Pitfalls of open-access sleep medicine: a case of missed congenital central hypoventilation syndrome

Clinical record

A 60-year-old woman was referred to the Princess Alexandra Hospital Sleep Disorders Centre in 2011 with a history of poor sleep despite continuous positive airway pressure (CPAP) for 4 years.

She had a general practitioner-referred home diagnostic sleep study performed in 2007 to investigate daytime somnolence. This showed severe obstructive sleep apnoea (OSA) with a saturation of oxygen nadir of 31%, and a CPAP device was recommended. In 2010, the patient had ongoing symptoms despite nightly CPAP, so her GP requested an in-laboratory CPAP study. This found ongoing severe hypoxia, similar to the previous study, so there was no change to treatment. It was not until symptoms of worsening sleepiness in 2011 that a sleep physician review was requested.

In early 2012, under sleep physician care, an in-laboratory study was performed with half the night in diagnostic mode to clarify the diagnosis of OSA and half the night with CPAP therapy over a range of pressures. The diagnostic phase showed OSA, which was controlled in the CPAP phase. However, there was ongoing hypercapnia, indicating that CPAP was not the appropriate ventilation modality and that complex bi-level ventilation was required. Bi-level ventilation is a form of non-invasive positive airway pressure that cycles between inspiratory and expiratory pressures to increase ventilation and thus control hypercapnia. In a subsequent bi-level ventilation study, hypercapnia and hypoxia were both controlled and the patient was provided with an appropriate ventilation device.

The patient’s family medical history was significant: three siblings had died in infancy, her son died of respiratory failure and her grandson was ventilator-dependent. Given this clinical presentation, a diagnosis of congenital central hypoventilation syndrome was suspected and confirmed with genetic testing. After 32 months of follow-up, the patient continues to experience good usage of bi-level ventilation and resolution of symptoms.

Congenital central hypoventilation syndrome is a rare autosomal dominant disorder (with an incidence of about 1 per 200 000 population) associated with sleep hypoventilation not due to a neuromuscular or respiratory disease and with PHOX2B gene mutation.1 The expression of this disorder is variable with patients presenting from the newborn period to adulthood.

Rare cases, such as the one described here, illustrate the pitfalls of non-specialist management of sleep disorders, resulting from a lack of education regarding “red flags”. Our patient had not been clinically assessed by a sleep physician, despite having had symptoms for 4 years, and thus was not identified as a “complex case” rather than “straightforward OSA”. The identification of the family history would have been an indicator of a more complex sleep disorder.

Australian data show increased demands on sleep testing services, with a doubling of polysomnographs funded by Medicare from 339 per 100 000 people in 2005 to 608 per 100 000 in 2012.2 The steep increase in the number of studies coincided with Medicare funding of home sleep studies and with increasing prevalence of OSA; for example, in a cohort of men aged 50–70 years, the prevalence of OSA from 1988 to 1994 was 38.5% and increased to 43.2% in the period 2007 to 2010.3 The major contributor to the increased prevalence of OSA is obesity and ageing.4 The relationship between OSA and cardiovascular mortality has become increasingly recognised,4 resulting in heightened awareness of the condition. Yet there has been little growth in the number of sleep physicians holding Fellowship of the Royal Australasian College of Physicians (RACP), and there are currently less than 300 accredited sleep physicians in Australia. This supply and demand imbalance has generated two trends: (i) the presence of companies providing direct-to-consumer (DTC) sales of positive airway pressure equipment without medical input; and (ii) sleep disorder patients requiring management in general practice without access to sleep physicians.

Traditional models for the management of OSA in Australia involved sleep physician consultation and performance of a diagnostic and treatment study (such as CPAP), with sleep physician consultation at each step. Patients then purchased equipment at a commercial outlet according to the physician’s prescription. However, in Australia the supply of positive airway pressure equipment is not restricted to physician prescription. As a result, there has been a proliferation of the DTC non-medical model, with companies offering both diagnostic sleep study testing and equipment sales through the one location.5 The DTC model raises an ethical issue, as these companies potentially receive financial benefit from both diagnostic testing and medical equipment sales. Medical professionals are discouraged from providing a product recommendation and gaining financial advantage from selling the product (eg, the RACP6 and Australian Medical Association position statements7); this is not necessarily the case in DTC models. The DTC approach represents at best a duality of interest, but at worst a conflict of interest. Further, the duty of care of such non-medical providers to ensure adequate follow-up and to notify patients of their legal obligations is unclear (eg, assessing fitness to drive and licensing).

As demand increases, interest has sparked in primary care models of service provision. In 2013, a study found that in carefully selected patients, a primary care team of up-skilled GPs and community nurses compared with a sleep physician program had similar outcomes in improved subjective sleepiness, with a cost saving of $960 per patient.8 Sleep medicine is only minimally covered in medical school curricula, so primary care providers do not currently possess the required knowledge to manage sleep disorders. Further, there is no formalised up-skilling educational program widely available in Australia. This could be achieved by either greater incorporation of sleep medicine in medical school curricula or establishment of formal postgraduate training programs. In such programs, modules should include diagnostic pathways to identify red-flag scenarios for sleep physician referral. The development of an integrated medical model would address supply and demand issues and fast-track complex cases to specialist centres.

The care of patients with sleep disorders is at a crossroad. The historical model is unsustainable in view of the increased prevalence of OSA; however, the burgeoning of non-medical models potentially increases the risk of patient harm and conflicts of interest. An up-skilled primary care model may provide the best compromise to this dilemma, similar to what has occurred in the management of type 2 diabetes over the past 20 years. However, substantial changes to current education and training are required to build knowledge in primary care, and collaboration between GPs and sleep physicians is necessary to ensure that complex sleep disorders are not missed under the mountain of uncomplicated OSA cases.

Lessons from practice

The prevalence of sleep disorders such as obstructive sleep apnoea is high and is increasing over time in the setting of an ageing population and increasing obesity.
There is evidence supporting the management of obstructive sleep apnoea in general practice in carefully selected patients.
Formal education pathways need to be established to support such primary care models in order to detect “red flags” and to ensure appropriate sleep physician referral.
Specialist sleep physician referral should be sought where patients have comorbidities, fail to respond to initial therapy or deteriorate on therapy.

Closing the million patient gap of uncontrolled asthma

Australia’s burden of asthma requires structural reform in health care delivery

Asthma control is the principal aim of asthma management. Uncontrolled asthma impairs quality of life, increases exacerbation frequency, heightens risk of death, and is four times more costly to treat than controlled asthma. Therefore, results from a web-based Australian asthma survey are disappointing and disquieting.1

One-quarter of respondents did not regularly use asthma preventers, despite having uncontrolled asthma. Another 20% of respondents had uncontrolled symptoms even while regularly using preventers. If these figures are truly representative of the nation’s 2.3 million people with asthma, they suggest that about one million Australians have uncontrolled asthma. This is despite the fact that asthma guidelines have been available for 26 years.2,3 Fundamental reforms to providing asthma care are therefore needed. A new National Asthma Strategy is on its way, and may provide a platform for structural changes.4

The first therapeutic gap highlighted by the web-based survey was the lack of regular preventer use by many patients, despite having uncontrolled symptoms.1 These patients seemed to favour immediate symptom relief over long term disease control.1 Ironically, the present dispensing system reinforces such behaviour. Relievers are readily available over the counter, but preventers require prescriptions, necessitating additional effort, time and expense.

The logical solution to this problem is to re-design access to asthma medications. Preventers must be made more accessible. It is encouraging that the possibility of dispensing low-dose inhaled corticosteroids without prescription is now under discussion.4

A less palatable but arguably more important measure would be to detect and attempt to reduce the high volume dispensing of relievers without adequate concomitant preventers, because this pattern of medication use is implicated in asthma deaths.5 Such a move would require electronic coordination across pharmacies, with the ability to trigger referral for asthma review.6

These proposals would increase the rate of preventer dispensing, but they cannot guarantee adherence. One reliable way to improve preventer use would be to launch and promote a combined short-acting reliever and steroid preventer in a single device. This would ensure that every dose of reliever was accompanied by a corresponding dose of preventer. There is now evidence that as-needed use of an inhaled corticosteroid combined with a short-acting β-agonist improves symptoms in mild persistent asthma.7 There is less support for this approach in moderate to severe asthma, but an inhaled corticosteroid combined with a long-acting β-agonist may be used instead in such patients, for prevention and relief.8

The second therapeutic gap identified by the survey relates to patients who claim to take regular preventers, but whose asthma remains uncontrolled. The drivers for this situation are complex. Important contributing factors to this problem probably include limited understanding of the disease, incorrect inhaler technique, ongoing smoking and insufficient attention to other asthma triggers, such as aero-allergens, occupational exposures and non-specific irritants.3 These problems are challenging to solve within general practice consultations, and rebates may need to be adjusted so they are based on realistic consultation times. An alternative approach also under consideration is to fund asthma educators and organise the appropriate credentials for them.4 Finally, more patients could be encouraged to schedule regular reviews; for example, by discounting medication costs for those who do.

Even with optimal asthma management in primary care, a small proportion of patients will continue to have uncontrolled asthma, some of whom may be insensitive to corticosteroid-based therapies.3,9 These patients need to be reviewed by respiratory specialists, and automated prompts to activate referrals should be built into asthma review programs.

For the most challenging patients, evaluation at a dedicated “difficult asthma” centre provides additional benefits for outpatient respiratory consultations.10 Many of these patients will have truly severe asthma, but there are also high rates of misdiagnosis, comorbidities and psychosocial factors. According to results from a recent uncontrolled study, dealing with these issues through comprehensive multidisciplinary assessment can improve quality of life and use of health care services, and can also define the patient subgroups most likely to respond to the expensive biological agents now entering clinical practice.11

In the United Kingdom, there are at least 11 specialised centres for treating difficult asthma that operate along similar lines.11 In Australia, this concept is less well developed, and services with interest in difficult asthma vary widely in the scope of their protocols and the extent of multidisciplinary support. Agreement is needed on which patients warrant extensive assessment, and how such patients should be evaluated. Resources could then be channelled to match demand.

We suggest radical steps to curb excessive reliance on relievers, enhance preventer adherence, encourage asthma review, and provide specialised evaluation for the most complex patients. The ultimate challenge is to fully integrate all these measures for maximal impact. Technological solutions are necessary for unhindered data sharing and seamless clinical transition across all levels of asthma care.6

Asthma management in Australia has come a long way, but innovative strategies are needed to bridge the remaining gaps.

When not doing something may be the best choice

X-rays for sprained ankles, antibiotics for ear infections and colds and colonoscopies to screen for bowel cancer are among more than 60 tests, treatments and procedures medical experts say should be avoided because they are wasteful and unnecessarily risky.

Fourteen specialist colleges, societies and associations have taken the lead in identifying 61 tests and procedures that should no longer be used because they expose patients to harm, undermine the effectiveness of lifesaving antibiotics and are a poor use of scarce health dollars.

The list, compiled under the Choosing Wisely initiative of NPS Medicinewise, includes many practices and treatments often considered routine and uncontroversial, but which evidence shows achieve little and are potentially harmful.

An area of particular focus is the use of antibiotics, amid fears that they are being overused, fostering bacterial resistance and the rise of superbugs impervious to known medicines.

In changes that could improve patient outcomes and potentially save millions of dollars, doctors and parents are being urged to make much more careful use of antibiotics, including in the treatment of middle ear infections in children, and in the treatment of colds and other upper respiratory tract infections.

The Royal Australian College of General Practitioners (RACGP) has recommended against the initial use of antibiotics for children aged between two and 12 years with a middle ear infection, where a review is possible in the following 24 to 48 hours.

AMA President Professor Brian Owler said it was important advice that would avert unnecessary treatment while helping to preserve the effectiveness of antibiotics.

“In the case of an ear infection, if there is a chance of review in 24 to 48 hours and the ear looks red, just come back and have a review rather than going straight to antibiotics, so that we try and reduce this over-prescribing of antibiotics,” Professor Owler told Channel Nine’s Today show.

The AMA President said it was advice aimed not only at doctors, but also parents and patients.

“Part of the problem here is not just to educate doctors in terms of when antibiotic prescribing is or isn’t called for, it is also to educate parents and patients themselves so that we don’t prescribe too many antibiotics, because we know if we do that we are likely to see more resistant infections. That’s going to mean that people’s infections are going to be much harder to treat in the future,” he said.

Two Bond University academics, Professor of Clinical Epidemiology Tammy Hoffmann and Professor of Public Health Chris Del Mar said the Choosing Wisely initiative was important not because of the money that could be saved, but because of a change in a approach that it represented.

They wrote in The Conversation that clinicians were guilty of doing too much rather than too little, and Choosing Wisely helped to signal “a very important departure from normal business for clinicians – thinking about not doing things”.

“The premise behind Choosing Wisely is not about cost-cutting. It is one of the few existing processes for dealing with the one-way ratchet caused by more treatments and tests being generated every year, all of which increases the amount of things that can – but not necessarily should – be provided to patients,” they wrote.

Other therapies that have come under question include chest x-rays, one of the test most commonly ordered by GPs.

The RACGP has advised that GPs should no longer, as a matter of routine, order chest x-rays for patients with acute uncomplicated bronchitis.

The Royal Australasian College of Surgeons, meanwhile, has recommended against CT scans for suspected appendicitis without first considering an ultrasound, the Australian Physiotherapy Association has advised that there is “no advantage from routine imaging of non-specific low back pain”, and the Australian and New Zealand Society of Palliative Medicine has advised against the use of stomach feed tubes for patients with advanced dementia.

Professor Owler said the initiative demonstrated that doctors were keen to get rid of wasteful and potentially harmful practices, and supported efforts to improve the effectiveness of health spending.

He said doctors took seriously their responsibility as stewards of the health care system, and were constantly reviewing their practices and the evidence to ensure patients received the best possible care.

His comments were echoed by Australasian College of Dermatologists President Associate Professor Chris Baker, who said that one of the challenges of modern medicine was to determine which of the multiplicity of tests and treatments available were of benefit to patients.

A/Professor Baker said his College had identified several instances where the use of antibiotics was unnecessary and could help undermine their effectiveness, including in the treatment of acne vulgaris, epidermal cysts and redness and swelling of both lower legs.

The Choosing Wisely campaign is running in parallel with, but is unrelated to, a Federal Government taskforce review of the Medicare Benefits Schedule, which was set up last year and is not expected to complete its work until 2017.

The goal of updating the MBS to reflect modern clinical practice has been backed by the AMA, but there are concerns that the Government wants to use it primarily as a cost-cutting exercise that will be quick to de-list old treatments but slow to add new ones.

Adrian Rollins

A rare cause of intrathoracic mass

A 47-year-old woman presented complaining of cough and dyspnoea. Corrective surgery for scimitar syndrome had been performed 4 years earlier, with relocation of the draining scimitar vein to the left atrium via right thoracotomy. A computed tomography scan of the chest revealed right middle lobe pneumonia and a cephalad malposition of the right kidney in a diaphragmatic hernia, giving an intrathoracic appearance. The patient had normal renal function according to biochemistry results. Malpositioning of the kidneys and renal ectopia are rare causes of intrathoracic mass and should be considered in the differential diagnosis.

Cut jail time to build on Indigenous health gains

Soaring Indigenous imprisonment rates and a stubbornly wide life expectancy gap underline calls for the Federal Government to fully fund the National Aboriginal and Torres Strait Islander Health Plan.

AMA President Professor Brian Owler said the latest update on Indigenous health and welfare from the Close the Gap Steering Committee was “a mixed bag”, showing improvement on measures such as child mortality and year 12 attainment, but weak gains in others.

The report found the target to halve the gap in child mortality by 2018 was on track, supported by a lift in immunisation rates that has seen more Indigenous children vaccinated by age five compared with their non-Indigenous counterparts, and Indigenous mortality rates, particularly from heart disease and stroke, are declining.

But the gap in life expectancy is not narrowing fast enough to close by the Council of Australian Government’s 2031 target.

The Close the Gap report shows that between 2005 and 2012, the life expectancy of Indigenous men increased by 1.6 years to 69.1 years, and for Indigenous women 0.6 of a year to 73.7 years (the life expectancy of non-Indigenous men in 2012 was 79.7 year and women, 83.1 years).

But the report’s authors cautioned that the improvements were within the margin of error “and could, in fact, be non-existent”.

Indigenous life expectancy is improving at an annual rate of 0.32 years for men and 0.12 years for women, but the Steering Committee said this would have to increase to between 0.6 and 0.8 years annually to reach the 2030 target.

Driving much of the improvement has been a 40 per cent fall in deaths from heart attacks and strokes, and fatal respiratory illnesses have declined by 27 per cent.

Despite this, heart attacks a strokes remain a major killer, accounting for a quarter of all Indigenous deaths between 2008 and 2012, while suicide was the leading cause of death due to external causes.

“It is disappointing that the target to close the gap in life expectancy by 2031 is not on track,” Professor Owler said. “This is a clear signal that we have to put politics aside and work together to reach this important milestone. Above all, we need consistent funding and support from all governments.”

In his report on Closing the Gap, Prime Minister Malcolm Turnbull agreed that a more concerted effort was needed.

“As a nation, we are a work in progress, and closing the substantial gaps in outcomes between Aboriginal and Torres Strait Islander people and other Australians is one of our most important tasks,” Mr Turnbull said. “There has been encouraging progress…but it is undeniable that progress…has been variable.”

Professor Owler said that to make improved gains, the Federal Government should reverse Budget cuts to programs like the Indigenous Advancement Strategy and the Indigenous Australian Health Program, and commit to genuine engagement with Aboriginal community controlled health services.

Nonetheless, a rapid narrowing of the health gap for infants and young children gives hope that eventually it will narrow for adults as well.

Though the infant mortality rate for Indigenous infants is 1.7 times that of other Australians, it declined 64 per cent between 1998 and 2012, making the gap 83 per cent narrower.

Close the Gap Campaign Co-Chair Dr Jackie Huggins said the long term impact of such improvements were yet to be seen and would take time to measure. The report advised no measurable improvements should be expected before 2018.

Furthermore, Dr Huggins said, “this should not be cause for complacency, because the overall health of Aboriginal and Torres Strait Islander peoples still lags behind the rest of the nation”.

The Campaign backed the AMA in calling for governments to reduce Indigenous incarceration rates.

It warned the nation was on track to have a record 10,000 Indigenous people behind bars this year, which is described as “a grim milestone”.

An AMA report highlighted that imprisonment exacerbated serious health problems and Indigenous incarceration rates needed to be reduced if the country was to close the health gap.

Adrian Rollins

[Comment] Offline: The reflection of ourselves we choose to ignore

Can medicine for the body and mind ever be united? The slogan “No health without mental health” was supposed to signify some kind of marriage (or truce might be a better word). But the physical and the mental still seem to occupy separate worlds, light years apart. In strategies to defeat non-communicable diseases (NCDs), the emphasis has been on four priorities—cardiovascular disease, cancer, diabetes, and chronic respiratory disease. These pathologies are important killers. They certainly deserve our attention.

[Comment] Brain health: widening the scope of NCDs

In 2011, WHO included only four groups of diseases in the non-communicable disease (NCD) category: cardiovascular diseases, cancer, respiratory diseases, and diabetes.1 Since then, there have been several WHO and UN initiatives that relate to NCDs. Yet the scope of NCDs in WHO’s NCD agenda still excludes many fatal and chronic disabling diseases. It is welcome that when the International Classification of Diseases 11th Revision comes to be implemented, in 2018, WHO statisticians will classify stroke—the second most common cause of death in people older than 60 years—as a brain disease.

Asbestos exposure: challenges for Australian clinicians

The unique properties of asbestos that still make it valuable for industry make it extremely hazardous to health

Due to the extensive past use of asbestos in Australia, known exposure is common and causes anxiety, especially because of the acknowledged increased risk of thoracic malignancies. With the increasing use of computed tomography for routine diagnostic purposes, more people are being identified with pleural plaques from minor asbestos exposure. This has led to increased concerns about the risks of more serious asbestos-related diseases (ARDs) developing, and has resulted in an increased number of diagnostic tests being performed, even though the presence of pleural plaques is not as such a risk factor for (pleural) malignant mesothelioma (MM) or bronchogenic cancer.1 Nevertheless, anxiety2 and the inability to reduce MM risk following exposure3 or to halt progression of established asbestosis result in significant health care problems and expenditure.

Although overall rates of MM in Australia have levelled off at around 50 per million per annum in men and tenfold less in women,4 the pattern of exposure of patients with MM is changing.5 Three waves of disease have been described: disease resulting from exposure to asbestos in the mining and milling of ore and the manufacturing of asbestos products; disease among people who have used asbestos products; and disease among those engaged in the repair, renovation and demolition of buildings.6 Landrigan also predicted disease resulting from serious environment exposure among residents, tenants and users of these buildings. These will continue to evolve. Since prohibition of the production and importation of asbestos in Australia in 2004, patterns of workforce and domestic exposure have further changed. Increasingly, claimants are presenting with MM arising solely from domestic exposure.7

Pleural plaques — the most common benign ARD — have minimal effect on lung function. However, plaques calcify with age and become more readily visible radiographically.

While there is no evidence that early diagnosis improves the survival of people with benign asbestos-related pleural diseases, asbestosis or MM, low-dose (albeit high-cost) computed tomography-based detection of early stage lung cancer in heavy smokers has been demonstrated to improve their survival, resulting in the establishment of screening programs.8 The level of risk justifying participation in such programs is yet to be established.

Asbestosis also remains a problem because it cannot be distinguished on clinical or pathological grounds from diffuse interstitial pulmonary fibrosis of other or unknown cause, other than on the basis of evidence (historical, radiological or pathological) of asbestos exposure.9–11 As exposure to asbestos in the community declines, it will be increasingly unlikely that clinicians will be mindful of the condition and diligent in taking an asbestos exposure history. There is still no treatment shown to be effective for asbestosis.

Lung cancer and MM remain the outcomes of asbestos exposure which are most feared in the community. As there is no exposure threshold for either asbestos or smoking in causing lung cancer, and because smoking and asbestos interact in lung cancer causation, it is difficult to attribute disease solely to asbestos unless an exposed patient has never smoked. The principles of treatment and prognosis of asbestos-related lung cancer are identical to those of lung cancer in non-asbestos-exposed patients, with special consideration of lung function in the assessment of fitness for surgical resection.

Epidemiological observations have shown that the risk of MM is doubled in first-degree relatives of index cases,12 leading to a need to understand the mechanism of such inheritance that could provide an understanding of the molecular changes in the process of carcinogenicity in general. MM has also become more readily and accurately diagnosed with cytology,9 reducing the need for more invasive diagnostic procedures. MM remains universally fatal, with a median survival of 9–12 months, and epithelioid disease is the least rapidly progressive.13 Most patients present with advanced disease, and palliative cytotoxic chemotherapy has been the mainstay of treatment for the past 15 years, prolonging survival modestly in selected patients.14 A recent randomised clinical trial reported a survival benefit from the addition of a monoclonal antibody targeting vascular endothelial growth factor,15 and there are early reports of responses to immunotherapies targeting the checkpoint blockade molecules cytotoxic T lymphocyte antigen 4 and programmed death 1. Immunotherapies currently provide the most promise for new treatment advances.

Fortunately, in the face of an ongoing ARD burden, liability issues in common law damages claims have largely been resolved across Australia, and most people with disabling ARD are compensated. However, workers’ compensation schemes for ARD vary among the states — there is still a disparity in the awards of general damages (for pain and suffering) in the various jurisdictions such that there is a strong case to harmonise the approach nationally.

[Comment] Ombudsman’s report for 2015

I became Ombudsman to the Lancet journals at the start of 2015, taking over the post from Wisia Wedzicha, who, having been appointed editor of the American Journal of Respiratory and Critical Care Medicine, had stepped down at the end of the previous year. To my knowledge I am the first holder of this post not resident in the UK—I was based in Malawi during most of 2015, but relocated to the UK in December.

Australia lagging in lung cancer screening: experts

Lung cancer kills more Australians than breast and colon cancer combined, however we are lagging behind other countries in researching and implementing targeted screening, experts argue.

In an article published today in the Medical Journal of Australia, consultant physician at the Sir Charles Gairdner Hospital in Perth Dr Fraser Brims and his coauthors write that the majority of lung cancer deaths are occurring in former smokers.

“In Australia, there are about 2 200 000 current or former smokers between the ages of 55 and 74 years who may be eligible for lung cancer screening,” they write.

In the US, low-dose chest computed tomography (CT) has been shown to reduce lung cancer mortality by 20%.

They said combined with smoking cessation initiatives and validated risk-prediction screening methods, targeted screenings can be cost-effective.

“The costs of treating advanced lung cancer are greater than the costs of treating the early stage disease”, Brims and his colleagues write.

They believe that in the absence of a coordinated approach, ad-hoc screening should be strongly discouraged.

Related: Screening needs ‘balance’

“The challenge facing Australia is the translation of international results into sustainable, cost-effective clinical practice, ensuring that the desired benefit outweighs the known harms, at the same time as enhancing tobacco control policies”, they conclude.

Read the full article in the Medical Journal of Australia.

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