Volume 208 Issue 1

Building leadership, governance and evaluation capacity to improve men’s health outcomes

James A Smith · Mick Adams · Jason Bonson

Policy decisions surrounding the regulation of e-cigarettes need to account for their potential unintended harm on youth

Luke Wolfenden · Emily Stockings · Sze Lin Yoong

Three methods which may be used when one commonly made assumption is not met

Alan Taylor

Obstetrics and gynecology in low-resource settings: a practical guide

Rupert G Sherwood

The new agents offer important safety and convenience advantages, but need to win the confidence of clinicians and patients

Ke Xu · Noel C Chan · John W Eikelboom

Women diagnosed with breast cancer also have a greater burden of other illness

Jacqueline H Chirgwin

NOACs could improve the convenience of anticoagulation therapy for patients in remote locations

Jamie W Bellinge · Jarrad J Paul · Liam S Walsh · Lokesh Garg · Gerald F Watts · Carl Schultz

Appropriate models of care are needed to manage the multiple comorbidities of breast cancer survivors

Huah Shin Ng · Bogda Koczwara · David M Roder · Theo Niyonsenga · Agnes I Vitry

Objectives: To review the accuracy of diagnoses of chronic obstructive pulmonary disease (COPD) in primary care in Australia, and to describe smokers’ experiences with and preferences for smoking cessation. Design, setting and participants: Patients were invited to participate if they were at least 40 years old and had visited participating general practice clinics in Melbourne at least twice during the previous 12 months, reported being current or ex-smokers with a smoking history of at least 10 pack-years, or were being managed for COPD. Interviews based on a structured questionnaire and case finding (FEV1/FEV6 measurement) were followed, when appropriate, by spirometry testing and assessment of health-related quality of life, dyspnoea and symptoms. Results: 1050 patients attended baseline interviews (February 2015 – April 2017) at 41 practices. Of 245 participants managed for COPD, 130 (53.1%) met the spirometry-based definition (post-bronchodilator FEV1/FVC < 0.7) or had a clinical correlation; in 37% of cases COPD was not confirmed, and no definitive result was obtained for 9.8% of patients. Case finding and subsequent spirometry testing identified 142 new COPD cases (17.6% of participants without prior diagnosis; 95% CI, 15.1–20.5%). 690 participants (65.7%) were current smokers, of whom 360 had attempted quitting during the previous 12 months; 286 (81.0% of those attempting to quit) reported difficulties during previous quit attempts. Nicotine replacement therapy (205, 57.4%) and varenicline (110, 30.8%) were the most frequently employed pharmacological treatments; side effects were common. Hypnotherapy was the most popular non-pharmacological option (62 smokers, 17%); e-cigarettes were tried by 38 (11%). 187 current smokers (27.6%) would consider using e-cigarettes in future attempts to quit. Conclusions: COPD was both misdiagnosed and missed. Case finding and effective use of spirometry testing could improve diagnosis. Side effects of smoking cessation medications and difficulties during attempts to quit smoking are common. Health professionals should emphasise evidence-based treatments, and closely monitor quitting difficulties and side effects of cessation aids. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12614001155684.

Jenifer Liang · Michael J Abramson · Nicholas A Zwar · Grant M Russell · Anne E Holland · Billie Bonevski · Ajay Mahal · Kirsten Phillips · Paula Eustace · Eldho Paul · Sally Wilson · Johnson George

General cognitive functioning, memory, and executive functioning were reduced in pregnant women, particularly during the third trimester

Sasha J Davies · Jarrad AG Lum · Helen Skouteris · Linda K Byrne · Melissa J Hayden

Current medical treatment remains far from ideal, although minimally invasive surgery can be effective, and managing patient expectations is essential

Eric Chung · Dominic Lee · Johan Gani · Michael Gillman · Christopher Maher · Janelle Brennan · Lydia Johns Putra · Laura Ahmad · Lewis LW Chan

All pregnant women who smoke should be offered NRT

Yael Bar-Zeev · Ling Li Lim · Billie Bonevski · Maree Gruppetta · Gillian S Gould

To the Editor: After extensive public consultation, the Therapeutic Goods Administration announced that all over-the-counter codeine preparations, including over-the-counter codeine-containing analgesics (OTC CCAs) will be rescheduled as prescription only in February 2018, citing the substantial risk of drug toxicity from deliberate misuse and the relative lack of efficacy compared with safer products. Codeine is a weak analgesic — even at doses of 60 mg — and the Australian Medicines Handbook notes that “there is no conclusive evidence that products containing 8–15 mg of codeine per tablet with paracetamol, aspirin or ibuprofen have any benefits over these non-opioids alone”.1 Misuse and harm are widespread, with people who are addicted to codeine taking 40 or more tablets a day. In 2016, more than 500 000 Australians aged 14 years or over used OTC CCAs non-medically. Despite more restrictive scheduling in 2010, a Poisons Information Centre described a 17.9% annual increase from 2004–2015 in calls concerning the misuse of ibuprofen–codeine analgesics.2 Moreover, drug clinics describe a 10-year four-fold increase in treatments where codeine was a drug of concern (Box). Prolonged high-dose ibuprofen exposure secondary to codeine addiction may cause bleeding or perforated gastric ulcers; non-steroidal anti-inflammatory drug-induced enteropathy, with diaphragm disease and bowel obstruction; anaemia; protein-losing enteropathy; hypoalbuminaemia; renal tubular acidosis and death. Medical practitioners should consider OTC CCA misuse in patients presenting with non-steroidal anti-inflammatory drug-related or paracetamol-related morbidity, as many patients do not disclose their misuse, therefore creating a failure to recognise the underlying cause of the presenting complaint.4 Apart from the human cost of serious injury and loss of life, there is also the cost of treatment for dependence; the cost of hundreds of hospital admissions, involving avoidable surgery, intensive care and serious morbidity;4,5 and the statistical cost of lives lost.6 Practitioners need to prepare for the forthcoming rescheduling to avoid substituting OTC CCAs with either prescription opioid analgesics or prescribing a codeine–paracetamol product, which may cause paracetamol hepatotoxicity. In addition, practitioners should treat codeine dependence by referral, opioid replacement therapy or medicated withdrawal with follow-up. The unfavourable risk–benefit profile for OTC CCAs means that the planned Australian rescheduling aligns with many other countries to minimise harm. Access to effective analgesics without a prescription is now provided by products with the non-addictive ibuprofen–paracetamol combination, which offer better analgesia than OTC CCAs.7 Box – Treatments provided for own drug use, by principal and additional drug of concern (codeine), from 2003–04 to 2013–143

Stephan A Schug · Malcolm DH Dobbin · Jennifer L Pilgrim

To the Editor: We read with interest the recent article by Bonevski and colleagues1 calling for targeting of tobacco cessation interventions to high-risk populations, including prisoners. People who cycle through prisons in Australia smoke tobacco at a rate five times that of the general population,2 and suffer disproportionately from smoking-related morbidity and mortality.3 However, the suggestion by Bonevski and colleagues1 that smoke-free policies in prisons “impact on reducing smoking” is unfortunately a case of misplaced optimism: although these policies reduce smoking in prisons, they have almost no effect on long term smoking behaviour in people who cycle through prisons. Research in the United States shows that about 60% of people released from smoke-free prisons resume smoking on the day of release,4 and 97% relapse within 6 months of release.5 Preliminary findings from a cross-sectional survey we have conducted with 114 ex-smokers released from smoke-free prisons in Queensland paint a similar picture, with 72% of participants reporting relapse on the day of release. Smoke-free policies in Australian prisons are an important public health initiative and should be supported. However, alone they are insufficient to reduce the remarkably high rates of smoking, and of related morbidity and mortality, in the vulnerable populations who cycle through these institutions. There is an urgent need for development and rigorous evaluation of smoking cessation and relapse prevention interventions targeting people released from prison in Australia. Building on the findings of a recent trial in the United States,4 we have recently been awarded funding from the Victorian Health Promotion Foundation to undertake a double-blinded, randomised controlled trial of an intervention designed to reduce relapse to smoking among people released from smoke-free prisons in Victoria. We hope that our study will provide new evidence to guide future efforts to reduce tobacco-related harm in this population. We echo Bonevski and colleagues’1 call for a comprehensive policy shift aimed at reducing tobacco use among disadvantaged populations in Australia. However, prison smoking bans alone are insufficient. Investment in evidence-based efforts to prevent smoking relapse after release from prison will be critical to reduce tobacco-related health disparities in this profoundly vulnerable, marginalised population and realise this important public health opportunity.

Cheneal Puljević · Stuart A Kinner

In reply

Billie Bonevski · David P Thomas · Robyn L Richmond

Professor Billie Bonevski is a world-renowned smoking cessation researcher and the mother of two. But don’t talk to her about work/life balance

Cate Swannell

This calendar will be updated each month. If you have an event you would like to add, please include relevant details in an email to cswannell@mja.com.au

Cate Swannell