As illustrated by this month’s image – the deceptively pretty Nicotiana tabacum, from which tobacco is made – the tricky question of whether the public health interest is served by publishing papers about harm-reducing but still harmful alternatives to tobacco is raised in the July issue of PLoS Medicine. Snus is a smokeless tobacco product that is widely used as an alternative to cigarettes in Sweden and is associated with less risk to health than smoking. In The PLoS Medicine Debate Carol Gartner and Wayne Hall argue the case for providing public information about snus, suggesting that it could be recommended to inveterate smokers. However, Simon Chapman and Becky Freedman argue that such an approach would simply play into the hands of the tobacco industry, which is already marketing the use of snus with slogans that promote smoking too. Bans on smoking in public places – such as the legislation that came into effect in England earlier this month – have not only benefited the non-smokers in the PLoS Cambridge office frequenting the Maypole public house every Friday lunch time, but have also stimulated smokers to quit. Should a medical journal advocate the abolition of all tobacco products? Or is the discussion of the use of a product such as snus as a harm reduction measure a legitimate topic? These issues are discussed in the the July Editorial and (not for the first time) the PLoS Medicine editors could not come to an agreement. What do you think?
The difficulty of changing behaviour is examined in a different context by Sally Munro and colleagues. They conducted a systematic review of the qualitative research into adherence to tuberculosis treatment; in other words, a review of the medical literature in which patients and their families had been asked to say how they felt about their treatment. From their careful appraisal they were able to classify the major structural, social and personal factors associated with the difficulty of completing treatment. Would the greater involvement of patients in the decisions made about their treatment improve adherence? The authors indicate that future interventions involving patients in decision-making could help reduce the global disease burden of tuberculosis.
Another research article in the issue investigates the difficulty of changing doctors’ prescribing habits. Antihypertensive drugs are a major part of national drug expenditure in developed countries, where nearly one person in ten is treated for uncomplicated hypertension (high blood pressure). The different classes of these drugs are all effective but their costs vary widely. Norway introduced a regulation requiring doctors to prescribe thiazides, which are a tenth of the price of many non-thiazide drugs. Atle Fretheim and colleagues evaluate the effects of the new reimbursement rule on drug expenditures and on the proportion of patients reaching their recommended blood-pressure goal.
Two magazine section papers on HIV that could have health policy implications are published in the July issue. Recent clinical trials in Africa – including a paper published in PLoS Medicine in 2005 – found that male circumcision reduces the risk of acquiring HIV from heterosexual sex. Patrick Sullivan and colleagues ask what the implications of these studies are for the United States. And in a policy forum relating to a recent court case against the US Agency for International Development, Nicole Frank Masenior and Chris Beyrer argue that the pledge organizations have to take condemning prostitution in order to receive US funding for HIV prevention has restricted the attempt to control the global HIV epidemic.
The latter piece has already provoked a number of replies that you can see in our reader response archive. As ever, we encourage our readers to contribute to the discussion through the blog or the reader response system.