Letters
issues may now be appreciated and considered in other prehospital cooling studies. Third, the primary results suggested that in a highly functioning emergency medical system, a modest but significant temperature decrease can be achieved before arrival at the emergency department. Whether other cooling methods such as intra-arrest evaporative cooling will achieve more rapid cooling and whether higher survival will be achieved following resuscitation remain unanswered questions. Nevertheless, a strategy of prehospital cooling using 4°C normal saline to improve survival was not supported.
Pierre-Nicolas Carron, MD Bertrand Yersin, MD Author Affiliations: Emergency Department, Lausanne University Hospital, Lausanne, Switzerland. Corresponding Author: Pierre-Nicolas Carron, MD, Emergency Department, Lausanne University Hospital, CH-1011 Lausanne, Switzerland (pierre-nicolas [email protected]).
Francis Kim, MD Charles Maynard, PhD Graham Nichol, MD, MPH
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Author Affiliations: Department of Medicine, University of Washington, Seattle (Kim, Nichol); Department of Health Services, University of Washington, Seattle (Maynard). Corresponding Author: Francis Kim, MD, Department of Medicine, University of Washington, 325 Ninth Ave, Seattle, WA 98104 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Nichol reported receiving institutional grant funding from the Asmund S. Laerdal Foundation for Acute Medicine, the National Heart, Lung, and Blood Institute, the National Institutes of Health, Medtronic Foundation, Velomedix Inc, Philips Healthcare Inc, Physio-Control Inc, HealthSine Technologies Inc, and Zoll Inc; serving on the board of Medic One Foundation; being part of a patent assigned to the University of Washington; and receiving travel reimbursement from the American Heart Association. No other disclosures were reported. 1. Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest. Crit Care Med. 2006; 34(7):1935-1940. 2. Kim F, Olsufka M, Longstreth WT Jr, et al. Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion of 4 degrees C normal saline. Circulation. 2007;115 (24):3064-3070. 3. Bernard SA, Smith K, Cameron P, et al; Rapid Infusion of Cold Hartmanns (RICH) Investigators. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation. 2010;122(7):737-742.
Cardiopulmonary Resuscitation With Mechanical Chest Compressions and Simultaneous Defibrillation To the Editor In the recently published LUCAS in Cardiac Arrest (LINC) randomized trial, cardiopulmonary resuscitation (CPR) with mechanical chest compressions and simultaneous defibrillation provided no significant improvement over classic manual CPR.1 The study protocol implied the delivery of defibrillation during compressions without pausing for rhythm analysis.2 This strategy was intended to eliminate the usual preshock pause to assess rhythm and to optimize the chest compression fraction throughout cardiac resuscitation. Nevertheless, this strategy is a matter of discussion. During chest compressions, the chest wall and the heart are subject to morphological changes, which could affect the success of defibrillation. In animal studies, the optimal timing for defibrillation during ongoing chest compression likely occurs during the upstroke phase of chest compression, both with manual and mechanical chest compressions.3,4 Defibrillation that is not coordinated with the cycle of mechanical chest 2234
compression-relaxation may therefore have played a negative role in the intervention group. Further analysis or study taking the timing of defibrillation into account seems mandatory to confirm the initial negative results of mechanical chest compression during CPR.
1. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA. 2014;311(1): 53-61. 2. Rubertsson S, Silfverstolpe J, Rehn L, et al. The study protocol for the LINC (LUCAS in Cardiac Arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation. Scand J Trauma Resusc Emerg Med. 2013;21:5. 3. Li Y, Wang H, Cho JH, et al. Defibrillation delivered during the upstroke phase of manual chest compression improves shock success. Crit Care Med. 2010;38 (3):910-915. 4. Li Y, Yu T, Ristagno G, et al. The optimal phasic relationship between synchronized shock and mechanical chest compressions. Resuscitation. 2010;81 (6):724-729.
In Reply Drs Carron and Yersin suggest that the timing of defibrillation in relation to the compression-decompression phase when using the mechanical CPR device might have influenced the outcome of the trial. The protocol for the LINC study was designed based on the knowledge available in 2006-2007.1 At that time, the study group concluded that minimizing predefibrillation and postdefibrillation pauses and, thus, delivering defibrillation during ongoing mechanical chest compressions irrespective of compression-decompression phase would be optimal. The knowledge today is still not conclusive that any other strategy is better. The studies mentioned by Carron and Yersin are experimental studies using either manual CPR or a loaddistributing device.2,3 The performance of chest compressions in these studies is not the same as with the device in the LINC study. However, the possibility that the strategy for delivering defibrillation in the LINC study might have influenced outcome cannot be dismissed. The investigators are planning a subgroup analysis to address this matter, but further studies designed to address this specific question are needed. Sten Rubertsson, MD, PhD Author Affiliation: Department of Surgical Sciences/Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden. Corresponding Author: Sten Rubertsson, MD, PhD, Department of Surgical Sciences/Anaesthesiology and Intensive Care, Uppsala University, SE 75185 Uppsala, Sweden ([email protected]).
JAMA June 4, 2014 Volume 311, Number 21
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/29/2015
jama.com
Letters
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported receiving funding for serving as a consultant to Physio-Control. 1. Rubertsson S, Silfverstolpe J, Rehn L, et al. The study protocol for the LINC (LUCAS in Cardiac Arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation. Scand J Trauma Resusc Emerg Med. 2013;21:5. 2. Li Y, Wang H, Cho JH, et al. Defibrillation delivered during the upstroke phase of manual chest compression improves shock success. Crit Care Med. 2010;38 (3):910-915. 3. Li Y, Yu T, Ristagno G, et al. The optimal phasic relationship between synchronized shock and mechanical chest compressions. Resuscitation. 2010;81 (6):724-729.
Guidelines for Cardiovascular Risk Assessment and Cholesterol Treatment To the Editor As the chairs of the 2013 guideline panels on risk assessment and cholesterol treatment,1,2 we would like to clarify some statements made in 3 Viewpoint articles3-5 and correct some misinterpretations or incorrect assumptions. Drs Psaty and Weiss3 reviewed the evolution of recommendations on cholesterol-lowering treatment over the last several decades. They correctly emphasized aspects of the rigorous process the panels undertook with the new guidelines and reinforced the message that the purpose of risk assessment in primary prevention is to identify individuals who should undergo a “… discussion of risks, benefits, and patient preferences before starting drug therapy,”3 rather than to mandate a statin prescription. Dr Ioannidis’ perspective4 ignored the fact that 1 in 3 US residents will die of a preventable or postponable cardiovascular event. More than half of US residents will at some point have a major vascular event, which places an enormous burden on the nation’s health care system and economy. The new guidelines suggest that perhaps 30 million asymptomatic US residents without diabetes should be considered for statin therapy, whereas perhaps 70 million of them should be considered for blood pressure–lowering therapy. Until society gets much more serious about public policies that will promote cardiovascular health across the lifespan, statins and antihypertensive drugs will be needed to curb this epidemic. The Viewpoint from Dr Montori and colleagues5 made a number of incorrect statements and assumptions. The authors did not refer to the extensive discussion in the guidelines regarding the choice of the 7.5% risk threshold or the recommendation that this level of risk should trigger a risk discussion and shared decision making between clinician and patient, not routine prescription of statins. They also used the risk estimation tool for a patient who appeared to have familial hypercholesterolemia (whose 10-year risk is likely much higher than the 10% estimate), even though the guidelines explicitly state that the tools should not be applied for such a patient. Practitioners who take the time to read and understand what is actually in the guidelines, rather than what was in misleading headlines, will, we hope, find these guidelines to be very useful tools. They will advance their ability to prevent ath-
erosclerotic cardiovascular disease (CVD) events in collaboration with their patients and, importantly, they can have confidence that the guidelines were founded based on the best available evidence. Donald M. Lloyd-Jones, MD, ScM David C. Goff Jr, MD, PhD Neil J. Stone, MD Author Affiliations: Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Lloyd-Jones); Colorado School of Public Health, Denver, Colorado (Goff); Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Stone). Corresponding Author: Donald M. Lloyd-Jones, MD, ScM, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Lloyd-Jones and Goff reported being co-chairs of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline on the assessment of cardiovascular risk. Dr Stone reported being the chair of the 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. 1. Goff DC, Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online November 12, 2013]. Circulation. doi: 10.1161/01.cir .0000437741.48606.98. 2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online November 12, 2013]. Circulation. doi:10.1161/01.cir.0000437738.63853.7a. 3. Psaty BM, Weiss NS. 2013 ACC/AHA guideline on the treatment of blood cholesterol: a fresh interpretation of old evidence. JAMA. 2014;311(5):461-462. 4. Ioannidis JP. More than a billion people taking statins? potential implications of the new cardiovascular guidelines. JAMA. 2014;311(5):463-464. 5. Montori VM, Brito JP, Ting HH. Patient-centered and practical application of new high cholesterol guidelines to prevent cardiovascular disease. JAMA. 2014; 311(5):465-466.
In Reply Dr Lloyd-Jones and colleagues clarify that the preferences of patients should be taken into account and that the guidelines on the use of statins should not be seen as mandates. However, given the credentials of the guideline panelists and the strong established tradition of the American College of Cardiology/American Heart Association (ACC/AHA) in generating highly influential guidelines, these documents end up being stronger than any absolute mandate. The intense conforming pressure that these guidelines exert on patients and clinicians1 cannot be underestimated. I do not understand why the fact that millions of people benefit from statins and antihypertensive treatment offers justification for recommending and prescribing statins for even more US residents who are asymptomatic. Moreover, in the guidelines, the choice of which patients should be recommended for use of statins is based on a new, poorly calibrated prognostic model that has never been tested in a randomized clinical trial. Regarding US residents, no mention is made of the approximately 250 million who could exercise more, the 42 million who could quit smoking, or all the individuals who could improve 1 or more aspects of their health-related lifestyle.2
jama.com
JAMA June 4, 2014 Volume 311, Number 21
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/29/2015
2235
issues may now be appreciated and considered in other prehospital cooling studies. Third, the primary results suggested that in a highly functioning emergency medical system, a modest but significant temperature decrease can be achieved before arrival at the emergency department. Whether other cooling methods such as intra-arrest evaporative cooling will achieve more rapid cooling and whether higher survival will be achieved following resuscitation remain unanswered questions. Nevertheless, a strategy of prehospital cooling using 4°C normal saline to improve survival was not supported.
Pierre-Nicolas Carron, MD Bertrand Yersin, MD Author Affiliations: Emergency Department, Lausanne University Hospital, Lausanne, Switzerland. Corresponding Author: Pierre-Nicolas Carron, MD, Emergency Department, Lausanne University Hospital, CH-1011 Lausanne, Switzerland (pierre-nicolas [email protected]).
Francis Kim, MD Charles Maynard, PhD Graham Nichol, MD, MPH
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Author Affiliations: Department of Medicine, University of Washington, Seattle (Kim, Nichol); Department of Health Services, University of Washington, Seattle (Maynard). Corresponding Author: Francis Kim, MD, Department of Medicine, University of Washington, 325 Ninth Ave, Seattle, WA 98104 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Nichol reported receiving institutional grant funding from the Asmund S. Laerdal Foundation for Acute Medicine, the National Heart, Lung, and Blood Institute, the National Institutes of Health, Medtronic Foundation, Velomedix Inc, Philips Healthcare Inc, Physio-Control Inc, HealthSine Technologies Inc, and Zoll Inc; serving on the board of Medic One Foundation; being part of a patent assigned to the University of Washington; and receiving travel reimbursement from the American Heart Association. No other disclosures were reported. 1. Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest. Crit Care Med. 2006; 34(7):1935-1940. 2. Kim F, Olsufka M, Longstreth WT Jr, et al. Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion of 4 degrees C normal saline. Circulation. 2007;115 (24):3064-3070. 3. Bernard SA, Smith K, Cameron P, et al; Rapid Infusion of Cold Hartmanns (RICH) Investigators. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation. 2010;122(7):737-742.
Cardiopulmonary Resuscitation With Mechanical Chest Compressions and Simultaneous Defibrillation To the Editor In the recently published LUCAS in Cardiac Arrest (LINC) randomized trial, cardiopulmonary resuscitation (CPR) with mechanical chest compressions and simultaneous defibrillation provided no significant improvement over classic manual CPR.1 The study protocol implied the delivery of defibrillation during compressions without pausing for rhythm analysis.2 This strategy was intended to eliminate the usual preshock pause to assess rhythm and to optimize the chest compression fraction throughout cardiac resuscitation. Nevertheless, this strategy is a matter of discussion. During chest compressions, the chest wall and the heart are subject to morphological changes, which could affect the success of defibrillation. In animal studies, the optimal timing for defibrillation during ongoing chest compression likely occurs during the upstroke phase of chest compression, both with manual and mechanical chest compressions.3,4 Defibrillation that is not coordinated with the cycle of mechanical chest 2234
compression-relaxation may therefore have played a negative role in the intervention group. Further analysis or study taking the timing of defibrillation into account seems mandatory to confirm the initial negative results of mechanical chest compression during CPR.
1. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA. 2014;311(1): 53-61. 2. Rubertsson S, Silfverstolpe J, Rehn L, et al. The study protocol for the LINC (LUCAS in Cardiac Arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation. Scand J Trauma Resusc Emerg Med. 2013;21:5. 3. Li Y, Wang H, Cho JH, et al. Defibrillation delivered during the upstroke phase of manual chest compression improves shock success. Crit Care Med. 2010;38 (3):910-915. 4. Li Y, Yu T, Ristagno G, et al. The optimal phasic relationship between synchronized shock and mechanical chest compressions. Resuscitation. 2010;81 (6):724-729.
In Reply Drs Carron and Yersin suggest that the timing of defibrillation in relation to the compression-decompression phase when using the mechanical CPR device might have influenced the outcome of the trial. The protocol for the LINC study was designed based on the knowledge available in 2006-2007.1 At that time, the study group concluded that minimizing predefibrillation and postdefibrillation pauses and, thus, delivering defibrillation during ongoing mechanical chest compressions irrespective of compression-decompression phase would be optimal. The knowledge today is still not conclusive that any other strategy is better. The studies mentioned by Carron and Yersin are experimental studies using either manual CPR or a loaddistributing device.2,3 The performance of chest compressions in these studies is not the same as with the device in the LINC study. However, the possibility that the strategy for delivering defibrillation in the LINC study might have influenced outcome cannot be dismissed. The investigators are planning a subgroup analysis to address this matter, but further studies designed to address this specific question are needed. Sten Rubertsson, MD, PhD Author Affiliation: Department of Surgical Sciences/Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden. Corresponding Author: Sten Rubertsson, MD, PhD, Department of Surgical Sciences/Anaesthesiology and Intensive Care, Uppsala University, SE 75185 Uppsala, Sweden ([email protected]).
JAMA June 4, 2014 Volume 311, Number 21
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/29/2015
jama.com
Letters
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported receiving funding for serving as a consultant to Physio-Control. 1. Rubertsson S, Silfverstolpe J, Rehn L, et al. The study protocol for the LINC (LUCAS in Cardiac Arrest) study: a study comparing conventional adult out-of-hospital cardiopulmonary resuscitation with a concept with mechanical chest compressions and simultaneous defibrillation. Scand J Trauma Resusc Emerg Med. 2013;21:5. 2. Li Y, Wang H, Cho JH, et al. Defibrillation delivered during the upstroke phase of manual chest compression improves shock success. Crit Care Med. 2010;38 (3):910-915. 3. Li Y, Yu T, Ristagno G, et al. The optimal phasic relationship between synchronized shock and mechanical chest compressions. Resuscitation. 2010;81 (6):724-729.
Guidelines for Cardiovascular Risk Assessment and Cholesterol Treatment To the Editor As the chairs of the 2013 guideline panels on risk assessment and cholesterol treatment,1,2 we would like to clarify some statements made in 3 Viewpoint articles3-5 and correct some misinterpretations or incorrect assumptions. Drs Psaty and Weiss3 reviewed the evolution of recommendations on cholesterol-lowering treatment over the last several decades. They correctly emphasized aspects of the rigorous process the panels undertook with the new guidelines and reinforced the message that the purpose of risk assessment in primary prevention is to identify individuals who should undergo a “… discussion of risks, benefits, and patient preferences before starting drug therapy,”3 rather than to mandate a statin prescription. Dr Ioannidis’ perspective4 ignored the fact that 1 in 3 US residents will die of a preventable or postponable cardiovascular event. More than half of US residents will at some point have a major vascular event, which places an enormous burden on the nation’s health care system and economy. The new guidelines suggest that perhaps 30 million asymptomatic US residents without diabetes should be considered for statin therapy, whereas perhaps 70 million of them should be considered for blood pressure–lowering therapy. Until society gets much more serious about public policies that will promote cardiovascular health across the lifespan, statins and antihypertensive drugs will be needed to curb this epidemic. The Viewpoint from Dr Montori and colleagues5 made a number of incorrect statements and assumptions. The authors did not refer to the extensive discussion in the guidelines regarding the choice of the 7.5% risk threshold or the recommendation that this level of risk should trigger a risk discussion and shared decision making between clinician and patient, not routine prescription of statins. They also used the risk estimation tool for a patient who appeared to have familial hypercholesterolemia (whose 10-year risk is likely much higher than the 10% estimate), even though the guidelines explicitly state that the tools should not be applied for such a patient. Practitioners who take the time to read and understand what is actually in the guidelines, rather than what was in misleading headlines, will, we hope, find these guidelines to be very useful tools. They will advance their ability to prevent ath-
erosclerotic cardiovascular disease (CVD) events in collaboration with their patients and, importantly, they can have confidence that the guidelines were founded based on the best available evidence. Donald M. Lloyd-Jones, MD, ScM David C. Goff Jr, MD, PhD Neil J. Stone, MD Author Affiliations: Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Lloyd-Jones); Colorado School of Public Health, Denver, Colorado (Goff); Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Stone). Corresponding Author: Donald M. Lloyd-Jones, MD, ScM, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Lloyd-Jones and Goff reported being co-chairs of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline on the assessment of cardiovascular risk. Dr Stone reported being the chair of the 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. 1. Goff DC, Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online November 12, 2013]. Circulation. doi: 10.1161/01.cir .0000437741.48606.98. 2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online November 12, 2013]. Circulation. doi:10.1161/01.cir.0000437738.63853.7a. 3. Psaty BM, Weiss NS. 2013 ACC/AHA guideline on the treatment of blood cholesterol: a fresh interpretation of old evidence. JAMA. 2014;311(5):461-462. 4. Ioannidis JP. More than a billion people taking statins? potential implications of the new cardiovascular guidelines. JAMA. 2014;311(5):463-464. 5. Montori VM, Brito JP, Ting HH. Patient-centered and practical application of new high cholesterol guidelines to prevent cardiovascular disease. JAMA. 2014; 311(5):465-466.
In Reply Dr Lloyd-Jones and colleagues clarify that the preferences of patients should be taken into account and that the guidelines on the use of statins should not be seen as mandates. However, given the credentials of the guideline panelists and the strong established tradition of the American College of Cardiology/American Heart Association (ACC/AHA) in generating highly influential guidelines, these documents end up being stronger than any absolute mandate. The intense conforming pressure that these guidelines exert on patients and clinicians1 cannot be underestimated. I do not understand why the fact that millions of people benefit from statins and antihypertensive treatment offers justification for recommending and prescribing statins for even more US residents who are asymptomatic. Moreover, in the guidelines, the choice of which patients should be recommended for use of statins is based on a new, poorly calibrated prognostic model that has never been tested in a randomized clinical trial. Regarding US residents, no mention is made of the approximately 250 million who could exercise more, the 42 million who could quit smoking, or all the individuals who could improve 1 or more aspects of their health-related lifestyle.2
jama.com
JAMA June 4, 2014 Volume 311, Number 21
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/29/2015
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