 October 2019 95 ESSAY U=U is a blessing but only for those patients with access to HIV treatment Fear of transmission is a major stigma that people with HIV face, writes Tamás Bereczky, but the message that an undetectable viral load makes the virus untransmittable is cold comfort for people lacking diagnostics and antiretroviral drugs

he U=U campaign WHAT IS U=U? (undetectable means untransmittable, see The Prevention Access It also proposes a “third U,” box) seeks to publicise Campaign was launched in universal access, and calls for 2016 by HIV activists led by access to HIV drugs for all who the science that shows its executive director, Bruce need them. Tthat people with an undetectable Richman. The U=U consensus viral load cannot transmit HIV. But Its U=U movement aims to statement has been endorsed my limited enthusiasm for this good “end the dual epidemics of by more than 850 community news often earns me the scorn of HIV and HIV related stigma organisations from nearly 100 fellow activists. by empowering people with countries. Many public health materials, and states it is “Don’t be such a sour apple,” accurate and meaningful institutions, researchers, funded by the US charity they say. “Don’t you understand information.” politicians, drug companies, Social and Environmental the importance of U=U for stigma It does this by disseminating and non-governmental Entrepreneurs and supported reduction?” “the revolutionary but largely organisations, including by Broadway Cares/Equity I know, sadly, that the message is unknown fact that people UNAIDS, support it. Fights AIDS, AIDS United, often still missing from the information living with HIV on effective Its website (www. Gilead, ViiV Healthcare, treatment do not sexually preventionaccess.org) presents Janssen, Elton John AIDS that healthcare providers and transmit HIV.” evidence and publicity Foundation, and Walgreens. counsellors give patients. Worse, U=U is meaningless for the many people with HIV worldwide who don’t have In 2008, the Swiss National AIDS suppression should be monitored to access to diagnostics and drugs—as the Commission issued a statement assure both personal health and public campaign acknowledges with a “third that said that people who are taking health benefits.” U”: universal access. effective antiretroviral treatment Thus it acknowledges the cannot transmit HIV through sexual importance of treatment and Fear of transmission contact. When I heard this, my initial diagnostics—but it is silent about I’ve had HIV for 16 years, and I scepticism ultimately gave way to how treatment adherence should be come from Hungary where stigma genuine relief: I didn’t pose any risk to achieved, especially if access to drugs and discrimination are rampant. my partners. is lacking or unreliable. I understand, particularly acutely, Communities of people with HIV The campaign website contains a how fear of transmission prevents worldwide have translated the U=U separate page about the “third U,” acceptance of people with HIV—and abbreviation and message for their universal access: “Our challenge for why it is so important to eliminate own languages and settings. the U=U community is to continue to this barrier. fight for universal access for all people The consensus statement with HIV regardless of what barriers BIOGRAPHY The U=U consensus statement, which may exist and regardless of where Tamás Bereczky works for the European has been signed by an impressive they may live.” It offers no proposals, Patients’ Academy on Therapeutic group of organisations, researchers, however, for how to attain this. Innovation, while also supporting, as a member, the European AIDS Treatment Group (EATG). and politicians, says, “People living He has been HIV positive since 2003. with HIV on antiretroviral therapy Lack of access to testing He was an EATG director for almost four years, was co-chair of with an undetectable viral load in their People with HIV are advised to the European Commission’s Civil Society Forum on HIV/AIDS blood have a negligible risk of sexual have their viral load tested every between 2013 and 2015, and has been involved in many EU transmission of HIV. Depending on the 3-6 months. Most tests measure a and global projects. drugs employed it may take as long as minimum of 40-50 copies of HIV RNA He has been a member of the BMJ Patient Panel since 2017. six months for the viral load to become in a millilitre of blood. Most people His research as a social psychologist concerns the undetectable. Continued and reliable receiving effective antiretroviral significance and perspectives of patient organisations HIV suppression requires selection treatment have a viral load of fewer in Europe. He is a PhD candidate of the ELTE University of of appropriate agents and excellent than 20 copies. The UK and most Budapest set to defend his thesis later this year. adherence to treatment. HIV viral of Europe define undetectable viral

96 19 October 2019 | the bmj load as fewer than 50 copies, when evidence shows that transmission of HIV becomes impossible. This has revolutionised thinking: the infection remains incurable but transmission can be stopped. Standard bulky laboratory devices require substantial initial investment and can be slow because they test one batch at a time. Without reliable, affordable, and portable devices, regular testing remains a challenge. Despite research initiatives and encouraging news in recent years, no novel equipment has been developed. One portable device can be used at the point of care but it is expensive. Some European countries, such as Greece, lack consistent reliable viral load testing. Others lack testing altogether—for example, IAS Serbia stopped viral load testing huge discrepancies in access to drugs The campaign What U=U should do three years ago, activists there say. because of affordability. offers no But enough of the complaints—I also So, many people with HIV cannot UNAIDS recently called for a scaling proposals have some suggestions. U=U know whether their viral load is up of the response to achieve the supporters should emphasise that as to how undetectable unless they have the 90-90-90 targets. access to drugs and diagnostics is as means to get tested abroad or through to attain important as access to the message. a private laboratory. Leveraging the message the third U: Large and effective patient and Activists in developed countries have universal civil society organisations such as Lack of access to antiretroviral drugs said that advocates in regions lacking access the European AIDS Treatment Group, The U=U message has rightly access to drugs and testing should use the Terrence Higgins Trust, the spread like wildfire through patient the U=U message to call more strongly International Treatment Preparedness communities, but people with HIV in for improvements. But this ignores the Coalition, and the International some regions, like eastern Europe and political, social, and cultural contexts AIDS Society are fighting for reliable central Asia, that lack reliable access in which people with HIV live. and affordable access to drugs. to affordable drugs can only dream The U=U message has spread U=U campaigners should consider about having untransmittable HIV. among communities, but political collaborating with them. The UNAIDS 90-90-90 global barriers often make it impossible to be The U=U movement should targets are the benchmark for ending more vocal without advocates risking demand more research to improve the epidemic. Their aim is that, by their liberty and physical integrity. the evidence on simplifying and 2030, 90% of all people with HIV Ideological dogma also acts against optimising treatment regimens. More should know their status; 90% of all people with HIV as well as men who affordable drugs and diagnostics, and people diagnosed should be having have sex with men, injecting drug consistent access to generics, could antiretroviral therapy; and 90% of all users, sex workers, and prisoners— mean more people get treatment. people receiving treatment should be that is, the key affected populations. U=U campaigners should virally suppressed. Take Russia’s anti-LGBT laws, state advocate for the development of Despite some regions making great sanctioned homophobia in Poland23 easy to use, reliable, portable, progress, we’re miles from achieving and Hungary, the lack of or cuts to and affordable viral load testing. these goals. In 2017, the rate of harm reduction services for people HIV patients’ advocates and people receiving treatment in Russia, who use drugs, and increasing new communities have an excellent track for example, was 42%, and the rate HIV diagnoses in eastern Europe and record in initiating and supporting of people who knew their status was central Asia. scientific research. We should also low. Some Russian territories Such cases suggest that an connect with researchers and try to regularly run out of drugs, as do many information strategy alone, like understand why development in this entire countries including Romania, U=U, may be insufficient to achieve area has stalled. which has exceptionally high universal access to testing and Tamás Bereczky, communications and course prevalence of HIV infection. A 2018 treatment. But—as I know—perceived director, European Patients’ Academy for study of treatment in central and criticisms are often quickly shut down Therapeutic Innovation, Berlin eastern Europe reported stock-outs in with verbal attacks, worryingly these [email protected] nine out of 23 countries. It also found are often sexually explicit. Cite this as: BMJ 2019;366:l5554 the bmj | 19 October 2019 97 US HEALTHCARE 27 million people uninsured As many countries commit to universal health coverage, US politicians are still arguing about whether everyone should have access to care. Julie Rovner explains the complicated, political, expensive, seemingly eternal US debate

he US is once again at least a minimum amount of The benefit spread rapidly, and deep in a debate healthcare to its residents. New a 1943 government ruling that over the future of statistics from the US Census the benefit would accrue tax free its health insurance Bureau show that in 2018, made it even more popular with system—a debate 8.5% of the population (27.5 both workers and management. Tthat has waxed and waned for million people) lacked health A decade later, President the better part of a century. This insurance, up from 7.9% the Harry Truman tried to add is ironic because the US doesn’t year before. compulsory health insurance actually have what one could But as costs have risen, the to the social security system, call a health insurance “system.” fight in the US is less about how but was rebuffed by a Rather, it has a hodgepodge many people have insurance Republican Congress and the of programmes—public and than about how much people American Medical Association, pharmaceutical companies, and private—that cover most, but far who are already covered are representing the nation’s other healthcare players who from all, of its residents. expected to pay. The media have doctors. The AMA famously feared they would lose income And as the cost of medical been full of stories about insured branded the effort as “socialist,” under the plan, as well as by services continues to grow patients who have nonetheless and hired popular actor Ronald Republicans who objected to faster than most incomes, even been billed amounts that cause Reagan, who would become increased federal oversight. people with private insurance severe financial hardship and US president, to record an It would take until 2010, coverage—which comes with even bankruptcy. impassioned 10 minute attack under President Barack Obama, rising expenses in the form of on socialised medicine. for the US government to expand deductibles and co-payments— A brief history John F Kennedy continued insurance coverage in a major are finding the cost of care Following European expansions the push to expand health way. Through a series of political becoming more than they can of health coverage in the late insurance. In 1965, two years deals and compromises, the afford. That’s also true for the 19th and early 20th centuries, after Kennedy’s assassination, Affordable Care Act was both government funded health Theodore Roosevelt became the President Lyndon Johnson signed a large step and a small one. It insurance programme for first American president to call the law that created Medicare, a expanded access to insurance, elderly and disabled people. for universal health insurance, public insurance programme for by dramatically increasing Fundamentally, this century- during his failed effort to senior citizens, and Medicaid, a the reach of the Medicaid long debate is focused on regain the presidency in 1912. joint federal-state programme programme and providing whether healthcare should be His younger cousin, Franklin to provide health services for subsidies to help those on directed more by the government Delano Roosevelt, also tried, but those with low incomes. By 2019 middle incomes to buy private or more by market forces failed, to make universal health Medicare and Medicaid recipients coverage. But it took only and private competition. For insurance part of the package accounted for more than a third minimal steps to tackle the rising decades, Democrats have pushed that became the US social of the population. But at the cost of medical services. for more government, while security programme, in 1935. same time, as fewer employers And because it was passed on Republicans have maintained As in England, the foundation offered coverage, the number a party line vote by a Democratic that a free market would work for US healthcare accessibility of people without insurance led Congress and signed by a more efficiently. Currently, just was laid during the second continued to rise, reaching more Democratic president, the law is over half of US healthcare is world war. Facing an acute than 30 million by the end of still the subject of heated partisan funded by federal, state, and local labour shortage that officials the 1980s—nearly 13% of the debate nearly 10 years later. governments, with the rest coming feared would cause devastating population. Republicans who unanimously from the private inflation, the federal That put the matter back opposed the law tried hard to sector. That means government imposed on the political front burner, repeal it when they took control nobody is truly strict wage controls. and when the next Democratic of Congress and the presidency steering the ship. That prompted president, Bill Clinton, was in 2017. And no one is very employers to elected in 1992, he made To their surprise, however, happy about that. compete for workers expanding health coverage it turned out the public did not The US is unique by offering fringe his top priority. But as with FD wish to see the law “repealed among developed benefits instead, Roosevelt and Truman, Clinton’s and replaced,” as they had been countries in that it largely private effort was rebuffed by fierce promising, and that effort failed doesn’t guarantee health insurance. lobbying by doctors, hospitals, as well.

98 19 October 2019 | the bmj A HISTORY OF DEBATE Theodore Roosevelt was the first president to call for universal health insurance in 1912. The row rumbled on for four decades. In 1953 Harry Truman’s attempt was blocked with the help of Ronald Reagan. Lyndon Johnson, Bill Clinton, Barack Obama, and Donald Trump have all attempted to reform the system

In 2018, 8.5% of the US population lacked health insurance 1953 KEVORK DJANSEZIAN/GETTY IMAGES KEVORK

Families without health insurance Medicare for All would create less concerned with how many queue last year to receive free care a federal government financed people have insurance—which from volunteer health professionals health programme that would has been the primary subject of at a sports centre in Los Angeles cover all Americans for virtually national political debate—than One of the ironies of this all medically necessary services, they are with the prices even back and forth debate has with little or no out of pocket insured people are expected to been that while Democrats expenses charged to patients pay for their medical care. and Republicans have fought at the point of service. It would In 2003, according to the over the role of government in be financed through the US’s Kaiser Family Foundation, a non- 1965 healthcare, the system itself has income tax system, but it remains partisan policy analysis group, increasingly become a hybrid of unclear exactly who would pay 60% of Americans surveyed said public and private. The Medicare those higher taxes and how much insurance coverage was the most and Medicaid programmes, for higher they would be. important health matter, with example, are now substantially Other Democrats running for 33% saying cost was the most administered by private insurance president, however, say starting important. In 2018, by contrast, companies. Meanwhile, private over with an entirely new system that had almost exactly reversed, insurance, largely as a result is unrealistic in a society as with 59% saying cost was the of the Affordable Care Act, is politically divided as the US. most important health matter in increasingly tightly regulated by Led by former vice president their lives, and only 26% saying the federal government, and is Joe Biden, they are pushing to coverage. A separate poll by 1992 increasingly costly—a new poll expand existing programmes in researchers from the Harvard TH shows the average worker with a more incremental way. Chan School of Public Health employer sponsored family health Trump, meanwhile, after and elsewhere also found insurance pays more than $6000 failing to get Congress to repeal healthcare costs near the top of (£4874) a year for healthcare. the Affordable Care Act, has voter concerns, with 70% calling pledged repeatedly to unveil his health affordability “a very big What next? plan, but he has yet to make good problem.” As the campaigns gear up for on that promise. Republicans in What happens next will the next presidential election general, however, have made it depend on which party leads in November 2020, those clear that they are united in their the government after the 2020 2010 Democrats competing to take on opposition to the idea of more elections. History suggests incumbent Republican Donald federal government involvement that whichever it is, it will, like Trump are arguing over whether in the health marketplace. They its predecessors, likely prove to build on the Affordable Care are once again charging that more unable to overcome the political Act or scrap the entire insurance government involvement equals obstacles to enacting major system and start again with a socialism. change. government run programme Julie Rovner, chief Washington often called “Medicare for All.” What does the public want? correspondent, Kaiser Health News The details have yet to be Ironically, most public opinion [email protected] worked out, but basically polls show that US residents are Cite this as: BMJ 2019;367:l5885 2017 the bmj | 19 October 2019 99 BRIEFING Outdoor smoking fair or foul? Around the world, governments are considering, or instituting, bans on smoking outside. Many hospitals in England already ban the habit on their grounds. Kim Painter considers the public health bene ts of a ban in open air public places

How common are outdoor smoking bans? risks for adults include more heart attacks, strokes, and lung cancer, the CDC says. Hospitality workers and those who live with smokers While much less common than indoor bans, they are catching on. may be at especially high risk. This summer, Sweden banned smoking in many outdoor spaces, But even intermittent, low level exposure has been linked with stroke including playgrounds, train platforms, and restaurant patios. and heart attack in people with pre-existing heart disease, says Steven The regional government of Catalonia has proposed a similar ban, Schroeder, professor of medicine and director of the Smoking Cessation prompting protests from restaurant owners in Barcelona. Smoking Leadership Center at the University of California San Francisco. has been banned on the grounds of more than two thirds of NHS In studies carried out in England, Scotland, and the US, hospitals in England, according to Public Health England. comprehensive smoking bans focused on indoor spaces, including restaurants and bars, have been linked with improvements in What are the arguments for prohibition? respiratory health and declines in heart attacks and stroke. The degree to which those risks are further reduced when smoking is Outdoor bans may make smoking less convenient and visible— banned outdoors would be diffi cult to prove, Schroeder says. Common possibly giving smokers more reasons to quit and giving non- sense dictates that a single person smoking on a beach poses a diff erent smokers, especially young people, fewer chances to see smoking as risk than dozens of people smoking in a crowded outdoor café, he a normal, acceptable habit. notes. They might also reduce direct harms to non-smoking bystanders. The position of major public health groups, including the World What’s the evidence that a ban will curb smoking? Health Organization and the US Centers for Disease Control and Prevention (CDC), is that there isn’t a risk free level of exposure to Bans in parks and on beaches do reduce smoking not only in tobacco smoke, and that even brief exposures can cause harm. those locations but in the vicinity, a number of studies show. College smoking bans in the US and UK that included outdoor spaces appeared to reduce both the number of on-campus smokers and the number of What evidence is there for open air smoke causing direct harms? cigarettes they smoked, according to a review of  studies. “Outdoor bans have more to do with the denormalisation of smoking While smoke levels outside can vary widely—depending on a than with the protection of bystanders from side stream smoke,” says range of factors including the number of smokers present and the Ronald Bayer, professor and co-chair at the Center for the History and wind direction—a review of  studies published in   found Ethics of Public Health at Columbia University’s Mailman School of that smoking in outdoor areas adjacent to indoor smoke free areas Public Health in New York. increased concentrations of smoke in both locations. “To the extent that there are public health benefi ts, they are related to It’s well established that chronic exposure to secondhand smoke making quitting more likely,” he says. can cause disease and premature death in non-smokers. The risks for children include more frequent and severe asthma attacks; the How do the arguments apply to e-cigarettes?

Even intermittent, Outdoor bans could help to denormalise vaping and make it less low level convenient, Schroeder says. Some vaping devices, however, can be exposure to used surreptitiously, making it easier for users to ignore the rules and cigarette smoke less likely for others to notice the practice, he says. has been linked In an evidence review published in  , Public Health England with stroke and said that “to date, there have been no identifi ed health risks of passive vaping to bystanders.” heart attack in Schroeder says the science on any secondhand risk is not settled and people with pre- is complicated by the fact that vaping devices and the substances used existing heart in them vary greatly. disease Kim Painter, McLean, Virginia, US [email protected] Cite this as: BMJ ;:l

100 19 October 2019 | the bmj