Editorial

384 www.thelancet.com Vol 383 February 1, 2014

Tobacco control in the USA: an end to political mythologyThe stated aim of World Cancer Day on Feb 4 is to reduce stigma and dispel myths about cancer, and this year’s mantra is “Debunk the myths”. The harms of tobacco use are very far from mythical, causing about 71% of lung cancer deaths and accounting for at least 22% of all cancer deaths worldwide.

So far, policies to eliminate tobacco use in the USA are insuffi cient. On Jan 22, the American Lung Association released its 12th annual report, State of Tobacco Control 2014, which assesses annual progress on key tobacco policies at the federal and state levels, and awards grades to specifi c laws and regulations on the basis of the eff ect of tobacco control (grade A represents excellent tobacco control policy, while F indicates inadequate policy). According to the report, the federal government’s results on tobacco control in 2013 were poor, achieving just three Ds—under policy categories for the US Food and Drug Administration’s regulation of tobacco products, cigarette taxation, and the Framework Convention on Tobacco Control, and one C for smoking cessation. Meanwhile, at state level, progress on tobacco control

policies has remained slow. Two states—Minnesota and Massachusetts—increased their cigarette tax to US$2·83 and $3·51 per pack, respectively. No states passed comprehensive smoke-free laws last year, however, with only 28 states having such legislation. Although 11 states increased funding for tobacco prevention and cessation programmes, only two states allocated funds at or above levels recommended by the US Centers for Disease Control and Prevention. The report issues an urgent call for policy makers to commit to eliminating tobacco-caused death and disease.

Although the recent US Surgeon General’s report, The Health Consequences of Smoking—50 years of Progress, has documented that the proportion of current smokers declined from 42% in 1965 to 18% in 2012, more than 42 million Americans still smoke. All US states should urgently expand and accelerate evidence-based, cost-eff ective policies and programme strategies to reduce—and ultimately eliminate—tobacco use, to prevent the enormous and unnecessary toll of tobacco-related disease and premature deaths. ■ The Lancet

Suicide: who should know?On average, every 2 hours in England, somebody ends their own life. Prevention of suicide is not the exclusive responsibility of any one sector of society, and a death by suicide certainly aff ects many individuals both personally and professionally involved with the deceased. Legal duties of confi dentiality can mean that doctors and nurses are blamed by grieving families and friends who feel let down because they were not aware of, or educated about, the risk facing their loved one. A new consensus statement coordinated by the Department of Health in England acts as a reminder to health-care providers about their rights and duty to make judgments about communicating risks facing their patients and the role of the family in cases of suicide.

This statement, published in January, 2014, is not an attempt to change the role of confi dentiality, but addresses the very sensitive balance between patient autonomy and patient safety. It posits that breaking confi dentiality and disclosing a patient’s suicide risk is sometimes in the interest of patient safety. The

statement only refers to patients who have lost the mental capacity to make a decision about whether to share information about their suicide risk. How to share the information and with whom should be carefully discussed with the patient. The statement stresses that this is not about shifting a burden, but allowing practitioners to use their judgment and provide the support family and friends need to care for and be vigilant and supportive of at-risk family members.

Confi dentiality versus safety is an ethical balance, and any shifting of the balance creates nervousness. Concerns could be raised that this statement might be interpreted as a step towards overturning a person’s capacitous decision, and questions clinical practice in general. But as results of a 1 year progress report on the new national suicide prevention strategy show a continuing rise in suicide incidence, this statement raises an important question of whether weighting the balance in fav our of autonomy puts suicidal patients at risk of unsafe practice. ■ The Lancet

For the consensus statement see https://www.gov.uk/

government/uploads/system/uploads/attachment_data/

fi le/271792/Consensus_statement_on_information_

sharing.pdf

For the national suicide prevention strategy report see

https://www.gov.uk/government/uploads/system/

uploads/attachment_data/fi le/271789/Annual_Report_

into_suicide.pdf

For the American Lung Association’s report—State of

Tobacco Control 2014 see http://www.stateoftobaccocontrol.org/

For the 2014 Surgeon General’s report see http://www.

surgeongeneral.gov/library/reports/50-years-of-progress/

full-report.pdf

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