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1.  Trends in smoking behaviour between 1985 and 2000 in nine European countries by education 
Objective: To examine whether trends in smoking behaviour in Western Europe between 1985 and 2000 differed by education group.
Design: Data of smoking behaviour and education level were obtained from national cross sectional surveys conducted between 1985 and 2000 (a period characterised by intense tobacco control policies) and analysed for countries combined and each country separately. Annual trends in smoking prevalence and the quantity of cigarettes consumed by smokers were summarised for each education level. Education inequalities in smoking were examined at four time points.
Setting: Data were obtained from nine European countries: Norway, Sweden, Denmark, Finland, the United Kingdom, the Netherlands, Germany, Italy, and Spain.
Participants: 451 386 non-institutionalised men and women 25–79 years old.
Main outcome measures: Smoking status, daily quantity of cigarettes consumed by smokers.
Results: Combined country analyses showed greater declines in smoking and tobacco consumption among tertiary educated men and women compared with their less educated counterparts. In country specific analyses, elementary educated British men and women, and elementary educated Italian men showed greater declines in smoking than their more educated counterparts. Among Swedish, Finnish, Danish, German, Italian, and Spanish women, greater declines were seen among more educated groups.
Conclusions: Widening education inequalities in smoking related diseases may be seen in several European countries in the future. More insight into effective strategies specifically targeting the smoking behaviour of low educated groups may be gained from examining the tobacco control policies of the UK and Italy over this period.
doi:10.1136/jech.2004.025684
PMCID: PMC1733079  PMID: 15831689
2.  Impact of UK National Health Service smoking cessation services: variations in outcomes in England 
Tobacco Control  2003;12(3):296-301.
Objectives: To determine the extent to which UK National Health Service (NHS) smoking cessation services in England reach smokers and support them to quit at four weeks, and to identify which service and area characteristics contribute to observed outcomes.
Design: Ordinary least squares regression was used to investigate local smoking outcomes in relation to characteristics of health authorities and their smoking cessation services.
Setting: 76 health authorities (from a total of 99) in England from April 2000 to March 2001.
Main outcome measures: Reach—number of smokers attending cessation services and setting a quit date as a percentage of the adult smoking population in each health authority. Absolute success—number of smokers setting a quit date who subsequently reported quitting at four weeks (not having smoked between two and four weeks after quit date). Cessation rate—number of smokers who reported quitting at four weeks as a percentage of those setting a quit date. Loss—percentage lost to follow up.
Results: A range of service and area characteristics was associated with each outcome. For example, group support proved more effective than one to one interventions in helping a greater proportion of smokers to quit at four weeks. Services based in health action zones were reaching larger numbers of smokers. However, services operating in deprived communities achieved lower cessation rates than those in more prosperous areas.
Conclusions: Well developed, evidence based NHS smoking cessation services, reflecting good practice, are yielding positive outcomes in England. However, most of the data are based on self reported smoking status at four weeks. It will be important to obtain validated data about continuous cessation over one year or more in order to assess longer term impact.
doi:10.1136/tc.12.3.296
PMCID: PMC1747752  PMID: 12958391
3.  Funding the NHS. Is the NHS sustainable? 
BMJ : British Medical Journal  1997;314(7076):296-298.
The survival of the NHS lies largely in the hands of government, and this article suggests steps that it should take to deal with pressures on the NHS in terms of funding, managing efficiency, and demands. Changes to the system of funding may be unfeasible, but management could be improved by research to allow greater understanding of the local effects of national policies. Alternatively health authorities could be given more freedom to manage funds, although this would have to be accompanied by stiff sanctions for those who failed. Demand could be contained by strengthening policies to ensure that new technologies are cost effective. The government could try to reduce demands arising from increased expectations by encouraging informed public debate about priorities and influencing the availability of private health care. All these efforts should be guided by the values underpinning the NHS, which should be debated and decided collectively and confirmed in a new charter for NHS's 50th anniversary in 1998.
PMCID: PMC2125746  PMID: 9022498
4.  Can the NHS cope in future? 
BMJ : British Medical Journal  1997;314(7074):139-142.
Four potential pressures are likely to determine whether the NHS will be able to cope in future: the change in population structure, changes in level of morbidity, introduction of new technologies, and increasing expectations of patients and NHS providers. New technology and changes in expectations are likely to have the biggest effect and are also the most difficult to quantify. Nevertheless, these pressures are to some extent amenable to control. If the growth in funding continues as it has in the past there is no convincing evidence that the NHS will not continue to cope.
PMCID: PMC2125614  PMID: 9006479
6.  Income distribution and life expectancy: a critical appraisal. 
BMJ : British Medical Journal  1995;311(7015):1282-1287.
In a series of papers published during the past decade Richard Wilkinson has advanced the view that income inequality is the key determinant of variations in average life expectancy at birth among developed countries. Yet a careful examination of the two sources of data on income distribution most often used by Wilkinson suggests that if they are analysed more appropriately they do not lend support to his claims. More recent data on income distribution is now available for several countries in the Organisation for Economic Development and Cooperation in the mid-1980s and for Great Britain from 1961 to 1991. The use of these data also casts doubt on the hypothesis that inequalities in the distribution of income are closely associated with variations in average life expectancy at birth among the richest nations of the world.
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PMCID: PMC2551188  PMID: 7496240
7.  Beyond class, race, and ethnicity: deprivation and health in Britain. 
Health Services Research  1995;30(1 Pt 2):163-177.
The concepts of class, race, and ethnicity figure prominently in health services research in Britain. Occupational class has been employed for nearly a century to investigate social inequalities in health and access to care. More recently, researchers have identified differences in health status and utilization between ethnic groups. This article examines how these constructs are defined in Britain and identifies some key research associated with them. It also draws attention to the considerable problems in using class and ethnicity to stratify the population. The authors conclude that a new approach that directly measures individuals' material and social resources needs to be developed.
PMCID: PMC1070047  PMID: 7721590
8.  Beyond health care. 
BMJ : British Medical Journal  1994;309(6967):1454-1455.
PMCID: PMC2541616  PMID: 7804035
9.  A new approach to weighted capitation. 
BMJ : British Medical Journal  1994;309(6961):1031-1032.
PMCID: PMC2541532  PMID: 7950728
10.  Equity in health care. 
BMJ : British Medical Journal  1994;309(6955):673.
PMCID: PMC2541505  PMID: 7802797
11.  Allocating resources for health and social care in England. 
BMJ : British Medical Journal  1994;308(6940):1363-1366.
The fair allocation of resources for health and social care in relation to the needs of the population in different parts of the United Kingdom has become particularly important since the implementation of the new arrangements for community care in April 1993. These depend on close collaboration between health authorities and local authority social services departments. Yet funding reaches these authorities by different means and according to different criteria. Most health authority funds come through a weighted capitation formula that overemphasises the effects of age, while family health services funding is largely not cash limited and hence demand led. Funds to local authorities for community care are being transferred from the social security budget but on a basis that partly reflects past provision of residential and nursing home care. None of these mechanisms responds to underlying needs that give rise to demands on the health and social care system as a whole, and none makes any attempt to compensate for defects in the others. The solution includes better research and a unified weighted capitation system for all sources of funding.
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PMCID: PMC2540240  PMID: 8019229
12.  Survey of the attitudes of British physicians to pacing. 
British Heart Journal  1994;71(1):96-101.
OBJECTIVES--To assess how the opinions of cardiologists, physicians, and general practitioners on the indications for permanent pacing compare with published guidelines, and to determine whether resources, pacing experience, and position influence referral practices. DESIGN--Anonymous postal survey by questionnaire from St Bartholomew's Hospital, London and the King's Fund Institute, London. The questionnaire established the respondent's position, resources, and previous pacing experience. Eleven clinical and electrocardiographic situations were described and respondents were asked to decide on whether pacing was indicated. The responses received were compared with the guidelines provided by the 1984 American College of Cardiology/American Heart Association task force. PARTICIPANTS--The 630 members of the British Cardiac Society, 1370 randomly selected general physicians, and 2000 general practitioners. RESULTS--Patients with symptoms were more likely to be referred for pacing than symptom free patients regardless of underlying aetiology. In relatively symptom free patients the frequency with which pacing was recommended was low, even when it was unequivocally indicated on prognostic grounds. Failure to recommend pacing was unrelated to diagnostic facilities or referral difficulties. Respondents with pacing experience were more likely to recommend pacing. CONCLUSIONS--The physicians surveyed had a conservative approach towards recommending pacing. Most physicians were influenced predominantly by symptoms and the prognostic indications for pacing were not well appreciated.
PMCID: PMC483621  PMID: 8297707
13.  Tackling inequalities in health: the Australian experience. 
BMJ : British Medical Journal  1993;306(6880):783-787.
Federal and state governments in Australia have embarked on a series of national initiatives which show a firm commitment to tackling social inequalities in health. The development of national goals and targets for health, for example, covers social and environmental conditions and sets differential targets for specific social groups with very poor health status. In a complementary initiative, a wide ranging analysis of the health care system--the National Health Strategy--has as one of its main objectives to improve the equitable impact of the health system. Where problems of access to and quality of services have been exposed, policies have been devised to deal with them. The exceptionally poor health of the Aboriginal community has elicited cross party support for action. Resources have been allocated to implement the National Aboriginal Health Strategy: to improve living and working conditions, education, and employment opportunities. Britain can glean much from the Australian experience.
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PMCID: PMC1677248  PMID: 8490345
14.  Health inequalities: new concerns about the children of single mothers. 
BMJ : British Medical Journal  1993;306(6879):677-680.
OBJECTIVES--To show that the exclusion from conventional class based analyses of child mortality of children whose parents are classified as "unoccupied" produces a misleading picture of health inequalities. DESIGN--Reanalysis of data published in the childhood supplement of the registrar general's decennial supplement on occupational mortality in England and Wales, which compares numerator data for registrations of deaths in children over the age of 1 but below their 16th birthday in 1979, 1980, 1982, and 1983 with data about children aged 1-15 who were enumerated at the 1981 census. RESULTS--Parents who are classified as "unoccupied" largely consist of economically inactive single mothers. Their children are estimated to represent 89% of the 614,000 aged 1-15 classified as "unoccupied" in the childhood supplement. They have the worst mortality record of all social groups--an age specific death rate of 68.8/100,000 a year, 42% worse than in social class V (48.4/100,000) and worse than that of social class I (22.8) by a factor of 3. At older ages (10-15 years) these children have a relative risk of death of 4.14 relative to classes I and II; the risk is 2.58 in children 0-4 and 2.56 in those 5-9. Relative risks of child mortality in social classes I and II in comparison to classes IV and V suggests a progressive shallowing from 2.08 at ages 1-4 to 1.37 at ages 10-15. When unoccupied parents were combined with classes IV and V and compared with classes I and II, however, inequalities seemed to be pervasive throughout childhood; the relative risks were 2.21 for those aged 1-4 and 1.98 for those aged 10-15. CONCLUSION--Children classified as unoccupied are almost certainly living in poverty as well as experiencing relatively high risks of mortality. Class based analyses which exclude them therefore produce a misleading picture of inequalities in child health. The implications for health policy are profound. Strategies to promote the nation's health should acknowledge the importance of material and social deprivation more explicitly.
PMCID: PMC1677053  PMID: 8471917
16.  Utilisation by homeless people of acute hospital services in London. 
BMJ : British Medical Journal  1991;303(6808):958-961.
OBJECTIVES--To estimate the numbers and distribution of homeless people in London; to quantify the utilisation of acute inpatient services by homeless people in two health authorities; and to predict the total numbers of admissions in homeless people in district health authorities across London. DESIGN--Data were collected from various sources on the distribution of homeless people across London boroughs. All unplanned acute inpatient admissions during November 1990 to relevant hospitals were identified. SETTING--Bloomsbury and Paddington and North Kensington, two former inner London district health authorities. SUBJECTS--Homeless people in London residing in bed and breakfast and private sector leased accommodation, residing in hostels, and of no fixed abode. MAIN OUTCOME MEASURES--Number and cost of acute unplanned admissions in homeless people in two health authorities in November 1990; predicted number of such admissions each year in district health authorities in London. RESULTS--There were at least 60,000 homeless people in London in March 1990. The majority were housed in temporary accommodation (55,412). There were at least 3295 hostel dwellers and 651 people sleeping rough. Homeless people accounted for 105 (8%) of the 1256 acute unbooked admissions in residents of Bloomsbury and Paddington and North Kensington health authorities in November 1990. Considerable variations in the pattern of acute unplanned admissions in homeless people were observed in the two districts with respect to housing status and specialty of admission. The total number of acute unplanned admissions in homeless people across London each year was estimated at 7598, ranging from 38 in Bexley to 1515 in Parkside. CONCLUSIONS--The results have fundamental implications for resource allocation across London. Allocation must take better account of the heterogeneity, uneven distribution, and extra health needs of homeless people.
PMCID: PMC1671322  PMID: 1954419
17.  America's uninsured and underinsured. 
BMJ : British Medical Journal  1991;302(6786):1163-1164.
PMCID: PMC1669885  PMID: 2043806
18.  Monitoring and evaluating Working for Patients. 
BMJ : British Medical Journal  1989;299(6712):1385-1387.
PMCID: PMC1838243  PMID: 2513973
19.  Direct cytotoxic action of Shiga toxin on human vascular endothelial cells. 
Infection and Immunity  1988;56(9):2373-2378.
To help explain a role of the Shiga toxin family in hemorrhagic colitis and hemolytic-uremic syndrome in humans, it has been hypothesized that these toxins cause direct damage to the vascular endothelium. We now report that Shiga toxin purified from Shigella dysenteriae 1 does indeed have a direct cytotoxic effect on vascular endothelial cells in cultures. Human umbilical vein endothelial cells (HUVEC) in confluent monolayers were reduced 50% by 10(-8) M Shiga toxin after a lag period of 48 to 96 h. In comparison, nonconfluent HUVEC were reduced 50% by 10(-10) M Shiga toxin within a 24-h period. These data suggest that dividing endothelial cells are more sensitive to Shiga toxin than are quiescent cells in confluent monolayers. Both confluent and nonconfluent HUVEC specifically bound 125I-Shiga toxin. However, in response to the toxin, rates of incorporation of [3H]leucine into protein were more severely reduced in nonconfluent cells than in confluent cells. Toxin inhibition of protein synthesis preceded detachment of cells from the substratum. The specific binding of 125I-Shiga toxin to human endothelial cells and the cytotoxic response were both toxin dose dependent and neutralized by anti-Shiga toxin antibody. Heat-denatured Shiga toxin was without the cytotoxic effect. In addition, the complete culture system contained less than 0.1 ng of bacterial endotoxin per ml, as measured by the Limulus amoebocyte lysate test.
PMCID: PMC259575  PMID: 3044997
20.  Loss of type I procollagen gene expression in SV40-transformed human fibroblasts is accompanied by hypermethylation of these genes. 
Nucleic Acids Research  1982;10(19):5879-5891.
Transformation of human lung fibroblasts (WI-38) by Simian Virus 40 (SV40) resulted in a decline of 25-30% in the amount of secreted collagen. The collagen produced by the transformed fibroblasts contained no type I collagen (i.e. alpha 1(I) and alpha 2 chains), which was the major collagen component produced by untransformed fibroblasts. Measurement of the procollagen mRNA levels by dot hybridization with nick-translated procollagen-cDNA clones showed that the absence of type I collagen was due to the absence of alpha 1(I) and alpha 2 procollagen mRNAs. This result was confirmed by hybridization of cDNA to total RNA with southern blots of the procollagen clones. To clarify the mechanism by which type I procollagen gene transcription is abolished in transformed cells, the methylation patterns of the alpha 1(I) and alpha 2 procollagen genes in normal and SV40-transformed fibroblasts were compared, using the chicken alpha 1(I) and alpha 2 procollagen-cDNA clones as probes. Methylated sites were detected by means of the restriction endonuclease isoschizomers HpaII and MspI. Methylation of the procollagen alpha 1(I) and alpha 2 genes was increased in the SV40-transformed fibroblasts, concurrently with the loss of type I collagen synthesis. DNA methylation may thus contribute to altered regulation of gene expression upon cell transformation.
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PMCID: PMC320937  PMID: 6292857
21.  Effect of metal ions on diphtheria toxin production. 
Infection and Immunity  1979;26(3):1065-1070.
The effect of several metal ions on the production of diphtheria toxin was tested. By using the gel immunodiffusion system for detecting toxin, a wide range of metal ion concentrations was conveniently surveyed. Five divalent cations, Fe2+, Cu2+, Co2+, Ni2+, and Mn2+ inhibited toxin production within a range of concentrations that did not inhibit growth of the producing strain. Growth and toxin production were inhibited at identical concentrations by both Cd2+ and Zn2+, whereas Al3+ and Sr2+ affected neither growth nor toxin production over the range of concentrations tested. The data showed that Fe2+ was the most effective inhibitor on an equivalence basis, followed by Cu2+, Co2+, and Ni2+ in descending order. All eight strains of Corynebacterium diphtheriae chosen from diverse ecological origins responded similarly to all metals at similar concentrations. A mutant strain which produces toxin at Fe2+ concentrations 500 times greater than are inhibitory for the parent strain had simultaneously acquired resistance to inhibitory concentrations of Cu2+, Co2+, Ni2+, and Mn2+. This suggests that there is at least one common point in the activity of all these metal ions, and that toxin may respond broadly to changes in metal ion concentrations in the environment.
PMCID: PMC414728  PMID: 118927

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