properly restricted to tobacconist shops. In "Tobacco Liability and Public Health Policy" Gostin et al1 comment that health warnings on cigarette packaging are "countermanded through advertising, as well as social and cultural norms and peer pressures." It has puz¬ zled me that the practice of selling cig¬ arettes in pharmacies and food stores has not attracted attention in the tort system or from health policy planners. Owen S. Surman, MD Massachusetts General Boston, Mass
Hospital
LO, Brandt AM, Cleary PD. Tobacco liability public health policy. JAMA. 1991;266:3178-3182.
1. Gostin
and
To the Editor.\p=m-\I am disappointed at Gostin and colleagues1 solution forthe tobacco menace in our country: more litigation. As a physician strongly committed to the elimination of tobacco from our society, I am nevertheless appalled at the notion that smokers' diseases are the fault of someone other than themselves. Unless Mrs Cipollone spent her life living on Mars, she had to know that smoking was hazardous. To argue that her infirmities were the fault ofthe tobacco industry and its failure to warn her of hazards is specious and insulting to the intelligence. If our society is seriously interested in ridding itself of the tobacco menace as it should be, there are some effective steps that can be taken. First, let us eliminate once and for all farm subsidies to tobacco growers. Let us also subject tobacco products to high-level taxation. We might also consider expanding the scope of the education of our children about the hazards of tobacco. I would hope that we could accomplish this highly valuable and necessary task without resorting to the dubious but highly revered watchword of tort litigation: if something in life goes wrong, it's somebody else's fault. David M. Priver, MD San Diego, Calif 1. Gostin LO, Brandt AM, Cleary PD. Tobacco liability and public health policy. JAMA. 1991;266:3178-3182.
In
Reply.\p=m-\Each
of the above letters
supports stronger governmental regu-
lation of tobacco manufacturers and sellers. Dr Priver, however, rejects indirect regulation through the tort system because smokers should not be permitted to shift responsibility for their own health decisions to tobacco companies. Certainly, individuals should heed public health advice and government warnings to stop smoking. But if smokers can demonstrate that cigarette manufacturers knowingly concealed information they had in their possession about the dangers of smoking or intentionally mislead consumers, why should the law shield producers from their responsibilities and po-
tential liability? As we state in our article, the worst outcome of the Cipollone case would be to grant cigarette companies preferred status when all other manufacturers still had to defend the safety of their products and the adequacy of their warnings in the court system. In January, the Supreme Court heard oral arguments in the Cipollone case for the second time. This suggests that the Court split four to four after the first hearing. Justice Thomas may become the deciding vote in this historic case. In addition to tort liability, we support the observations of Drs Largey and Feil, Surman, and Priver that further legal and public health measures could help to curb tobacco use. A comprehensive strategy for significantly reducing tobacco use would include stricter regulation of printed advertisements, particularly in magazines marketed to the young; man¬ datory counter-advertising; restrictions on the sale of tobacco in pharmacies and children's candy stores; higher levels of taxation and termination of tobacco farm subsidies; and well-targeted education in schools and neighborhoods. We reserve judgment on the suggestion of a legal age for smoking because enforcement of cur¬ rent law prohibiting retailers from selling to minors may be preferable to imposing legal penalties on children and adoles¬ cents who smoke. Given the overwhelming health haz¬ ards of tobacco and the fact that a new generation of smokers is actively being
cultivated, legal
measures
to
protect
public health must be examined afresh.
Lawrence O. Gostin, JD American Society of Law and Medicine Boston, Mass Paul D. Cleary, MD Harvard Medical School Boston, Mass Allan M. Brandt, MD University of North Carolina Chapel Hill
Multiresistant Salmonella Organisms in India To the Editor. \p=m-\In developing countries, multiresistant Salmonella organisms are being increasingly reported.1-3 From April 1990 to April 1991 we isolated 190 strains of Salmonella typhi from blood cultures of patients in and around the city of Bombay, India. Of these, 141 were multiresistant to chloramphenicol,
ampicillin, co-trimoxazole, tetracycline, and streptomycin (by Kirby Bauer disk diffusion) giving an incidence of resistance of 74%. Minimum inhibitory con-
centration (MIC) done on 50 representative strains by agar dilution technique (modified National Committee for Clinical Laboratory Standards) confirmed the
Downloaded From: http://jama.jamanetwork.com/ by a UQ Library User on 06/14/2015
disk diffusion result in 40 of 50 strains, wherein an MIC value above break point was considered resistant. Resistance was found to be plasmid-mediated (100 mega-
dalton, plasmid isolated). Salmonella typhi remains sensitive to nalidixic acid and the fluoroquino lones ciprofloxacin, oflaxacin, and norfloxacin. These drugs have been used successfully in epidemics of enteric fever caused by multiresistant organisms.3,4 However, a decrease in susceptibility of multiresistant Salmonella typhimurium to this class of drugs may compromise their efficacy against the
genus.5 We have found three cases where
the MIC to ciprofloxacin against S typhi (normal value, 0.025 µg/mL) was raised to 0.125 µg/mL. In all three patients the dose had to be increased from 1 g daily to 1.5 g daily orally or from 400 mg to 600 mg intravenously daily for a clinical response. With the widespread use of nalidixic acid for diarrheal diseases, the chance of bac¬ teria mutating as a result of this drug is increased. This may increase the possibil¬ ity of fluoroquinolone resistance develop¬ ing in the near future.
Ajita Mehta, MD Camilla Rodriques, MD V. R. Joshi, MD P. D. Hinduja National Hospital & Medical Research Centre
Mahim, Bombay, India 1. Dravid
M, Bhore AY, Joshi BN, Phadke S. Salmonewport isolations from a general hospital in Pune. J Commun Dis. 1989;21:133-136. 2. Saxena SN, Kumari N, Saihi SS, Soni DV, Pahwa RK, Jayasheela M. Surveillance of Salmonella in India for drug resistance. Indian J Med Sci. 1989:43:145-150. 3. Anand AC, Kataria VK, Singh W, Chatterjee SK. Epidemic multiresistant enteric fever in Eastern India. Lancet. 1990;335:352. 4. Yang F, Gu X-J, Zhang MF, Tai T-Y. Treatment of typhoid fever with ofloxacin. J Antimicrob Chemother. nella
1989;23:785-788.
5. Piddock LJV, Whale K, Wise R. Quinolone resistance in Salmonella: clinical experience. Lancet. 1990:335:1459.
Medical and Sociological Violence in America: An Invitation to Readers
Aspects of
The June 10, 1992, issue of JAMA will be devoted to papers of varying length on vio¬ lence in America. Since new concepts are best expressed in a few sentences, we invite our readers who have original ideas on this subject to submit a Letter to the Editor. Such letters are, like other manuscripts, ex¬ pected to be scholarly and are subjected to peer review. They differ from other manu¬ scripts only in length; Letters to the Editor should be no longer than 500 words. We ask that letter writers conform to the Guidelines for Letters published in each issue of The JOURNAL. The deadline for receipt is April 10, 1992. We look forward to receiving your letters and to publishing the best of them. —EDS.
Hospital
LO, Brandt AM, Cleary PD. Tobacco liability public health policy. JAMA. 1991;266:3178-3182.
1. Gostin
and
To the Editor.\p=m-\I am disappointed at Gostin and colleagues1 solution forthe tobacco menace in our country: more litigation. As a physician strongly committed to the elimination of tobacco from our society, I am nevertheless appalled at the notion that smokers' diseases are the fault of someone other than themselves. Unless Mrs Cipollone spent her life living on Mars, she had to know that smoking was hazardous. To argue that her infirmities were the fault ofthe tobacco industry and its failure to warn her of hazards is specious and insulting to the intelligence. If our society is seriously interested in ridding itself of the tobacco menace as it should be, there are some effective steps that can be taken. First, let us eliminate once and for all farm subsidies to tobacco growers. Let us also subject tobacco products to high-level taxation. We might also consider expanding the scope of the education of our children about the hazards of tobacco. I would hope that we could accomplish this highly valuable and necessary task without resorting to the dubious but highly revered watchword of tort litigation: if something in life goes wrong, it's somebody else's fault. David M. Priver, MD San Diego, Calif 1. Gostin LO, Brandt AM, Cleary PD. Tobacco liability and public health policy. JAMA. 1991;266:3178-3182.
In
Reply.\p=m-\Each
of the above letters
supports stronger governmental regu-
lation of tobacco manufacturers and sellers. Dr Priver, however, rejects indirect regulation through the tort system because smokers should not be permitted to shift responsibility for their own health decisions to tobacco companies. Certainly, individuals should heed public health advice and government warnings to stop smoking. But if smokers can demonstrate that cigarette manufacturers knowingly concealed information they had in their possession about the dangers of smoking or intentionally mislead consumers, why should the law shield producers from their responsibilities and po-
tential liability? As we state in our article, the worst outcome of the Cipollone case would be to grant cigarette companies preferred status when all other manufacturers still had to defend the safety of their products and the adequacy of their warnings in the court system. In January, the Supreme Court heard oral arguments in the Cipollone case for the second time. This suggests that the Court split four to four after the first hearing. Justice Thomas may become the deciding vote in this historic case. In addition to tort liability, we support the observations of Drs Largey and Feil, Surman, and Priver that further legal and public health measures could help to curb tobacco use. A comprehensive strategy for significantly reducing tobacco use would include stricter regulation of printed advertisements, particularly in magazines marketed to the young; man¬ datory counter-advertising; restrictions on the sale of tobacco in pharmacies and children's candy stores; higher levels of taxation and termination of tobacco farm subsidies; and well-targeted education in schools and neighborhoods. We reserve judgment on the suggestion of a legal age for smoking because enforcement of cur¬ rent law prohibiting retailers from selling to minors may be preferable to imposing legal penalties on children and adoles¬ cents who smoke. Given the overwhelming health haz¬ ards of tobacco and the fact that a new generation of smokers is actively being
cultivated, legal
measures
to
protect
public health must be examined afresh.
Lawrence O. Gostin, JD American Society of Law and Medicine Boston, Mass Paul D. Cleary, MD Harvard Medical School Boston, Mass Allan M. Brandt, MD University of North Carolina Chapel Hill
Multiresistant Salmonella Organisms in India To the Editor. \p=m-\In developing countries, multiresistant Salmonella organisms are being increasingly reported.1-3 From April 1990 to April 1991 we isolated 190 strains of Salmonella typhi from blood cultures of patients in and around the city of Bombay, India. Of these, 141 were multiresistant to chloramphenicol,
ampicillin, co-trimoxazole, tetracycline, and streptomycin (by Kirby Bauer disk diffusion) giving an incidence of resistance of 74%. Minimum inhibitory con-
centration (MIC) done on 50 representative strains by agar dilution technique (modified National Committee for Clinical Laboratory Standards) confirmed the
Downloaded From: http://jama.jamanetwork.com/ by a UQ Library User on 06/14/2015
disk diffusion result in 40 of 50 strains, wherein an MIC value above break point was considered resistant. Resistance was found to be plasmid-mediated (100 mega-
dalton, plasmid isolated). Salmonella typhi remains sensitive to nalidixic acid and the fluoroquino lones ciprofloxacin, oflaxacin, and norfloxacin. These drugs have been used successfully in epidemics of enteric fever caused by multiresistant organisms.3,4 However, a decrease in susceptibility of multiresistant Salmonella typhimurium to this class of drugs may compromise their efficacy against the
genus.5 We have found three cases where
the MIC to ciprofloxacin against S typhi (normal value, 0.025 µg/mL) was raised to 0.125 µg/mL. In all three patients the dose had to be increased from 1 g daily to 1.5 g daily orally or from 400 mg to 600 mg intravenously daily for a clinical response. With the widespread use of nalidixic acid for diarrheal diseases, the chance of bac¬ teria mutating as a result of this drug is increased. This may increase the possibil¬ ity of fluoroquinolone resistance develop¬ ing in the near future.
Ajita Mehta, MD Camilla Rodriques, MD V. R. Joshi, MD P. D. Hinduja National Hospital & Medical Research Centre
Mahim, Bombay, India 1. Dravid
M, Bhore AY, Joshi BN, Phadke S. Salmonewport isolations from a general hospital in Pune. J Commun Dis. 1989;21:133-136. 2. Saxena SN, Kumari N, Saihi SS, Soni DV, Pahwa RK, Jayasheela M. Surveillance of Salmonella in India for drug resistance. Indian J Med Sci. 1989:43:145-150. 3. Anand AC, Kataria VK, Singh W, Chatterjee SK. Epidemic multiresistant enteric fever in Eastern India. Lancet. 1990;335:352. 4. Yang F, Gu X-J, Zhang MF, Tai T-Y. Treatment of typhoid fever with ofloxacin. J Antimicrob Chemother. nella
1989;23:785-788.
5. Piddock LJV, Whale K, Wise R. Quinolone resistance in Salmonella: clinical experience. Lancet. 1990:335:1459.
Medical and Sociological Violence in America: An Invitation to Readers
Aspects of
The June 10, 1992, issue of JAMA will be devoted to papers of varying length on vio¬ lence in America. Since new concepts are best expressed in a few sentences, we invite our readers who have original ideas on this subject to submit a Letter to the Editor. Such letters are, like other manuscripts, ex¬ pected to be scholarly and are subjected to peer review. They differ from other manu¬ scripts only in length; Letters to the Editor should be no longer than 500 words. We ask that letter writers conform to the Guidelines for Letters published in each issue of The JOURNAL. The deadline for receipt is April 10, 1992. We look forward to receiving your letters and to publishing the best of them. —EDS.
