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• W2007727536 abstract "David Nutt and colleagues' latest ranking of drugs in terms of harm to society (Nov 6, p 1558)1Nutt DJ King LA Phillips LD on behalf of the Independent Scientific Committee on DrugsDrug harms in the UK: a multicriteria decision analysis.Lancet. 2010; 376: 1558-1565Summary Full Text Full Text PDF PubMed Scopus (958) Google Scholar now places alcohol first (having been fifth in his 2007 assessment2Nutt D King LA Saulsbury W Blakemore C Development of a rational scale to assess the harm of drugs of potential misuse.Lancet. 2007; 369: 1047-1053Summary Full Text Full Text PDF PubMed Scopus (800) Google Scholar); does not mention street methadone or barbiturates (considered respectively the third and fourth most harmful drugs in society last time around); and ranks tobacco sixth, below alcohol, heroin, crack cocaine, metamfetamine, and cocaine.Every year in the UK, tobacco smoking causes around 100 000 premature deaths, reducing average life expectancy in regular smokers by 10 years. Smoking in pregnancy causes more than 5000 fetal or neonatal deaths, and more than 20 000 premature or low-birthweight births.3Royal College of PhysiciansPassive smoking and children. A report by the Tobacco Advisory Group of the Royal College of Physicians. RCP, London2010Google Scholar Passive smoking causes 40 sudden infant deaths, more than 160 000 cases of childhood illness, smoking uptake in around 25 000 children, and nearly 11 000 deaths in adults.3Royal College of PhysiciansPassive smoking and children. A report by the Tobacco Advisory Group of the Royal College of Physicians. RCP, London2010Google Scholar Smoking is the largest reversible cause of social inequality in health in the UK,4Jha P Peto R Zatonski W Boreham J Jarvis MJ Lopez AD Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America.Lancet. 2006; 368: 367-370Summary Full Text Full Text PDF PubMed Scopus (323) Google Scholar a significant contributor to poverty, and costs the National Health Service £5·2 billion per year.5Allender S Balakrishnan R Scarborough P Webster P Rayner M The burden of smoking-related ill health in the UK.Tobacco Control. 2009; 18: 262-267Crossref PubMed Scopus (95) Google Scholar Tobacco smuggling accounts for about 13% of the cigarette market and is a major focus for organised crime. Two of the five multinational tobacco companies fuelling the global smoking epidemic are British.These harms, which for mortality alone exceeds that of all the other assessed drugs combined, seem again to have been either underestimated or overlooked, perhaps because no-one with expertise in tobacco was involved in the assessment. We agree that drug regulation and classification should be related to harm, but the failure to recognise the harm caused by tobacco in this study suggests to us that it is fundamentally flawed.RW does research and consultancy for, and has received hospitality and travel funds from, manufacturers of smoking cessation medications, and has a share of a patent for a novel nicotine delivery device. All other authors declare that they have no conflicts of interest. David Nutt and colleagues' latest ranking of drugs in terms of harm to society (Nov 6, p 1558)1Nutt DJ King LA Phillips LD on behalf of the Independent Scientific Committee on DrugsDrug harms in the UK: a multicriteria decision analysis.Lancet. 2010; 376: 1558-1565Summary Full Text Full Text PDF PubMed Scopus (958) Google Scholar now places alcohol first (having been fifth in his 2007 assessment2Nutt D King LA Saulsbury W Blakemore C Development of a rational scale to assess the harm of drugs of potential misuse.Lancet. 2007; 369: 1047-1053Summary Full Text Full Text PDF PubMed Scopus (800) Google Scholar); does not mention street methadone or barbiturates (considered respectively the third and fourth most harmful drugs in society last time around); and ranks tobacco sixth, below alcohol, heroin, crack cocaine, metamfetamine, and cocaine. Every year in the UK, tobacco smoking causes around 100 000 premature deaths, reducing average life expectancy in regular smokers by 10 years. Smoking in pregnancy causes more than 5000 fetal or neonatal deaths, and more than 20 000 premature or low-birthweight births.3Royal College of PhysiciansPassive smoking and children. A report by the Tobacco Advisory Group of the Royal College of Physicians. RCP, London2010Google Scholar Passive smoking causes 40 sudden infant deaths, more than 160 000 cases of childhood illness, smoking uptake in around 25 000 children, and nearly 11 000 deaths in adults.3Royal College of PhysiciansPassive smoking and children. A report by the Tobacco Advisory Group of the Royal College of Physicians. RCP, London2010Google Scholar Smoking is the largest reversible cause of social inequality in health in the UK,4Jha P Peto R Zatonski W Boreham J Jarvis MJ Lopez AD Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America.Lancet. 2006; 368: 367-370Summary Full Text Full Text PDF PubMed Scopus (323) Google Scholar a significant contributor to poverty, and costs the National Health Service £5·2 billion per year.5Allender S Balakrishnan R Scarborough P Webster P Rayner M The burden of smoking-related ill health in the UK.Tobacco Control. 2009; 18: 262-267Crossref PubMed Scopus (95) Google Scholar Tobacco smuggling accounts for about 13% of the cigarette market and is a major focus for organised crime. Two of the five multinational tobacco companies fuelling the global smoking epidemic are British. These harms, which for mortality alone exceeds that of all the other assessed drugs combined, seem again to have been either underestimated or overlooked, perhaps because no-one with expertise in tobacco was involved in the assessment. We agree that drug regulation and classification should be related to harm, but the failure to recognise the harm caused by tobacco in this study suggests to us that it is fundamentally flawed. RW does research and consultancy for, and has received hospitality and travel funds from, manufacturers of smoking cessation medications, and has a share of a patent for a novel nicotine delivery device. All other authors declare that they have no conflicts of interest. Drugs and harm to society – Authors' replyIt is pleasing to see that our paper has generated a good deal of interest. John Britton and colleagues, and Richard Peto and Jillian Boreham, claim that mortality is higher for tobacco than all the other assessed drugs combined, which is probably true. However, nobody dies directly from tobacco itself; that is why we scored it a zero for drug-specific mortality, although we did consider it the most harmful of all the drugs on drug-specific damage, and second only to heroin for drug-related mortality. Full-Text PDF" @default.
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